GONIOTOMY EYE SURGERY DIAGNOSIS AFTERCARE
Category: Ophthalmology
Abstract : The clinical signs of congenital and infantile glaucoma may be detected within a few months after birth. They include an enlarged eye, called buphthalmos; corneal swelling; decreased vision; tearing; sensitivity to light; and blepharospasm, or uncontrolled twitching of the eyes. These signs, however, are usually absent in JOAG. As a result, glaucoma in the older child may go undetected until the c
The clinical signs of congenital and infantile glaucoma may be detected within a few months after birth. They include an enlarged eye, called buphthalmos; corneal swelling; decreased vision; tearing; sensitivity to light; and blepharospasm, or uncontrolled twitching of the eyes. These signs, however, are usually absent in JOAG. As a result, glaucoma in the older child may go undetected until the child loses vision.
The examiner must take some measurements in order to confirm a diagnosis of glaucoma, including measurement of the corneal diameter and the axial length of the eye. The corneal diameter is usually less then 10 mm in an infant and only 11–12 mm in a one-year-old, but can be as large as 14 mm in a child with advanced glaucoma. The axial length is measured with an A-scan, which is a type of ultrasound. The doctor will also determine the intraocular pressure with either Schiotz tonometry or a TonoPen. An elevated intraocular pressure is not always present in congenital glaucoma; unless it is extremely high, it is only one factor in the diagnosis of glaucoma.
Gonioscopy, a technique used to examine the interior structures of the eye, is performed by placing a special contact lens on the eye. This lens, used in combination with a biomicroscope, allows the surgeon to evaluate the structures of the anterior part of the eye. The condition of the optic nerve is also evaluated; photos or drawings may be taken for future comparison. Since cooperation is difficult for infants and young children, these assessments may be done either under anesthesia or with the use of a sedative. Older children are examined in a manner similar to adults.
Preparation
Once the diagnosis of glaucoma is confirmed, goniotomy is often the first line of treatment. If goniotomyis determined to be the best procedure and there is a lot of corneal haze, the surgeon may treat the patient for several days pre-operatively with azetozolamide to lower the IOP and increase the clarity of the cornea. Or, he may elect to perform another procedure called a trabeculotomy, which is the preferred surgery if the corneal diameter is greater than 14 mm. The patient is given antibiotics for several days before surgery. Obtaining the family’s informed consent is anotherimportant part of preparing for a goniotomy. The surgeon tells the family that the child will need general anesthesia, and that several postoperative visits with anesthesia or sedation will be necessary after the goniotomy.
Aftercare
The patient will continue to be given antibiotics,corticosteroids, and miotics for one to two weeks after surgery. If the surgeon believes that the procedure was not successful, then he or she may give the patient acetazolamide by mouth in addition to these medications for up to 10 days to lower the IOP.
The patient will be anesthetized again three to six weeks after surgery for a reevaluation of the anterior chamber of the eye. This examination is repeated every three months for the first year; every six months during the second year; and once a year thereafter. Once the child is older, usually three to four years old, the physician can perform the follow-up examination in his or her office without anesthesia or sedation. Since a visual field test is difficult or impossible to do on an infant or young child, the doctor measures the cornea to assess progression of the disease. An increase in corneal diameter indicates that the glaucoma is getting worse. Visual field testing will be performed when the child is old enough to understand it. A visual field test can establish the extent of vision loss that has occurred because of glaucoma.
An important aspect of managing glaucoma patientsafter surgery is assessing the degree of nearsightness andastigmatism, both of which result from the stretching of the eye caused by increased intraocular pressure. If the child needs eyeglasses, they should be given as early in life as possible to decrease the probability of amblyopia. Amblyopia is a condition in which the vision cannot be corrected completely, even with glasses, and is common for pediatric glaucoma patients. Although almost 80% of children with congenital glaucoma can have their vision corrected to 20/50 or better, patching of an eye and vision therapy is often required to achieve this level of correction. About 10% of goniotomy patients will experience a recurrence of the glaucoma or have it develop in the unaffected eye. As a result, the patient will need periodic eye examinations for the rest of his/her life. If glaucoma does recur later in life, then either medical or surgical treatment is instituted depending on the cause.
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