Cutting Edge Glaucoma - Issue 2

CHILDHOOD GLAUCOMA SURGERY IN DEVELOPING COUNTRIES • 19  However, in the developing world, this is further compounded by the fact that most children with PCG are born to consanguineous parents [66] with more severe disease at presentation and usually with delayed diagnosis [42, 67]. Causes of late presentation in the developing world are thought to include delayed diagnosis (lack of awareness of disease) and the limited access to and unaffordability of health care. Furthermore, the majority of cases require repeat surgical interven- tion to control IOP. Hence, it is not surprising that children in the developing world who are blind from glaucoma have a high degree of consanguinity [56, 68]. Furthermore, the initial benefits of glaucoma surgery may be lost if there is no continuity of care for these children when they fail to attend follow-up appointments. There may also be issues with continuing medical therapy due to the inability to prescribe or afford medications [41, 43]. Therefore, the burden of blindness due to pediatric glaucoma in the developing world is significant with three-fourths of the world’s blind children living in developing countries [69]. The above points are illustrated by a number of studies. Ben-Zion et al . reported the average age at diagnosis of congenital glaucoma in Ethiopia to be 3.3 years [43] compared to the Western counterparts, where the average age was less than 1 year of age [6, 70]. Close to 50% of the eyes continued to have elevated IOP beyond 22 mmHg even after surgery, and the majority needed second intervention for IOP control. Also Mandal et al . showed that the success rate of CTT in advanced glaucoma (with corneal diameter ≥ 14 mm) was 75.5% at 1 year but decreased to 60.5% at 6 years [67]. Furthermore, Al-Hazmi reported a retrospective review of 820 eyes of 532 PCG patients with variable degrees of severity and less than 1 year of age who underwent goniotomy, trabeculotomy, or CTT with MMC [42]. The mild form of PCG had high success rates with all techniques (81–100%). Eyes with moderate glaucoma following CTT with MMC had an 80% success rate, and those with advanced PCG (corneal diameter of >14.5 mm) 70% at 1–3 years. In moderate to advanced PCG, the other techniques had poor outcomes. A study from northern Tanzania reporting the outcomes in secondary childhood glaucoma of TSCPC (18%) compared to trabeculectomy (48%, with higher rate of complications) noted that a third of children did not return for follow-up after 1 year [71]. Distance to the hospital of greater than 100 km was a significant risk factor for trabeculectomy failure and was also speculated to contribute to late pres- entation and erratic follow-up. The same group published results in children with PCG comparing various surgical techniques. Their conclusion recommended that for early disease, goniotomy and trabeculotomy were options and for severe disease trabeculectomy showed moderate success. TSCPC had poor success rate of 17% at 1 year [72]. A number of strategies have been initiated in the developing world to expedite diagnosis and improve prognosis. For example, in India the training of pediatricians and neonatologists for timely referral is in progress, along with public education and childhood glaucoma awareness pro- grams through the media. To alleviate the fear surrounding the diagnosis of glaucoma, potential blindness, and surgery, various education strategies and special support groups for children with glaucoma and families have also been implemented.