Challenges of Treating Childhood Glaucoma

“The stakes are high in childhood glaucoma — sight or blindness — and early diagnosis and treatment of the disease are imperative,” says Elias Traboulsi, MD, Head of the Department of Pediatric Ophthalmology and Director of the Center for Genetic Eye Diseases at Cleveland Clinic’s Cole Eye Institute.

Intraocular pressure is critical in defining the disease in children. The goal of treatment is to reduce it to normal limits. In adults, however, the objective is to reduce it to even lower target levels in some.

Types of childhood glaucoma and treatments

• One rare type of inherited childhood glaucoma, present at birth or shortly thereafter, is called infantile or congenital glaucoma. This is related to an anatomic predisposition of the anterior chamber angle for elevated pressure, Dr. Traboulsi says. Treatment is to either open the channels for drainage of aqueous humor or provide new drainage channels.

A challenge is that children’s eye tissues heal much better than those in adults, so much so that they can close the drainage openings. Another consequence of infantile glaucoma is a distended and more myopic eye.

In congenital glaucoma, vision is lost to damage of the optic nerve as well as to children not using their vision well, which can lead to amblyopia. “Treatment of glaucoma in babies is not only aimed at reducing IOP, but also at managing other visual complications of changes in the ocular structures from elevated pressure,” says Dr. Traboulsi.

• Another kind of glaucoma, anterior segment dysgenesis, occurs in children as they get older. In this genetically determined condition, anterior segment channels don’t form properly, predisposing the patient to glaucoma. “The problem may not show at birth, but rather not until a child is 5 to 10 or 15 years old,” says Dr. Traboulsi, noting that the risk for glaucoma is lifelong. “These children need to be followed up periodically for pressure checks, generally every four to six months,” he says.
• According to Dr. Traboulsi, the third setting for childhood glaucoma is in cases of aphakia or pseudophakia. Here, cataracts have been removed in babies or early in life, with subsequent development of elevated IOP.

The mechanisms of this condition have yet to be identified. “We don’t know why these children are at risk for elevated IOP, but we bring them back quite frequently after they’ve had their cataract surgery to check their eye pressures, and we do this for their lifetime,” says Dr. Traboulsi.

Such children can develop IOP either very soon after cataract surgery or many years later. Treatment is usually medical, starting with eye drops, followed by medications and/or surgery.

• Injuries to the eye can also cause adhesions between the iris and the cornea, or damage to the anterior chamber angle, either of which can interrupt the drainage of fluid out of the eye. Traumatic or post-traumatic glaucoma is treated with medications and eye drops and, if those fail to lower IOP enough, surgery.

Outcomes

Dr. Traboulsi says that outcomes depend on the type of glaucoma, the age at which it was identified and compliance with treatments. “Compliance can be a big problem. Unless the family and the parents are very diligent, know how to give the drops and can afford them, some children can go untreated or be very poorly treated,” he says.

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