Transcript Treatment-of-pediatric

IN THE NAME OF GOD
TREATMENT OF PEDIATRIC
GLAUCOMA
S.M SHAHSHAHAN M.D
FEB 2013
MEDICAL MANAGEMENT
• FOR JUVENILE AND APHAKIC OPEN- ANGLE
GLAUCOMA
• FOR MOST CASES OF SECONDARY OPENANGLE GLAUCOMA
• BEFORE AND AFTER GLAUCOMA SURGERIES
• FOR MOST CHILDHOOD AND INFANTILE
GLAUCOMA, ANGLE SURGERY OFFERS THE
BEST INITIAL TREATMENT OPTION, WITH
SUCCESS RATE RANGING 75-90%.
POOR VISUAL AUTCOMES
ARE ASSOCIATED WITH
• HIGH MYOPIA
• AXIAL STREA (AMBLYOPIA)
• CATARACT
• PROGRESSIVE OPTIC DISC DAMAGE
• CORNEAL DECOMPENSATION
NEWBORN GLAUCOMA TENDS TO HAVE WORSE
SURGICAL OUTCOMES .
TRABECULATOMY
• DESCRIBED IN 1960 BY SMITH WHO USES A NYLON
SUTURE TO RAPTURE THE TM .
• BURIAN ACHIEVED THE SAME WITH A SPECIALLY
DESIGNED INSTRUMENT CALLED A TRABECULATOME .
PREOPERATIVE CONSIDERATION
• CORNEAL TRANSPARENCY
• SURGEON’S EXPERIENCE
• MEDICATIONS FOR MAXIMALLY REDUCTION THE
IOP AND SO REDUCTION OF CORNEAL EDEMA
• PILOCARPIN- MIOCHOL
TO PERFORMING GONIOTOMY
SUCCESSFULLY
• ADEQUATE ACCESS
• VISUALIZATION
OF
THE
DEBRIDMENT)
• MAINTENANCE OF THE AC
ANGLE
(EPITHELIAL
TRABECULATOMY
• A FORNIX OR LIMBAL- BASED CONJUNCTIVAL FLAP
• INFERIOR QUADRANTS IS PREFERRED
• A TRABECULECTONY SCLERAL FLAP IS FASHIONED
• A SMALL RADIAL INCISION AT THE LIMBUS NEAR THE GRAY
ZONE (LOCATING THE SCHLEMM’S CANAL)
TRABECULATOMY
HAS
THE
ADDED
ADVANTAGE
(OVER
GONIOTOMY) THAT IS POSSIBLE TO COMBINE IT WITH
TRABECULECTOMY .
COMBINED TRABECULECTOY- TRABECULATOMY WITH MMC
RESULTED IN BETTER IOP CONTROL THAN TRABECULATOMY
ALONE IN MODERATE TO SEVERE FORMS OF THE CONDITION.
DEEP SCLERECTOMY IN PEDIATRIC
GLAUCOMA
• RECENTLY DEEP SCLERECTOMY HAS BEEN PERFORMED IN CONGENITAL
GLAUCOMA CASES IN AN ATTEMPT TO REDUCE COMPLICATIONS .
• IN ONE STUDY PRELIMINARY SUCCESS RATE IN A SMALL SERIES OF DEEP
SCLERECTOMY WAS 75% .
• LUKE ET AL HIGHLIGHT IN THEIR SERIES THE RISK OF DEEP SCLERECTOMY IN
BUPHTHALMIC EYES WITH THIN SCLERA AND OBNORMAL LIMBUS AND
LOCATION OF SCHLEMM’S CANAL.
COMPLICATION OF
GONIOTOMY
BY A SKILLED SURGEON IT HAS MINIMAL
COMPLICATIONS (2% OF CASES)
• IRIDODIALYSIS
• CYCLODIALYSIS
• SERIOUS HYPHEMA
COMPLICATIONS OF TRABECLOTOMY
• ARE SELDOM SERIOUS BUT MAY BE MORE FREQUENT THAN WITH
GONIOTOMY (11%- 39%) BECAUSE PROCEDURE IS PERFORMED WITHOUT
DIRECT VISUALIZATION OF ANGLE .
• STRIPPING OF DESCMETS MEMBRANE
• IRIS PROLAPSE
• IRIDODIALYSIS
• LENS SUBLUXATION
• SIGNIFICANT HYPHEMA
• INADVERTENT BLEB FORMATION
FURTHER SURGICAL OPTIONS IN
CHILDREN
IN SOME AREA OF INDIA AND MIDDLE EAST INITIAL
FAILURE RATES OF ANGLE SURGERY ALONE ARE
REPORTEDLY HIGHER. IN THESE CASES AS WELL AS
SECONDARY GLAUCOMAS (STURG-WEBER- APHAKIA-
ANIRIDIA,…), ALTERNATIVE TREATMENTS SHOULD BE
CONSIDERED.
SURGICAL OPTIONS FOR REFRACTORY
PEDIATRIC GLAUCOMAS
1) GLAUCOMA DRAINAGE DEVICE IMPLANTATION
(PREFERRED)
2) FILTERING SURGERY (LESS DESIRABLE)
3) CYCLODESTRUCTIVE
DESIRABLE)
PROCEDURE
(LEAST
FILTERING IN PEDIATRIC
GLAUCOMA
SIGNIFICANT FRUSTRATIONS:
1) ANATOMIC VARIATIONS IN THE BUPHTHALMIC EYES
2) REDUCED SCLERAL RIGIDITY LEADING TO VITREOUS
PROLAPSE
3) INCREASED HEALING RESPONSE
4) THE EXAMINATION MAY BE VERY LIMITED IN THE CLINIC
(PRESENTATION WITH ENDOPHTHALMITIS)
COMBINED TRABECULATOMYTRABECULECTOMY
• THIS PROCEDURE HAS BEE TOUTED AS A PRIMARY TREATMENT
FOR PEDIATRIC GLAUCOMA IN INDIA AND SAUDI-ARABIA WHERE
SUCCESS WITH PRIMARY TRABECULATOMY MAY BE LOWER.
(SUCCESS WAS 87% WITH AN AVERAGE OF 1YEAR OF FOLLOWUP)
• TRABECULECTOMY HAS POOR RESULTS IN INFANTS AND TUBE
SHUNTS ARE MORE SUCCESSFUL THAN TRABECULETOMIY. (72%
V/S 24%)
• TRABECULECTOMY WITH MMC IS AN EXCELLENT OPTION FOR
PHAKIC PATIENTS OVER 2 YEARS OF AGE.
• AGE LESS THAN 1 YEAR , APHAKIA,AND SECONDARY
GLAUCOMAS ARE SIGNIFICANT RISK FACTORS FOR FAILURE.
A LIMBUS BASED V/S FORNIXED BASED PERITOMY IN
TRABECULECTOMY WITH MMC IN OLDER CHILDREN
THERE IS A SIGNIFICANTLY GREATER INCIDENCE OF CYSTIC BLEBS IN THE
LIMBUS- BASED GROUP.
 THE IOP TENDED TO BE HIGHER IN THE FORNIXED-BASED GROUP
 AN EQUAL NUMBER OF PATIENTS FROM EACH GROUP REQUIRED FURTHER
INTERVENTION FOR INCREASED IOP (20%)
 20% OF LIMBUS- BASED TRABECULECTOMIES DEVELOPED BLED- RELATED
INFECTIONS (COMPARED WITH NON OF THE FORNITED- BASED)
trabeculectomy in pediatric glancomas
 Avoid long duration and high concentration of mitomycin C (2-
4 min of 0.2 mg/cc)
 Avoid tenon’s capsule resection, which can lead to thin,
avascular blebs.
 Consider a fornixed- based surgical approach and a broad area
of MMC application
 Surgically revise thin, leaky filtering blebs
CYCLODESTRUCTIVE PROCEDURES
• THE INITIAL CYCLODETRUCTIVE PROCEDURE WAS CRYOTHERAPY. IT WAS
INTIMATELY LINKED WITH SEVERE INFLAMMATION, PAIN, RETINAL
DETACHMENT, LOSS OF VISION AND PHTHISIS.
• THIS PROCEDURE LATER EVOLVED INTO TRANSSCLERAL PHOTOCOAGULATION,
WHICH WAS FAR BETTER TOLERATED WITH FEWER DEVASTATING
COMPLICATIONS.
• MOST
RECENTLY
ATTENTION
HAS
BEEN
GIVEN
TO
ENDOCYCLOPHOTOCAGULATION, WHERE THE CILIARY PROCESSES ARE
ABLATED UNDER DIRECT VISUALIZATON (BUPHTHALMIC EYES HAVE
DISTORTED ANATOMY)
ENDOSCOPIC DIODE
CYCLOPHOTOCOAGULATION
(IN ONE STUDY ON 36 PEDIATRIC GLAUCOMA
EYES)
• ONLY 34% OF EYES WERE SUCCESSFUL AFTER ONE TREATMENT .
• SUCCESS RATE INCREASED SLIGHTLY TO 43% AFTER REPEAT PROCEDURE .
• INFLAMMATION WAS APPARENTLY MILD AND NO CATARACTS DEVELOPED IN
THE PHAKIC EYES .
• TWO PATIENTS DEVELOPED EXTENSIVE RETINAL DETACHMENT AND ONE
PATIENT LOST VISION DUE TO GLAUCOMA AND ONE PATIENT DEVELOPED
CHRONIC HYPOTONIA .
GLAUCOMA MEDICATIONS IN PEDIATRIC
GLAUCOMA
PACKAGE INSERTS ON TOPICAL MEDICATIONS WORN THAT “SAFETY AND
EFFICACY HAS NOT BEEN ESTABLISHED IN CHILDREN” DESPITE THIS FACT, MOST
TOPICAL DROPS ARE USED IN CHILDREN AND ARE SAFE.
CHILDREN ARE AT GREATER RISK FOR SYSTEMIC SIDE EFFECTS BECAUSE; 1DOSING IS NOT WEIGHT-ADJUSTED DIFFERENTLY.
2- CHILDREN MAY METABOLIZED MEDICATIONS DIFFERENTLY.
3- THE BLOOD VOLUME IS SIGNIFICANTLY SMALLER THAN OF AND ADULT.
WHICH MEDICATIONS CAN BE USED AS FIRST
LINE AGENTS IN CHILDREN?
.BETABLOCKERS; (BETAXOLOL 0.25% OR TIMOLOL 0.25% BD)
.TOPICAL CAIS; 2-3 TIMES DAILY(AT THE COMMERCIALLY
AVAILABLE CONCENTRATIONS ).
WHAT ARE THE SIDE EFFECTS OF BETA BLOCKERS
IN THE PEDIATRIC GROUP?
•RESPIRATORY DYSTRESS (COUGHING AS OPPOSED TO
WHEEZING IN ADULTS)
•BRADYCARDIA
•MASKED HYPOGLYCEMIA
•LOCAL SIDE EFFECTS
SMALL INFANTS AND PREMATURES ARE PARTICULARLY
CAIS IN THE PEDIATRIC GROUP
TOPICAL TREATMENT IS WELL TOLERATED AND MAY HAVE A
GREATER IOP LOWERING EFFECT THAN SEEN IN ADULT.
SYSTEMIC THERAPY PRODUCES A GREAT IOP REDUCTION (10-20
MG/KG/D- MAXIMUM 750 MG/ D) FOR CHILDREN AGED 1 MONTH
OR MORE)
IT IS GENERALLY USES AS A LAST CHOICE
CAN TOPICAL ALPHA-AGONIST BE USED IN
CHILDREN?
• BRIMONIDIN SHOULD NOT BE USED IN INFANTS YOUNGER THAN 2 YEARS AND
SHOULD BE USED WITH CAUTION IN CHILDREN YOUNGER THAN 6 YEARS (A
WEIGHT OF AT LEAST 18-20 KG)
• MOST COMMON SIDE EFFECT IS SOMNOLENCE AND DECREASED ALERTNESS
(50%- 83%)
• IN INFANTS THERE HAVE BEEN REPORTS OF SEVERE RESPIRATORY
DEPRESSION, HYPOTENSION AND CNS CHANGES.
CAN PROSTAGLANDIN- ANALOGUES BE USEFUL IN
CHILDREN ?
• LATANOPROST SEEMS TO WORK BETTER IN OLDER
CHILDREN .
• THE UVEOSCLERAL OUTFLOW PATHWAY
MAY BE
ABNORMAL IN YOUNG CHILDREN WITH GLAUCOMA.
SHOULD PARASYMPATHOMIMETICS BE USED IN PEDIATRIC
GLAUCOMA?
• PARASYMPATHOMIMETICS HAVE NOT BEEN FOUND TO
BE VERY EFFECTIVE IN PCG (DUE TO ANGLE DYSGENESIS)
AND HAVE A PARADOXICAL EFFECT .
• PILOCARPIN IS POORLY TOLERATED IN MANY CHILDREN
DUE TO INDUCED MYOPIA .
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