Management Of Pediatric Glaucoma Research Articles

Micropulse cyclophotocoagulation compared to continuous wave cyclophotocoagulation for the management of refractory pediatric glaucoma.

Micropulse cyclophotocoagulation (MPCPC) has been shown in adults to offer a favorable post-operative safety profile compared to continuous wave transscleral cyclophotocoagulation (CWCPC) in the management of glaucoma. The purpose of this study is to evaluate the long term efficacy, safety, and effectiveness of MPCPC in the management of pediatric glaucoma when compared to CWCPC. IRB approved retrospective chart review of patients with pediatric glaucoma that underwent MPCPC and CWCPC at 2 separate institutions. Success was defined as intraocular pressure (IOP) between 5 and 21mmHg on any number of topical glaucoma medication without requiring additional surgical intervention or oral IOP lowering medication. Of the 48 patients in the study, 22 (26 eyes) underwent MPCPC and 26 (30 eyes) underwent CWCPC. At 1 year, 7 out of 26 eyes (26.9%) achieved success in the MPCPC group compared to 13 out of 30 eyes (43.3%) in the CWCPC group. Survival analysis unveiled a statistically significant difference in success between the two groups (p = 0.03). In pediatric glaucoma patients undergoing cyclophotocoagulation procedures, CWCPC outperformed MPCPC using default settings in terms of achieving long-term IOP control. Additional studies are required to evaluated augmented MPCPC settings in pediatric glaucoma patients.

One-year results of circumferential trabeculotomy in pediatric glaucoma following cataract surgery

The management of pediatric glaucoma following cataract surgery (GFCS) is challenging. This study looks at the results of two-site trabeculotomy in eyes with pediatric aphakic and pseudophakic glaucoma, 1 year postoperatively.

Best practice patterns: how to effectively use OCT in pediatric ophthalmology

As optical coherence tomography (OCT) technology has advanced, and become more widely available, it is being used more commonly in pediatric ophthalmology. As the technology demonstrates value as an integral part of the evaluation of the pediatric eye, it is critical for pediatric ophthalmologists to understand how to incorporate OCT into their clinical flow, interpret results, and make clinical decisions based on OCT findings. The purpose of this workshop is to review basic OCT interpretation and discuss recent advances in OCT technology, including OCT angiography. We will discuss the pearls and pitfalls in utilizing OCT in the evaluation and management of pediatric glaucoma, genetics, and retina.

Cyclodiode photocoagulation in the management of pediatric glaucomas over a 15-year period

Cyclodiode photocoagulation in the management of pediatric glaucomas over a 15-year period

Best practice patterns: how to effectively use OCT in pediatric ophthalmology

As optical coherence tomography (OCT) technology has advanced, it has become more widely utilized in pediatric ophthalmology. It is critical for pediatric ophthalmologists to understand how to incorporate OCT into their clinical flow, interpret results, and make clinical decisions based on OCT findings. The purpose of this workshop is to review basic OCT interpretation and discuss recent advances in OCT technology, including OCT angiography. We will discuss the pearls and pitfalls in utilizing OCT in the evaluation and management of pediatric glaucoma, optic neuropathies, and pediatric retinal pathology.

Does this child have glaucoma or something else? Applying newer technologies to the diagnosis and management of pediatric glaucoma

The workshop is designed to highlight the sometimes challenging clinical entity of the “glaucoma suspect,” with emphasis on newer ophthalmic technologies and how they may assist in our diagnostic evaluation of these cases. Medication update and pearls for use in children will be included.

The use of Ahmed glaucoma valve in the management of pediatric glaucoma

To assess the intraocular pressure control (IOP), changes in visual acuity, complications, reoperation rates and risk factors for failure following Ahmed glaucoma valve implantation in pediatric eyes with glaucoma. The medical records of consecutive patients with glaucoma who underwent Ahmed glaucoma valve implantation from January 2000 to December 2009) were retrospectively reviewed. Only one eye of each patient was included. Subgroup analysis was performed in three groups; group 1 included phakic eyes with primary congenital glaucoma, juvenile open-angle glaucoma, or glaucoma associated with ocular anomalies; group 2 included eyes with glaucoma in aphakia or pseudophakia; group 3 included eyes with other diagnoses. A successful outcome was defined as final IOP between 6 mm Hg and 18 mm Hg without loss of light perception or reoperation for glaucoma. A total of 71 eyes in 71 patients: 15 (21%) in group 1, 47 (66%) in group 2, and 9 (13%) in group 3 were included Successful IOP control was achieved in 44 eyes of 44 patients (62%). Cumulative probabilities of success by Kaplan-Meier analysis at 12 and 24 months was 97% and 80% for the entire group, 100% and 82% for group 1, 95% and 86% for group 2, and 90% and 42% for group 3. Reoperation was necessary for 18 patients (25%), either for tube-related complications or for IOP control. The only significant risk factor for failure was the category of diagnosis (P = 0.029). Ahmed glaucoma valve implantation is an option in the management of pediatric glaucoma; however, reoperations for tube related complications or for persistent elevated IOP is frequently needed.

Intraobserver reliability of contact pachymetry in children

Central corneal thickness (CCT) is an important measurement in the treatment and management of pediatric glaucoma and potentially of refractive error, but data regarding reliability of CCT measurement in children are limited. The purpose of this study was to evaluate the reliability of CCT measurement with the use of handheld contact pachymetry in children. We conducted a multicenter intraobserver test-retest reliability study of more than 3,400 healthy eyes in children aged from newborn to 17 years by using a handheld contact pachymeter (Pachmate DGH55; DGH Technology Inc, Exton, PA) in 2 clinical settings--with the use of topical anesthesia in the office and with the patient under general anesthesia in a surgical facility. The overall standard error of measurement, including only measurements with standard deviation ≤5 μm, was 8 μm; the corresponding coefficient of repeatability, or limits within which 95% of test-retest differences fell, was ±22.3 μm. However, standard error of measurement increased as CCT increased, from 6.8 μm for CCT less than 525 μm, to 12.9 μm for CCT 625 μm and greater. The standard error of measurement including measurements with standard deviation >5 μm was 10.5 μm. Age, sex, race/ethnicity group, and examination setting did not influence the magnitude of test-retest differences. CCT measurement reliability in children via the Pachmate DGH55 handheld contact pachymeter is similar to that reported for adults. Because thicker CCT measurements are less reliable than thinner measurements, a second measure may be helpful when the first exceeds 575 μm. Reliability is also improved by disregarding measurements with instrument-reported standard deviations >5 μm.

Does this child have glaucoma? Applying newer technologies to the diagnosis and management of pediatric glaucoma

Does this child have glaucoma? Applying newer technologies to the diagnosis and management of pediatric glaucoma. Synopsis: Pediatric glaucoma sometimes presents with clear objective signs that make its diagnosis (though not necessarily its successful treatment!) rather straightforward. Yet at other times, abnormalities of the optic nerve or other features of the child's case raise suspicion of the glaucoma diagnosis but doubt remains. This workshop is intended to review cases of known and suspected glaucoma, with emphasis on newer technologies and thorough discussion of what the ‘experts’ really use to make (or exclude) the diagnosis of pediatric glaucoma. Technologies to be discussed include: central corneal thickness and other features affecting pressure evaluation (including new devices for measuring intraocular pressure), optic nerve head (and macular?) imaging (optical coherence tomography, etc.), visual field evaluation, and modern strategies for medical management of the high-risk or confirmed glaucoma case. A case-based format will be utilized, and attendee questions and comments will be encouraged.

136: Does this child have glaucoma? Applying newer technologies to the diagnosis and management of pediatric glaucoma

Pediatric glaucoma sometimes presents with clear objective signs that make its diagnosis (though not necessarily its successful treatment!) rather straightforward. Yet at other times, abnormalities of the optic nerve or other features of the child's case raise suspicion of the “glaucoma” diagnosis but doubt remains. This workshop is intended to review cases of known and suspected glaucoma, with emphasis on newer technologies and thorough discussion of what the “experts” really use to make (or exclude) the diagnosis of pediatric glaucoma. Technologies to be discussed include central corneal thickness and other features affecting pressure evaluation (including new devices for measuring intraocular pressure), optic nerve head (and macular?) imaging (optical coherence tomography, etc.), visual field evaluation, and modern strategies for medical management of the high-risk or confirmed glaucoma case. A case-based format will be used, and attendee questions and comments will be encouraged.

The Additive Effect of Topical Dorzolamide and Systemic Acetazolamide in Pediatric Glaucoma

The effect of adding oral to topical carbonic anhydrase inhibitors in the management of pediatric glaucoma is unknown. We undertook a retrospective analysis of children with a diagnosis of glaucoma before the age of 16 years who initially were treated with topical dorzolamide or dorzolamide-timolol combination and then treated with oral acetazolamide. Children who had uveitic glaucoma or who had ocular surgery within 3 months before or during oral acetazolamide therapy were excluded. Various methods of intraocular pressure (IOP) measurement were used in the study. However, in each case, the IOP was measured using the same technique, once at the last visit before the addition of oral acetazolamide and once at the first examination after the addition of oral acetazolamide. Twenty-two patients were included in the study with an age range of 8 months to 15 years. Seventeen children were boys. Oral acetazolamide treatment was via a daily dose (13.3 to 30 mg/kg, mean 22.5 mg/kg), and duration (6 to 31 days, mean 18.1 days). The intraocular pressure (mean +/- SD) before acetazolamide (32.2 +/- 6.5 mm Hg) was significantly different than after acetazolamide (21.8 +/- 6.3 mm Hg) with a mean difference of 10.36 mm Hg (p < 0.0001) and a mean decrease in IOP of 29.6%. The addition of oral acetazolamide to topical dorzolamide may provide additional reduction in IOP in some children already being treated with topical carbonic anhydrase inhibitors. This possible additive effect has not been observed in adults treated with a combination of topical and systemic carbonic anhydrase inhibitors.

Optical Coherence Tomography in Normal and Glaucomatous Pediatric Eyes: Nerve Fiber Layer and Macular Analysis versus Optic Disc Morphology

Introduction: Optic nerve head (ONH) stereophotography is integral to the evaluation of adults with glaucoma. Optical coherence tomography (OCT) analysis of the peripapillary nerve fiber layer (NFL) and macular thickness in adults has recently also proven valuable. Comparing OCT analysis of NFL and macula in children, Hess et al. (AmJ Ophthalmol 2005;139:509-17) found a significant difference between normal and glaucomatous eyes of children. We further propose a correlation between glaucomatous ONH damage and macular and NFL analysis by OCT. Purpose: To compare analysis of macular and nerve fiber layer thickness by OCT3, to ONH morphology based upon stereophotography. Methods: Normal and glaucomatous eyes of children aged 4 to 17 years were included. OCT 3 (Carl Zeiss Meditec, Dublin, CA) was used to obtain a fast macular and NFL thickness map for each eye. ONH stereophotographs were taken and evaluated by two masked observers, using a grading system of 0 to 6 based on both cupping ratio and morphology. OCT3 analyses were compared across OHN grades for the superior, inferior, and temporal macula, as well as for the NFL at several locations around the ONH (Hess et al. AJO 2005;139:509-17). Results: Analysis included OCT values and ONH grading for 159 eyes (99 children). Spearman correlation revealed a moderate relationship between ONH grade and both macular thickness, as well as NFL thickness in all areas measured; for example, for the macular volume the correlation coefficient was 0.47 (P< 0.0001) with a slope of −7.95 (P< 0.0001). Conclusion: We report that OCT measured NFL and macular thickness decline with increasing glaucomatous damage to the ONH in children. Further study will help quantify the value of OCT in the diagnosis and management of pediatric glaucoma.

Pediatric Glaucomas: Update and Management Controversies

Synopsis: This workshop is intended for those who already have a basic background in the diagnosis and management of pediatric glaucomas. We will update participants on new developments in diagnostics and the medical and surgical management of the common forms of primary and secondary pediatric glaucoma, with emphasis on a case-based format. Special attention will be paid to surgical tricks that may help participants avoid difficulties already encountered by those instructing. Controversies in management and differences in surgical approach will be highlighted by the panel of instructors. Videos will be included to illustrate appropriate surgical points. Attendee questions and comments will be encouraged. (Outline available on request.)

Baerveldt glaucoma implant in the management of refractory childhood glaucomas

Purpose To evaluate the effectiveness and safety of the Baerveldt glaucoma drainage implant (GDI) in the management of pediatric glaucomas. Design Retrospective noncomparative case series. Participants Sixty-two children younger than 18 years who underwent Baerveldt GDI surgery. Main outcome measures Intraocular pressure (IOP), intraoperative and postoperative complications, number of glaucoma medications, and VA. Success was defined as IOP of <22 mmHg and ≥5 mmHg with or without medications, no loss of light perception, and no further surgical intervention for glaucoma. Outcomes were compared for patients with primary and secondary glaucomas. Results Sixty-two eyes of 62 patients were identified. The mean patient age (± standard deviation) at time of Baerveldt glaucoma implant surgery was 6.5±5.6 years (range, 6 weeks–17 years). With an average follow-up of 23.4±21.7 months (range, 1–106), IOP was reduced from a mean of 35.0±8.7 mmHg (range, 17–54) preoperatively to 17.6±8.4 mmHg (range, 5–45) at last follow-up visit ( P<0.001). Kaplan–Meier survival analysis showed a cumulative success of 85% at 6 months, 80% at 12 months, 67% at 24 months, and 60% in months 28 through 106. There was no difference between primary (N = 23) and secondary glaucoma (N = 39) patients in terms of length of follow-up, final IOP, number of medications, or cumulative success ( P = 0.21). Conclusion Baerveldt glaucoma implant surgery seems to be an effective treatment for primary and secondary refractory glaucomas in children. There is a risk of retinal detachment that may be related to the implant or other ocular conditions.

Diagnosis and management of pediatric glaucoma.

Appropriate diagnosis of pediatric glaucoma in toddlers and school-aged children is aided by an understanding of the signs and symptoms of infantile-onset glaucoma, along with its associated conditions. Unlike adults with glaucoma, the management of pediatric glaucoma is frequently surgical, with medical therapy playing an adjunctive role. The ultimate goal of pediatric glaucoma management is not control of IOP but preservation of vision. The visual prognosis in children with glaucoma is correlated with the severity of the associated ocular pathology. Primary congenital glaucoma has the best visual prognosis, with 52% to 79% having visual acuity of 20/50 or better. Glaucomas associated with congenital ocular anomalies and secondary glaucomas have a worse visual prognosis, with 30% to 50% of eyes noted to be 20/50 or better. Amblyopia and uncontrolled glaucoma are the two main factors associated with reduction in vision. Control of the glaucoma by medical and surgical means and treatment of amblyopia during susceptible ages are the essential factors in the management of pediatric glaucoma.