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EW NEWS & OPINION 28 February 2017 by Liz Hillman EyeWorld Staff Writer Dr. Chang said for primary con- genital glaucoma and older children with open-angle glaucoma, he'll per- form either GATT or an ab externo trabeculotomy through a scleral flap. If prior surgery or inflammation has caused angle closure or if the patient has had a failed angle surgery, often he will use a tube shunt. Dr. Panarelli said that while MIGS addressed a big concern in glaucoma for adults, pediatric cases are not as amenable to some of the MIGS procedures due to differences in pathology. "In children, the primary pathology is at the trabecular meshwork, whereas in adults with advanced disease, the downstream collector channels more often con- tribute significantly to the overall resistance to outflow. This is one reason (in addition to safety) why Schlemm's canal-based surgery is the primary treatment of choice for most children with open-angle glau- coma. External drainage procedures are, however, helpful in children when initial angle surgery fails or in patients for whom angle surgery is contraindicated. Though glaucoma drainage implants and trabeculec- tomy have evolved over the years with advances in surgical technique and better ways to modulate wound healing, they are still challenging to perform in the pediatric popula- tion and carry significant risks. As an alternative, could you place an InnFocus MicroShunt [InnFocus, Miami] or XEN Gel Stent [Allergan, Dublin, Ireland]? Are these less risky procedures with the potential to lower IOP sufficiently?" Dr. Panarelli said. "The answer is yes, they could be. These must first be tested exten- sively in adults before we'd consider eye can look bigger than average, he added. In older children, the eye might drift and the child might have poor vision. Pediatric ophthalmol- ogists and optometrists are usually consulted first, then the family is referred to a glaucoma specialist. Such was one referral that Dr. Panarelli received in 2016. The mother of a then 1-month-old noticed her child squinting while in the sun and rubbing her eyes. She saw her infant was no longer reaching for toys or doing things she had before. "Clearly, there was something wrong with her vision," Dr. Panarelli said. Once he confirmed that the infant had congenital glaucoma, Dr. Panarelli performed a 360-degree trabeculotomy using the iTrack Microcatheter (Ellex, Adelaide, Australia). Dr. Panarelli called this device "a significant advance that has allowed traditional angle surgery (trabeculectomy) to be performed in a more complete and elegant fashion." "The major advantages to using the catheter are that it helps to pre- cisely localize Schlemm's canal and the trabecular meshwork, and we are able to treat the entire angle in a single procedure," he said. Dr. Panarelli prefers to take an ab externo approach to trabeculo- tomy, but acknowledged research suggesting possible benefits to an ab interno approach. Grover et al. introduced a retrospective review of gonioscopy-assisted transluminal trabeculotomy (GATT) in the British Journal of Ophthalmology. 1 The results of 14 eyes of 10 patients found that GATT was promising. said Joseph Panarelli, MD, assistant professor of ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York. "Pediatric glaucoma is one of those conditions that can be devas- tating if not treated promptly and correctly. Though it is extremely challenging to treat, it has become the most rewarding aspect of my practice," Dr. Panarelli said, adding that about a quarter of his glaucoma cases are pediatric. Parents are usually the first to notice something off with their chil- dren. Ta Chen Chang, MD, assistant professor of clinical ophthalmology and pediatrics, Bascom Palmer Eye Institute, Miami, said warning signs usually consist of light sensitivity, refusal to open eyes, and tearing. The cornea may look hazy and the Does microinvasive glaucoma surgery offer options for pediatric cases? T he advent of microinvasive glaucoma surgery (MIGS) has revolutionized how the disease is treated in adults with mild to moderate cases wishing to reduce the use of med- ication, but what does MIGS offer for pediatric glaucoma patients, if anything? Though primary congenital glaucoma and juvenile open-angle glaucoma are rare, there are many congenital ocular abnormalities as well as systemic abnormalities that are associated with glaucoma, making childhood glaucoma more prevalent than one would expect, MIGS and pediatric glaucoma patients Dr. Panarelli inserts the iTrack Microcatheter in a pediatric glaucoma case. Source: Mount Sinai Health System she added. "Oral pressure-lowering agents can be used, but the best way to resolve it is to stop the drug," she said. When the drug is stopped, most angle closures resolve quickly, and most patients regain vision. Glucocorticoids Dr. Wellik describes glucocorticoids as "an oldie but goodie" used to treat many conditions. However, this type of drug can cause elevated IOP, cataract formation, and central serous chorioretinopathy in certain patients. Stay alert for certain risk factors that can make patients more prone to these side effects, including a history of glaucoma, history of glaucoma suspect, or even a first rel- ative with glaucoma; and diabetes, high myopia, and connective tissue disease. Looking forward There's emerging research to show that other systemic drugs may have ocular effects, Dr. Wellik said. This includes the loss of meibomian gland dysfunction years after reti- noid use to treat acne, and systemic antihypertensive drugs implicated in normal tension glaucoma. Still, there's not enough data yet to make clinical recommendations in these areas, she said. EW Reference 1. Marmor MF, et al. Recommendations on screening for chloroquine and hydroxychloro- quine retinopathy (2016 revision). Ophthalmol- ogy. 2016;123:1386–1394. Editors' note: The physicians have no financial interests related to their comments. Contact information Goldhardt: rgoldhardt@med.miami.edu Wellik: swellik@med.miami.edu Systemic continued from page 26

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