Juvenile Glaucoma
Chat Highlights
May 21, 2003

Norma Devine, Editor

On Wednesday, May 21, 2003, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Juvenile Glaucoma."

Moderator:  Dr. Wilson, welcome back to chat.  Will you please start by defining juvenile glaucoma?  

Dr. Rick Wilson:  Juvenile glaucoma is glaucoma of childhood and adolescence, usually diagnosed before the age of 18.  If you developed glaucoma before that age, you would be diagnosed as having juvenile glaucoma your whole life.

P:  Are there different causes of juvenile glaucoma?  

Dr. Rick Wilson:  A variety of genetic defects have been discovered in juvenile glaucoma.  Usually there is a problem with the development of the outflow channel of the eye.  That defect can be just inside the trabecular meshwork, at the level of Schlemm's canal, or in the collection system, on the outside of the eye.

P:  Are the treatments for juvenile glaucoma the same as for adult glaucoma?  

Dr. Rick Wilson:  No, because in babies there is often a membrane holding the iris up over the trabecular meshwork.  The membrane can be cut, and the drain opened with a fairly non-traumatic procedure called a goniotomy.  A slightly more traumatic operation opens up the canal of Schlemm into the eye to eliminate any resistance at that level.  Both of these operations are usually performed before the trabeculectomy or shunt surgery used in adults. 

P:  Can an eye injury as a child cause glaucoma many years later as an adult?

Dr. Rick Wilson:  Yes, an eye injury that can cause a visible injury to the drain in the eye is associated with at least a 5% chance of glaucoma later in life, perhaps much later.

P:  How does juvenile glaucoma vary according to age?  

Dr. Rick Wilson:  It can be present before birth, so that the baby is born with it (congenital glaucoma).  It can also become apparent during the first three years of life (infantile glaucoma).  The older the child is, the more likely it is that the glaucoma will affect only one eye.

P:  How is juvenile glaucoma treated differently than other types?  Are timolol and Xalatan  common medications for all glaucoma types?

Dr. Rick Wilson:  Glaucoma in young children is treated more often with surgery than with medications because of the difficulty of checking the IOPs (intraocular pressure) of young children.  When medications are used, Alphagan is contraindicated because of side effects in children under eight years of  age.  Prostaglandins like Xalatan, Travatan, and Lumigan work much more variably in children than in adults.  Timolol and Trusopt/Azopt and their combination, Cosopt, are the most used medications.

P:  Could someone have juvenile glaucoma and not be aware of it?  Are there always symptoms, or might the symptoms not show up until the age of 20 or 30?

Dr. Rick Wilson:  Congenital glaucoma has symptoms of light sensitivity and tearing.  Young eyes cannot withstand the pressure.  The cornea suffers deleterious side effects, which cause the symptoms.  Unlike adults, older children usually have no symptoms.  This can lead to extremely sad cases.  Children are not brought in for eye examinations by their parents until they are falling over the furniture, which they can no longer see. 

P:  Do you use shunts and lens implants in children and juveniles?  If so, are the shunts small versions of  those used in adults?

Dr. Rick Wilson:  The human eye reaches adult size usually by age one.  We use adult-size shunts in children over one year of age.  Obviously, this can lead to trouble, especially in children with small orbits and big eyes from the glaucoma.  We usually have little other choice.  Lens implants are slowly being used in this age group.  It is hard, however, to guess what the power should be, because the eye changes as the child grows, which is not the case in adults.

Moderator:  How about monkey shunts?

Dr. Rick Wilson:  A small Molteno shunt that was developed for research in monkey eyes was used in infants.  I now use the 250 Baerveldt for that age group.  

P:  How long will the shunts work for children?

Dr. Rick Wilson:  That varies tremendously.  Both trabeculectomies and shunts show a gradual fall-off in effect with time.  Some fail quickly; others last for many years.  Some of my first shunt patients' shunts are still working after nearly 20 years.

P:  Why are children more difficult to treat than adults?

Dr. Rick Wilson:  Children are more difficult to treat because their eye tissue is so soft and malleable.  That can cause the tube to "migrate, " or end up pointing elsewhere from where it was originally aimed, or to become closed off by scar tissue.  Children heal better than adults and can generate tremendous amounts of scar tissue, which may render the shunt minimally effective after a while.

P:  If the eye reaches adult size at age two, why does myopia increase until the teens?

Dr. Rick Wilson:  Only if the eye doctor looks at the optic nerve or becomes suspicious because the eye is getting larger (more nearsighted) faster than it should and checks the IOP.

P:  What options are available if a child's shunt fails?  

Dr. Rick Wilson:  The good thing about shunts is that they are just plumbing.  If the opening of the tube in the anterior chamber of the eye is open and clear, then the problem must lie with the other eye.  We usually soak the scar tissue around the shunt reservoir (plate) with mitomycin C to retard scar tissue formation, and then cut off the scar tissue around the plate.  Until it gets too thick, the function will be returned.

P:  Should newborns and children be screened if there is glaucoma in the family? 

Dr. Rick Wilson:  Is it adult glaucoma or glaucoma of childhood?  If it's adult glaucoma, the usual suggestion is to have the child checked before kindergarten, if there are no signs or symptoms of problems.  If there's childhood glaucoma in the family, the children should be checked earlier and more often.

End of highlights for May 21, 2003.

On May 28, Dr. Werner discussed "Training a Glaucoma Specialist" in the Chat room. Click here for highlights of that meeting.

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