Cutting Edge Glaucoma - Issue 2

10 • CUTTING EDGE - GLAUCOMA Challenges of Managing Childhood Glaucoma in Developing Countries Several problems and issues are associated with the effective management of childhood glaucoma in developing countries [4] and include: 1. The burden of disease is greater in the developing world. Primary congenital glaucoma (PCG) is the most common form of childhood glaucoma. A recent published report from an urban centre in Miami, Florida, U.S.A., reported that PCG constituted the largest group (32%) among all types of childhood glaucoma [5]. However, its incidence varies widely, occurring in approximately 1 in 20,000 in Western populations [6, 7] but more frequently in the devel- oping world. PCG is often transmitted in an autosomal recessive pattern and may occur up to ten times more frequently in certain ethnic and religious populations where consanguineous marriage is socially and culturally acceptable. The highest reported prevalence is found in Slovakian gypsies at 1 in 1250 [8], and among Saudi Arabians, it is 1 in 2500 [9]. In southern India, prevalence of PCG is estimated at 1 in 3300 live births, accounting for 4.2% of overall childhood blindness [10]. 2. More severe disease phenotype and late presentation of the disease in an advanced stage when it is less amenable to successful surgical treatment. 3. Limited number of trained personnel with the appropriate skill sets (surgeon, anesthesiolo- gist, nursing staff, and other professionals) for microsurgical treatment and postoperative care. 4. Cultural fear of surgical treatment, which must be overcome. 5. Incurable disease that needs ongoing follow-up, which is often inadequate in treated cases leading to poor prognosis. So the initial benefits of glaucoma surgery may be lost if there is no continuity of care for these children. 6. Limited access to health care and long travel distances to health-care centres. 7. Poor socioeconomic status of the family and lack of affordability of health care. 8. Barriers to affordability and availability in rural areas of topical medications along with vari- able nature and efficacy (quality) of available generic medication. Surgical Therapy of Childhood Glaucoma in Developing Countries Goniotomy The classic surgery for PCG is goniotomy as described by Barkan [11]. PCG, which occurs in India, the Middle East, South Africa, and several other parts of the developing world, is mostly familial compared to the West and responds less favorably to goniotomy [4]. Furthermore, in developing countries, the disease is of a more severe phenotype and presents late with severe corneal edema precluding goniotomy [12, 13]. Compared to Western and European populations, a large number of Indian children (>80%) present with a severely cloudy cornea at birth, thus in whom goniotomy is technically impossible [14]. In such cases trabeculotomy ab externo is advo- cated as the initial surgical procedure of choice by several authors [15–19]. However, if corneal