Chat Highlights
Pediatric Glaucoma
September 27, 2000

Norma Devine, Editor

On Wednesday, September 27, 2000, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Pediatric Glaucoma." 

Moderator:  The topic tonight is Pediatric Glaucoma.

P:  Dr. Wilson, my 12-year-old son was just diagnosed with juvenile open-angle glaucoma.  He's on the fourth kind of eye drop and his intraocular pressure is still up at 29 mm Hg.  How many different  drops would you try before resorting to surgery?

Dr. Wilson:  That is a difficult age for surgery to work well.  Therefore, before going to surgery, I would usually try a combination of two or three kinds of drops, if they did not cause any side effects.  Laser surgery is not used for open-angle glaucoma at that age.

P:   Why would you want to hold off on surgery for a 12-year-old child?  

Dr. Wilson:  They heal quite well, they are very active and could get hit in the eye, and a trabeculectomy exposes them to later infection.  If it cannot be avoided, I would go ahead; if it can be avoided, I would avoid it.  

P:  What is the difference between a goniotomy, a trabeculotomy, and a trabeculectomy?

Dr. Wilson:  A goniotomy cuts open any membrane on the inside of the eye covering the trabecular meshwork (the drain of the eye) and blocking it.  A trabeculotomy is a probe or a suture threaded into the Canal of Schlemm (which is right on the outside of the trabecular meshwork), and is then used to break open the canal into the inside of the eye so nothing blocks the flow of aqueous into the drain.  A trabeculectomy is a flap valve through the wall of the eye. An article I wrote about trabeculectomy is on the Web pages.  Please read the information, as I couldn't do the subject justice in a chat room.  

P:   My nephew was diagnosed a month ago with congenital glaucoma.  His pressures were in the mid 40's.  He had surgery immediately.  The pressure in his right eye is now in the low 20's, and in the left eye it is still in the low 30's.  He's having another surgery next week.

Dr. Wilson:   I'm sorry to hear that.  I hope all goes well.  Where is the surgery taking place?

P:  At Duke hospital.  Sharon Freedman is his doctor.

Dr. Wilson:   I spoke at Duke last Spring.  Dr. Freedman has a lot of experience.

P:  Is Dr. Freedman a good choice?  What would you say the average prognosis is? 

Dr. Wilson:  Dr. Freedman is an excellent choice.  Most of the time (>80%), the pressure can be controlled with one or more surgeries.  Corneal problems and the development of a lazy eye are concurrent problems in many patients.

P:  What about the other 20%?  

Dr. Wilson:  The other 20% have complications that may result in some loss of sight.

P:  If  the second surgery, trabeculotomy, is not successful, what would be the next step, in your opinion?

Dr. Wilson:  I do a trabeculectomy, but I think Dr. Freeman does an aqueous shunt. 

P:  Can people be tested to further research in families?

Dr. Wilson:  Yes, we are making excellent progress in identifying the genes that cause disease.  But it usually is a recessive gene.

P:  What level of  intraocular pressure is considered dangerously high for an infant?  What would be the normal range?

Dr. Wilson:  Infants usually have IOP's of  8 to 12.  The IOP norm increases as they get older.  

Moderator:  What is the difference between congenital and pediatric glaucoma?  Is it just the age when diagnosed?  

Dr. Wilson:  The divisions of childhood glaucoma are congenital (at birth), infantile (birth to 1 or 2 years), and juvenile (up to the mid teens).

P:  What is open-angle glaucoma called when the patient is past the mid teens?  

Dr. Wilson:  From mid teens to old age, it is called  Primary Open Angle Glaucoma (POAG).

P:  Are there any circumstances under which newborns or children are screened for high pressures, or other indications of glaucoma?

Dr. Wilson:  Newborns should be screened for the three cardinal signs of congenital glaucoma:  enlarged, cloudy corneas, tearing, and light sensitivity.

P:  Is that tearing as in torn? Or tearing as in tears falling?

Dr. Wilson:  Tearing, as in tears welling up in the eye.

P:  My niece is two-and-a-half years older than my nephew, who has congenital glaucoma.  She does not have it, but could she get it later?   

Dr. Wilson:  Yes, but it would be very unusual, unless she has some kind of genetic syndrome.

P:  With only adult glaucoma in the family, should we worry that pediatric glaucoma will show up at some time?

Dr. Wilson:   There seem to be several genes for pediatric glaucoma, with a different inheritance.  Most of the time it may be the combination of several recessive genes that come together to cause a problem.

P:  Did you say what chances our children have of inheriting glaucoma?

Dr. Wilson:  Having a close relative with glaucoma raises the chances of one getting it by 8 to 15 times, depending upon the study you read.

P:  Can the pressures reduce naturally as the child ages?  I had surgery in one eye at age 16, but  now I'm 40 and both eyes have low pressures.  Can my son expect the same good luck?

Dr. Wilson:  Not necessarily. 

P:  Is there an age when surgery is a safe choice in kids?

Dr. Wilson:  Surgery is always available for children of any age. In infants, we prefer surgery to drops. In juvenile glaucoma, we prefer drops to surgery.

P:  I have congenital glaucoma and am now 45.  With the right medications, I have preserved my sight so far.

End of highlights for September 27th chat.

On October 4th, Dr. Rick Wilson discussed "Malignant Glaucoma" in the Chat room. Click here for highlights of that meeting.

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