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While glaucoma might be thought of as an age-related disease, it is possible for children to develop glaucoma, even as newborns. No one should have to worry about loss of vision, and it is difficult to imagine the lifelong challenge faced by those who develop glaucoma at an early age.
We need new and better treatments for pediatric glaucoma. Thankfully, progress in micro-invasive techniques aimed at adults with glaucoma gives researchers reason to hope. Even though the overall treatment approach is different for children and adults, innovative surgical techniques being used for adults are now being modified for children.
In many ways, pediatric glaucoma is more challenging to diagnose and treat than adult glaucoma. The most obvious difference is the fact that they’re children—often newborns and toddlers—who do not have the ability to clearly communicate pain or discomfort. Not to mention, they must sit perfectly still or undergo general anesthesia so eye pressure can be measured, and they may need eye drops administered daily, which is difficult for the child as well as the person administering the drops.
Additionally, eye doctors may have a hard time seeing the optic nerve due to a cloudy cornea. This is a common symptom that’s unique to children. In adults, one of the first signs of glaucoma is a change in the optic nerve. In children, the earliest sign is a change in the cornea. The cornea is a protective shield covering the eye that’s normally clear and invisible. When children have glaucoma, it often turns cloudy gray and becomes opaque, which prevents doctors from getting a good look inside the eye.
Perhaps the biggest difference between children and adult is in the preferred type of treatment. Medication to keep eye pressure under control is often the first choice for adults. If that fails, then surgery is considered. For children, surgery is the first-line treatment.1
Surgery achieves the best results in young children with glaucoma. The gold standard for pediatric glaucoma treatment is angle surgery, which can be performed using two different techniques called goniotomy and trabeculotomy. Both surgeries lower eye pressure by creating a small opening in the eye’s malfunctioning drainage system—the trabecular meshwork.
If angle surgery doesn’t lower intraocular pressure sufficiently, another option is the trabeculectomy. This procedure can be tricky to perform on young children, who naturally heal more quickly than adults. This is often an an advantage, but in this case, it’s not. Trabeculectomy helps eye fluid drain through a surgically cut drainage hole in the sclera, or the white part of the eye. This new opening needs to heal slowly so that it holds its shape. Children often heal so quickly that the hole closes up too soon, defeating the purpose of the surgery.
Minimally invasive glaucoma surgery, or MIGS, is a general term for a variety of procedures that use tiny devices to perform surgery through a small incision. In adults, MIGS is currently used to remove tissue that blocks the trabecular meshwork or to implant a stent, but new procedures are on the way, ones that may help children suffering from glaucoma in ways that more traditional surgical treatments cannot.
A procedure called ab interno trabeculotomy is one example of MIGS that may work well for children. Where other surgical techniques cut the conjunctiva (the membrane that covers the front of the eye and eyelids), ab interno trabeculotomy bypasses the conjunctiva by making a small incision in the cornea. Leaving the conjunctiva intact is beneficial if future surgery is needed, something most children with glaucoma will need as they age and their eyes change.
Many other innovative advances are in the works that will help children in the future. New microsurgical devices are being developed that will make it easier to see inside the eye through an opaque cornea or to lower the risk of complications following surgery. Other new pieces of surgical equipment will target different parts of the eye, creating more options for draining fluid and lowering intraocular pressure when angle surgery isn’t an option.2
1 “Pediatric Glaucoma: A Review of the Basics,” April 2014, https://www.reviewofophthalmology.com/article/pediatric-glaucoma-a-review-of-the-basics
2 “MIGS in Kids,” September/October 2016, http://glaucomatoday.com/2016/10/migs-in-kids/
Last reviewed on June 17, 2021