α-Adrenergic agonists

α-Adrenergic agonists lower IOP by both diminishing aqueous production and increasing uveoscleral outflow. The α2-adrenergic agonist brimonidine crosses the blood–brain barrier and therefore has significant effects on the central nervous system. Infants and young children are particularly susceptible to brimonidine’s adverse effects, including apnea, hypotension, bradycardia, hypotonia, hypothermia, and somnolence. α2-Adrenergic agonists are contraindicated in children younger than 3 years. There is some debate about the age at which children can safely use brimonidine. In general, this agent should be used with caution in children between the ages of 3 and 10. The lowest dose should be used and punctal occlusion employed to minimize systemic absorption.

The α-agonist apraclonidine is better tolerated systemically in children, but the risk of follicular conjunctivitis increases with long-term use. Apraclonidine acts as a vasoconstrictor and can be used to minimize bleeding during intraocular surgery.

Prostaglandin analogues

Prostaglandin analogues lower IOP by increasing uveoscleral outflow. They have minimal systemic side effects in children and have been shown to effectively lower IOP in JOAG. They can exacerbate uveitis in postoperative glaucoma patients and should be avoided with uncontrolled uveitis. Their once-daily dosing is helpful for minimizing the stress involved in administering eyedrops to children. Adverse effects include conjunctival hyperemia, hypertrichiasis, periocular pigmentation (reversible), and darkening of irides (permanent) except in blue-eyed patients.

Cholinergic agonists

Cholinergic agonists (miotics) lower IOP by increasing aqueous outflow through the trabecular meshwork. With the newer medications that are available, these agents are rarely used on a long-term basis, but they have a role intraoperatively by inducing miosis, which facilitates angle surgery.

Prognosis and Follow-Up

The long-term prognosis for pediatric glaucoma patients has greatly improved with the development of effective surgical techniques. This is particularly true for PCG patients who are asymptomatic at birth and who present with onset of symptoms between 3 and 12 months of age; IOP can be controlled with angle surgery in approximately 80% of these children. When symptoms are present at birth or when the disease is diagnosed after 12 months of age, the outlook for surgical control of IOP is more guarded.

Pediatric patients whose IOP is controlled by surgery may still experience morbidities related to the previous IOP elevation. These can cause serious lifelong visual compromise and include amblyopia, corneal scarring, strabismus, anisometropia, cataract, lens subluxation, susceptibility to trauma (as occurs in an eye with a thinned sclera), and recurrent glaucoma in the affected or unaffected eye. Clinicians should address these conditions and be prepared to coordinate care with other specialists as needed.

Amblyopia is a common cause of visual compromise, particularly in patients with unilateral glaucoma, corneal opacification, and/or anisometropia. The clinician should aggressively treat amblyopia, addressing conditions contributing to its development, such as refractive error, strabismus, cataract, and corneal clouding. Elevated IOP can lead to buphthalmos in patients with PCG and to progressive myopia and anisometropia in patients with juvenile glaucoma. Haab striae and corneal scarring may cause astigmatism. Refractive errors should be corrected with spectacles, and

use of protective eyewear should be encouraged.

Strabismus may result from glaucoma drainage devices or amblyopia. When performing surgery to correct strabismus, the surgeon should try to minimize conjunctival scarring in anticipation of future glaucoma surgeries and should be cognizant of the sites of prior trabeculectomies and glaucoma drainage device implants.

All cases of childhood glaucoma require lifelong follow-up to monitor IOP and to observe for any complications of prior surgeries and any secondary vision-threatening issues. As relapses of glaucoma may occur even years later, care should be coordinated between glaucoma specialists and pediatric specialists. Educating parents about the need for lifelong care of the child with glaucoma and involving these children in their own care enhance the long-term management of this challenging disease.

Barkan O. Goniotomy for the relief of congenital glaucoma. Br J Ophthalmol. 1948;32(9):701–728.

Beck AD, Lynch MG. 360-degree trabeculotomy for primary congenital glaucoma. Arch Ophthalmol. 1995;113(9):1200–1202. Bothun ED, Guo Y, Christiansen SP, et al. Outcome of angle surgery in children with aphakic glaucoma. J AAPOS. 2010;14(3):235–

239. Epub 2010 Mar 11.

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

Moore W, Nischal KK. Pharmacologic management of glaucoma in childhood. Paediatr Drugs. 2007;9(2):71–79.

Neely DE, Plager DA. Endocyclophotocoagulation for management of difficult pediatric glaucomas. J AAPOS. 2001;5(4):221– 229.

O’Malley Schotthoefer E, Yanovitch TL, Freedman SF. Aqueous drainage device surgery in refractory pediatric glaucomas: I. Long-term outcomes. J AAPOS. 2008;12(1):33–39.

O’Malley Schotthoefer E, Yanovitch TL, Freedman SF. Aqueous drainage device surgery in refractory pediatric glaucoma: II. Ocular motility consequences. J AAPOS. 2008;12(1):40–45.

Sarkisian SR Jr. An illuminated microcatheter for 360-degree trabeculectomy in congenital glaucoma: a retrospective case series. J AAPOS. 2010;14(5):412–416.

Wright TM, Freedman SF. Exposure to topical apraclonidine in children with glaucoma. J Glaucoma. 2009;18(5):395–398.