Prognosis and Follow-Up
The prognosis for control of IOP and preservation of vision is poor for patients with PCG who present at birth; at least half of these patients become legally blind. If the horizontal diameter of the cornea 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 from corneal scarring. Careful treatment of refractive errors and amblyopia is necessary 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 in children 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, a young child who has an IOP of about 20 mm Hg but shows evidence of clinical improvement may be observed 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.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.