This document presents a case study of a 7-month-old male child brought to the pediatric ophthalmology clinic with watering and mucopurulent discharge from the left eye for 7 months. Examination found enlarged discs and asymmetric cupping between the eyes. The child was diagnosed with nasolacrimal duct obstruction and congenital glaucoma in the left eye. Over several follow up visits, treatment with eye drops and surgery was performed to manage intraocular pressure and treat the glaucoma. The case highlights the evaluation, management, and long term follow up of congenital glaucoma in infants.

1. BUPHTHALMOS
(EVALUATION & TREATMENT)
PRESENTER:
DR.ANKIT AHIR
DR.PRAKHAR CHAUDHARY
MODERATOR:
DR.SHAHINUR TAIYAB

2. CASE 1
21-06-2019
A 7 month old MALE child ,brought to Paediatric Ophthalmology OPD at
SSN with –
Complain of – watering from left eye (OS) associated with mucopurulent
discharge since last 7 months.
HISTORY OF UNKNOWN EYE DROP INSTILLATION IN LEFT EYE (OS) FOR 3
MONTHS.

3. OD OS
VISION CSM CSM
LIDS N N
CONJUNCTIVA N N
CORNEA NORMAL NORMAL
COVER TEST ORTHO ORTHO
ANTERIOR CHAMBER NORMAL NORMAL
IRIS NORMAL NORMAL
PUPIL NORMAL NORMAL
LENS CLEAR CLEAR
IOP(FINGER TENSION) NORMAL NORMAL
DISC CDR 0.2 CDR 0.5
DIAGNOSIS : LEFT EYE (OS)- NASOLACRIMAL DUCT OBSTRUCTION
- LARGE DISC
ACTION PLAN : CONJUCTIVAL SWAB FOR SENSITIVITY AND GLAUCOMA CLINIC OPINION

4. 21-06-2019
Case seen by Glaucoma clinic Doctor.
O/E –
Cornea – Clear
Pupil – Dilated
IOP (TONOPEN) OD- 36 OS- 43
ACTION PLAN : OBSERVE FOR SIX WEEKS AND REVIEW AFTER THAT
DIAGNOSIS : OU- NASOLACRIMAL DUCT OBSTRUCTION
- ASYMMETRIC CUP

5. 28-06-2019
Case seen by Pediatric ophthalmologist and based on culture sensitivity
report , the child was started on –
TOBRAMYCIN E/D - 3 TIMES / DAY X 2 weeks
TOBRAMYCIN E/O - 2 TIMES / DAY X 2 weeks
CRIGGLER MASSAGE
ADVICED TO REVIEW AFTER 1 MONTH

6. 30-07-2019
Case seen by Paediatric Ophthalmologist first, and noticed improvement in
symptoms, so was advised to continue CRIGGLER MASSAGE and to Review in
Glaucoma clinic.
GLAUCOMA CLINIC –
O/E –
Cornea – Clear, Appears larger
Pupil – Dilated
No haab’s striae
IOP (TONOPEN) OD- 21 OS- 41/43
DIAGNOSIS : OU- NASOLACRIMAL DUCT OBSTRUCTION
- ASSYMETRIC CUP
OS - CONGENITAL GLAUCOMA
- MEGALOCORNEA
ADVICE: EUA (SEVOFLURANE) +/-
REFRACTION,CCT,BIOMETRY,FUNDUS PHOTO +/- SYRINGING

7. 16-09-2019 OD OS
HEAD CIRCUMFERENCE --- ---
FACE NAD NAD
ORBIT NORMAL NORMAL
LID NORMAL NORMAL
CONJUCTIVA NORMAL NORMAL
CORNEA CLEAR
12 MM
CLEAR
13MM
ANTERIOR CHAMBER DEEP DEEP
IRIS NORMAL NORMAL
PUPIL NORMAL NORMAL
LENS CLEAR CLEAR
IOP (TONOPEN) 17mm of Hg 33mm of Hg
GONIOSCOPY Anterior insertion of iris
with prominent iris process
Anterior insertion of iris
with prominent iris process
FUNDUS 0.5 VCDR ,PINK, HEALTHY 0.2 VCDR,PINK,HEALTHY
KERATOMETRY K1- 38.25
K2- 40.75 *66°
K1- 36.25
K2- 38.25 *27°

8. ADVICE: GONIOTOMY ON TABLE
Patient was started on –
Tobramycin E/D - 6 TIMES / DAY x 7 DAYS
- 4 TIMES / DAY x 7 DAYS
- 2 TIMES / DAY x 7 DAYS

9. 17-09-2019 ( FIRST POST –OP)
O/E - Clear cornea with white and quite eye
- No abnormal lid swelling noted
ADVICE: EUA , REFRACTION AND IDO AFTER 1 MONTH
19-09-2019 ( SECOND POST OP)
O/E - Clear cornea with white and quite eye
- Minimal conjunctival congestion
- No abnormal lid swelling noted
IOP (Tonopen ) – left eye (OS) - 10 mm Hg
ADVICE: EUA , REFRACTION AND IDO AFTER 1 MONTH

10. 18-10-2019
OD OS
FACE NAD NAD
ORBIT NORMAL NORMAL
LID LACERATION – UPPER EYE LID NORMAL
CONJUCTIVA NORMAL NORMAL
CORNEA ABRASSION ON RIGHT SIDE CLEAR
ANTERIOR CHAMBER DEEP DEEP
IRIS NORMAL NORMAL
PUPIL NORMAL NORMAL
LENS CLEAR CLEAR
IOP (TONOPEN) 9mm of Hg 13/14mm of Hg
GONIOSCOPY Anterior insertion of iris with
prominent iris process
Anterior insertion of iris with
prominent iris process
FUNDUS 0.4:1 0.9:1
REFRACTION -1.50 D sph -1.50 D sph
OS- SUTURE REMOVED
ADVICE: REPEAT EUA AFTER 6 MONTHS, VISUAL REHABILITATION IN PEDIATRIC OPHTHALMOLOGY CLINIC
ADV: TOBRAMYCINE E/D-
TDS x 7 DAYS

11. DEFINITION
Buphthalmos is a term used to describe the abnormal enlargement of
an infant’s eye secondary to elevated IOP.
In extreme cases,these eyes are vulnerable to lens-subluxationand
rupture even with even minor trauma.

12. Isolated congenital glaucoma
1. Isolated maldevelopment of the trabecular meshwork
2. No other developmental ocular anomalies or ocular diseases that can raise IOP.
3. Recognized with in first month
Infantile glaucoma
1. Synonymous with congenital glaucoma.
2. 1 month to 3 years
Juvenile glaucoma
1. Primary glaucoma occurring later in child hood or early adulthood
2. 3 years to 35 years

13. Three years of age is generally taken as the division between infantile and
juvenile glaucoma.
After this age the eye no longer expands in response to raised intraocular
pressure.
 Juvenile glaucoma doesn’t havecorneal enlargement or Haabstriae

14. EPIDEMIOLOGY
1. 1 in 10000births
2. 50%isolated congenital
3. 60%diagnosed by 6 months and 80%by 1 year
4. 65%affected are males
5. 70%bilateral involvement

15. CLINICALFEATURES
Classic Triad ……symptoms
1. Epiphora
2. Photophobia
3. Blepharospasm
Other symptoms are
cloudy cornea , red eye, enlarged cornea or eye , irritability , poor vision and pain
In older children, astigmatism, progressive axial myopia cause symptomatic decreased VA and
refractive amblyopia.

16. SIGNS
IOP
Cornealoedema Haabsstriae

17. 1. Breaks in Descmet’s membrane –as
cornea stretches- acute localized edema
& deposition of new basement
membrane into hyalineridges.
2. Horizontal, curvilinear and parallel to
the limbus in the peripheralcornea.
Haab’s striae

18. SIGNS
IOP
buphthalmos Sclerathin
andblue

19. SIGNS
IOP
Flatand
subluxatedlens iridodonesis

20. 1. Anterior chamber becomesdeep
2. Optic nerve cupping
◦ Develop early and rapidly
◦ Reversalof cupping with IOPreduction

21. EVALUATION
Examination in clinic
Observe
1. Cornea Size and Clarity
2. degree of tearing/photophobia
3. Any discharge /swelling –sac area
4. Iris/pupil Hypoplasia/corectopia andAniridia

22. EVALUATION UNDERGA
OTHER USEFUL DIAGNOSTIC TESTS:
 CCT
 Ultrasound (Axial Length Measurement / B
Scan)
 Optic Nerve Photography
 Refraction
1. Vision Testing (Acuity and Visual field)
2. Tonometry ( After Induction And Before Intubation )
3. External Examination
4. Anterior Segment Examination
5. Corneal Diameter Measurement
6. Gonioscopy
7. Optic Nerve &Fundus Examination

23. VISION TESTING :
 Varies with patient’s age and Cognitive function
 Central , maintained fixation behaviour and absent Nystagmus – Infants
 Optotype Testing with Proper Refraction – Older Children
VISUAL FIELD TESTING:-
 Difficult in children with Nystgmus and in Young Children.
 Children with associated Neurological condition ( sturgeweber
syndrome) may have underlying homonymous hemifield vision loss
independent of Glaucoma.

24. EXTERNAL EXAMINATION:
 Important to identify evidence of other associated abnormalities –
o Neurofibromatosis
o Facial haemangioma
o Photophobia
o Nasolacrimal duct obstruction
o Facial features s/o Metabolic disorder , Connective tissue disorder, Chromosomal
abnormalities.
 -Exclude other causes of epiphora, photophobia and blepharospasm.
 -Most common cause of epiphora in new-born and infant – congenital NLDO
 -Others :- Conjunctivitis (infectious, chemical)
Corneal epithelial defect/ abrasion
Keratitis
Inflamed ant segment (uveitis, trauma)

25. CORNEAL EXAMINATION :
REF: SHIELD’S TEXTBOOK OF GLAUCOMA – 6TH
EDITION

26. Horizontal diameter from white to white……..
The vertical diameter is fallaciously lowered by
encroachment of sclera at the superior limbus

27. Also Document
Corneal edema/ clouding, breaks in Descemet’s membrane (Haab’s striae)
Other causes of corneal clouding
Sclerocornea
Tears in D membrane
Ulcers
Metabolic disease
Peters anomaly
Endothelial dystrophies
Dystrophy e.g congenital hereditary stromal dystrophy

28. TONOMETRY:
1. IOPshould be measured using Perkin’shand-held applanation tonometer or
tonopen
2. Most anesthetic agents reduceIOP
3. Should be measured early during earliest possible moments afteranesthesia
induction, before intubation.
4. AsymmetricIOPmore suggestiveof abnormality than B/Lborderline IOP

30. Chloralhydrate isthe agent doesn’t haveanyeffect onIOP,so best…..

31. ANTERIOR SEGMENT EXAMINATION
(BIO-MICROSCOPY) :
 Assess corneal size, symmetry, clarity.
 Bio microscopy ( handheld slit lamp) adds improved examination and detail of
corneal architecture specially Haab’s striae.
 IOP normalised  Descemet's tear repair  corneal edema clears , but
linear corneal opacities persists  associated with reduced endothelial count
 Permanent scaring  Refractive errors.
 Limbus may be dramatically stretched and thinned by ocular stretching in
infant eye with Glaucoma and Anterior chamber deepens.

32. GONIOSCOPY:
Koeppe (14-16mm) lens provides surgeon with appropriate view of the
angle.- Infants
Indirect Goniocopy – Zeiss or Sussman lens – Older Children.
In normal newborn
1. Iris inserts posterior to scleral spur.
2. TM appears more translucent than that of adult.
In primary congenital glaucoma
1. Anterior insertion of iris (flat or concave) directly into TM.
2. Surface of TM has stippled appearance and meshwork may appear thicker
3. Occasionally loops of blood vessels from major arterial circle may be seen
(LOCH NESS monster phenomenon)

33. OPTICNERVE & FUNDUS:
1. C:D ratio >0.3 and asymmetry are suggestive evidence of glaucoma.
2. The infant glaucomatous cup is more often round , steep walled central &
surrounded by uniform pink NRR. Tends to enlarge circumferentially with
progression of glaucoma.
3. Cupping is reversible

34. REFRACTION :-
 Enlargement of globe due to elevated IOP , creates myopic shift in refractive
error  Amblyopia , if significant anisometropia is present.
 Haab’s striae  significant Astigmatism  Amblyopia ,especially in unilateral /
asymmetric cases.

35. ULTRASONOGRAPHY:-
 Important ,because stabilisation and even reduction in axial length can occur
in enlarged eye with stable IOP.
 In aphakic eyes of infants after filtration surgery OR implantation of Glaucoma
drainage device – axial length changes within days after a significant IOP
reduction.
 Glaucoma filtration surgery – size of implant
 B- scan helps in confirming Retinal status in eyes with opaque media -- aids in
assessing patency of glaucoma drainage devices when bleb is not seen.

36. CENTRAL CORNEAL THICKNESS:-
 CHILDREN ( 6- 23 MONTHS ) – 540 µm
 OLDER CHILDREN – 550- 560 µm
 White people thinner CCT than Black people.
 CCT is thinner in children with congenital glaucoma than other children.
 Eyes with Aniridia, Aphakia -- thicker CCT
 Importance of CCT in evaluation & management in children with Glaucoma
is still uncertain…...

37. IMAGING TECHNIQUES:-
FUNDUS PHOTOGRAPHY -
OPTICAL COHERENCE TOPOGRAPHY (OCT) –
 Documentation
 OCT – measure thickness of peripapillary nerve fibre layer ,
Macular area ,
Volume
 Newly developed Handheld Spectral- domain OCT may be used, in uncoop
or children who can not assessed by standard technology.

38. DIFFERENTIAL DIAGNOSIS:
EXCESSIVE
WATERING
LARGE CORNEA TEAR IN DESCEMET’S
MEMBRANE
CORNEAL
OPACIFICATION
• NLD OBSTRUCTION
• RED EYE
• UVEITIS
• KERATITIS
• MEGALOCORNEA
• HIGH MYOPIA
• FORCEPS DELIVERY
- VERTICAL & OBLIQUE
• HAAB’S STRIAE
- HORIZONTAL & CONCENTRIC
• DEVELOPMENTAL-
SCLEROCORNEA
• DYSTROPHIES
• CHORISTOMAS
• EDEMA DUR TO BIRTH
TRAUMA
• IUI
• METABOLIC D/S

39. THANK YOU..!!!