| Pediatric Glaucoma |
Question: What is the normal size for an infant's cornea?
Answer:
Normal size for a newborn cornea is about 10.5 mm, growing to 12 mm by 18 months.
Dr. Rick Wilson
August 2, 2006
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Question: What is meant by a "cracked" cornea in an infant with congenital glaucoma?
Answer:
The "cracks" are breaks in Descemet's membrane, the fourth of five layers starting from the outside of the eye and moving inward. When the soft, flexible tissue of the infant eye is stretched too fast by a pressure in the eye too high for it, the Descemet's membrane may not be able to stretch fast enough and may break. This allows fluid from the inside of the eye into the cornea making it swollen (edematous) and cloudy.
Dr. Rick Wilson
August 2, 2006
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Question: What are the likely outcomes in an infant with congenital glaucoma?
Answer:
In congenital and infantile glaucoma, the reason the fluid doesn't get out through the trabecular meshwork into Schlemm's Canal to be drained is that the iris is abnormally attached over it. A goniotomy is a surgical procedure where a tiny sharp blade is used to cut the tissue that holds the iris forward over the trabecular meshwork and open the outflow channel. I know college graduates that had a goniotomy at that age and never had to do anything else surgically. Many may need a medicinal drop to keep their IOP low enough. The goniotomy is usually about 65% to 75% successful, so not infrequently other surgeries are needed.
Dr. Rick Wilson
August 2, 2006
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Question: The surgeon who did my infant's goniotomy said he would only cut a distance of "five clock hours", and that two surgeries in each eye would probably be necessary. Why couldn't this all be done in one operation?
Answer:
I do at least "10 hours" distance at the first operation and see no reason, except historical precedent, not to. In babies where the risk of anesthesia is higher than the risk of an intraocular eye infection, I and many doctors do both eyes in one operation. However, there has been the report of one baby that got an intraocular infection in both eyes and lost both eyes. Therefore, in our litigious society, as the babies get older and anesthesia is not as much a risk, more doctors do one eye at a time.
Dr. Rick Wilson
August 2, 2006
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Question: What ages correspond to pediatric, juvenile, and adult glaucoma?
Answer:
Congenital is at birth, infantile is during the first 3 years, juvenile after 3 years and through at least the teens.
Dr. Rick Wilson
June 21, 2006
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Question: What special glaucoma difficulties occur in children?
Answer:
Children, especially infants and toddlers, heal much quicker and are very prone to inflammatory membranes in the anterior chamber. Their tissue is soft, and tubes placed in good position can be pulled out of alignment much more readily than in adults.
Dr. Rick Wilson
June 21, 2006
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Question: Is it possible for a toddler to have glaucoma?
Answer:
Glaucoma mainly affects older people, but a small number of people get glaucoma at younger ages. People at any age can develop glaucoma, and congenital glaucoma is present at birth.
Dr. Richard Lee
May 11, 2005
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Question: What are likely treatments for a toddler with glaucoma?
Answer:
Children are some of the most difficult patients to treat not only because of social issues (i.e., a baby cannot communicate), but also because of the risk of developing amblyopia, and because of other associated issues such as the frequent requirement for general anesthesia for evaluation and treatment. For little kids, goniotomy and trabeculotomy are often the first surgical treatment modalities. However, glaucoma drainage implants, such as the Ahmed and Baerveldt, are increasingly used in treating kids as ophthalmologists gain more experience with these devices.
Dr. Richard Lee
May 11, 2005
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Question: Do shunts cause disfigurement in children?
Answer:
Shunts usually do not cause any disfigurement, although there is a risk of strabismus (cross-eye) in children.
Dr. Richard Lee
May 11, 2005
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Question: How does the success rate of the Ahmed Shunt compare to other procedures in children?
Answer:
I am not aware of any large prospective studies that compare the Ahmed shunt to other surgical treatments such as goniotomy or trabeculotomy in terms of long-term success in children.
Dr. Richard Lee
May 11, 2005
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Question: My child's corneas are large and look bulgy. Will getting the intraocular pressure (IOP) under control make the cornea smaller and less bulgy?
Answer:
Well, the large corneas are a function of the high pressure. They will always be large, but hopefully if the IOP is reduced, then the rest of the eye will grow and the large corneas won't be as much of an issue.
Dr. Jeff Henderer
May 25, 2005
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Question: What would be a good endpoint to determine whether a child's treatment is working?
Answer:
In children with a cupped optic nerve head, a good endpoint to determine if the treatment is having the desired effect would be to see a reversal [decrease] of the cupping. A reversal means that the stress has been taken off the nerve and that "stunned" nerve cells have more or less returned to an anatomically correct appearance. However, there may be some functional deficits that persist.
Dr. Jeff Henderer
May 25, 2005
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Question: I want to get good baseline measurements for my child. Should I request a photo image of the optic nerve? What questions should I ask?
Answer:
I am sure your doctor will need a photo of the optic nerve. Ask questions such as these: What is the prognosis? Am I doing all I can? How can I make my children feel as close to normal as possible, not focusing overly on the glaucoma while still making sure the intraocular pressure is appropriate?
Dr. Rick Wilson
February 5, 2006
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Question: Can glaucoma drops cause harm to a fetus?
Answer:
Prostaglandins like Lumigan have been used in horses to cause abortions, so they are not good to have in the body even in small doses. Propine, betoptic, and Iopidine are probably the safest glaucoma drops to use during pregnancy.
Dr. Rick Wilson
September 14, 2005
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Question: What is the difference between a trabeculotomy and a trabeculectomy? Which is more risky in children?
Answer:
The trabeculectomy takes a piece of the wall of the eye out and leaves a flap of sclera overlying so the fluid has to seep out slowly. The trabeculotomy opens up the canal of Schlemm into the eye to eliminate any abnormal blockage of aqueous getting into the canal. A trabeculectomy is more risky, but usually more effective as the children age.
Dr. Rick Wilson
September 14, 2005
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Question: Can cupping in an infant be reversed?
Answer:
Yes, cupping can be improved slightly even in older ages, but is most noticeable in the young because the sclera surrounding the hole that the nerve goes through is elastic. The younger the patient, the more distensible (stretchable) the canal is that the optic nerve goes through. Raising the intraocular pressure not only kills nerve fibers (showing up as an increasing cup in the middle of the nerve), but also increases the width of the canal. That makes the central cup look much bigger than it really is. When the IOP is dropped to normal, the canal shrinks back to normal and the central cup is smaller.
Don't confuse reversibility of cupping with improvement in the amount of nerve damage. That rarely improves more than a little bit.
Dr. Rick Wilson
February 16, 2005 |
