used with caution in children with coexisting corneal disease.

A combined β-adrenergic antagonist–CAI (dorzolamide/timolol) is available for children who require dual therapy.

Prostaglandin analogues are effective in many pediatric patients. Their low systemic risk and oncedaily dosage are advantageous.

Miotics are rarely used in children; perioperative pilocarpine, however, may facilitate angle surgery. Pilocarpine and echothiophate may be effective for patients with aphakic glaucoma.

The α2-adrenergic agonist apraclonidine may be useful for short-term IOP reduction, but it has a high incidence of tachyphylaxis and allergy in young children. The α2-adrenergic agonist brimonidine effectively reduces IOP in some cases of pediatric glaucoma. Both medications can produce somnolence and respiratory depression in infants and small children. Brimonidine is contraindicated in children younger than 2 years.

Oral medications

CAIs may be used effectively in children, particularly to delay the need for surgery or to clear the cornea before goniotomy. The usefulness of oral CAIs may be limited because of their systemic adverse effects.

Coppens G, Stalmans I, Zeyen T, Casteels I. The safety and efficacy of glaucoma medication in the pediatric population. J Pediatr Ophthalmol Strabismus. 2009;46(1):12–18.

Prognosis and Follow-Up

If PCG presents at birth, the prognosis for IOP control and visual preservation is poor; at least half of these patients become legally blind. If the corneal diameter is greater than 14 mm at diagnosis, the visual prognosis is similarly poor. Up to 90% of cases in the “favorable prognostic group” (onset at 3–12 months of age) can be controlled with angle surgery and medications. The remaining 10%, and many of the remaining cases of primary and secondary glaucomas, often present a lifelong challenge.

Vision loss in childhood glaucoma is multifactorial. It may result from corneal scarring and opacification, optic nerve damage, myopic astigmatism, and associated anisometropic and strabismic amblyopia. Myopia results from axial enlargement of the eye in the setting of high IOP; astigmatism may result from unequal expansion of the anterior segment or corneal scarring. Careful treatment of refractive errors and amblyopia is needed to optimize outcomes.

All cases of childhood glaucoma, as well as suspected but unconfirmed glaucoma, require diligent follow-up. After any surgical intervention or change in medical therapy, control of IOP should be assessed within a few weeks. Examination under sedation or anesthesia is often necessary for accurate assessment. The IOP should be considered not as an isolated finding but rather in conjunction with other measurements obtained from the examination, including refractive error (measured serially), corneal diameter, axial length, and cup–disc ratio. If the IOP is less than 20 mm Hg under anesthesia but clinical evidence shows persistent corneal edema or enlargement, progressive optic nerve cupping, or myopic progression, further intervention should be pursued despite the IOP reading. In contrast, an IOP of about 20 mm Hg in a young child who shows evidence of clinical improvement may be followed carefully.

Long-term follow-up of children with glaucoma is important. Relapse can occur years later, with elevated IOP and subsequent vision loss. Parents, and patients themselves as they become older, should be educated about the need for lifelong monitoring and management.

Walton DS, Katsavounidou G. Newborn primary congenital glaucoma: 2005 update. J Pediatr Ophthalmol Strabismus. 2005;42(6):333–341.