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Johns Hopkins Pediatric

Pediatric Ophthalmologist Courtney Kraus on Glaucoma in Children

Gary Logan
Jult 26, 2018

Courtney Kraus specializes in treating amblyopia, or lazy eye, cataract and corneal diseases in children, and glaucoma.

Courtney Kraus

Children, just like older adults, can get glaucoma?
Glaucoma is more common in the elderly but it can develop at any age, even in infants and children, though they tend to have different signs and symptoms than adults.

What kinds of signs and symptoms?
For congenital glaucoma present at birth, or infantile glaucoma between the ages of 1 and 24 months, common symptoms include excessive tearing, light sensitivity and an enlarged, cloudy cornea. For children with congenital glaucoma, the classic triad is blinking a lot, tearing up a lot, and photophobia, or sensitivity to light. In addition, the cornea becomes cloudy and hazy, and takes on a bluish appearance.

What causes glaucoma?
Congenital glaucoma is believed to be due to a malformation of the drainage pathway for fluid that fills the eye. If the fluid cannot get out fast enough because drainage is obstructed, intraocular pressure builds up and damages the optic nerve, resulting in vision loss. Glaucoma in children can also be associated with specific congenital conditions such as Sturge-Weber syndrome, trauma, or cataract surgery. Pediatric glaucoma is also associated with medications such as steroids for treating conditions such as juvenile idiopathic arthritis. These disorders each require a specific tailored treatment depending on the original root cause of the glaucoma.

How are symptoms picked up?
Oftentimes, the signs are not present or are missed until much later, and children present with eyes that have grown much larger. Unlike adults who get glaucoma, the young child’s eyes are still flexible and when pressure rises, the entire eye expands. Both the cornea and the white part of the eye grow larger. The parent, pediatrician or someone at school notices that the child’s eye does not look right. An ophthalmologist makes the diagnosis through identifying the appearance of the eye and measuring the child’s eye pressure.

How do you measure eye pressure?
In the past, we used devices that were big and cumbersome to determine intraocular pressure, which required us to hold the infant down. Needless to say, the child would cry and scream, resulting in extremely elevated pressures. In some cases, sedation was needed. We now use a newer hand-held tonometer, which registers a reading before the child has a chance to blink. Hands down, it has reduced the number of exams under anesthesia.

How is pediatric glaucoma treated?
For very young babies, surgery is the first line treatment and has been proven very effective—65 to 70 percent of children with congenital or infant glaucoma can be treated and cured with one surgery. Trabeculotomy and goniotomy, which open the drainage canals, are the most common surgical interventions. For older children, as with adults, we treat with eye drops and oral medications first and then go on to surgery. Medications may be necessary to control the intraocular pressure even after surgery.

Any new approaches in surgery?
Right now, the hot topic in adult glaucoma is minimally invasive glaucoma surgery, which has been shown to be effective in juvenile glaucoma cases, too. In determining treatment in children, there is a trickle-down effect—you want to see something with a good long efficacy in adults before we bring it into the pediatric realm. We are expanding our repertoire of treatments in juvenile glaucoma cases, the goals being more effective and less invasive approaches with fewer complications that can lead to vision loss.

What are the risks of glaucoma surgery?
The big thing you want to avoid when you operate on a child with glaucoma is infection, which can result in the loss of vision. Unfortunately, infections are more common after glaucoma surgery in children than in adults. Other concerns are bleeding, which in a child can mean a period where they cannot see—also a bigger problem in young developing eyes. Any surgical intervention inside the eye can potentially damage the natural lens, which could create a cataract. Cataracts in children are also a difficult problem. Glaucoma is a challenging disorder.

Are there risks with delayed treatment?
Kraus: Children who are missed or are a little bit behind in being referred to us have more time with elevated eye pressure. Their corneas have more scarring and their eyes are larger, which means they are far more nearsighted right from the get go. Their nerves have spent more time exposed to high eye pressure, and this in turn means more damage and more vision loss. The earlier the diagnosis and treatment, the better.

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