Incidence and clinical characteristics of childhood glaucoma: a population-based study

Omidenepag Isopropyl Versus Timolol in Patients With Glaucoma or Ocular Hypertension: Two Randomized Phase 3 Trials (SPECTRUM 4 and 3)

PURPOSE

The SPECTRUM 4 and 3 studies assessed the intraocular pressure (IOP)-lowering efficacy and safety of omidenepag isopropyl (OMDI) 0.002% vs timolol 0.5% in patients with glaucoma or ocular hypertension (OHT).

DESIGN

Phase 3, randomized, controlled, double-masked, noninferiority studies.

METHODS

Multicenter studies in the US. Inclusion criteria for adults ≥ 18 years (SPECTRUM 4 [N = 409] and 3 [N = 413]) were open-angle glaucoma or OHT, and IOP ≥ 22 mm Hg and ≤ 34 mm Hg; and for pediatric patients < 18 years (N = 13, SPECTRUM 3) were pediatric glaucoma or OHT. The primary objective in both studies was OMDI noninferiority to timolol in reducing IOP (3 months). SPECTRUM 3 included an additional 9 months of OMDI treatment. Safety evaluations were of ocular/non-ocular adverse events (AEs).

RESULTS

The IOP-lowering range of OMDI remained consistent in SPECTRUM 4 and 3 (-5.6 to -5.9 vs -5.3 to -5.7 mm Hg, respectively); however, timolol efficacy varied (-5.4 to -6.1 vs -6.4 to -7.0 mm Hg, respectively). OMDI noninferiority was achieved in SPECTRUM 4. Efficacy was maintained with 12-month treatment in SPECTRUM 3. Both studies reported more ocular AEs with OMDI, but lower rates of appearance-altering AEs vs timolol. No new safety concerns were identified. Rates of macular edema in pseudophakic patients increased with prolonged OMDI exposure.

CONCLUSIONS

SPECTRUM 4 and 3 demonstrated consistent 3-month IOP-lowering efficacy and safety of OMDI vs timolol in patients with glaucoma or OHT. The 12-month data from SPECTRUM 3 suggest OMDI may have long-term benefits in patients with glaucoma or OHT.

Continuous Wave Transscleral Cyclophotocoagulation and Endoscopic Cyclophotocoagulation in Childhood Glaucoma: A Meta-Analysis

PRCIS

Transscleral cyclophotocoagulation (TS-CPC) and endoscopic cyclophotocoagulation (ECP) were effective in reducing intraocular pressure (IOP) and glaucoma medications in childhood glaucoma.

OBJECTIVE

To report the outcomes of continuous wave TS-CPC and ECP in childhood glaucoma.

MATERIALS AND METHODS

We performed a systematic search of relevant databases. We collected data on age, follow-up duration, type of glaucoma, previous surgical interventions, preoperative and postoperative IOP, preoperative and postoperative number of glaucoma medications, adverse events, number of sessions, and success rates at different time points. The main outcome measures are the amount of IOP and glaucoma medication reduction.

RESULTS

We included 17 studies studying 526 patients (658 eyes); 11 evaluated the effectiveness of TS-CPC (268 patients, 337 eyes), 5 evaluated ECP (159 patients, 197 eyes), and one study compared both techniques (56 patients, 72 eyes for TS-CPC vs 43 patients, 52 eyes for ECP). The median duration of follow-up was 28 months in the TS-CPC group and 34.4 months in the ECP group. The mean number of treatment sessions was 1.7 in the TS-CPC and 1.3 in the ECP. In the TS-CPC group, the mean IOP was significantly reduced from 31.2 ± 8 to 20.8 ± 8 mm Hg at the last follow-up ( P < 0.001). The mean number of glaucoma medications was reduced from 2.3 ± 1.3 to 2.2 ± 1.3 ( P = 0.37). In the ECP group, there was also a significant reduction in the mean IOP from 32.9 ± 8 mm Hg with a mean of 1.7 ± 0.7 glaucoma medications to 22.6 ± 9.8 mm Hg ( P < 0.0001) on 1.2 ± 1.1 medications ( P = 0.009) at the last follow-up.

CONCLUSION

Both TS-CPC and ECP were effective in reducing the IOP and glaucoma medications in childhood glaucoma. Multiple treatment sessions were required.

Epidemiology of Pediatric Ocular Surface Inflammatory Diseases in the United States Using the Optum Labs Data Warehouse

PURPOSE

To benchmark the epidemiologic features of pediatric ocular surface inflammatory diseases (POSID).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients 18 years of age or younger with a medical claim for a diagnosis of POSID in the Optum Labs Data Warehouse between 2007 and 2020.

METHODS

Patients with claims of blepharokeratoconjunctivitis (BKC), herpes simplex keratoconjunctivitis (HSK), or vernal keratoconjunctivitis (VKC) were included. Those with less than 6 months of follow-up before the initial diagnosis of POSID were excluded. Odds ratios (ORs) were derived from multivariable logistic regression analyses evaluating the associations between epidemiologic variables and POSID development.

MAIN OUTCOME MEASURES

The primary outcome was the estimated prevalence of POSID. Prevalence of POSID subtypes and changes in prevalence over time were also evaluated.

RESULTS

Two thousand one hundred sixty-eight patients with POSID were identified from 2018 through 2019, yielding an estimated prevalence of 3.32 per 10 000. The prevalence of POSID was higher among children between 5 and 10 years of age, male children, those of Asian descent, and those living in the Northeast and the West census regions of the United States. The prevalence (per 10 000) of BKC, HSK, and VKC in the same period were 0.59 (95% confidence interval [CI], 0.53-0.65), 0.74 (95% CI, 0.68-0.81), and 1.99 (95% CI, 1.88-2.10), respectively, and significant differences were found in terms of age, sex, racial, ethnic, and regional distributions among the diagnoses. Between 2008 through 2009 and 2018 through 2019, a significant increase in POSID was noted among Asians (from 6.26 [95% CI, 5.28-7.36] to 11.80 [95% CI, 10.40-13.34]) driven by changes in VKC. Multivariable analysis demonstrated that age older than 5 years (OR, 2.57-3.75; 95% CI, 2.17-4.34), male sex (OR, 1.38; 95% CI, 1.26-1.50), Asian descent (OR, 3.12; 95% CI, 2.70-3.60), and Black or African American descent (OR, 1.26; 95% CI, 1.02-1.55) were associated with POSID development.

CONCLUSIONS

This study provides an estimated prevalence of POSID and its 3 common subtypes in the United States, with important epidemiologic differences among them.

FINANCIAL DISCLOSURE(S)

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

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.].

Chromatic vision and structural assessment in primary congenital glaucoma

Primary congenital glaucoma is a rare disease that occurs in early birth and can lead to low vision. Evaluating affected children is challenging and there is a lack of studies regarding color vision in pediatric glaucoma patients. This cross-sectional study included 21 eyes of 13 children with primary congenital glaucoma who were assessed using the Farnsworth D-15 test to evaluate color vision discrimination and by spectral domain optical coherence tomography to measure retinal fiber layer thickness. Age, visual acuity, cup-to-disc ratio and spherical equivalent data were also collected. Global and sectional circumpapillary and macular retinal fiber layer thicknesses were measured and compared based on color vision test performance. Four eyes (19%) failed the color vision test with diffuse dyschromatopsia patterns. Only age showed statistical significance in color vision test performance. Global and sectional circumpapillary and macular retinal fiber layer thicknesses were similar between the color test outcomes dyschromatopsia and normal. While the color vision test could play a role in assessing children with primary congenital glaucoma, further studies are needed to correlate it with damage to retinal fiber layer thickness.

The associations of self-perception, movement competence, and clinical features of young school-aged children with glaucoma

The purpose of the study was to determine the associations of self-perception, motor skills, and clinical features of young school-age children with glaucoma (CG). This is a cross-sectional observational study. Children from preschool to second grade, including CG (N = 19), children with amblyopia (CA, N = 28), and controls (N = 32), completed the Manual Dexterity and Aiming and Catching Scales of the Movement Assessment Battery for Children-2nd edition (MABC-2), including Manual Dexterity, Aiming and Catching, and Balance. CG, CA, and their parent completed the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children, respectively, assessing the child's cognitive competence, peer acceptance, physical competence, and maternal acceptance. The Kruskal-Wallis H test and Bonferroni post hoc test compared motor skills among groups. Spearman's correlation analysis evaluated the correlations between motor skills, self-perception, and clinical features. The CG reported lower peer acceptance than CA (P = 0.040), and the parents of CG reported lower cognitive competence than CG reported (P = 0.046). Compared with controls, CG had worse performance of Aiming and Catching, and Balance (P = 0.018 and P = 0.001), and CA had worse performance of Balance (P = 0.009). The motor skills were comparable between CG and CA. For CG, older age correlated with worse competence of Aiming and Catching (r =  - 0.620, P = 0.005), better best-corrected visual acuity of better-seeing eye correlated with higher competence of Manual Dexterity and Balance (r =  - 0.494, P = 0.032, and r =  - 0.516, P = 0.024), and longer duration of glaucoma correlated with worse competence of Manual Dexterity (r =  - 0.487, P = 0.034).

CONCLUSION

 Glaucoma and amblyopia have significant negative impacts on children's daily motor skills. The acuity of a better-seeing eye is an important factor influencing motor movement.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, ChiCTR2100050415.

WHAT IS KNOWN

• The state of mental health in early childhood influences the development of their future personality and physical development. The prognosis and management of glaucoma may seriously impair the mental health development of the affected children. However, the exploration of psychological aspects and motor movement of childhood glaucoma was limited.

WHAT IS NEW

• Children with glaucoma have impaired motor skills and self-perception development, especially in terms of peer socialization.

Non-penetrating deep sclerectomy versus combined trabeculotomy-trabeculectomy in primary congenital glaucoma

Background

The primary mode of therapy in children with primary congenital glaucoma (PCG) and mild or no corneal edema is goniotomy, which has a high success rate. However, in developing countries, the diagnosis of PCG is usually delayed, and corneal cloudiness interferes with goniotomy. Therefore, trabeculotomy may be the best choice in such eyes. We compared the short-term efficacy and safety of primary combined trabeculotomy-trabeculectomy (primary CTT) with that of non-penetrating deep sclerectomy (NPDS) in managing PCG.

Methods

This prospective, randomized, comparative study included patients with PCG referred to Al-Azhar University Hospitals within a 1-year period. Eyes were randomly allocated to one of two groups: eyes in NPDS group underwent NPDS, and those in primary CTT group underwent primary CTT. Baseline and frequent postoperative assessments of intraocular pressure (IOP), cup-to-disc ratio (C/D ratio), corneal diameter, and axial length were performed for up to 6 months. The success rates were recorded in both groups.

Results

Forty eyes of 26 patients were included, with 20 eyes allocated to each group. The mean (standard deviation) age of all patients was 12.9 (9.5) months, with comparable ages and sex ratios between groups (both P > 0.05). Both groups demonstrated a significant reduction in IOP and C/D ratio at each postoperative visit compared to the baseline visit (all P < 0.001), with no significant difference detected between the groups (all P > 0.05), except for a significantly lower IOP in NPDS group at 1 month (P < 0.05). The corneal diameter and axial length were comparable between groups at baseline and remained unchanged at all postoperative visits (all P > 0.05). The groups had comparable success rates (P > 0.05). No serious complications were detected.

Conclusions

CTT and NPDS both yielded reasonable IOP control and reversal of cupping in eyes with PCG. We observed equal effectiveness of the surgical procedures without major safety concerns. Further large-scale clinical trials with longer follow-up periods are needed to verify our preliminary findings.

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.

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.

Analysis of glaucoma genes in Finnish patients with juvenile open-angle glaucoma

PURPOSE

To identify germline variants in myocilin (MYOC) and other known monogenic glaucoma genes in Finnish patients with juvenile open-angle glaucoma (JOAG).

METHODS

Finnish patients with JOAG treated between 2010 and 2018 at the Department of Ophthalmology, Helsinki University Hospital, Finland, were enrolled. We sequenced all exonic regions and flanking splice sites of MYOC for five patients and one healthy relative using Sanger sequencing. In 48 patients, we performed exome sequencing to identify variants also in 28 other glaucoma-related genes.

RESULTS

Fifty-three individuals with JOAG from 50 pedigrees, and one healthy relative, participated. The mean age at diagnosis was 30.8 years [SD 7.6; range 11 to 39]. Five probands had probably pathogenic variants in MYOC: c.1102C>T p.(Gln368Ter), c.1109C>T p.(Pro370Leu), c.1130C>T p.(Thr377Met), c.1132G>A p.(Asp378Asn) and c.1456C>T p.(Leu486Phe). Four of these patients had a family history of dominantly inherited JOAG. The frequency of MYOC variants was 10% (5 of 50 families). One patient and his mother with JOAG had a novel loss-of-function variant in the FOXC1 gene, c.366G>A p.(Trp122Ter). A patient with sporadic JOAG had a homozygous likely pathogenic variant in the LTBP2 gene, c.3938G>A p.(Cys1313Tyr). The genetic variants explained 14% (7 out of 50 families; 95% CI, 6%-23%) of JOAG in our cohort.

CONCLUSIONS

The frequency of pathogenic variants in previously known glaucoma-associated genes is low in Finnish patients with JOAG. Because of the distinct genetic background of Finns, it might be possible to identify novel glaucoma genes through our JOAG series in the future.

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.

Challenges and Opportunities in P450 Research on the Eye

Of the 57 cytochrome P450 enzymes found in humans, at least 30 have ocular tissues as an expression site. Yet knowledge of the roles of these P450s in the eye is limited, in part because only very few P450 laboratories expanded their research interests to studies of the eye. Hence the goal of this review is to bring attention of the P450 community to the eye and encourage more ocular studies. This review is also intended to be educational for eye researchers and encourage their collaborations with P450 experts. The review starts with a description of the eye, a fascinating sensory organ, and is followed by sections on ocular P450 localizations, specifics of drug delivery to the eye, and individual P450s, which are grouped and presented based on their substrate preferences. In sections describing individual P450s, available eye-relevant information is summarized and concluded by the suggestions on the opportunities in ocular studies of the discussed enzymes. Potential challenges are addressed as well. The conclusion section outlines several practical suggestions on how to initiate eye-related research. SIGNIFICANCE STATEMENT: This review focuses on the cytochrome P450 enzymes in the eye to encourage their ocular investigations and collaborations between P450 and eye researchers.

Conversion to Glaucoma in Pediatric Glaucoma Suspects

PRCIS

In this retrospective review of pediatric glaucoma suspects, 11.5% of eyes progressed to glaucoma over an average of 6.5 years; eyes with ocular hypertension had an 18-fold increased risk of progression compared with eyes with suspicious disc appearance.

PURPOSE

The purpose of this study was to describe the rate of progression to glaucoma of a large cohort of pediatric glaucoma suspects at a quaternary academic center.

DESIGN

Retrospective case series.

PARTICIPANTS

One thousand three hundred seventy-five eyes (824 individuals) followed as pediatric glaucoma suspects at the Wilmer Eye Institute between 2005 and 2016.

METHODS

Retrospective study of pediatric patients monitored as glaucoma suspects at the Wilmer Eye Institute between 2005 and 2016.

MAIN OUTCOME MEASURES

Progression to glaucoma, defined according to Childhood Glaucoma Research Network criteria or by surgical intervention; initiation of intraocular pressure-lowering therapy.

RESULTS

One hundred fifty-eight (11.5%) eyes from 109 unique patients met the criteria for conversion to glaucoma during follow-up; rates of conversion ranged between 34.1% for eyes monitored for ocular hypertension, 16.2% for eyes with prior lensectomy, 12.1% for eyes monitored for other ocular risk factors, 2.4% for eyes with suspicious disc appearance, and 0.4% for eyes monitored for systemic risk factors. The first criterion met for conversion to glaucoma was ocular hypertension in 149 eyes (94.3%) and enlarged cup-to-disc ratio (CDR) in 9 eyes (5.7%); the most common second criterion met was the enlargement of CDR since initial presentation (45 eyes, 28.5%), surgical intervention (33 eyes, 20.9%), visual field changes (21 eyes, 13.3%), and asymmetric CDR change compared with fellow eye (20 eyes, 12.7%). The Kaplan-Meier survival curves across the different indications for being monitored as a glaucoma suspect significantly differed ( P <0.0001). Eyes being monitored for ocular hypertension had an 18-fold increased risk of conversion to glaucoma than those followed for suspicious disc appearance [hazard ratio (HR) 18.33, 95% CI, 10.05-33.41). Eyes monitored for prior lensectomy and for other ocular risk factors had a 6-fold and 5-fold increased risk of conversion to glaucoma than those followed for suspicious disc appearance, respectively (HR: 6.20, 95% CI, 3.66-10.51; HR: 5.43, 95% CI, 3.00-9.84). Eyes followed for ocular hypertension were nearly 4 times more likely to convert to glaucoma than those followed for prior lensectomy (HR: 3.72, 95% CI, 2.28-6.07).

CONCLUSIONS

Eyes being followed as pediatric glaucoma suspects for ocular hypertension had higher rates of progression to glaucoma than eyes being monitored for prior lensectomy, other ocular risk factors, suspicious disc appearance, or systemic risk factors.

Outcome measures in childhood glaucoma: a systematic review of randomized controlled trials

PURPOSE

To synthesize the outcome measures used by randomized controlled trials (RCTs) for childhood glaucoma.

METHODS

MEDLINE, EMBASE, and Scopus were searched from inception to February 17, 2023. Randomized controlled trials and observational studies related to childhood glaucoma were included. Primary and secondary outcomes were extracted and the data was used to generate a literature review.

RESULTS

This review identified 42 unique reports pertaining to childhood glaucomas. Most of the studies originated from Egypt, India, and the USA. Intraocular pressure (IOP) outcomes were the most frequent outcomes studied, followed by clinical outcomes and safety outcomes. Clinical outcomes were the most common secondary outcomes studied, followed by IOP outcomes and safety outcomes.

CONCLUSIONS

This systematic review found heterogenous outcomes with IOP outcomes as the most studied primary outcome. As the remaining outcomes were not consistently utilized, this review highlights the need for a consensus on studies of pediatric glaucoma.

Adherence to Follow-Up and the Related Factors of Paediatric Glaucoma at a Tertiary Care Centre in Western Saudi Arabia

INTRODUCTION

Glaucoma is a main cause of blindness globally. In Saudi Arabia, congenital glaucoma is believed to affect 1 in every 2500 live births. In this study, we identified the adherence and evaluated the factors associated with non-compliance (non-adherence) to recommended follow-up appointments at King Abdulaziz University Hospital, a tertiary centre in Jeddah, Saudi Arabia.

METHODS

The medical records of paediatric patients diagnosed with glaucoma between 2009 and April 2022 were reviewed retrospectively. Demographic information, visit dates, scheduled follow-ups, and specific patients' glaucoma histories were all extracted from the records. Patients were categorized as adherent, non-adherent, or lost to tertiary follow-up (LTTF).

RESULTS

Of 91 patients, 52 (57.1%) were adherent, 20 (22%) were non-adherent, and 19 (20.9%) were LTTF. Most adherent patients were Saudi (59.3% adherent, 26.5% non-adherent, 14.2% LTTF) (P = 0.02). Adherent patients were far likelier to live further away from the ophthalmology clinic (P = 0.03). The frequency of clinical encounters was statistically significantly different between adherence statuses. The non-adherent group had a higher average number of prescribed ocular medications (P = 0.03). The adherent patients had more frequent visits with elevated intraocular pressure (P = 0.02).

CONCLUSION

A significantly high percentage of paediatric glaucoma patients were non-adherent to follow-up visits. When determining the non-compliance risk among paediatric glaucoma patients, physicians must consider the factors contributing to adherence status, which include nationality, distance to the ophthalmology clinic, and number of prescribed ocular medications.

A comparative study on surgical outcomes of trabeculectomy with and without anti-metabolites in juvenile open-angle glaucoma

Purpose

To compare the surgical outcomes of trabeculectomy with and without anti-metabolites in patients with juvenile open-angle glaucoma (JOAG).

Methods

This retrospective comparative case series included 98 eyes of 66 patients with JOAG who underwent either trabeculectomy without anti-metabolites (group A, n = 53 eyes) or with anti-metabolites (group B, n = 45 eyes) with a minimum of 2 years follow-up. The main outcome measures were intra-ocular pressure (IOP), number of glaucoma medications, visual acuity, additional surgical interventions, surgical complications, and risk factors for failure. Surgical failure was defined as IOP >18 mmHg or failure to reduce IOP by <30% from the baseline value or IOP ≤5 mmHg or re-operation for refractory glaucoma or a complication or loss of light perception vision.

Results

The mean post-operative IOP reduced significantly from baseline at all post-operative visits until 6 months and thereafter. The cumulative probability of failure at 2 years was 28.7% in group A [95% confidence interval (CI) = 17.6-44.8%] and 29.1% in group B (95% CI = 17.1-46.7%) (P = 0.78). Surgical complications occurred in 18 eyes (34%) in group A and 19 eyes (42%) in group B. Re-operations for glaucoma or complications were performed in two eyes (3.8%) in group A and two eyes (4.4%) in group B. Cox-hazard regression model revealed male gender (HR = 0.29; P = 0.008), baseline high IOP (HR = 0.95; P = 0.002), and an increased number of pre-operative glaucoma medications (HR = 2.08; P = 0.010) as significant factors associated with failure.

Conclusion

: Our study results on trabeculectomy in JOAG revealed a success of 71% in both groups at 2 years follow-up. There was no significant difference in success or failure rates between the two groups. The risk factors for poor surgical outcome in JOAG were male gender, baseline high IOP, and an increased number of glaucoma medications.

Approaching rehabilitation in patients with advanced glaucoma

Vision loss from advanced glaucoma is currently irreversible and impairs functional visual ability to effectively perform everyday tasks in a number of distinct functional domains. Vision rehabilitation strategies have been demonstrated to be effective in low vision populations and should be utilized in persons with advanced glaucoma to reduce disability and improve quality of life. Initial challenges to rehabilitation include an incomplete understanding of vision rehabilitation by the physician and patient, motivation to integrate rehabilitation into the plan of care, and availability of suitable providers to deliver this care. Physicians, working with well-trained vision rehabilitation providers can maximize function in important visual domains customized to the patient based on their needs, specific complaints, severity/pattern of visual damage, and comorbidities. Potential rehabilitative strategies to be considered for reading impairment include spectacle correction, visual assistive equipment, and sensory substitution, while potential strategies to facilitate driving in those deemed safe to do so include refractive correction, lens design, building confidence, restriction of driving to safer conditions, and avoiding situations where cognitive load is high. Mobility is frequently disrupted in advanced glaucoma, and can be addressed through careful distance refraction, behavior modification, home modification, mobility aids, walking assistance (i.e., sighted guide techniques), and smartphone/wearable technologies. Visual motor complaints are best addressed through optimization of lighting/contrast, sensory substitution, IADL training, and education. Special rehabilitative concerns may arise in children, where plans must be coordinated with schools, and working adults, where patients should be aware of their rights to accommodations to facilitate specific job tasks.

Glaucoma and Systemic Disease

Glaucoma is the leading cause of irreversible blindness in the world. Due to its potential to cause permanent vision loss, it is important to understand how systemic conditions and their respective treatments can be associated with or increase the risk for developing glaucoma. In this review, we examined the literature for up-to-date discussions and provided commentary on glaucoma, its pathophysiology, and associated risk factors. We discuss systemic diseases and the impact, risk, and mechanism for developing glaucoma, including pharmacologically induced glaucoma; inflammatory and auto-immune conditions; infectious, dermatologic, cardiovascular, pulmonary, renal, urologic, neurologic, psychiatric and systemic malignancies: intraocular tumors; as well as pediatric, and genetic conditions. The goal of our discussion of systemic conditions including their commonality, mechanisms, treatments, and associations with developing glaucoma is to emphasize the importance of ocular examinations and follow-up with the multidisciplinary teams involved in the care of each patient to prevent unnecessary vision-loss.

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.

Clinical outcomes in children and adolescents referred for increased cup:disk ratio at a tertiary referral center

PURPOSE

To report clinical outcomes and risk factors for glaucoma in children and adolescents referred for increased cup:disk ratios (CDRs) to a tertiary referral center.

METHODS

This retrospective, single-center study examined all pediatric patients evaluated for increased CDR at Wills Eye Hospital. Patients who had previous known ocular disease were excluded. Demographic data, including sex, age, and race/ethnicity were recorded, as were baseline and follow-up ophthalmic examination findings, including intraocular pressure (IOP), CDR, diurnal curve, gonioscopy findings, and refractive error. Risks of glaucoma diagnosis based on these data were analyzed.

RESULTS

A total of 167 patients were included, of whom 6 were found to have glaucoma. Despite more than 2 years' follow-up on 61 patients, all glaucoma patients were identified within the first 3 months of evaluation. Baseline IOP was statistically significantly higher in glaucomatous patients than nonglaucomatous patients (28 ± 7 vs 15 ± 4, resp. [P = 0.0002]), as was maximum IOP on diurnal curve (24 ± 3 vs 17 ± 3 [P = 0.0005]).

CONCLUSIONS

In our study cohort, diagnosis of glaucoma was apparent in the first year of evaluation. Baseline IOP and maximal IOP on diurnal curve were found to be statistically significantly associated with glaucoma diagnosis in pediatric patients referred for increased CDR.

Outcomes of Penetrating Canaloplasty in Childhood Glaucoma

PRCIS

Penetrating canaloplasty was safe and effective for the management of refractory childhood glaucoma.

PURPOSE

The purpose of this paper is to report the safety and efficacy of penetrating canaloplasty for the management of childhood glaucoma.

MATERIALS AND METHODS

This single-center prospective interventional case series enrolled 50 eyes of 32 patients with childhood glaucoma between July 2017 and July 2020. Penetrating canaloplasty to create direct communication between the anterior chamber and tensioning suture-dilated the Schlemm canal was performed through a trabecular meshwork ostium in the affected eyes. Preoperative and postoperative intraocular pressure (IOP), number of glaucoma medications, and procedure-related complications were recorded. Qualified and complete success was defined as IOP≥5 and ≤21 mm Hg with or without glaucoma medications, respectively.

RESULTS

A total of 43 eyes (86.0%) achieved 360 degrees catheterization of Schlemm canal and completed penetrating canaloplasty. The median age at surgery was 5 years (range, 10 d-17 y, mean 6.20±5.46 y). The mean IOP decreased from 33.11±10.89 mm Hg on 2 medications (median, range: 0-5) before surgery to 13.46±4.71 mm Hg on 0 medications (median, range:0-2) postoperatively at 12 months ( P <0.001). Complete and qualified success rates were 81.08% and 89.19%, respectively, at the 12-month follow-up. Hyphema (6/43, 13.95%) and a transient shallow anterior chamber with hypotony (5/43, 11.63%) were the most commonly observed early complications.

CONCLUSION

Penetrating canaloplasty demonstrated good safety and efficacy in eyes with childhood glaucoma, and may be considered an option for managing refractory childhood glaucoma.

Topical netarsudil 0.02% as adjunctive therapy in refractory pediatric glaucoma

PURPOSE

To evaluate the efficacy of topical netarsudil 0.02% as adjunctive therapy in children with refractory pediatric glaucoma.

METHODS

The medical records of patients ≤18 years diagnosed with pediatric glaucoma treated with topical netarsudil 0.02% from June 2019 to March 2022 were reviewed retrospectively. Data collected included age, sex, ethnicity, etiology of glaucoma, history of previous or subsequent glaucoma surgery, and intraocular pressure (IOP) before and after the addition of topical netarsudil.

RESULTS

A total of 21 eyes of 16 patients (11 males) were included. Five patients used topical netarsudil in both eyes. Eight patients were Hispanic. The mean number of glaucoma surgeries and medications before initiating topical netarsudil was 1.8 ± 1.2 and 3.7 ± 0.5, respectively. The mean age prior to starting topical netarsudil was 8.9 ± 4.1 years. The mean follow-up after initiating topical netarsudil was 11.3 ± 8.2 months. The IOP was significantly reduced from 26.3 ± 6.2 mm Hg before topical netarsudil to 19.6 ± 6.02 mm Hg at 1 month in 15 eyes (P < 0.01), 18.2 ± 6.9 mm Hg at 3-months in 18 eyes (P < 0.01), 18.3 ± 7.3 mm Hg at 6 months in 13 eyes (P = 0.01), 17.6 ± 5.07 mm Hg at 9 months in 14 eyes (P = 0.002), and 17.4 ± 3.1 mm Hg at 12 months in 13 eyes (P = 0.002). Nine eyes (43%) underwent additional glaucoma surgery due to long-term failure of topical netarsudil to reduce IOP despite an initial reduction, and one eye had persistent IOP elevation ≥21 mm Hg despite the addition of topical netarsudil.

CONCLUSIONS

In our small cohort of patients with refractory pediatric glaucoma, the addition of topical netarsudil reduced IOP, potentially delaying the need for surgery.

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.

Pediatric glaucoma suspects: characteristics and outcomes

PURPOSE

To determine the characteristics of children diagnosed with glaucoma suspect (GS) status, their clinical outcomes, and risk factors for progression to a diagnosis of glaucoma.

METHODS

This was a retrospective sequential cohort study of children <18 years diagnosed as GS between 2013 and 2019, based on clinical (C-GS) and CGRN (CGRN-GS) criteria. Children with penetrating ocular trauma, steroid-response, treated ocular hypertension, and glaucoma at presentation were excluded. Outcomes included glaucoma, treated ocular hypertension, nonglaucomatous cupping (pseudoglaucomatous or physiologic), or persistent GS. Secondary outcomes were characteristics of children who progressed to glaucoma.

RESULTS

A total of 887 children (mean age, 9.3 ± 4.7 years) were diagnosed as C-GS, because of optic nerve appearance (83%), family history (25%), ocular hypertension (15%), periocular lesion (4% [eg, Sturge-Weber]), blunt-trauma history (3%), ocular anomaly (2%), and systemic/genetic syndrome (1.5%). Outcomes among 487 children with one or more follow-up visits (mean, 1.7 ± 1.6 years) included 14 (3%) with glaucoma, 98 (20%) with physiologic cupping, 50 (10%) with prematurity-associated cupping, and 1 (0.2%) with treated ocular hypertension; 324 (67%) remained GS. Of children lost to follow-up, 116 (29%) were suspected physiologic or pseudoglaucomatous. Glaucoma diagnosis occurred at a mean age of 8.4 ± 5.5 years, based on elevated intraocular pressure (IOP; 79%), optical coherence tomography changes (43%), disk changes (21%), or field defects (14%). Risk factors for glaucoma were baseline IOP of ≥24 (P = 0.01) and periocular lesion (P = 0.008). Results from 773 children who met CGRN-GS criteria were similar.

CONCLUSIONS

Risk of conversion to glaucoma diagnosis among children with glaucoma suspect status appears low. Baseline cup:disk ratio and family history of glaucoma were not predictive of glaucoma diagnosis. Baseline IOP >24 and presence of a periocular lesion carry higher risk.

Etiology and outcomes of childhood glaucoma at a tertiary referral center

PURPOSE

To describe the etiology, clinical features, and outcomes for a large contemporary cohort of children presenting with glaucoma at a tertiary referral center.

METHODS

The medical records of patients presenting to Boston Children's Hospital from January 2014 to July 2019 with a diagnosis of childhood glaucoma were retrospectively reviewed. Data regarding etiology, treatment, and visual and anatomic outcomes were collected; visual acuity outcomes were analyzed by laterality and diagnosis categories, using the Childhood Glaucoma Research Network (CGRN) classifications.

RESULTS

A total of 373 eyes of 246 patients (51% males) diagnosed with glaucoma before 18 years of age were identified. Mean follow-up was 7.04 ± 5.61 years; 137 cases were bilateral. The mean age at diagnosis was 4.55 ± 5.20 years. The most common diagnoses were glaucoma following cataract surgery (GFCS, 36.5%) and primary congenital glaucoma (PCG, 29.0%). Overall, 164 eyes (44.0%) underwent at least one glaucoma surgery. Intraocular pressure (IOP) was ≤21 mm Hg with or without glaucoma medications in 300 eyes (80.4%) at the last follow-up visit. Poor final best-corrected visual acuity (≤20/200) was found in 110 eyes; patients with poor final visual acuity tended to have poor visual acuity at presentation. The most common reason for poor vision was amblyopia. Uncontrolled IOP was an uncommon cause for vision loss.

CONCLUSIONS

Childhood glaucoma can be challenging to manage, but poor vision usually results from amblyopia or presence of other ocular abnormalities or syndromes rather than glaucomatous optic neuropathy.

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.

Factors affecting the surgical success of trabeculectomy performed as the first surgery in primary pediatric glaucoma

PURPOSE

To present the outcomes and factors affecting the success of trabeculectomy performed as the first surgery in primary pediatric glaucoma.

METHODS

Pediatric patients with primary glaucoma who underwent trabeculectomy as the first surgery were retrospectively reviewed. Age, gender, preoperative intraocular pressure (IOP), operation age, axial length, corneal diameter, anterior segment findings, antimetabolite used, complications, and 1-month, 3-months, 1-year, and most recent postoperative findings were recorded. Postoperative IOP with/without medication of 18 mmHg or less was considered successful. Factors that may have affected surgical success were also evaluated using multivariate analysis.

RESULTS

Included in the study were 48 patients, of whom 30 had primary congenital glaucoma and 18 had juvenile glaucoma. The mean preoperative IOP was 36.84 ± 6.30 mmHg, and the mean follow-up time was 7.95 ± 6.93 years. The median operation age value was 100.00 ± 100.83 (median: 60; IQR: 153) months. The postoperative IOP at the 1-month, 3-months, 1-year, and most recent follow-ups were 15.39 ± 6.88, 15.70 ± 7.36, 16.28 ± 7.86, and 17.48 ± 8.44 mmHg, respectively (p = 0.565). While there were no postoperative complications in 24 of the patients (50.0%), the most common complications were choroidal detachment and hypotony. Postoperative complication development was found to be significant as a factor affecting surgical success in the multivariate logistic regression analysis. Surgical success rates for all of the patients were 71.7%, 65.9%, 65.0%, and 61.4% at the 1-month, 3-months, 1-year, and most recent follow-ups, respectively. A significant difference was found between the congenital and juvenile groups in terms of surgical success only at 3 months (p = 0.953, p = 0.042, p = 0.191, p = 0.218; respectively).

DISCUSSION/CONCLUSION

The fact that surgical success was partially higher in the juvenile group confirmed the idea that the results of trabeculectomy will be more favorable in patients of older age and without anterior segment anomalies.

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.

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.

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.

Profile of primary childhood glaucoma at a child eye health tertiary facility in Malawi

BACKGROUND

To describe the clinical characteristics and treatment of primary childhood glaucoma at Queen Elizabeth Central Hospital in Blantyre, Malawi.

METHODS

A retrospective case notes review was undertaken of all medical records of patients aged less than 16 years with a diagnosis of primary glaucoma according to the Childhood Glaucoma Research Network Classification (CGRN) who presented from January 2016 to December 2018. The parameters extracted from the case files included age at presentation, sex, type of glaucoma, presenting complaints, laterality of ocular involvement, examination findings and the treatment modality instituted. The Mann-Whitney test was used to investigate factors associated with the intraocular pressure (IOP) in eyes that had a higher presenting IOP value compared to contralateral eyes.

RESULTS

A total of 45 subjects (80 eyes) were identified, 42 with primary congenital glaucoma (PCG) and 3 with juvenile open angle glaucoma (JOAG). The mean age for the population was 2.6 years (S.D ± 3.7) and most of the patients were male, with a male-female ratio of 2:1. The majority of patients had bilateral disease (n = 35, 77.8%) with the commonest presenting complaint being a whitish appearance of the eye (57.5%). The eyes studied had a mean IOP of 30.1 mmHg (CI 27.4-32.9), a mean horizontal corneal diameter (HCD) of 13.6 mm (CI 13.1-14.2) and a mean cup-disc-ratio `(CDR) of 0.73 (CI 0.66-0.79). In addition, 62 eyes (77.5%) had corneal haze on examination. Most patients (n = 59, 73.8%) underwent a combined trabeculotomy - trabeculectomy surgery within the study period. The median presenting IOP was significantly higher with JOAG compared to PCG (P = 0.02).

CONCLUSION

PCG was the most common primary childhood glaucoma at Queen Elizabeth Central Hospital and most patients presented with bilateral eye involvement. Most of the eyes had corneal haze and JOAG was associated with a higher presenting IOP compared to PCG. Further studies to investigate the outcomes of combined trabeculotomy - trabeculectomy surgery in primary childhood glaucoma in Malawi are recommended.

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.

Ophthalmic complications in retinopathy of prematurity in the first decade of life in Korea using the national health insurance database

The aim of this study is to investigate the epidemiology of ophthalmic complications of retinopathy of prematurity (ROP) after preterm birth using population-based database in South Korea. Using the National Health Insurance database, ophthalmic complications among premature infants born in 2007-2008 during their 10-year follow-up period were identified. Annual cumulative incidence rate and period prevalence of complications at each age were analyzed among those with ROP and those who underwent treatment for ROP (tROP). The hazard ratios (HRs) according to the presence of ROP and treatment for ROP were also analyzed. We identified 18,256 premature infants, 6995 of whom had ROP. The prevalence at 10th year for overall ophthalmic complications was 11.1% and 35.9% among ROP and tROP, respectively. Strabismus, amblyopia, and glaucoma were the three most common complications. The presence of ROP was associated with higher risk of complications (HR 1.53, 95%CI 1.44-1.61) among premature infants, and the presence of treatment for ROP was associated with higher risk of complications (HR 4.31, 95%CI 3.74-4.98) among ROP cases. This study reports the nationwide epidemiologic data on ophthalmic complications of ROP during the first decade of life, which will help advance our understandings and establish national strategies in managing ROP.

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.

Multiple XEN Gel Stents for Refractory Pediatric Glaucoma

Although trabeculotomy and goniotomy are currently the mainstay of surgical management for congenital glaucoma, XEN Gel Stent (Allergan) implantation and other microinvasive glaucoma surgery technologies may offer the advantage of having a lower risk of postoperative complications than conventional techniques. A 10-year-old boy presented with aphakic glaucoma in his left eye secondary to previous cataract surgery. Intraocular pressure (IOP) in the left eye at initial presentation was 31 mm Hg with maximal tolerated medical therapy. Surgical history included tube shunt, shunt revision, and subsequent shunt removal. Shunt surgery and revision had been unsuccessful at achieving target IOP. The patient underwent two treatments of micro-pulse transscleral laser therapy that failed to achieve target IOP. At this time, an open conjunctiva ab externo superior XEN Gel Stent (Allergan) was implanted. Within 1 month of surgery, conjunctival dehiscence and contraction occurred. Following this, ab interno inferonasal air-ophthalmic viscosurgical device XEN Gel Stent implantation was performed. In the 6 months following the second XEN Gel Stent, IOP in the left eye was stable at 6 to 8 mm Hg. This report describes the effective use of a XEN Gel Stent implant in the management of congenital glaucoma, while also highlighting a complication. Further studies are required to determine the comparative outcomes of this technique with conventional surgical management. [J Pediatr Ophthalmol Strabismus. 2022;59(1):e11-e14.].

Prevalence of MYOC risk variants for glaucoma in different populations

PURPOSE

To assess the clinical relevance of myocilin (MYOC) gene variants as risk factors for glaucoma in literature and to estimate their prevalence in different populations.

METHODS

We reviewed the literature for published MYOC variants in glaucoma patients and estimated their prevalence in general population using gnomAD and BRAVO databases. We used several bioinformatics tools and the criteria of the American College of Medical Genetics and Genomics (ACMG) to assess the pathogenicity of the variants. We evaluated the carrier frequency of the variants in gnomAD, including its subpopulations.

RESULTS

We found 13 missense and 5 loss-of-function (LOF) reported variants in MYOC that were both probable pathogenic or risk variants and listed in gnomAD. Six likely pathogenic missense variants were p.(Cys25Arg), p.(Gln48His), p.(Gly326Ser), p.(Thr353Ile), p.(Thr377Met) and p.(Gly399Val). They were most prevalent in East and South Asia (frequency, 0.92% and 0.81%, respectively). The most common missense variants were p.(Thr353Ile) (0.91% in East Asia) and p.(Gln48His) (0.79% in South Asia). Five LOF variants were p.(Arg46Ter), p.(Arg91Ter), p.(Arg272Ter), p.(Gln368Ter) and p.(Tyr453MetfsTer11). We considered these glaucoma risk variants. They were most prevalent in the East Asian and the Finnish population (0.93% and 0.33%, respectively).

CONCLUSION

Pathogenic MYOC variants appear to be population-associated. Our results highlight allelic heterogeneity of MYOC variants in open-angle glaucoma. Many of the probable pathogenic variants are over-represented in some of the populations causing doubt of their status as monogenic disease-causing variants.

Glaucoma Syndromes: Insights into Glaucoma Genetics and Pathogenesis from Monogenic Syndromic Disorders

Monogenic syndromic disorders frequently feature ocular manifestations, one of which is glaucoma. In many cases, glaucoma in children may go undetected, especially in those that have other severe systemic conditions that affect other parts of the eye and the body. Similarly, glaucoma may be the first presenting sign of a systemic syndrome. Awareness of syndromes associated with glaucoma is thus critical both for medical geneticists and ophthalmologists. In this review, we highlight six categories of disorders that feature glaucoma and other ocular or systemic manifestations: anterior segment dysgenesis syndromes, aniridia, metabolic disorders, collagen/vascular disorders, immunogenetic disorders, and nanophthalmos. The genetics, ocular and systemic features, and current and future treatment strategies are discussed. Findings from rare diseases also uncover important genes and pathways that may be involved in more common forms of glaucoma, and potential novel therapeutic strategies to target these pathways.

Childhood Glaucoma Profile in a Brazilian Tertiary Care Center Using Childhood Glaucoma Research Network Classification

PURPOSE

To apply the Childhood Glaucoma Research Network (CGRN) classification in children from a pediatric glaucoma outpatient clinic in a tertiary Brazilian care center to better understand the prevalence and the demographic and clinical characteristics of each subtype of childhood glaucoma.

METHODS

This was a retrospective study in which medical records were collected from patients assisted in childhood glaucoma's clinic at the Department of Ophthalmology and Visual Sciences, Federal University of São Paulo from January 2010 to January 2018. The initial diagnosis and new diagnosis according to CGRN classification were collected. In addition, age, sex, visual acuity, and affected eye were recorded.

RESULTS

From 624 ophthalmic consultations in the clinic, 496 had confirmed diagnosis of childhood glaucoma or glaucoma suspect. Mean age at diagnosis of the entire group was 3.62±4.23 years (range, 0 to 17 y). Two hundred eight-one (56.65%) of all patients were male and 349 patients (81.16%) had bilateral disease. All patients fit 1 of the 7 categories of the new classification. In all, 48.59% of diagnoses were changed upon reclassification. According to CGRN classification, 220 patients (44.35%) had primary glaucoma (juvenile open-angle glaucoma and primary congenital glaucoma); 210 patients (42.34%) had secondary glaucoma (glaucoma associated with nonacquired ocular anomalies; glaucoma associated with nonacquired systemic disease or syndrome; glaucoma associated with acquired condition; and glaucoma following cataract surgery); and 66 patients (13.31%) were glaucoma suspect. The most common diagnoses found were primary congenital glaucoma with 218 cases (43.95%) and the last common diagnosis was juvenile open-angle glaucoma with 2 cases (0.40%).

CONCLUSION

The CGRN classification provides a useful method for classifying childhood glaucoma. A single, standardized classification system is important for diagnosis and management these patients, in addition, may improve physician communication, and future research.

Early Experience With Ahmed Clear Path Glaucoma Drainage Device in Childhood Glaucoma

PURPOSE

The aim was to evaluate the short-term outcomes of Ahmed clear path (ACP) valveless glaucoma drainage device in childhood glaucoma.

METHODS

Retrospective chart review of all patients 16 years or below with childhood glaucoma who had ACP implantation at Boston Children's Hospital from December 2019 to June 2020 with at least 6 months follow-up period.

RESULTS

The study included 7 eyes of 5 patients implanted by a single surgeon. The median follow-up was 12 months. The mean intraocular pressure (IOP) was reduced from 36±3.5 mm Hg on a mean of 2.7±0.6 glaucoma medications preoperatively to a mean IOP of 12.4±2.8 mm Hg (P<0.001) on a mean of 0.7±0.8 medications postoperatively at final follow-up (P=0.0009). Complete success was achieved in 4 eyes while qualified success was achieved in 3 eyes.

CONCLUSION

The ACP glaucoma drainage device provided good short-term IOP control and technical advantages for implantation for pediatric eyes were observed.

Incidence, Comorbidity, and Mortality of Primary Congenital Glaucoma in Korea from 2001 to 2015: A Nationwide Population-based Study

Purpose

To report incidence rates of primary congenital glaucoma in Korea and evaluate comorbidity and mortality from 2001 to 2015.

Methods

This study is a nationwide and retrospective population-based study. We used claims data from the Korean National Health Insurance Service database between 2001 and 2015. Data for all patients diagnosed with primary congenital glaucoma were retrieved using the Korean Electronic Data Interchange and Korean Standard Classification of Diseases-6 codes.

Results

The number of patients with primary congenital glaucoma between 2001 and 2015 was 776, of which 437 were male (56.31%) and 339 were female (43.69%). The annual prevalence demonstrated a general decreasing trend since 2011, but this was not significant. Over the total survey period, the incidence rate was 11.0 per 100,000 births, with 12.0 cases among males and 10.0 among females. The incidence according to age was 518 (68.78%) patients at age 0, 112 (13.66%) at 1 year, 70 (8.39%) at 2 years, and 76 (9.17%) at 3 years. Of the 776 patients diagnosed with primary congenital glaucoma in the study population, 27 died. The observed mortality per 100,000 people is about 10 times higher than that of the general infant and child population under the age of 4 years. Visual impairment was the most common accompanying disability, followed by brain lesion.

Conclusions

Our study's estimates of the nationwide population-based incidence of primary congenital glaucoma in a Korean population will expand our understanding of the disease and allow healthcare systems to plan for primary congenital glaucoma.

A Service Coverage Analysis of Primary Congenital Glaucoma Care Across the United States

PURPOSE

To assess the number of infants at risk of delayed primary congenital glaucoma (PCG) evaluation due to long travel times to specialists.

DESIGN

Cross-sectional geospatial service coverage analysis.

METHODS

All American Glaucoma Society (AGS) and American Association for Pediatric Ophthalmology and Strabismus (AAPOS) provider locations were geocoded using each organization's member directory. Sixty-minute drive time regions to providers were generated using ArcGIS Pro (Esri). The geographic intersection of AGS and AAPOS service areas was computed because patients typically require visits to both types of specialists. American Community Survey data were then overlaid to estimate the number of infants within and beyond the AGS/AAPOS service areas.

RESULTS

One thousand twenty-nine AGS and 1,040 AAPOS provider locations were geocoded. The analysis yielded 944,047 infants age 0-1 year (23.6%) who live beyond the AGS/AAPOS service areas. Therefore, approximately 14-94 new PCG cases/year may be at risk of delayed diagnosis as a result of living in a potential service desert. Compared with children living within the AGS/AAPOS service areas, children aged <6 years in these potential service deserts were more likely to live in households earning below the US federal poverty level, lack health insurance, and live in a single-parent home. These communities are disproportionately likely to experience other rural health disparities and are more prevalent across the Great Plains.

CONCLUSION

Service coverage analysis is a useful tool for identifying underserved regions for PCG referrals and evaluation. These data may assist in targeting screening programs in low access areas for pediatric glaucoma care.

Falsely high rebound tonometry

BACKGROUND

Rebound tonometry (RBT) can be used to measure intraocular pressure (IOP) in children unable to tolerate measurement with applanation tonometry (AT) while awake. RBT readings are often 2-3 mm Hg higher than AT. We have experienced children with a repeatedly higher difference between RBT and AT measurements (≥6 mm Hg). The purpose of this study was to identify demographic and ocular characteristics that contribute to this artifactuous discrepancy.

METHODS

The medical records of pediatric patients with IOP measured by RBT followed by AT within 6 months without intervening surgery or change in medical management were retrospectively reviewed to identify potential predictors of greater difference between RBT and AT readings.

RESULTS

A total of 123 eyes of 65 patients were included. In patients with normal IOP (≤24 mm Hg), 18.5% had a ≥6 mm Hg difference between RBT and AT, with RBT being higher. Risk factors for this included presence of persistent fetal vasculature (PFV), increased corneal diameter, and higher initial RBT value (>20). In patients with elevated IOP (>24 mm Hg), 77% had ≥6 mm Hg difference, with larger corneal diameter being the sole predictor. Eyes were less likely to have significant RBT-AT difference if there was corneal opacity or iris abnormalities in eyes with elevated IOP (>24 mm Hg).

CONCLUSIONS

In some children, RBT readings are ≥ 6 mm Hg higher than AT readings. Caution should be taken when interpreting RBT values in patients with PFV, increased corneal diameter, and higher initial RBT values.