Congenital Glaucoma Surgery in Infants | PristynCare

Risk Factors

Risk factors for congenital glaucoma and complications include:

• Family history of congenital glaucoma (autosomal recessive inheritance)
• Associated syndromes (Sturge-Weber, Axenfeld-Rieger, aniridia)
• Delayed diagnosis allowing prolonged elevated IOP
• Poor compliance with post-operative follow-up in young children
• Amblyopia risk is high due to the critical period of visual development in infants

Who Needs Surgery

All infants diagnosed with congenital glaucoma require surgery as medical therapy alone is not effective long-term. Surgery should be performed as soon as the diagnosis is confirmed, ideally within the first weeks of life. Delayed treatment increases the risk of irreversible optic nerve damage, amblyopia, and permanent vision loss.

Diagnosis

Diagnosis of congenital glaucoma involves examination under anesthesia (EUA) including:

• IOP measurement under general anesthesia using applanation or Perkins tonometer
• Corneal diameter measurement (normal under 11 mm at birth)
• Gonioscopy to visualize the anterior chamber angle
• Fundus examination for optic disc cupping assessment
• Corneal pachymetry and B-scan ultrasonography
• Assessment for associated systemic syndromes

Treatment Plan

Medical therapy with topical beta-blockers or carbonic anhydrase inhibitors may temporarily control IOP while awaiting surgery. Surgery is the definitive treatment. Goniotomy is the first-line surgery for primary congenital glaucoma with a clear cornea, with a success rate of 80 to 90% after one or two procedures. Trabeculotomy or combined procedures are performed when the cornea is hazy. Post-surgical follow-up under anesthesia may be required in young children.

Goniotomy Procedure Steps

Goniotomy for congenital glaucoma is performed as follows:

• General anesthesia in infants and young children
• The operating microscope and gonioscopy contact lens are set up
• The surgeon visualizes the anterior chamber angle through the gonioscope
• A fine goniotomy knife or needle is passed into the anterior chamber through a corneal incision
• The trabecular meshwork is incised over 120 degrees (one third of the circumference)
• The incision opens the obstructed drainage pathway in the angle
• The anterior chamber is reformed with balanced salt solution
• Post-operative IOP control is monitored within 24 to 48 hours
• A second goniotomy may be performed on the remaining angle if IOP remains elevated

Post-Surgery Recovery

Post-operative care after congenital glaucoma surgery includes:

• Topical antibiotic and steroid drops are started post-operatively
• IOP is checked within 24 hours of surgery
• Regular examination under anesthesia (EUA) every 3 to 6 months in young infants
• Amblyopia treatment (patching of the fellow eye) if one eye is more affected
• Glasses or contact lenses for refractive correction as soon as possible
• Long-term follow-up for glaucoma, refraction, and visual development is essential

Risks and Complications of Congenital Glaucoma Surgery

Possible complications of congenital glaucoma surgery include:

• Hyphema: Blood in the anterior chamber from angle incision; usually self-resolving
• Damage to the lens: Risk from instruments passing close to the crystalline lens
• Intraocular infection: Endophthalmitis, though rare
• IOP failure: Elevated IOP despite surgery requiring repeat goniotomy or additional procedures
• Amblyopia: Deprivation amblyopia from corneal clouding or refractive error requires aggressive patching
• Anesthesia risks: All surgeries in infants carry general anesthesia risks