paediatrics glaucoma
TRANSCRIPT
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Evaluation and Diagnosis of
Paediatric Glaucoma
Dr Ashwin Sainani
Consultant Paediatric Ophthalmologist
P.D. Hinduja Hospital
Mumbai
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Paediatric Glaucoma
Paediatric glaucoma represents a rare,complex collection of diversepathophysiological entities. This type of
glaucoma occurs early in life and usuallyresults from structural mal-development ofthe anterior segment and angle structures.
Predominantly sporadic
Inherited in 10%27 %
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Classification of Paediatric
glaucomaPrimary congenital glaucoma
Juvenile glaucoma
Secondary glaucomas:Angle anomaly :
Sturge Weber syndrome
Aniridia
NF
Ant segment anomalies:
Peters anomaly
Axenfeld Riegers syndrome
ICE syndrome
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Secondary glaucomas
Iris Lens diaphragm Abnormalities
Marfans syndrome
Spherophakia
Ectopia Lentis
Homocystinuria
PHPV
ROP
Aphakic glaucoma
Trauma
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Secondary glaucomas
Uveitis
JRA
Sarcoid
Idiopathic
Tumours
Retinoblastoma
Juvenile Xanthogranuloma
Steroid induced
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Diagnosis
Presentations:
ObviousBuphthalmos (
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Differential Diagnosis of cloudy
cornea
Ant segment anomalies
Peters anomaly
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D.D. (contd)
Sclerocornea
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D.D. (contd)
Corneal dermoid
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D.D. (contd)
Congenital infections
Rubella
CMV
Herpes simplex
Influenza
Trauma
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D.D. (contd)
Corneal Dystrophies
PPMD (Post polymorphous dystrophy)
CHED(Congenital Hereditary Endothelial Dystrophy)
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D.D. (contd)
Metabolic Diseases
Gangliosidosis (GM 1)
Mucopolysaccharidosis (Hurlers disease)
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Presentation
ElusiveEpiphora, photophobia, blepharospasm, subtle
corneal enlargement. (bilat)
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Examination
Clinic (>5 yrs)
EUA:
Short inhalational induction with face mask.
Laryngeal mask
Anaesthetic agents:
GasesSevofluraine, halothane
IVPropofol, ketamine, pentothal Muscle Relaxants:
Succinylcholine
Atracurium
vecuronium
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Effects of Anaesthetic agents on IOP
Most anaesthetic agents cause reduction in
IOP.
Ketamine and Succinylcholine cause a rise
in IOP and are thus avoided in an EUA for
glaucoma.
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Evaluation
Corneal Diameter: (Vernier Caliper)
Newborn9.5 to 10.5mm
1 yr11mm
2-3 yrs12mm
(>12 mm in an infant less than a year is
abnormal)
Corneal Haze / Haabs Striae: (Portable Slit
Lamp)
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Corneal Measurements
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Evaluation (contd)
Ant /Post Segment examination: (Portable slit lamp) Cornea
Opacification
Posterior Embryotoxon
Iris
Iris hypoplasia
Iris strands
Correctopia/polycorrea Ectopia uveae
AC
Uveitis
hyphema
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Evaluation (contd)
Lens Cataract
Subluxation
Aphakia
Kerato-lenticular touch
Vitreous
Retrolental fibrosis
Vitritis Retina
Tumours
ROP
Choroidal hemangioma
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Evaluation (contd)
IOP: (Perkins, Tonopen, Shiotz)
Normal IOP in infantsUpper teens
21mm is still a useful upper limit
Not the only critical parameter
Comparison with other eye is useful inunilateral disease.
Measured as early as possible after anaesthesia
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Perkins Tonometry
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Evaluation (contd)
Cup:Disc ratio
Rapid increase in cupping
May show reduction in cupping when IOP is
controlled.
Due to reduction in elastic components notreversal of axonal atrophy
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Evaluation (contd)
Gonioscopy: (Koeppes lens, Barkans lens)
Anterior insertion of iris
Absent scleral spur
Iris processes
Membranous structure covering the meshwork
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Evaluation (contd)
A scanBuphthalmic eye would have an
increased axial length.
B scan / UBM
Hazy cornea
Retinoscopy
Myopic shift
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Diagnosis
Diagnosis is based on the entire clinicalpicture and not on any single parameter:
IOP
Size of corneaCorneal oedema
Cupping
Evidence of trabeculodysgenesisAnterior segment abnormalities
Evidence of progression is highlysignificant.
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Follow up
Frequency depends on the stage ofglaucoma
Includes regular EUAs to monitor effect oftreatment and progression of disease
Management of Amblyopia:Cycloplegic refraction
Patching - The only proof of the presence ofamblyopia is the improvement of vision onpatching.
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