Glaucoma is a condition that results in damage to the optic nerve (the nerve that carries messages from the eye to the brain) where it leaves the eye. This type of damage affects the quality of vision.
This type of damage seen in children is almost always accompanied by high intraocular pressure. Increased intraocular pressure may be due to inflammation or other
reasons affecting the eye. This type of glaucoma is considered Secondary Glaucoma. Glaucoma that develops in early childhood is called Congenital or Developmental Glaucoma. We encounter this type of Glaucoma with a frequency of one in 10,000 live births.
What factors control intraocular pressure?
The eye resembles a ball. The pump function of this ball is performed by the fluid (aqueous humor) that fills the inside of the eye and is formed by the part called the ciliary body. This object is ring-shaped and is located right next to the iris, which is the colored part of the eye. The iris divides the eye into two parts; anterior chamber and posterior chamber. The aqueous humor progresses from the gap in the center of the iris (pupil, pupil) to the front of the eye.
The transparent tissue that covers the front of the eye like a dome is called the horn. The drainage (filtration) system of the eye is located at the root of the cornea. The aqueous humor passes through this drainage system (trabecular network) to the collecting canal (Schlem canal) and from there to the blood vessels outside the eye. The resistance that will occur in this drainage system will cause the intraocular pressure to increase. The reason for increased intraocular pressure in children is mostly due to the improper functioning of this drainage system. This blockage (resistance) may be due to many reasons.
Glaucoma symptoms in babies and children
- Big eye
- Light sensitivity
- Blurry Cornea
- Watering eyes
- Low vision and trembling eyes (nystagmus)
- Strabismus (strabismus)
- Big eye
In babies, the front layer of the eye (sclera) is more flexible and
softer than in adults.
Therefore, when intraocular pressure increases, the eye becomes a It will expand and grow like a balloon. For this reason, Congenital glaucoma was formerly called buphthalmus (ox eye). This symptom is one of the best signs of high intraocular pressure in babies.
This is when the intraocular pressure is within the normal range. Although it does not cause the eye to regress (to normal size), it will stop its progression.
Light sensitivity
Babies with high intraocular pressure are often very sensitive to light. There are many reasons for this. The horn, which is the front window of the eye, may cause discomfort because it is edematous and cloudy. When the cornea is not completely transparent, it reflects the rays passing through it and creates shine. In such cases, the use of dark glasses in bright environments is not very harmful. This sensitivity will disappear over time when the intraocular pressure is reduced to normal limits.
Cloudy Cornea
There are small cells on the inner surface of the cornea that remove aqueous humor from the cornea and thus maintain the transparency of the cornea. When intraocular pressure suddenly rises, the humor leaks into the cornea through the aqueous cells, making it edematous and cloudy. If there are small scars on the surface of the horn, they may also create a blurry image. When the intraocular pressure drops to normal limits, the blurriness subsides over time, but this may sometimes take a few months or more.
Eye watering
Watering is a natural response to irritation. If there are light reflections and corneal edema due to high intraocular pressure, watering will develop as a natural reflex. When the pressure is reduced to normal limits, watering will disappear.
Low vision and trembling eyes (nystagmus)
Horn blurring or optic nerve (the nerve that carries the visual message from the eye to the brain) due to high intraocular pressure. Poor vision and eye tremor may develop due to its damage.
Strabismus
In some babies, a misalignment may develop in the low vision eye, this shift may be towards the root of the nose (inwards) or outwards.
Why should we consult a genetic counselor?
Not all types of Developmental Glaucoma are inherited. However, you can get information about the problems you may encounter and the risks of the disease from the genetic counselor. This information is also important for the child's future.
Which type of Glaucoma can develop in children?
There are various types of Glaucoma that can affect children and babies.
Aniridi
- Sturge Weber Syndrome
- Glaucoma developing after cataract surgery
- Inflammation
- Primary Congenital Glaucoma
- Axenfeld or Reiger Anomaly
- Peter's Anomaly
Aniridia
Glaucoma in children may sometimes be due to the absence or very small size of the iris.
Sturge Weber Syndrome
Glaucoma can also be seen in Sturge Weber Syndrome; In these patients, birthmarks and vascular formations are seen on the forehead and face, which are specific to the disease, also known as port wine stains. Children with this type of appearance should be monitored for glaucoma and treated when necessary.
Glaucoma that develops after cataract surgery
Glaucoma in children can also develop following cataract surgery. If the lens is dense, this condition is called cataract and must be treated surgically. Postoperative glaucoma may develop due to surgery or medications administered.
Treatment is usually glaucoma surgery.
Inflammation
There is a possibility of developing glaucoma after inflammation. After arthritis that develops in childhood, the trabecular network may become blocked with inflammatory cells and thus glaucoma may develop. Cortisone drugs used in the treatment of these diseases can also increase intraocular pressure.
Primary Congenital Glaucoma
It constitutes the majority of childhood glaucomas. In such patients, the trabecular network, which is the drainage system of the eye, does not develop normally and as a result, aqueous humor outflow becomes difficult and intraocular pressure increases. We generally think that this type of disease is genetic, but since the type of inheritance is recessive, there may be no family history.
Axenfeld or Reiger Anomaly
It bears the name of the physician who first described this disease. In this type of glaucoma, there is a congenital anomaly in the trabecular network, iris or cornea. Apart from this, there may be anomalies in the teeth, face, ears and other limbs. Glaucoma may not develop in all patients with Axenfeld or Reiger Syndrome, but patients with glaucoma require close follow-up.
Peter Anomaly
This is a lens anomaly. Sometimes the lens has developed to contact the cornea
Follow-up and treatment scheme of the child with glaucoma
Examination under anesthesia< br /> All babies and children should be examined under anesthesia from the beginning. If intraocular pressure is found to be high, surgery must be performed. It is necessary to inform the family that another examination under anesthesia may be required each time. It is necessary to talk to the child over the age of 5 and persuade him to perform an examination without anesthesia, but this may not always be possible.
Surgical techniques that can be applied
Goniotomy
It is usually the first preferred surgical method. With the help of a very thin blade, an incision is made on the filtration system by entering the anterior chamber. This process is done to open developmentally closed channels. Special lenses called gonioscopes are used to see inside the eye during surgery. In order to obtain a quality image, the epithelium layer, which is the front surface of the cornea, can sometimes be peeled off. This tissue grows back spontaneously within 1 or 2 days. During this time, the child may be uncomfortable and sleepless. In this case, painkillers syrups can be used. Most of the time, this procedure is sufficient to reduce intraocular pressure, but in some cases the procedure may need to be repeated.
When it is impossible to intervene in the channels from the inside again, other surgical methods can be applied to create new drainage channels (trabeculectomy).
Trabeculotomy >
In this surgical method, Schlemm's canal, which is an important collector canal, is entered with the help of a very thin instrument (probe). After advancing through the canal with the help of this tool, the anterior chamber is entered and a new drainage route is created. This method is preferred in some types of glaucoma or when there is no clear enough cornea for goniotomy. This method can be done alone or combined with Trabeculectomy (surgery to drain the eye fluid under the conjunctiva through an artificial canal opened surgically without using the eye canals)
Trabeculectomy
The strong front wall of the eye is the sclera and the covering it There is conjunctiva tissue. With this method, new drainage channels are created within the eye. Usually, a flap (tissue flap) is removed surgically close to the area under the upper lid. This flap is then stitched back into place with thin threads and covered with the conjunctiva, the front layer of the eye. The intraocular fluid flows under the conjunctiva through this channel and from there it flows through the blood vessels. It is removed with . After surgery, a small swelling may appear just under the upper lid (bleb). This condition occurs when intraocular fluid accumulates under the conjunctiva.
Tube implantation
In some children, specially designed tubes are used to remove intraocular fluid. This method is preferred in cases where other methods, such as the flap created in trabeculectomy, are insufficient. Sometimes, it may be necessary to inject gas or gel into the eye to control the intraocular pressure, which remains very low 1 or 2 weeks after surgery. As children grow older, tube replacement is not required; in some cases, the tube remains in the eye for up to 25 years.
What is the success rate of surgical approaches?
The average 5-year success rate of surgeries is 75%. In children whose intraocular pressure rises again, additional drug therapy or reoperation may be required to control the intraocular pressure.
Side effects and complications
Cataracts may develop after glaucoma surgery. Cataract is a condition in which the intraocular lens becomes cloudy. In these cases, blurred vision and foggy vision occur. The treatment is surgery; the lens that has lost its transparency is removed and an artificial lens is placed in its place. Long-term complications include infection.
How will my child's vision be after the treatment?
It is very difficult to say anything definitive about this, especially if the child is very young. Many children who were treated for glaucoma in childhood have excellent vision as adults. Once the intraocular pressure is under control, good results can be achieved with both glasses and occlusion treatment. As the child grows older, something more precise can be said about his final vision. An important part of the success of the treatment is constant repeated checks. These babies should be followed throughout their lives.
Closure treatment
If the glaucoma is especially in one eye, the patient's vision may remain low even if the intraocular pressure is brought to normal levels after the surgical procedures. Special exercises are needed to improve his vision. Closing the healthy eye and operating the low vision eye are among the primary methods, and are as important as the treatment of glaucoma. Laziness is low (weak)
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