The British Infantile and Childhood Glaucoma (BIG) Eye Study

Predicting the risk of glaucoma-related adverse events following secondary intraocular lens implantation in paediatric eyes: a 3-year study

AIMS

To establish and evaluate predictive models for glaucoma-related adverse events (GRAEs) following secondary intraocular lens (IOL) implantation in paediatric eyes.

METHODS

205 children (356 aphakic eyes) receiving secondary IOL implantation at Zhongshan Ophthalmic Center with a 3-year follow-up were enrolled. Cox proportional hazard model was used to identify predictors of GRAEs and developed nomograms. Model performance was evaluated with time-dependent receiver operating characteristic (ROC) curves, decision curve analysis, Kaplan-Meier curves and validated internally through C-statistics and calibration plot of the bootstrap samples.

RESULTS

Older age at secondary IOL implantation (HR=1.5, 95% CI: 1.03 to 2.19), transient intraocular hypertension (HR=9.06, 95% CI: 2.97 to 27.67) and ciliary sulcus implantation (HR=14.55, 95% CI: 2.11 to 100.57) were identified as risk factors for GRAEs (all p<0.05). Two nomograms were established. At postoperatively 1, 2 and 3 years, model 1 achieved area under the ROC curves (AUCs) of 0.747 (95% CI: 0.776 to 0.935), 0.765 (95% CI: 0.804 to 0.936) and 0.748 (95% CI: 0.736 to 0.918), and the AUCs of model 2 were 0.881 (95% CI: 0.836 to 0.926), 0.895 (95% CI: 0.852 to 0.938) and 0.848 (95% CI: 0.752 to 0.945). Both models demonstrated fine clinical net benefit and performance in the interval validation. The Kaplan-Meier curves showing two distinct risk groups were well discriminated and robust in both models. An online risk calculator was constructed.

CONCLUSION

Two nomograms could sensitively and accurately identify children at high risk of GRAEs after secondary IOL implantation to help early identification and timely intervention.

Systematic Review of Instruments for the Assessment of Patient-Reported Outcomes and Quality of Life in Patients with Childhood Glaucoma

TOPIC

To identify patient-reported outcome measures (PROMs) that have been used in children and adolescents with glaucoma and to evaluate their methodologic quality.

CLINICAL RELEVANCE

Childhood glaucoma impairs vision and quality of life (QoL) throughout all stages of life. Thus, a PROM needs to cover many different age groups and topics. Various instruments have been used to evaluate patient-reported outcomes (PROs) in patients with childhood glaucoma, however, it is unclear which PROM has the highest methodologic quality and complies best with the needs of patients with childhood glaucoma.

METHODS

A systematic literature review was performed searching MEDLINE (PubMed), the Cochrane Library, Web of Science, and PsycINFO (EBSCO). We included peer-reviewed full-text articles of the past 10 years in English, German, or Spanish language that reported PROMs in children with glaucoma. The study selection and methodologic quality assessment of the identified PROMs was performed by 2 independent reviewers using a 7-point checklist. The content was mapped onto the World Health Organization International Classification of Functioning, Disability and Health. The systematic review was prospectively registered in PROSPERO (ID CRD42022353936).

RESULTS

The search strategy retrieved 3295 matches. A total of 2901 studies were screened, and 11 relevant articles were identified using 10 different instruments. The instruments addressed functional visual ability, vision-related QoL, health-related QoL, and life satisfaction. Six instruments were applicable for the use in children. Seven of the questionnaires received the highest number of positive ratings (5/7). None of the instruments considered the views of patients with childhood glaucoma during their development.

CONCLUSION

This systematic review provides a descriptive catalog of vision-specific and generic health PRO instruments that have been used in childhood glaucoma cohorts. An instrument specifically developed for childhood glaucoma is lacking which might result in missing important factors, such as permanent treatment with eye drops, repeated surgeries, and heritability of the disease, when investigating the QoL in children with glaucoma.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Improving the Yield of Genetic Diagnosis through Additional Genetic Panel Testing in Hereditary Ophthalmic Diseases

Numerous hereditary ophthalmic diseases display significant genetic diversity. Consequently, the utilization of gene panel sequencing allows a greater number of patients to receive a genetic diagnosis for their clinical manifestations. We investigated how to improve the yield of genetic diagnosis through additional gene panel sequencing in hereditary ophthalmic diseases. A gene panel sequencing consisting of a customized hereditary retinopathy panel or hereditary retinitis pigmentosa (RP) panel was prescribed and referred to a CAP-accredited clinical laboratory. If no significant mutations associated with hereditary retinopathy and RP were detected in either panel, additional gene panel sequencing was requested for research use, utilizing the remaining panel. After additional gene panel sequencing, a total of 16 heterozygous or homozygous variants were identified in 15 different genes associated with hereditary ophthalmic diseases. Of 15 patients carrying any candidate variants, the clinical symptoms could be tentatively accounted for by genetic mutations in seven patients. However, in the remaining eight patients, given the in silico mutation predictive analysis, variant allele frequency in gnomAD, inheritance pattern, and genotype-phenotype correlation, fully elucidating the clinical manifestations with the identified rare variant was challenging. Our study highlights the utility of gene panel sequencing in achieving accurate diagnoses for hereditary ophthalmic diseases and enhancing the diagnostic yield through additional gene panel sequencing. Thus, gene panel sequencing can serve as a primary tool for the genetic diagnosis of hereditary ophthalmic diseases, even in cases where a single genetic cause is suspected. With a deeper comprehension of the genetic mechanisms underlying these diseases, it becomes feasible.

Increasing the diagnostic yield of childhood glaucoma cases recruited into the 100,000 Genomes Project

Childhood glaucoma (CG) encompasses a heterogeneous group of genetic eye disorders that is responsible for approximately 5% of childhood blindness worldwide. Understanding the molecular aetiology is key to improving diagnosis, prognosis and unlocking the potential for optimising clinical management. In this study, we investigated 86 CG cases from 78 unrelated families of diverse ethnic backgrounds, recruited into the Genomics England 100,000 Genomes Project (GE100KGP) rare disease cohort, to improve the genetic diagnostic yield. Using the Genomics England/Genomic Medicine Centres (GE/GMC) diagnostic pipeline, 13 unrelated families were solved (13/78, 17%). Further interrogation using an expanded gene panel yielded a molecular diagnosis in 7 more unrelated families (7/78, 9%). This analysis effectively raises the total number of solved CG families in the GE100KGP to 26% (20/78 families). Twenty-five percent (5/20) of the solved families had primary congenital glaucoma (PCG), while 75% (15/20) had secondary CG; 53% of this group had non-acquired ocular anomalies (including iris hypoplasia, megalocornea, ectopia pupillae, retinal dystrophy, and refractive errors) and 47% had non-acquired systemic diseases such as cardiac abnormalities, hearing impairment, and developmental delay. CYP1B1 was the most frequently implicated gene, accounting for 55% (11/20) of the solved families. We identified two novel likely pathogenic variants in the TEK gene, in addition to one novel pathogenic copy number variant (CNV) in FOXC1. Variants that passed undetected in the GE100KGP diagnostic pipeline were likely due to limitations of the tiering process, the use of smaller gene panels during analysis, and the prioritisation of coding SNVs and indels over larger structural variants, CNVs, and non-coding variants.

Epidemiological analysis of congenital glaucoma: a national scenario

INTRODUCTION

Congenital glaucoma is a disease that involves increased intraocular pressure and can result in irreversible visual deterioration. The study of epidemiology allows the delineation of the characteristics associated with patients and specific risk factors.

OBJECTIVE

The objective of this study was to examine epidemiological trends, place of residence, duration of gestation, sex, and race of the newborn diagnosed with congenital glaucoma in Brazil.

METHODS

Data from SINASC (National Live Birth System) were used to analyze the period from 2017 to 2021 in Brazil. Linear regression and analysis of variance tests were employed to assess significance. The statistical significance was determined by p<0.05.

RESULTS

A total of 47 cases of congenital glaucoma were identified in Brazil during the study period, with the highest incidence between the years of 2018 and 2021. The analysis of the distribution indicated that the states with the highest incidence were São Paulo, followed by Rio Grande do Sul and Pernambuco. Approximately 60% of cases occurred in male individuals, compared with 19 female cases. The ethnic analysis showed the highest incidence among whites and mixed. Regarding the length of pregnancy, statistical differences were observed between newborns of different periods of gestation. Infants born from pregnancies lasting between 28 and 31 weeks and 32 and 36 weeks were significant when analyzed with the group between 37 and 41 weeks.

CONCLUSION

Studies on the mechanisms of congenital glaucoma seek to improve knowledge about the disease. Epidemiological evaluation is essential for identifying demographic and clinical patterns of the disease.

Clinical Characteristics and Surgical Outcomes of Turkish Patients With Pediatric Glaucoma Who Underwent Glaucoma Surgery in a University Hospital

PURPOSE

To describe the clinical characteristics and outcomes of a pediatric cohort surgically treated for primary or secondary pediatric glaucoma (PPG/SPG).

METHODS

A retrospective chart review was conducted of all patients with pediatric glaucoma who had surgery between 2013 and 2021. Relevant demographic and clinical data were cumulated and analyzed.

RESULTS

Forty-two eyes of 29 patients (18 girls and 11 boys) were included: 22 (52.4%) primary congenital glaucoma (PCG), 7 (16.7%) juvenile open-angle glaucoma, and 13 (30.9%) SPG. Mean ages at presentation were 2.57 ± 2.87, 131.96 ± 27.71, and 62.09 ± 65.12 months, respectively. In this study, eyes with PCG presented the earliest, with the highest intraocular pressure (IOP) and thickest central corneal thickness (CCT). The mean number of glaucoma surgeries was 1.48 ± 0.71, with 38.1% of the eyes needing two or more glaucoma surgeries; trabeculectomy was the most frequent glaucoma surgery in this cohort. After surgical intervention, the overall mean IOP dropped from 32.25 ± 12.97 to 18.10 ± 9.23 mm Hg (P < .001). Moreover, the percentage using antiglaucoma medications decreased from 100% to 35.7% at the final visit, as did the number of medications prescribed per eye (2.69 ± 0.92 vs 1.05 ± 1.46, P ≤ .001). Mean best corrected visual acuity (BCVA), in patients who could have their BCVA measured, improved from 0.61 ± 0.61 to 0.53 ± 0.51 logMAR at final follow-up.

CONCLUSIONS

Surgical intervention was shown to provide a well-controlled IOP, decrease dependance on glaucoma medications, and improve BCVA in both PPG and SPG. Multiple surgical interventions may be necessary in the treatment of some pediatric patients with glaucoma. Prognostically, thicker CCT was significantly associated with worse IOP control, more glaucoma surgeries, and more antiglaucoma medications at the final visit. Initial BCVA correlated significantly with BCVA at the final visit. [J Pediatr Ophthalmol Strabismus. 2024;61(3):188-197.].

Secondary intervention after failed initial intervention for primary congenital glaucoma

AIM

To report on the outcome of subsequent interventions after failed initial intervention for primary congenital glaucoma (PCG).

METHODS

Retrospective chart review of children presenting with PCG and failed the initial glaucoma surgery in Alexandria Main University Hospital from 2005 to 2017. The data included demographics, preoperative, operative and postoperative clinical characteristics. Success was defined as IOP<16mmHg and <20% from the presenting IOP and C/D ratio like or better than presentation.

RESULTS

The charts of 531 (260 right, 49%) eyes of 360 (224 males, 62%) children presenting with PCG and failed the initial glaucoma surgery (58 [31 right, 53%] eyes [10.9%] of 50 [28 males, 56%] children) revealed that at initial presentation, the mean±standard deviation (range, median) of the age of the children subjected to one successful glaucoma procedure and the study children was 8.6±11.7 (0.6-109, 5.2) and 4.9±6.1 (0.5-34.4, 3.0) months, respectively. Each of the study eyes was subjected to 2.6±0.8 (2-5.2) glaucoma procedures. The mean±standard deviation (range, median) duration between the initial and second glaucoma surgery and the duration of follow-up was 6.9±7.8 (0.7-39,3.9) and 61.5±32.1 (12.0-139.1, 60.1) months, respectively. At the final follow-up visit success was reported in 41 (70.1%) eyes by IOP<16mmHg criterion, 39 (67.2%) eyes by IOP>20% reduction criterion and in 28 (out of 35 eyes, 80.0%) by the optic nerve condition (C/D ratio) criterion. Success by all 3 criteria was reported in 25 (out of 35 eyes, 71%) eyes.

CONCLUSIONS

A repeat glaucoma surgical procedure maybe needed in up to 11% of operated PCG eyes, with the subsequent glaucoma surgical procedures being successful by about 70%.

Ophthalmic sequelae of prematurity in late childhood and adulthood: A review

Advances in the care of premature infants have resulted in unprecedented rates of survival of these infants into adulthood, including those born at very low gestational ages. Ophthalmologists have historically followed premature infants to assess for the presence of and potential need for treatment of retinopathy of prematurity. However, a growing body of literature suggests that the ophthalmic consequences of prematurity extended beyond retinopathy of prematurity and that ophthalmic sequelae of prematurity can endure through adulthood even among formerly preterm adults who were never diagnosed with retinopathy of prematurity. These abnormalities can include a range of both anterior segment and posterior segment sequelae, including higher rates of corneal aberrations, ocular hypertension, strabismus, foveal anomalies, and retinal tears and detachments. This review aims to summarise this literature, underscoring the importance of lifelong examinations and regular monitoring for these complications among adults who were born prematurely.

The correlation of anterior segment structures in primary congenital glaucoma by ultrasound biomicroscopy with disease severity and surgical outcomes

PURPOSE

To evaluate the anterior segment structures using ultrasound biomicroscopy (UBM) in primary congenital glaucoma (PCG) and explore their correlation with disease severity and surgical outcomes.

METHODS

Clinical information of PCG patients who underwent UBM prior to their first glaucoma surgeries from September 2014 to March 2021 were reviewed. The study included 214 UBM images of 154 PCG eyes and 60 fellow unaffected eyes. Anterior segment characteristics were analyzed. UBM parameters, including the iris thickness (IT) at variant distances from the pupil edge and iris root, anterior chamber depth (ACD), and pupil diameter (PD), were compared between two groups and their relationship with clinical factors and surgical outcomes were analyzed in PCG eyes.

RESULTS

PCG eyes had unclear scleral spur, thin iris, wide anterior chamber angle, deep anterior chamber, rarefied ciliary body, elongated ciliary processes, and abnormal anterior iris insertion. ITs were thinner, ACD was deeper, and PD was larger in PCG eyes than fellow unaffected eyes (all P < 0.001). In PCG eyes, thinner ITs correlated with bilateral involvement and earlier age at presentation, and larger PD correlated with earlier age at presentation (P = 0.030) and higher intraocular pressure (P < 0.001). Thinner IT2 (P = 0.046) and larger PD (P = 0.049) were identified as risk factors for surgical failure.

CONCLUSION

UBM is a powerful technique to exam anterior segment structures in PCG. The anatomical features are associated with disease severity and surgical outcomes, providing essential clinical insights.

Childhood glaucoma profile in a Southwestern Ethiopia tertiary care center: a retrospective study

BACKGROUND

Childhood glaucoma is a major cause of childhood blindness worldwide. The profile of childhood glaucoma has not been well characterized in sub-Saharan Africa. Thus, this study was designed to describe demographics, clinical features, managements of childhood glaucoma, and improvements in visual acuity (VA) and intraocular pressure (IOP) from baseline to final visit.

METHODS

This retrospective study included glaucoma patients below 18 years old who were diagnosed between September 2019 to August 2022. Childhood glaucoma diagnosis and classification was made as per the Childhood Glaucoma Research Network Classification (CGRN).

RESULTS

A total of 105 children (181 eyes) were diagnosed with glaucoma. The most common type of childhood glaucoma was primary congenital glaucoma (PCG) constituting (42%, n = 76 eyes, 95% confidence interval (CI), 34.7-49.5%; P = 0.037), followed by glaucoma suspect (22.1%, n = 40 eyes, 95% CI, 16.3-28.9%; P < 0.001) and juvenile open-angle glaucoma (JOAG) (15.5%, n = 28 eyes, 95% CI, 10.5-21.6%; P < 0.001). While the most common type of secondary glaucoma was steroid-induced glaucoma, followed by glaucoma following cataract surgery. Bilateral glaucoma was found in 72.4% (n = 76 children, 95% CI, 62.8-80.7%; P < 0.001) of children. In both primary and secondary glaucoma, boys were affected more than girls, in ratio of 2:1 and 2.7:1, respectively. The mean age at presentation for patients with PCG was 2.7 years. Close to 93.4% (71) of PCG eyes were managed surgically, of which majority underwent combined trabeculotomy and trabeculectomy (CTT). Most of secondary glaucoma cases were treated medically. Overall, 85.3% (111) of eyes had successful control of IOP ≤ 21 mmHg.

CONCLUSION

PCG was the most common type of childhood glaucoma. One of a well-recognized challenge in developing countries, late presentation of patients with PCG, was also observed in our study. Which highlights, the need of increasing access to eye-care service and awareness of childhood glaucoma as a major public health issue. Steroid-induced glaucoma was the most common type of secondary glaucoma; appropriate measures should be taken to prevent this preventable glaucoma.

Profile of Newly Diagnosed Childhood Glaucoma in India: Indian Childhood Glaucoma Study (ICGS) Group 1

OBJECTIVE

To report the profile of newly diagnosed childhood glaucoma using the Childhood Glaucoma Research Network (CGRN) classification, presenting over 1 year from across centers in India.

DESIGN

Prospective observational multicentric study.

SUBJECTS

Newly diagnosed children aged < 18 years diagnosed with childhood glaucoma according to CGRN criteria presenting between January and December 2019 to 13 centers across India.

METHODS

All children underwent a comprehensive ocular examination, including examination under anesthesia for younger children, and were diagnosed with childhood glaucoma as per CGRN. Data were entered in a standard Excel chart. Refraction and visual acuity assessments were done when feasible.

MAIN OUTCOME MEASURES

The profile of newly diagnosed childhood glaucoma in different parts of India and the severity of glaucoma at presentation.

RESULTS

A total of 1743 eyes of 1155 children fulfilled the definition of glaucoma and were analyzed. Primary congenital glaucoma (PCG) comprised the single largest group (34.4%), most of which were infantile onset (19%). Neonatal-onset PCG comprised 6.2% of all glaucoma. Secondary glaucoma constituted 53.4% of all glaucoma, one-half of which were acquired conditions (28%), followed by isolated ocular anomalies (14.7%), glaucoma after cataract surgery (6.7%), and glaucoma with nonacquired systemic diseases (4.5%). Of the 1743 eyes with glaucoma, all 3 parameters for severity grading were available in 842 eyes, of which 501 (59.5%) eyes presented with mild, 320 (38%) with moderate, and 21 (2.5%) with severe glaucoma. Nearly one-third of the children (28.5%) were not brought back for follow-up after the initial treatment given.

CONCLUSIONS

Our study has one of the largest numbers of consecutive children with glaucoma classified according to the CGRN classification. Despite a widely diverse population, the profile of childhood glaucoma was relatively uniform across India. Childhood glaucoma is a significant problem in India, primarily treated in tertiary care hospitals. The data presented may be the tip of the iceberg because we have only reported the children who reached the hospitals offering treatment for this challenging disease.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Ophthalmologic and neuro-ophthalmologic findings in children with Down syndrome

Down syndrome, also known as Trisomy 21, is a genetic disorder associated with mild-to-moderate intellectual disability, delays in growth, and characteristic facial features. A wide range of ocular complications are seen in children with Down syndrome, including strabismus, nystagmus, refractive errors, congenital cataracts, the presence of keratoconus, and decreased visual acuity. Early ophthalmic examination is needed for early diagnosis and treatment in patients. This narrative review examines ocular manifestations in children with Down syndrome and the importance of prompt ophthalmic interventions for treatment.

Microcatheter-Assisted Circumferential Trabeculotomy After Failed Glaucoma Surgeries in Childhood Glaucoma

PURPOSE

To evaluate the outcomes of microcatheter-assisted trabeculotomy (MAT) in childhood glaucoma (primary congenital glaucoma [PCG], juvenile open-angle glaucoma [JOAG], and secondary childhood glaucoma [SCG]) after failed glaucoma surgery.

DESIGN

Retrospective interventional case series.

METHODS

Patients with childhood glaucoma who underwent MAT after failed glaucoma surgery with at least 12 months of follow-up were evaluated. Pre- and postoperative intraocular pressure (IOP) and the number of glaucoma medications were recorded and compared. Success was defined as an IOP ≤21 mm Hg with or without glaucoma medication. Analysis of variance was used to compare the glaucoma subgroups.

RESULTS

Forty-five eyes (42 patients) with a median follow-up period of 19 months were included. The median age at the time of MAT was 10 (range, 0.8-33) years. The mean number of previous surgeries was 1.3 ± 0.5. The IOP had significantly reduced from baseline in all PCG, JOAG, and SCG patients (27.9 ± 4.5 vs 16.3 ± 8.0 mm Hg, P = .001; and 30.8 ± 9.4 vs 13.5 ± 3.0 mm Hg, P < .001; and 31.5 ± 7.1 vs 16.5 ± 5.3 mm Hg, P = .001, respectively). Fewer glaucoma medications were needed after MAT in all 3 groups (each P < .001). At the last visit, the total success rates in PCG, JOAG, and SCG were 93.8%, 100%, and 88.9%, respectively. No severe complications were observed.

CONCLUSION

MAT can effectively manage PCG, JOAG, and SCG after failed surgeries, providing successful outcomes and no serious complications. Following failed glaucoma surgeries, MAT may offer these patients with childhood glaucoma an excellent opportunity to achieve IOP control.

Thrombospondin Mutations and Patients With Primary Congenital Glaucoma in a United States Population

Mutations in the thrombospondin 1 ( THBS1 ) gene have been previously reported in primary congenital glaucoma (PCG) pedigrees that exhibit autosomal dominant inheritance with low penetrance. We sought to determine the role of THBS1 mutations in a cohort of 20 patients with PCG and 362 normal controls from Iowa using a combination of Sanger sequencing and whole exome sequencing. We detected 16 different THBS1 variants, including 4 rare, nonsynonymous variants (p.Thr611Met, p.Asn708Lys, p.Gln1089His, and p.Glu1166Lys). However, none of these variants were judged to be disease-causing mutations based on: 1) prevalence in cases and controls from Iowa, 2) prevalence in the public database gnomAD, 3) mutation analysis algorithms, and 4) THBS1 DNA sequence conservation. These results indicate THBS1 mutations are not a common cause of PCG in patients from Iowa and may be a rare cause of PCG overall.

Glaucoma in rural China (the Rural Epidemiology for Glaucoma in China (REG-China)): a national cross-sectional study

OBJECTIVE

This study aimed to investigate the prevalence of glaucoma with associated factors in the rural populations of 10 provinces in China.

DESIGN

A population-based cross-sectional study.

METHODS

All participants aged 6 years or older from 10 provinces completed visual acuity testing, slit-lamp examination, ophthalmoscopy and non-contact tonometry. Glaucoma suspects underwent fundus photography, Goldmann applanation tonometry, visual field testing and gonioscopy. Glaucoma was determined according to the International Society of Geographical and Epidemiological Ophthalmology classification scheme. Associations of demographics and medical factors with glaucoma were assessed using multiple logistic regression models.

RESULTS

From June 2017 to October 2018, 48 398 of 52 041 participants were included in the final analyses. The age-standardised prevalence of glaucoma was 1.7% (95% CI 1.55% to 1.78%) among the participants older than 6 years, which was 2.1% (95% CI 1.93% to 2.23%) in participants aged over 40 years. The constituent ratios of glaucoma were: 44.4% primary angle-closure glaucoma (PACG), 34.7% primary open-angle glaucoma, 2.6% congenital glaucoma and 18.3% other types of glaucoma. Increasing age, smoking, cerebral stroke, type 2 diabetes, higher education (college or more) and higher personal income were significant risk factors for PACG. The unilateral and bilateral blindness rates in the entire study population were 4.692% and 1.068%, respectively. A family history of glaucoma was a significant risk factor for the prevalence of glaucoma and blindness in at least one eye.

CONCLUSIONS

Rural populations have a high prevalence of glaucoma, which should be included in chronic disease management programmes in China for long-term care.

Axenfeld-Rieger syndrome in the pediatric population: A review

Axenfeld-Rieger syndrome (ARS) is a rare autosomal-dominant neurocristopathy that presents with a variety of classical ocular and systemic findings. The pathophysiology of the disease involves anterior segment dysgenesis, and patients may present with ophthalmic complications early in life, including secondary glaucoma, high refractive errors, amblyopia, and permanent visual damage. There are a limited number of studies in the literature that focus primarily on pediatric patients with ARS. The purpose of this article was to review the current literature on clinical presentation, genetic associations, diagnosis, secondary complications, and treatment of ARS in pediatric patients. Evaluating the essential clinical aspects of the disease in children may allow for earlier diagnosis and treatment and prevent visual morbidity from amblyopia and secondary glaucoma that may result in permanent visual damage.

The impact of childhood glaucoma on psychosocial functioning and quality of life: a review of the literature

We present a novel comprehensive literature review of studies of the psychosocial functioning (PF) and quality of life (QoL) of patients with childhood glaucoma and their caregivers. Our findings demonstrate variable study quality and approach, as well as inconsistent results relating to the association of glaucoma-specific factors and sociodemographic variables with measured PF and QoL. Future studies should focus on the development of culturally cognizant and standardized assessment tools, execution of multi-center longitudinal studies with global representation, evaluation of PF and QoL among siblings and childhood glaucoma providers, and implementation of interventions to improve patient and caregiver PF and QoL.

Approach to primary congenital glaucoma: A perspective

Primary congenital glaucoma (PCG) occurs worldwide and has a broad range of ocular manifestations. It poses a therapeutic challenge to the ophthalmologist. A proper diagnostic evaluation under anesthesia is advisable for all children who do not cooperate for an office examination. Medical therapy only serves as a supportive role, and surgical intervention remains the principal therapeutic modality. Angle incision surgery such as goniotomy or trabeculotomy ab externo is the preferred choice of surgery in the Caucasian population. Primary combined trabeculotomy-trabeculectomy with or without antifibrotic therapy is the preferred choice in certain regions such as India and the Middle East where the disease usually presents with severe forms of corneal edema along with megalocornea. In refractory cases, trabeculectomy with antifibrotic therapy or glaucoma drainage devices are available options in the armamentarium. Cycloablative procedures should be reserved for eyes with poor visual potential. Myopia is common among children with PCG, and appropriate optical refractive correction in the form of glasses or contact lenses should be provided. Amblyopia therapy should be instituted to ensure overall visual development in the early developmental years. Low-vision rehabilitation services should be provided to children with vision impairment. Long-term follow-up is mandatory and carers of children with PCG should be counseled and educated about this need. Regardless of the visual outcomes, clinicians should emphasize the need for education of these children during the clinic visit. The overall goal of the management should be to improve the overall quality of life of the children with PCG and their carers.

Epidemiology and long-term outcomes of primary congenital glaucoma: a population-based study

BACKGROUND/OBJECTIVES

to establish the incidence, prevalence and long-term outcomes of primary congenital glaucoma (PCG) in Northern Ireland's general and Irish Traveller (IT) populations over a 59-year period.

SUBJECTS/METHODS

chart review of all PCG cases in Northern Ireland between 1962 and 2020. Incidence and prevalence were calculated with the aid of national population statistics. Long-term outcomes were analysed for eyes with at least 5 years follow up. Visual outcomes were stratified into groups: good-VA ≥ 6/12; moderate-VA 6/12 to 6/60, poor-VA < 6/60. Kaplan-Meier analysis was constructed to determine the probability of eyes retaining a good visual outcome over time. Outcomes of different surgeries were compared with regard to final vision, re-operations and complications.

RESULTS

57 PCG cases were identified between 1962 and 2020. Overall incidence was 3.4 per 100,000 live births. PCG prevalence in general and IT populations in 2019 was 4.3 per 100,000 and 238 per 100,000, respectively. Sixty eyes had sufficient data for long-term outcome analysis with a mean of 20.5 years follow up, 58% of which had good final visual outcome. Fifty-seven percent of eyes required multiple surgeries. Visual outcomes between trabeculectomies and tubes were comparable; however, there were more serious complications and reoperations associated with tubes.

CONCLUSIONS

Incidence of PCG in NI is similar to Great-Britain and Ireland; however, PCG appears to be particularly prevalent within IT community. Although a good visual outcome can be achieved in the majority of patients, a subset of cases remain challenging to manage despite surgical advances.

Comparison between ocular biometry parameters in patients with unilateral congenital glaucoma

Purpose

To compare the axial length (AL) and corneal diameter between glaucomatous eye (GE) and fellow normal eye (NE) in patients with unilateral congenital glaucoma and to obtain a normative database for ocular growth among Indian children below 3 years of age.

Methods

Retrospective longitudinal study. Patients who had a follow-up of 3 years from diagnosis with ocular biometry parameters being recorded at least thrice (once a year) and fellow eye being normal were included. Data collected were age, gender, intraocular pressure (IOP), AL, corneal diameter, optic disc findings, diagnosis, and surgery details.

Results

Eleven patients were analyzed. All GE underwent combined trabeculotomy with trabeculectomy. Mean (SD) baseline IOP, AL, and corneal diameter were 17.1 (6.7) mmHg, 18.9 (1.1) mm and 12 (0.91) mm in GE, and 11.1 (3.8) mmHg, 17.8 (0.44) mm, and 10.5 (0.58) mm in NE, respectively. Increase in AL was 3.1 mm in the first year followed by 0.6 mm in second year and 0.4 mm in third year in GE compared to 2.6, 0.6, and 0.5 mm in NE, respectively. Corneal diameter increased by 1.1 mm in GE in the first year and remained stable thereafter compared to 0.7 mm in first year followed by 0.3 mm in second year and stable thereafter in NE. The percentage of success was 73% at 3 years.

Conclusion

Axial length and corneal diameter were higher in GE than NE at all-time points. With prompt intervention, the growth curve of the GE was made parallel to that of NE.

Outcomes of Corneal Transplant in Childhood Glaucoma

PRCIS

Childhood glaucoma produces alterations in the postnatal development and function of various ocular structures, including the cornea. Childhood glaucoma patients present lower corneal transplant survival rates. Our series shows outcomes of corneal transplant in childhood glaucoma with survival rates of 29% at 2 years.

OBJECTIVE

To investigate the surgical outcome of different types of keratoplasty in eyes with childhood glaucoma.

PATIENTS AND METHODS

A retrospective review was made of the medical records from 17 eyes of 15 patients who were diagnosed with childhood glaucoma and received a corneal transplantation between January 2010 and July 2020. Patient demographics, intraocular pressure, previous ocular surgery, comorbidities, corneal transplant surgery, and follow-up outcome were collected. The primary efficacy endpoint was graft survival (in months) until failure, the latter being considered as irreversible loss of corneal transparency. Secondary efficacy points were the need for an increase in topical hypotensive therapy and the need for additional surgery.

RESULTS

Seventeen eyes of 15 patients were included, 11 eyes (10 patients) with primary congenital glaucoma and 6 with other types of childhood glaucoma. Corneal transplantation was performed at the mean age of 23.76 ± 14.86 years. At the time of the transplantation, the number of topical medications was 1.35 ± 1.27, intraocular pressure was 15.00 ± 8.34 mm Hg, and patients had received up to 7 glaucoma surgeries. Descemet stripping automated endothelial keratoplasty was performed in 13 eyes (76%) and penetrating keratoplasty in 4 (24%). After surgery, 7 (41%) eyes required increased topical treatment and 2 (12%) glaucoma surgery. Twelve eyes (71%) developed graft failure at 24 months, the mean time of survival being 13.88 ± 8.25 months.

CONCLUSIONS

Management of corneal decompensation in childhood glaucoma poses a challenge. In this series of childhood glaucoma with corneal transplantations, the survival rate was 29% at 24 months.

Deep-learning approach to detect childhood glaucoma based on periocular photograph

Childhood glaucoma is one of the major causes of blindness in children, however, its diagnosis is of great challenge. The study aimed to demonstrate and evaluate the performance of a deep-learning (DL) model for detecting childhood glaucoma based on periocular photographs. Primary gaze photographs of children diagnosed with glaucoma with appearance features (corneal opacity, corneal enlargement, and/or globe enlargement) were retrospectively collected from the database of a single referral center. DL framework with the RepVGG architecture was used to automatically recognize childhood glaucoma from photographs. The average receiver operating characteristic curve (AUC) of fivefold cross-validation was 0.91. When the fivefold result was assembled, the DL model achieved an AUC of 0.95 with a sensitivity of 0.85 and specificity of 0.94. The DL model showed comparable accuracy to the pediatric ophthalmologists and glaucoma specialists in diagnosing childhood glaucoma (0.90 vs 0.81, p = 0.22, chi-square test), outperforming the average of human examiners in the detection rate of childhood glaucoma in cases without corneal opacity (72% vs. 34%, p = 0.038, chi-square test), with a bilateral corneal enlargement (100% vs. 67%, p = 0.03), and without skin lesions (87% vs. 64%, p = 0.02). Hence, this DL model is a promising tool for diagnosing missed childhood glaucoma cases.

Profile of Childhood Glaucoma Attending a Tertiary Eye Care Center in Northern India

Purpose

To ascertain the prevalence and clinical features of the various types of childhood glaucoma at a tertiary eye care hospital in Northern India.

Materials and methods

Retrospective chart review of all children less than 16 years of age with childhood glaucoma who presented from 1st April 2014 to 31st March 2019, who was diagnosed to have any subtype of childhood glaucoma as per Childhood Glaucoma Research Network (CGRN) classification and advised appropriate management.

Results

Out of 405 children with childhood glaucoma, 36% had primary glaucoma, whereas the rest had secondary glaucoma. Primary congenital glaucoma (PCG) was the most common form of primary glaucoma. Glaucoma associated with acquired conditions was the most common cause of secondary glaucoma. Primary glaucoma was mostly bilateral in contrast to secondary glaucoma. The most common age of presentation with primary glaucoma was <1 year of age, and in children with secondary glaucoma was 11-16 years. On presentation, 80% of eyes had intraocular pressure (IOP) of >20 mm Hg and 70% had cupping of >0.7. Eyes with PCG were primarily managed surgically.

Conclusion

In our cohort, PCG was the most common primary childhood glaucoma. Traumatic glaucoma was the most common secondary glaucoma. Since childhood glaucoma is an important cause of visual morbidity in children, its timely diagnosis and prompt management are essential to prevent irreversible visual loss.

Clinical significance

Understanding the disease pattern, their presenting features, and the proportion of different types of childhood glaucoma can help in planning appropriate eye care services, create awareness and better allocate resources to plan appropriate management strategies. Screening programs and counseling of parents should also be strengthened.

How to cite this article

Dubey S, Jain K, Pegu J, et al. Profile of Childhood Glaucoma Attending a Tertiary Eye Care Center in Northern India. J Curr Glaucoma Pract 2023;17(2):68-74.

Comparative efficacies of 13 surgical interventions for primary congenital glaucoma in children: a network meta-analysis of randomized clinical trials

BACKGROUND

Timely and proper intraocular pressure (IOP) management is vital to the prevention of visual impairment in children with primary congenital glaucoma (PCG). Although various surgical interventions have been proposed, no well-founded evidence exists on their comparative efficacies. We aimed to compare the efficacies of surgical interventions for PCG.

METHODS

We searched relevant sources up to 4 April 2022. Randomized controlled trials (RCTs) entailing surgical interventions for PCG in children were identified. A network meta-analysis (NMA) was performed, comparing 13 surgical interventions: Conventional partial trabeculotomy ([CPT] control), 240-degree trabeculotomy, Illuminated microcatheter-assisted circumferential trabeculotomy (IMCT), Viscocanalostomy, Visco-circumferential-suture-trabeculotomy, Goniotomy, Laser goniotomy, Kahook dual blade ab-interno trabeculectomy, Trabeculectomy with mitomycin C, Trabeculectomy with modified scleral bed, Deep sclerectomy, Combined trabeculectomy-trabeculotomy with mitomycin C, and Baerveldt implant. The main outcomes were mean IOP reduction and surgical success rate at postoperative 6 months. The mean differences (MDs) or odds ratios (ORs) were analyzed by a random-effects model, and the efficacies were ranked by P -score. We appraised the RCTs using the Cochrane risk-of-bias (ROB) tool (PROSPERO: CRD42022313954).

RESULTS

Sixteen RCTs were eligible for NMA, including 710 eyes of 485 participants and 13 surgical interventions, which formed a network of 14 nodes comprising both single interventions and intervention combinations. IMCT was superior to CPT in both IOP reduction [MD (95% CI): -3.10 (-5.50 to -0.69)] and surgical success rate [OR (95% CI): 4.38 (1.61-11.96)]. The MD and OR comparing the other surgical interventions and intervention combinations with CPT were not statistically significant. The P -scores ranked IMCT as the most efficacious surgical intervention in terms of success rate ( P -score =0.777). Overall, the trials had a low-to-moderate ROB.

CONCLUSION

This NMA indicated that IMCT is more effective than CPT and might be the most efficacious of the 13 surgical interventions for management of PCG.

Current surgical techniques for the management of pediatric glaucoma: A literature review

Pediatric glaucoma surgery is challenging due to its diverse and complex pathophysiology, altered anterior segment anatomy, greater potential for failure, and complications compared to adult patients. Moreover, numerous challenges are associated with long-term postoperative management. Thus, when dealing with childhood glaucoma, it is important to consider the potential complications in addition to the benefits of each intervention. The purpose of this article is to review recently published literature to shed light on the most recent surgical techniques for the safe and effective treatment of childhood glaucoma. Current literature shows that goniotomy and trabeculotomy are the first choices for the management of primary congenital glaucoma. Although older children with phakic eyes seem to benefit from trabeculectomy with adjunctive mitomycin C, it carries a long-term risk of bleb-related endophthalmitis. Glaucoma drainage devices may be preferred for patients with secondary or refractory glaucoma. However, hypotony or tube-related complications are common and encountered more often in children than in adults. Cyclodestructive procedures are also an option for cases in which filtering surgery has failed, but they can also be used as a temporizing measure to reduce the rate of complications in high-risk patients. However, their outcomes can be unpredictable, in terms of efficiency and complications. Finally, minimally invasive glaucoma surgery (MIGS) as the sole alternative treatment or as an adjunctive surgical procedure is a relatively new path for pediatric patients.

[Glaucoma in infancy and childhood]

Glaucoma in infancy and childhood is a rare disease. An immediate diagnosis and treatment are absolutely necessary to prevent blindness of affected children. Childhood glaucoma is characterized by a heterogeneous phenotype: besides primary congenital glaucoma, secondary types often exist and the individualized treatment requires an experienced interdisciplinary team. The pathogenesis is not always discernible and genetic alterations sometimes cause the disease. A surgical procedure is usually necessary to lower the intraocular pressure. Refractive and orthoptic care are equally important to avoid amblyopia. This article gives an overview of childhood glaucoma and outlines the most important diagnostic and therapeutic aspects.

Impacts of heatwaves and cold spells on glaucoma in rural China: a national cross-sectional study

China faces increasing health risks from climate change. The structure and function of the eye and vision were affected by extreme heat and cold. The study aimed to evaluate the impacts of heatwaves and cold spells on glaucoma. A national cross-sectional study of the Rural Epidemiology for Glaucoma (REG-China) was conducted in ten provinces of China, and 36,081 adults aged 40 years or more were included. Glaucoma signs were assessed via a standard examination. A total of 15 heatwave definitions, based on intensity (95th to 99th percentiles of temperature distribution) and duration (≥2 days, 3 days, and 4 days), were used to quantify heatwave effects, and 6 cold spell definitions were defined based on threshold temperature percentile (5th and 10th) and duration (3 days, 5 days, and 9 days). Multivariable-adjusted logistic regression models paired with interaction analysis were performed to investigate the impacts of heatwaves and cold spells on glaucoma, and the dose-response relationships were assessed using a restricted cubic spline (RCS) model. Subgroup analysis was conducted stratified by gender, age, smoking status, occupation, and family history of glaucoma. The overall prevalence of glaucoma was 2.1% (95% CI 1.94-2.25%). Higher heatwaves were significantly correlated with higher OR of glaucoma, with the OR (95% CI) ranging from 1.014 (1.009, 1.018) to 1.090 (1.065, 1.115) by different definitions. Glaucoma was affected by heatwaves more strongly than by cold spells. The effects of both heatwaves and cold spells were higher in males than females and in smokers than nonsmokers. These results of the present study evoked the attention of prospective research to elucidate the relationship between extreme temperatures and eye diseases.

Ophthalmological Manifestations of Axenfeld-Rieger Syndrome: Current Perspectives

Axenfeld-Rieger syndrome (ARS) is a rare congenital disease that is primarily characterized by ocular anterior segment anomalies but is also associated with craniofacial, dental, cardiac, and neurologic abnormalities. Over half of cases are linked with autosomal dominant mutations in either FOXC1 or PITX2, which reflects the molecular role of these genes in regulating neural crest cell contributions to the eye, face, and heart. Within the eye, ARS is classically defined as the combination of posterior embryotoxon with iris bridging strands (Axenfeld anomaly) and iris hypoplasia causing corectopia and pseudopolycoria (Rieger anomaly). Glaucoma due to iridogoniodysgenesis is the main source of morbidity and is typically diagnosed during infancy or childhood in over half of affected individuals. Angle bypass surgery, such as glaucoma drainage devices and trabeculectomies, is often needed to obtain intraocular pressure control. A multi-disciplinary approach including glaucoma specialists and pediatric ophthalmologists produces optimal outcomes as vision is dependent on many factors including glaucoma, refractive error, amblyopia and strabismus. Further, since ophthalmologists often make the diagnosis, it is important to refer patients with ARS to other specialists including dentistry, cardiology, and neurology.

Childhood glaucoma profile in a tertiary centre in Egypt according to the childhood glaucoma research network classification

PURPOSE

To describe the prevalence and clinical characteristics of a large cohort of childhood glaucoma patients that presented to a tertiary Egyptian children's hospital using the childhood glaucoma research network (CGRN) classification.

METHODS

A retrospective review of the medical records of all patients ≤ 14 years with a diagnosis of childhood glaucoma or glaucoma suspects who presented to Children's Hospital between January 2014 to December 2019 was conducted. Data collected included age at the time of diagnosis, gender, laterality, prenatal history, parental history, including consanguinity, intraocular pressure, horizontal corneal diameter, and cup-to-disc ratio.

RESULTS

A total of 1113 eyes of 652 patients with diagnoses of either childhood glaucoma or glaucoma suspects were included in the study. Six hundred and sixteen patients (94%) were born full-term. A history of positive parental consanguinity was identified in 334 patients (51.2%). Almost 60% of patients were males. Primary congenital glaucoma (PCG) was the most prevalent diagnosis (68.2%), followed by glaucoma suspects (10.4%) and glaucoma following cataract surgery (GFCS) (8.4%). Juvenile open-angle glaucoma was the least prevalent category (0.3%). Other categories including glaucoma associated with non-acquired systemic disease, glaucoma associated with non-acquired ocular disease, and glaucoma associated with acquired conditions represented 5.8%, 4.7%, and 1.9%, respectively.

CONCLUSIONS

PCG is the most common form of glaucoma in Egypt. More than half of the pediatric glaucoma patients had a positive history of parents' consanguinity.

Medication Adherence and Common Barriers for Caregivers of Preschool Children with Pediatric Glaucoma

Purpose. To investigate the medication adherence among caregivers of preschool children with pediatric glaucoma and to elucidate common barriers leading to poor adherence. Methods. A cross-sectional study. Caregivers of preschool children with pediatric glaucoma completed a questionnaire on demographic information of caregivers, demographic and disease characteristics of children, caregivers-reported medication adherence (by an adapted Morisky Adherence Scale), and possible 13 barriers. Results. Overall 132 questionnaires were considered valid. Thirty-six percent of all reported poor medication adherence. Caregivers’ age and self-evaluated knowledge about pediatric glaucoma showed a significant difference between the adherent and nonadherent groups ( $P<0.05$ ). Nineteen percent of all reported only one barrier as important, 65% cited multiple barriers, and 16% cited no barriers. Anxiety and depression were cited as important by most caregivers in both groups. Univariate logistic regression analysis demonstrated that difficulty with the acquisition of medications (OR, 2.5; 95% CI, 1.1–5.7; $P=0.025$ ), difficulty with medication schedule (OR, 2.3; 95% CI, 1.0–5.0; $P=0.043$ ), and high expenses for medications (OR, 4.8; 95% CI, 1.4–15.9; $P=0.011$ ) were significantly associated with higher odds of poor adherence. Conclusions. Over one-third of caregivers of preschool children with pediatric glaucoma were in poor medication adherence. Nearly two-thirds of caregivers cited multiple barriers simultaneously as important hindrances to medication usage. Anxiety and depression, difficulty with the acquisition of medications, difficulty with the medication schedule, and high expenses for medications were prominent barriers. Individualized solutions should be provided according to reported barriers by each caregiver and the other most common barriers.

Clinical and demographic profile of patients less than 40 years of age presenting to glaucoma services at a tertiary care eye hospital in South India

Purpose

To study the clinical and demographic profile of patients less than 40 years of age presenting to glaucoma services including the reasons for referral.

Methods

Patients in the age group of 5 to 39 years, visiting the glaucoma clinic, who were either suspected to have glaucoma or who had been newly/previously diagnosed with glaucoma were included in the study. After informed written consent, basic demographic details of the participants including age, gender, education, socioeconomic status, and family history were obtained. A comprehensive ophthalmological evaluation was performed by glaucoma specialists.

Results

The proportion of glaucoma in the study population (n = 384) was found to be 31.25%, and the incidence of glaucoma among new patients was found to be 11.9%. Among all glaucomas (n = 120), 44.2% of patients had secondary glaucomas, 27.5% had primary glaucomas, and 28.3% had congenital glaucomas. Also, 67.3% of all glaucoma patients were males. Newly diagnosed glaucoma patients presented with a mean intraocular pressure (IOP) of 32.9 mmHg and mild-moderate disc damage with a mean cup-disc ratio of 0.65. Nearly one-third of them had a presenting visual acuity worse than 5/60. The most common reason for referral was raised IOP. Univariate and multivariate analysis revealed that the odds of developing glaucoma were less in females (P = 0.04) and in patients with a higher standard of living index (P < 0.001).

Conclusion

One-third of the patients had glaucoma and another one-third were suspects. Secondary glaucomas are more common than primary/congenital glaucomas. A comprehensive eye evaluation is a must, especially in those with predisposing factors.

Universal newborn eye screening: a systematic review of the literature and review of international guidelines

Background

This systematic review assessed the effectiveness of universal screening for newborn eye abnormalities compared with no screening in improving infant vision and health outcomes.

Methods

We searched CENTRAL (Cochrane Library), MEDLINE, Embase, Global Health, Global Index Medicus, clinical trials databases, and bibliographies of relevant articles. We included randomized and observational studies of all newborns, regardless of illness or risk factors, that compared universal screening for any eye abnormality by eight weeks of age with no universal screening. Two authors independently selected studies, extracted data, and evaluated the risk of bias. We used GRADE to assess the certainty of evidence. We also reviewed available recommendations on newborn eye screening.

Results

Fourteen studies were identified but only three compared universal red reflex screening with no screening. Findings suggest that universal red reflex testing in maternity wards (MWs) may increase the number of newborns with congenital cataracts referred for eye care from MWs or well-baby clinics (WBCs) in the first year of life (risk ratio (RR) = 9.83, 95% confidence interval (CI) = 1.36-71.20; low certainty evidence). However, the effect of screening in WBC is uncertain (RR = 6.62, 95% CI = 0.87-50.09). The effect of MW or WBC screening on referral from any health care facility (MWs, WBCs, paediatrician clinic, other) in the first year is uncertain (MW screening: RR = 1.22, 95% CI = 0.63-2.39; WBC screening: RR = 0.97, 95% CI = 0.46-2.05). However, referral or surgery by 6 weeks of age may be higher with universal MW screening (early referral: RR = 4.61, 95% CI = 1.12-19.01; early surgery: RR = 8.23, 95% CI = 1.13-59.80; low certainty evidence). The effect of WBC screening on early referral and surgery is uncertain (early referral: RR = 1.98, 95% CI = 0.43-9.19; early surgery: RR = 3.97, 95% CI = 0.50-31.33; very low certainty evidence). Universal red reflex testing may increase clinical conjunctivitis (OR = 1.22, 95% CI = 1.01-1.47; low certainty evidence) but the effect on confirmed bacterial conjunctivitis is uncertain (OR = 1.20, 95% CI = 0.76-1.90; very low-certainty evidence). Nine guidelines recommended universal newborn eye screening using red reflex testing.

Conclusions

Evidence supports the role of red reflex testing shortly after birth to increase early identification, referral, and surgery for congenital cataracts.

Anterior segment optical coherence tomography findings in the Infant Aphakia Treatment Study (IATS): a secondary analysis of a randomized clinical trial

PURPOSE

To correlate the diagnosis of glaucoma among children in the Infant Aphakia Treatment Study (IATS) by age 10 years with anterior segment optical coherence tomography (AS-OCT) findings.

METHODS

A multicenter randomized controlled trial of 114 infants with unilateral congenital cataract who were 1-6 months of age at surgery. Data on long-term glaucoma-related status and outcomes were collected when children were 10.5 years old. Participants were randomized at cataract surgery to either primary intraocular lens (IOL) or no IOL implantation (contact lens [CL]). AS-OCT findings in eyes with glaucoma were compared to eyes which did not have glaucoma and to the fellow eyes, between fellow and treated eyes, and between the IOL and CL groups.

RESULTS

There were no significant differences in the mean nasal and temporal anterior chamber angle (ACA) or mean nasal and temporal angle opening distance (AOD) for nonglaucomatous, glaucomatous, and fellow eyes (P = 0.31, 0.16, 0.43, 0.08 resp.). There were also no significant differences in mean nasal and temporal ACA and AOD between fellow and treated eyes (P = 0.44, 0.67, 0.57, 0.38 resp.), or between IOL and CL groups (P = 0.36, 0.35, 0.49, 0.44, resp.).

CONCLUSIONS

AS-OCT confirmed that eyes with glaucoma in IATS had predominantly open angles with similar ACA and AOD to eyes without glaucoma and to fellow eyes. Furthermore, congenital cataract surgery with or without an IOL did not result in a significant difference in ACA or AOD compared to fellow eyes in IATS.

Study of Optimal Perimetric Testing In Children (OPTIC): developing consensus and setting research priorities for perimetry in the management of children with glaucoma

BACKGROUND

Perimetry is important in the management of children with glaucoma, but there is limited evidence-based guidance on its use. We report an expert consensus-based study to update guidance and identify areas requiring further research.

METHODS

Experts were invited to participate in a modified Delphi consensus process. Panel selection was based on clinical experience of managing children with glaucoma and UK-based training to minimise diversity of view due to healthcare setting. Questionnaires were delivered electronically, and analysed to establish 'agreement'. Divergence of opinions was investigated and resolved where possible through further iterations.

RESULTS

7/9 experts invited agreed to participate. Consensus (≥5/7 (71%) in agreement) was achieved for 21/26 (80.8%) items in 2 rounds, generating recommendations to start perimetry from approximately 7 years of age (IQR: 6.75-7.25), and use qualitative methods in conjunction with automated reliability indices to assess test quality. There was a lack of agreement about defining progressive visual field (VF) loss and methods for implementing perimetry longitudinally. Panel members highlighted the importance of informing decisions based upon individual circumstances-from gauging maturity/capability when selecting tests and interpreting outcomes, to accounting for specific clinical features (e.g. poor IOP control and/or suspected progressive VF loss) when making decisions about frequency of testing.

CONCLUSIONS

There is commonality of expert views in relation to implementing perimetry and interpreting test quality in the management of children with glaucoma. However, there remains a lack of agreement about defining progressive VF loss, and utilising perimetry over an individuals' lifetime, highlighting the need for further research.

Consanguinity and severity of primary congenital glaucoma

PURPOSE

To evaluate the severity of primary congenital glaucoma (PCG) among children born of consanguineous marriage.

METHODS

In this case-control study, the medical records of unrelated consanguineous patients and unrelated nonconsanguineous (control) PCG patients seen at a single tertiary eye care facility were retrospectively reviewed. Those with a minimum of 5 years' follow-up were included. Data collected included age at presentation, corneal diameter, axial length, corneal haze at presentation and its persistence after surgery, need for repeat surgery, and final visual acuity.

RESULTS

A total of 130 PCG patients were included: 30 patients born of consanguineous marriage and 100 nonconsanguineous control patients. The median age of presentation for consanguineous cases was 3 months (range, 1-36) compared with 10 months (range, 2-24) for nonconsanguineous cases (P < 0.001). Mean corneal diameter for consanguineous cases was 13 ± 0.82 mm and for nonconsanguineous cases was 12.41mm ± 1.18 mm (P = 0.002). Consanguineous cases also had a significantly higher prevalence of corneal haze persisting after surgery (P < 0.001) and need for repeat IOP-lowering surgery (P = 0.039). The consanguineous group had 44 eyes (73%) with severe PCG compared with 69 (34.5%) in the nonconsanguineous group (P < 0.001).

CONCLUSIONS

In this study cohort, children with PCG born of consanguineous parents were more severely affected at presentation compared with children born of nonconsanguineous parents; they also had poorer outcomes with IOP-lowering surgery independent of severity at presentation. It is however possible that a founder effect with consanguinity over multiple generations could account for our observations.

Normal intraocular pressure in Egyptian children and meta-analysis

OBJECTIVE

To determine the normal intraocular pressure in a sample of Egyptian children 0-12 years of age, and compare it to that recorded in previous studies.

METHODS

This is a prospective cross-sectional study, including 345 eyes. All children underwent complete history taking and ophthalmic examination. Any glaucomatous patients or glaucoma suspects were excluded. Intraocular pressure was measured using Haag Streit Perkins M2 handheld applanation tonometer under topical or general anaesthesia. Three readings were recorded for each eye and the average was calculated. Central corneal thickness was measured, using handheld pachymeter (Pachmate 2), whenever possible.

RESULTS

The study included 345 eyes of 187 children (101 males and 86 females), aged 2 months to 12 years (mean: 5.69 ± 3.42 years). The recorded IOP was 5-20 mm Hg (mean: 11.5 ± 2.34 mm Hg). Central corneal thickness was 469-742 μm (mean: 564.8 ± 42.72 μm). The mean recorded intraocular pressure showed positive correlation with increased age (p = 0.026) and increased central corneal thickness (p = 0.037), with a difference of 1 mm Hg for every 100-μm change in central corneal thickness. The mean IOP was significantly lower than that recorded by most previous studies. A detailed comparative analysis is presented comparing our findings with other studies including grouped analysis, by country, ethnicity and tonometers used.

CONCLUSIONS

The mean IOP in a group of normal Egyptian children was 11.5 ± 2.34 mm Hg, with positive correlation to age and central corneal thickness. This mean intraocular pressure was lower than that previously reported in any other population.

Anterior chamber angle features in primary congenital glaucoma infants using hand-held anterior segment-oct

PURPOSE

To describe anterior chamber angle (ACA) structures and parameters in primary congenital glaucoma (PCG) and normal infant eyes, using Hand-held anterior segment optical coherence tomography (HH AS-OCT), as an in-office, non-contact technique.

METHODS

Normal and PCG-infants <24 months were examined, using HH AS-OCT (RTVue RT- 100, Optovue Inc., Fremont, CA). Sedation was not required. Corneal pachymetry map, ACA width and iris thickness (IT) were measured. Trabecular meshwork (TM), Schlemm's canal (SC), and scleral spur (SS) identification were assessed in both groups.

RESULTS

Forty-eight infants; (26 PCG-eyes and 22 normal-eyes) aged 9.12 ± 6.7 months, were included. Nasal and temporal ACA width in PCG infants was found significantly larger (39.3 ± 6.6° vs. 30.4 ± 5.6, and 40.1 ± 5.3° vs. 32.5 ± 6.2 respectively) (p < 0.001). IT was significantly reduced (121.7 ± 43.9 μm in PCG-infants, vs. 160.3 ± 38.6 μm in normal-eyes) (p < 0.01). TM was identified in all normal eyes (100%) and nine (34.6%) PCG- eyes. SC was identified in 16 (72.7%) normal eyes versus four (15.4%) PCG. In PCG-eyes, an abnormal structure occluding the angle was seen in seven (26.9%), and a hyper-reflective membrane in five (19.2%), the iris was anteriorly inserted in all PCG-eyes, and iridotrabeculodysgenesis was clearly identified (with constant iris anterior insertion). The abnormal tissue obscuring the angle was seen in younger PCG-infants and iris thinning appeared to be part of the pathology, not a result of IOP elevation.

CONCLUSION

Using HH AS-OCT permits tomographic examination of the ACA in PCG infants and may help in the understanding of disease pathology. Hence, may assist in optimizing treatment.

Kindliche Glaukomerkrankungen

Glaukomerkrankungen im Kindesalter sind selten. Da ohne Behandlung in der Regel die Erblindung eintritt, ist eine umgehende Diagnosestellung und Therapie von höchster Bedeutung. Die Heterogenität der Erkrankung erfordert eine genaue Kenntnis der möglichen Ursachen und deren individuelle Behandlung. Dieser Artikel soll einen Überblick über die kindlichen Glaukome vermitteln und die wichtigsten Aspekte der Therapie aufzeigen.

[Childhood Glaucoma]

Childhood glaucoma is a rare disease. Since a lacking therapy normally leads to blindness an immediate diagnosis and appropriate treatment are crucial. The heterogeneity of childhood glaucoma requires a comprehensive knowledge of possible underlying pathomechanisms of primary and secondary childhood glaucoma types. Several types of childhood glaucoma are accompanied with ocular or systemic syndromes and hereditary causes are frequent. Thus, an interdisciplinary team of ophthalmologists, orthoptists, pediatricians, human geneticists, and anesthesiologists is vital for a successful supply. Most cases rely on a dysgenesis of trabecular meshwork with impaired outflow. Thus, usually a surgical approach is indicated. To handle a surgery in a buphthalmic eye an experienced hand is required. Special attention should be paid on the correct prescription of topical antiglaucomatous therapy in children since they are more prone to develop side effects. This article aims to provide an overview about the different childhood glaucoma types and to point out the most important aspects of their individual treatment strategies.

Clinical Analysis of Pediatric Glaucoma in Central China

Purpose

We aimed to describe the characteristics, epidemiology, management, and outcomes of glaucoma in pediatric patients in central China.

Methods

This study retrospectively analyzed inpatients with pediatric glaucoma at Henan Provincial People's Hospital, Henan Eye Institute, and Henan Eye Hospital between 2017 and 2020.

Results

Overall, 239 cases (276 eyes) of pediatric glaucoma in patients, comprising 87 girls (36.40%) and 152 boys (63.60%) were analyzed. The mean age was 6.65 ± 4.46, and 2.93% of the patients had a family history of glaucoma. Primary congenital glaucoma (PCG) was the most common type of glaucoma, followed by traumatic glaucoma in 8.33% of the patients, which was considered secondary glaucoma. The most common signs and symptoms were elevated intraocular pressure (IOP) and eye pain. Trabeculotomy (Trab) and microcatheter-assisted 360° trabeculotomy (MAT) combined with Trab were the most commonly performed surgeries. The IOP of patients with PCG, juvenile open-angle glaucoma (JOAG), and secondary glaucoma were 15.27 ± 7.48 mmHg, 17.16 ± 10.05, and 18.65 ± 8.55, respectively, at the final follow up. The rate of re-operations in patients with PCG, JOAG, and secondary glaucoma were 9.15%, 6.78%, and 4.69%, respectively. The mean visual acuity of the eyes with PCG, JOAG, and secondary glaucoma was 0.79 ± 0.68, 0.51 ± 0.48, and 0.53 ± 0.50, respectively.

Conclusion

PCG, JOAG, and traumatic glaucoma were the most prevalent subtypes in patients with pediatric glaucoma in central China. Trab and MAT combined with Trab were the most common interventions used in this study. Pediatric amblyopia might require full attention during the entire treatment, especially after glaucoma surgery. Effective preventive measures and more public education on glaucoma prevention and the importance of early diagnosis and treatment is necessary.

Combined trabeculotomy-trabeculectomy for primary congenital glaucoma: long-term experience from a tertiary referral centre in a developing nation

PURPOSE

To evaluate the long-term visual and surgical outcomes, and associated risk factors for poor outcomes in patients with primary congenital glaucoma (PCG).

METHODS

Retrospective review of medical records of children who underwent combined trabeculotomy-trabeculectomy (CTT) without mitomycin-C as the first surgical procedure by a single surgeon between January 1990 and December 2010. Success was defined as intraocular pressure (IOP) <16 mmHg without (complete) or with (qualified) one glaucoma medication. We used the WHO criteria of vision loss to categorize the levels of vision impairment (VI). For purposes of statistical analysis, we randomly chose one eye of patients for bilateral PCG and affected eye in unilateral PCG.

RESULTS

The cohort included 653 consecutive PCG patients (1128 eyes; mean age, 26 months), of whom 475 (73%) underwent simultaneous bilateral CTT. Kaplan-Meier survival analysis revealed 1-, 5-, 10-, 15-, and 19-year complete success rates of 92.6% (n = 372), 75.5% (n = 173), 55.9% (n = 72), 44.7% (n = 19), and 21.6% (n = 3), respectively. Multivariate analysis revealed independent associations between failure, preoperative corneal clarity, and prior glaucoma surgery. Mean follow-up was 41 ± 51 months (range, 6 months to 19 years; median, 1 year). Of the visual acuity (VA) data in the affected eyes obtained at last follow-up (n = 333, 51%), seventy-four patients (22%) had VA of ≥6/12. Of the remaining 259 patients, 18 (7%) had mild VI, 87 (34%) had moderate VI, 58 (22%) had severe VI, and 96 (37%) were blind. No serious complications were noted.

CONCLUSIONS

Primary CTT may be safely employed to control IOP and may provide long-term benefits in PCG patients.

Results of childhood glaucoma surgery over a long-term period

PURPOSE

To evaluate long-term results of glaucoma surgery in newborn and infants with glaucoma.

METHODS

Seventy-nine eyes of 52 children (age: 3 weeks-15.3 years) with primary congenital or secondary glaucoma treated between 2015 and 2017 were included. The median follow-up time was 3.9 years. Conventional probe trabeculotomy, 360° catheter-assisted trabeculotomy, filtering and cyclodestructive surgery were compared. Strict criteria for surgical success were applied: Complete surgical success (IOP below target IOP, no further surgery) and incomplete surgical success (additional surgery allowed) were analyzed, and IOP at baseline and last follow-up was compared.

RESULTS

Intraocular pressure (IOP) was significantly reduced in primary congenital (preoperative IOP: 27.8 ± 7.5 mmHg vs. postoperative IOP: 14.2 ± 4.5 mmHg) and secondary glaucoma (preoperative IOP: 29.2 ± 9.1 mmHg vs. postoperative IOP: 16.6 ± 4.7 mmHg). 90% of all eyes reached target IOP with or without medication allowing for additional surgeries. As first surgery, 360° catheter-assisted trabeculotomy had a tendency to higher surgical success than other surgical approaches, while cyclodestructive procedures had lowest.

CONCLUSIONS

We found very promising surgical results in our childhood glaucoma patient group. Surgical success in both congenital and secondary glaucoma was high.

Approach to childhood glaucoma: A review

Childhood glaucoma represents a heterogenous group of rare ocular conditions that may result in significant sight threatening complications related to elevated intraocular pressure (IOP). It can be classified as either primary or secondary and the latter may have systemic associations. This review will be based on the work of the childhood glaucoma research network (CGRN) and will focus on the diagnosis and management of the most common types of childhood glaucoma. These include primary congenital glaucoma (PCG) and juvenile open angle glaucoma (JOAG) as well as secondary causes of glaucoma associated with non-acquired ocular anomalies (Axenfeld-Rieger anomaly; Peters anomaly and Aniridia), glaucoma associated with systemic disease (Sturge Weber syndrome and Neurofibromatosis), those due to acquired conditions (Uveitic glaucoma, trauma and tumours) and importantly glaucoma following cataract surgery.

Early-Onset Glaucoma in egl1 Mice Homozygous for Pitx2 Mutation

Mutations in PITX2 cause Axenfeld–Rieger syndrome, with congenital glaucoma as an ocular feature. The egl1 mouse strain carries a chemically induced Pitx2 mutation and develops early-onset glaucoma. In this study, we characterized the glaucomatous features in egl1 mice. The eyes of egl1 and C57BL/6J control mice were assessed by slit lamp examination, total aqueous humor outflow facility, intraocular pressure (IOP) measurement, pattern electroretinography (PERG) recording, and histologic and immunohistochemistry assessment beginning at 3 weeks and up to 12 months of age. The egl1 mice developed elevated IOP as early as 4 weeks old. The IOP elevation was variable and asymmetric within and between the animals. The aqueous humor outflow facility was significantly reduced in 12-month-old animals. PERG detected a decreased response at 2 weeks after the development of IOP elevation. Retinal ganglion cell (RGC) loss was detected after 8 weeks of IOP elevation. Slit lamp and histologic evaluation revealed corneal opacity, iridocorneal adhesions (anterior synechiae), and ciliary body atrophy in egl1 mice. Immunohistochemistry assessment demonstrated glial cell activation and RGC axonal injury in response to IOP elevation. These results show that the eyes of egl1 mice exhibit anterior segment dysgenesis and early-onset glaucoma. The egl1 mouse strain may represent a useful model for the study of congenital glaucoma.

Childhood glaucoma registry in Germany: initial database, clinical care and research (pilot study)

Objective

The aim of this prospective pilot study is to establish an initial database to register patients diagnosed with different types of childhood glaucoma and the set-up of a national registry for childhood glaucoma (ReCG) in Germany. 28 children with different types of diagnosed childhood glaucoma, who were admitted and treated at the Childhood Glaucoma Center of the University Medical Center Mainz, Germany were included. Main outcome measures were the type of childhood glaucoma, mean intraocular pressure (IOP) and genetic data of the patients.

Results

The documents and questionnaires for each individual included: informed consent form of the parents, medical history form of the child, patient’s gestational history questionnaire and general anesthesia examination form. Primary congenital and secondary childhood glaucoma were revealed in 11 (39%) and 17 (61%) patients, respectively. The mean IOP measured with Perkins tonometer in all patients under general anesthesia at the time of inclusion was 17.5 ± 11.8 mmHg in the right and 17 ± 8.9 mmHg in the left eyes. In 33% of children with glaucoma mutations in the CYP1B1, FOXC1, LTBP2 and TEK genes were found. The development of specific questionnaires for childhood glaucoma provides detailed baseline data to establish a ReCG in Germany for the first time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-05921-8.

A systematic review of clinical practice guidelines for childhood glaucoma

Objective

To conduct a systematic review to identify and critically appraise clinical practice guidelines on the assessment, diagnosis and management of childhood glaucoma.

Methods and analysis

A systematic literature search of databases and professional websites for clinical practice guidelines published on eye conditions between 2010 and April 2020 in English was conducted. Identified guidelines were screened for relevance to childhood glaucoma and exclusion criteria applied. Guidelines that passed the screening and quality appraisal with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool and, if they achieved a mean score of ≥45 and ≥3 on subsets of 9 and 5 AGREE II items, respectively, were selected for inclusion and data extracted using a standardised form.

Results

Following screening and critical appraisal, three guidelines were included for data extraction. None of the three guidelines was specifically developed for childhood glaucoma. A consistent recommendation was that children should undergo some form of eye screening examination or a comprehensive eye assessment to detect paediatric eye disease. Children at high risk of childhood glaucoma should undergo additional screening. One clinical practice guideline recommended interventions for childhood glaucoma consisting of tube surgery and topical beta-blockers or carbonic anhydrase inhibitors. Recommended interventions for childhood glaucoma were based on low-quality to moderate-quality evidence or expert opinion.

Conclusion

Based on our selection criteria, we did not identify any high-quality clinical practice guidelines specifically targeted at childhood glaucoma. This is compounded by the lack of high-quality evidence on childhood glaucoma.

Characteristics and long-term outcomes of childhood glaucoma: a retrospective-cohort study

Purpose: To evaluate the clinical characteristics and treatment outcomes of patients with childhood glaucoma.

Methods: We retrospectively reviewed the data of patients with childhood glaucoma who visited the glaucoma clinics at the Queen Sirikit National Institute of Child Health and the King Chulalongkorn Memorial Hospital between January 2008 and January 2018. The diagnosis was based on the Childhood Glaucoma Research Network classification. We recorded their clinical characteristics and requirement of any glaucoma interventions.

Results: A total of 691 eyes from 423 patients were included in this study. The patients predominantly comprised boys. The average follow-up duration was 71.3±63.8 months. The mean age at presentation was 3.9±4.4 years. Most patients presented with a high initial intraocular pressure (IOP). The average intial IOP of all patients was 28.5±11.2 mmHg. Glaucoma associated with non-acquired ocular anomalies (22.9%) was the most common subtype, followed by primary congenital glaucoma (20.8%). We recorded a family history of glaucoma in 6.4% of patients of the 234 patients with an available family history. Most patients had bilateral glaucoma (63.4%) and required at least one intervention (51.5%). The average IOP at the latest follow-up visit was 19.1±10.8 mmHg. All glaucoma types had significantly lower IOP, compared to that at their baselines (all p<0.001). Moreover, most patients had an unfavourable visual acuity (49.5%) at their latest visit.

Conclusions: Secondary glaucoma associated with non-acquired ocular anomalies is the most common subtype of glaucoma. The majority of patients had unfavourable visual outcomes. These real-world findings are fundamental to acquire a better understanding of childhood glaucoma.

Microcatheter-Assisted Circumferential Trabeculotomy in Primary Congenital Glaucoma: Long-Term Clinical Outcomes

Purpose: The purpose of this study was to report the long-term efficacy and clinical outcomes of microcatheter-assisted circumferential trabeculotomy (MCT) in children with primary congenital glaucoma (PCG). Methods: This is a single-center retrospective study including consecutive children with PCG who underwent MCT with > two years follow up. The primary outcome was surgical success, defined as intraocular pressure (IOP) ≤ 21 mmHg with (qualified) or without (complete) medications, measured at six months, one year, and then annually. Secondary outcomes were visual acuity (VA), refraction, axial length (AXL), complications, reinterventions, and number of medications. Results: Twelve eyes of ten patients were included. In eight children only one eye was affected. The mean ± standard deviation (SD) age at surgery was 6.3 ± 4.1 months. The mean postoperative follow-up was 66 ± 35 months. The mean IOP was 34.3 ± 9.6 mmHg preoperatively and 14.6 ± 2.3 mmHg postoperatively at the last visit (p < 0.001). Complete success was achieved at all time points in 10 out of 12 eyes, while 2 eyes had a qualified success. At three years of age, the mean VA of the operated eyes was 0.25 ± 0.12 logMAR, the mean spherical equivalent was −0.78 ± 1.43 diopters, and the mean AXL was 23.78 mm. Transient hyphema was the only complication observed. None of the children required additional glaucoma surgery. Conclusions: Circumferential trabeculotomy for PCG effectively lowers the IOP at more than two years after surgery. Following this procedure, the prognosis for the visual function is good, and the refractive error is low. Postoperative complications were not significant.

Long-term outcomes in Primary congenital glaucoma, aniridia and anterior segment dysgenesis

Aim

To determine the long-term outcomes of a cohort of complex patients with primary congenital glaucoma, aniridia and anterior segment dysgenesis.

Methods

Retrospective consecutive series between 1990–2021 in two UK tertiary centres: Guy's and St Thomas’ NHS Foundation Trust and King's College Hospital NHS Foundation Trust. We recorded the number and types of surgical and laser treatments along with preoperative and postoperative data, including intraocular pressures (IOP) and anti-glaucoma medications.

Results

A total of 41 eyes of 21 patients were included. Primary diagnoses were primary congenital glaucoma in 16 eyes (39.0%), aniridia in 14 eyes (34.2%), and anterior segment dysgenesis in 8 eyes (19.5%). Sixteen eyes (39.0%) had one or more glaucoma surgery or laser procedures for advanced glaucoma, and the long-term follow-up was 12.8 ± 3.6 years. There was a significant decrease in postoperative IOP (mmHg) at 3 months (16.5 ± 1.6; p = 0.0067), 6 months (18.7 ± 2.1; p = 0.0386), 12 months (18.6 ± 1.7; p = 0.0229), 3 years (14.7 ± 1.2; p = 0.0126), 5 years (15.5 ± 1.8; p = 0.0330) and 10 years (15.4 ± 2.3; p = 0.7780), compared to preoperatively (24.1 ± 2.6). Surgical success (complete and qualified) was 62.5%, 50.0%, 43.8%, 46.2%, 45.5% and 28.6% at 3 months, 6 months, 12 months, 3 years, 5 years and 10 years, respectively. There was no significant change in the number of anti-glaucoma drugs postoperatively (p > 0.05). Four eyes (25.0%) had postoperative complications (hyphaema, hypotony) that resolved after conservative management.

Conclusions

Surgical management of these complex eyes with advanced glaucoma is challenging. Overall, the cohort had good surgical outcomes with a significant decrease in IOP by 36.1% after long-term follow-up.