Paediatrics Glaucoma

7/29/2019 Paediatrics Glaucoma

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Evaluation and Diagnosis of

Paediatric Glaucoma

Dr Ashwin Sainani

Consultant Paediatric Ophthalmologist

P.D. Hinduja Hospital

Mumbai


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Paediatric Glaucoma

Paediatric glaucoma represents a rare,complex collection of diversepathophysiological entities. This type of

glaucoma occurs early in life and usuallyresults from structural mal-development ofthe anterior segment and angle structures.

Predominantly sporadic

Inherited in 10%27 %


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Classification of Paediatric

glaucomaPrimary congenital glaucoma

Juvenile glaucoma

Secondary glaucomas:Angle anomaly :

Sturge Weber syndrome

Aniridia

NF

Ant segment anomalies:

Peters anomaly

Axenfeld Riegers syndrome

ICE syndrome


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Secondary glaucomas

Iris Lens diaphragm Abnormalities

Marfans syndrome

Spherophakia

Ectopia Lentis

Homocystinuria

PHPV

ROP

Aphakic glaucoma

Trauma


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Secondary glaucomas

Uveitis

JRA

Sarcoid

Idiopathic

Tumours

Retinoblastoma

Juvenile Xanthogranuloma

Steroid induced


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Diagnosis

Presentations:

ObviousBuphthalmos (


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Differential Diagnosis of cloudy

cornea

Ant segment anomalies

Peters anomaly


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D.D. (contd)

Sclerocornea


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D.D. (contd)

Corneal dermoid


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D.D. (contd)

Congenital infections

Rubella

CMV

Herpes simplex

Influenza

Trauma


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D.D. (contd)

Corneal Dystrophies

PPMD (Post polymorphous dystrophy)

CHED(Congenital Hereditary Endothelial Dystrophy)


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D.D. (contd)

Metabolic Diseases

Gangliosidosis (GM 1)

Mucopolysaccharidosis (Hurlers disease)


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Presentation

ElusiveEpiphora, photophobia, blepharospasm, subtle

corneal enlargement. (bilat)


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Examination

Clinic (>5 yrs)

EUA:

Short inhalational induction with face mask.

Laryngeal mask

Anaesthetic agents:

GasesSevofluraine, halothane

IVPropofol, ketamine, pentothal Muscle Relaxants:

Succinylcholine

Atracurium

vecuronium


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Effects of Anaesthetic agents on IOP

Most anaesthetic agents cause reduction in

IOP.

Ketamine and Succinylcholine cause a rise

in IOP and are thus avoided in an EUA for

glaucoma.


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Evaluation

Corneal Diameter: (Vernier Caliper)

Newborn9.5 to 10.5mm

1 yr11mm

2-3 yrs12mm

(>12 mm in an infant less than a year is

abnormal)

Corneal Haze / Haabs Striae: (Portable Slit

Lamp)


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Corneal Measurements


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Evaluation (contd)

Ant /Post Segment examination: (Portable slit lamp) Cornea

Opacification

Posterior Embryotoxon

Iris

Iris hypoplasia

Iris strands

Correctopia/polycorrea Ectopia uveae

AC

Uveitis

hyphema


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Evaluation (contd)

Lens Cataract

Subluxation

Aphakia

Kerato-lenticular touch

Vitreous

Retrolental fibrosis

Vitritis Retina

Tumours

ROP

Choroidal hemangioma


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Evaluation (contd)

IOP: (Perkins, Tonopen, Shiotz)

Normal IOP in infantsUpper teens

21mm is still a useful upper limit

Not the only critical parameter

Comparison with other eye is useful inunilateral disease.

Measured as early as possible after anaesthesia


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Perkins Tonometry


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Evaluation (contd)

Cup:Disc ratio

Rapid increase in cupping

May show reduction in cupping when IOP is

controlled.

Due to reduction in elastic components notreversal of axonal atrophy


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Evaluation (contd)

Gonioscopy: (Koeppes lens, Barkans lens)

Anterior insertion of iris

Absent scleral spur

Iris processes

Membranous structure covering the meshwork


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Evaluation (contd)

A scanBuphthalmic eye would have an

increased axial length.

B scan / UBM

Hazy cornea

Retinoscopy

Myopic shift


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Diagnosis

Diagnosis is based on the entire clinicalpicture and not on any single parameter:

IOP

Size of corneaCorneal oedema

Cupping

Evidence of trabeculodysgenesisAnterior segment abnormalities

Evidence of progression is highlysignificant.


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Follow up

Frequency depends on the stage ofglaucoma

Includes regular EUAs to monitor effect oftreatment and progression of disease

Management of Amblyopia:Cycloplegic refraction

Patching - The only proof of the presence ofamblyopia is the improvement of vision onpatching.


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Paediatrics Glaucoma