Ординатура / Офтальмология / Английские материалы / The Glaucomas Volume 1 Pediatric Glaucomas_Sampaolesi, Zarate_2009

In the past 4 years we have received 62 pediatric referrals asking for a second opinion: 49 children had a diagnosis of glaucoma, 46 with indications of unilateral or bilateral surgery, but 44 of these patients were normal and the surgical indication had to be cancelled. Forty-eight of the diagnoses were false-positives and the most common cause was megalopapilla. Six of these had been operated unilaterally or bilaterally even though they did not have the disease, and their optic nerves and visual fields were normal. It seems best to give a summary by presenting just four cases, two of Dr. Roberto Sampaolesi’s and two of Dr. Juan Sampaolesi’s.

Clinical History No. 1

Clinical history no. 1 was an 8-year-old boy who was brought by his parents, both of whom are pediatricians, with a diagnosis of congenital glaucoma and an indication to perform surgery immediately on both eyes.

The daily pressure curve (DPC) can be seen in Fig. 27.1. In this case, I had already operated three patients in this family: both the paternal grandparents and the child’s father for open-angle glaucoma. The diagnosis for the child had been bilateral megalopapilla (falsepositive) (Figs. 27.2, 27.3). I performed an iridencleisis on the grandfather in 1971, who maintained 20/20 vision in both eyes and visual field in stage II until 1996 when I operated him for cataract. He kept 20/20 vision and at the last appointment in 1998 I indicated an intraocular lens in the right eye. His visual field was unchanged and his vision was 20/20. I saw him last in 1999. When his wife was 66, I diagnosed her with glaucoma in both eyes with a visual field stage II, which was regulated with medical treatment. I attended their son as well, when he was 43, for open-angle glaucoma at a perimetric stage. The optic nerve was phase III in both eyes with normal visual field, and medical treatment regulated the pressure well.

Clinical History No. 2

Clinical history no. 2 was a 9-year-old boy. In the ophthalmological examination in 2002, his IOP was found to be 22 mmHg in the right eye and 24 mmHg in the left eye. No daily pressure curve was done. He was operated immediately with a diagnosis of congenital glaucoma. Trabeculotomy was performed in the right eye and in the same year trabeculotomy in the left eye. The left eye was reoperated in 2004 with a trabeculectomy. His 4-year-old brother was operated with trabeculotomy. The family history shows only one grandfather with glaucoma.

He was medicated with Alphagan. When the medication was suspended for 1 month, there was no increase of the IOP. The visual fields were repeated three times.

Clinical History No. 3

Case history no. 3 was a female, aged 10 years. She had had a recent diagnosis of congenital glaucoma with an indication for glaucoma surgery in both eyes. She was treated with brimonidine tartrate (bid). Previous studies included CVF: level III (both eyes), HRT: phase III (both eyes). The child’s family history was unknown (the patient had been adopted).

The visual fields that the patient presented, the two top images in Fig. 27.9, are known in campimetry as a clover-leaf visual field, and this is typical in children showing defects that do not really exist.

Five years later HRT and visual field are normal. Her definitive diagnosis is normal, false-positive glaucoma, for asymmetry of the papillary area (Fig. 27.10).

Fig. 27.6 Optic disc right and left eyes: papillary asymmetry

Clinical History No. 4

Case history no. 4 was a young woman aged 18 years who had been diagnosed with normal pressure glaucoma. She was told that the prognosis was poor, as the optical nerve becomes damaged even with normal IOP. She wanted a second opinion. The family history included glaucoma in her mother treated with cortisone. She also had a personal history of migraine and headaches.

Fig. 27.11 Patient’s optic disc

Management: washout 40 days, then perform DPC without treatment

Daily pressure after washout: normal in both eyes