Anterior Segment Examination

To evaluate further opacities of the ocular media, the cornea, anterior chamber, iris, and lens should be
evaluated with slit-lamp biomicroscopy if possible.[A:III] Slit-lamp biomicroscopic evaluation is
indicated for older children or for younger children who are cooperative. In infants and young children,
a hand-held slit-lamp biomicroscope may be helpful. Some children may need to be restrained, sedated,
or undergo an eye examination under general anesthesia when apparent abnormalities warrant a
detailed examination.

Funduscopic Examination
Posterior segment structures should be examined, preferably with an indirect ophthalmoscope. [A:III]
The optic disc, macula, retina, vessels, and the choroid of the posterior regions should be examined.
[A:III] In the awake child, it may be difficult or impossible to examine the peripheral retina.
Examination of the peripheral retinal and scleral indentation, if indicated, may require sedation or
general anesthesia (e.g., evaluation for retinoblastoma).

Intraocular Pressure Measurement

Measuring IOP is not a routine part of the comprehensive ophthalmic evaluation of the
infant or child because glaucoma is rare in this age group and, when present, is associated
with additional manifestations. In addition, IOP measurement is difficult to perform and
frightening for the patient; some children and teenagers may become alarmed at the
procedure to the detriment of

15 Section II. Comprehensive Ophthalmic Evaluation

important parts of the subsequent examination. Intraocular pressure should be measured whenever risk
factors or ocular signs and symptoms of glaucoma exist.[A:III] Because IOP measurement is difficult
in young children or those with special needs, a separate examination with the patient sedated or
anesthetized may be required. The introduction of more compact instruments such as the Tonopen
(Reichert, New York) has facilitated testing of IOP in children.

A thorough, accurate clinical evaluation is essential for diagnosis, classification and

treatment of pediatric glaucoma, which may be primary or secondary. Primary
congenital glaucoma (PCG) occurs in about 1 in 10,000 births, representing 50 to 70
percent of congenital glaucoma cases and 22 percent of all pediatric glaucomas.
Examination of a pediatric patient can be challenging, especially for certain
glaucoma-specific exam elements or when the patient is uncooperative or unwilling.
This article discusses the most important exam elements for glaucoma diagnosis and
management.

Tonometry: Intraocular Pressure

Intraocular pressure (IOP) is the key exam element in the diagnosis, classification
and treatment of pediatric glaucoma. Optimal IOP measurements are obtained in the
office because IOP is usually lowered by most anesthetic agents and sedatives.1,2
Normal IOP in infants ranges from 10 to 15 mmHg under anesthesia.2 If an exam
under anesthesia (EUA) is needed, IOP should be measured as soon as possible
after anesthesia is induced.2 In contrast, other medications, such as ketamine and
succinylcholine, may raise IOP.1,2 Since crying and screaming also elevate IOP,
measurements should ideally be taken in the office when the baby is not crying or is
distracted. Although chloral hydrate does not appear to affect IOP in either normal or
glaucomatous eyes,1,3 this is not a convenient method for repeat office exams.

A variety of methods can be used for office IOP measurement. Parents can be told
not to feed the baby for two hours prior to the appointment, at which time the patient
is fed. While the baby is drinking from a bottle, IOP can often easily be measured. In
children who are older but still under four to five years of age, the portable Perkins
applanation tonometer (Haag-Streit USA, Inc.) is a dynamic method that allows the
examiner to know the child's IOP between cries or when not squeezing. A lid
speculum is not recommended because it often upsets both parents and patients.
Plus, by manually holding the eyelids open, the examiner can assess when the
patient is not squeezing and when IOP measurement is most accurate. Slit-lamp
Goldmann applanation tonometry is still the gold standard; so when the patient is a
few years old and certainly by age four or five, attempts should be made to check the
IOP at the slit lamp. Other authors have also used the Tono-Pen XL (Medtronic
Solan) for infants and young children.1,4,5

Central Corneal Thickness

Since the importance of central corneal thickness (CCT) measurement was
emphasized by the Ocular Hypertension Treatment Study (OHTS) in 2001, CCT
measurement has become an integral part of the glaucoma exam.6 Thicker central
corneas are associated with artifactually higher IOP readings. CCT measurements
can be obtained with a portable device, such as the Pachmate DGH55 (DGH
Technology, Inc.).
In adults, mean normal CCT has been reported as 537 m (with a range from 427 to
620 m).7 In normal children, CCT does not vary significantly with age (Table 1).
Although CCT appears to be similar in normal children and those with PCG, thicker
CCT has been noted in various disease states, such as aphakic glaucoma, SturgeWeber syndrome, aniridia and microcornea (Table 2).

Information extracted from Hussein MA, Paysse EA, Bell NP, et al. Corneal thickness
in children. Am J Ophthalmol. 2004;138(5):744-748.
Table 1. Normal central corneal thickness (CCT) values by age.

Information was extracted from Lopes JE, Wilson RR, Alvim HS, et al. Central
corneal thickness in pediatric glaucoma. J Pediatr Ophthalmol Strabismus.
2007;44(2):112-117.
Table 2. Central corneal thickness (CCT) values in eyes with pediatric glaucoma or
related conditions.

Corneal Exam
Normal horizontal corneal diameter is 9.5 to 10.5 mm in full-term newborns and
smaller in premature newborns.1 A buphthalmic eye with corneal diameter larger than
12 mm in the first year of life may be an indication of elevated IOP.1,2 High IOP may
also be associated with corneal edema and tears in Descemet's membrane (Haab's
striae).1,2 Both of these corneal changes can be detected using a slit lamp and often

account for symptoms of epiphora, photophobia and blepharospasm.

Gonioscopy
Gonioscopy findings are a critical component in pediatric glaucoma diagnosis,
treatment decisions and prognostic determinations. During an EUA, one can use a
Koeppe lens with either a portable slit lamp or a hand-held binocular microscope and
Barkan illuminator. Other options include using the operating microscope with either
a Goldmann lens or operating direct gonioscopy lens.
Angle evidence of PCG may be difficult to discern since normal angle findings in
infants are different from adults.8 Nevertheless, significant angle findings in PCG
include an open angle, a high flat iris insertion, absent angle recess, peripheral iris
hypoplasia, peripheral iris pigment epithelium tenting, thickened uveal trabecular
meshwork, scalloped iris root and prominent major arterial circle vascular loops.1,2

Ophthalmoscopy: Optic Nerve Head Evaluation

Aside from office evaluation, an EUA affords the best evaluation of the optic nerve
head (ONH). In a preoperative EUA in which the pupil is ideally not dilated prior to
angle surgery, direct ophthalmoscopy of the ONH can be performed through a
Koeppe lens. If the pupil can be dilated, photographic documentation of the ONH can
be made with a portable fundus camera, such as Nidek's NM-200D hand-held
nonmydriatic fundus camera or Clarity Medical Systems' RetCam 3.
Glaucomatous cupping in childhood is characterized by preferential loss of
neuroretinal rim tissue in both the superior and inferior poles and enlargement of the
scleral canal.1,2 Scleral canal enlargement is unique to pediatric glaucoma and may
cause cupping without significant neural tissue loss.1,2 These changes also explain
the apparent reversal of cupping that can occurs when IOP decreases.

Indirect Indicators of Uncontrolled IOP: Increasing Axial Length and

Myopia
Uncontrolled elevated IOP may result in buphthalmos, which can be reflected by
increasing myopia and axial length greater than expected for normal eye growth.
Thus refraction and ultrasonography may provide indirect signs of high IOP.1,2

Prevention of Amblyopia
Amblyopia is the leading cause of visual acuity of worse than 20/40 in pediatric
glaucoma patients.9 Refractive errors need to be treated as early as possible in order
to prevent amblyopia from myopia (e.g., due to increasing axial length and
buphthalmos) and astigmatism (e.g., due to Haab's striae).

Conclusions
In summary, IOP measurement, CCT evaluation, corneal examination, gonioscopy,
ophthalmoscopy and refraction are essential for the accurate diagnosis and
treatment of pediatric glaucoma. If an ophthalmologist is not comfortable with these
exam elements, referral to a pediatric glaucoma specialist may be warranted.

References
1.
2.

Congenital glaucoma. In:Allingham RR, Damji KF, Freedman S, Moroi SE,

Shafranov G, eds: Shields' Textbook of Glaucoma. Philadelphia, Pa:
Lippincott Williams & Wilkins; 2005:235-251.
Childhood Glaucoma. In: Cioffi GA, Durcan FJ, Girkin CA, et al, eds. Basic
and Clinical Science Course Section 10 Glaucoma. San Francisco, Calif:
American Academy of Ophthalmology; 2008:155-165.

3.
4.
5.
6.
7.
8.
9.

Jaafar MS, Kazi GA. Effect of oral chloral hydrate sedation on the intraocular
pressure measurement. J Pediatr Ophthalmol Strabismus. 1993;30(6):372376.
Bordon AF, Katsumi O, Hirose T. Tonometry in pediatric patients: a
comparative study among Tono-pen, Perkins, and Schitz tonometers. J
Pediatr Ophthalmol Strabismus. 1995;32(6):373-377.
Lasseck J, Jehle T, Feltgen N, Lagrze WA. Comparison of intraocular
tonometry using three different non-invasive tonometers in children. Graefes
Arch Clin Exp Ophthalmol. 2008;246(10):1463-1466.
Brandt JD, Beiser JA, Kass MA, Gordon MO. Central corneal thickness in the
Ocular Hypertension Treatment Study (OHTS). Ophthalmology.
2001;108(10):1779-1788.
Wolfs RC, Klaver CC, Vingerling JR, Grobbee DE, Hofman A, de Jong PT.
Distribution of central corneal thickness and its association with intraocular
pressure: The Rotterdam Study. Am J Ophthalmol. 1997;123(6):767-772.
Freedman SF, Walton DS. Approach to infants and children with glaucoma. In:
Epstein DL, Allingham RR, Schuman JS, eds: Chandler and Grant's
Glaucoma. Baltimore, Md.: Williams & Wilkins; 1997:586-597.
Biglan AW. Glaucoma in children: are we making progress? J AAPOS.
2006;10(1):7-21.

El examen bajo anestesia cuando es necesario , provee una

oportunidad para examinar detalladamente el ojo. La anestesia
debe ser administrada en el quirfano por individuos entrenados
que tengan experiencia con pacientes peditricos. Para un exmen
breve muchas veces el uso de anestesia intravenosa y es masara es
suficiente. Para exmenes ms prolongados es necesario el uso de
un tubo endotraqueal.

Oftalmoscopia
LA evaluacin del disco ptico es un parte esencial de examen. La
oftalmoscopia bajo anestesia general es ms fcilmente realizada a
travs de una pupila dilatada.
La midriasis puede ser obtenida utilizando una gota de fenilefrina al
2.5% y ciclopentolato al 1%. Esto rara vez influencia la presin
intraocular o la presin arterial. Si la ciruga se contempla la
oftalmoscopia debe ser realizada sin dilatacin.
La cabeza del nervio ptico en recin nacidos normales es
normalmente rosa, pero puede tener un ligera palidez y una
pequea copa es frecuente. En la mayora de los caos la excavacin
asimtrica es sugestiva de evidencia de glaucoma. Radios copa
discos mayores a 0.3 son raros en nios normales pero comunes en

pacientes con glaucoma y deben considerarse sospechosos. La

excavacin del nervio ptico es un signo temprano de presin
intraocular incrementada. La excavain del nervio ptico ocurre
mucho ms rpido y a menores presiones introculares que en
adultos.

IOP

Para el examen bajo anestesia, si la medicin de la presin

intraocular esta plenada es importante recordad que la presin
intraocular vara con la profundidad de la anestesia entre ms
profundamente anestesiado est el paciente menor presin
intraocular se obtendr. Algunos cirujanos solicitan menors
concentraciones de anestsicos inhalados o el uso de ketamina IV o
intramuscular para obtener lecturas de PIO ms exactas. La mayora
de los exmens bajo anestesia pueden ser realizados con el
paciente respirando anestsico inhalado espontneamente a
travs de una mascarilla laringea.

Las presiones intraoculares pueden ser realizadas utilizando un

tonmetro porttil de aplanacin , un Tonopen o un
pneumotonmetro. Es importante notar que la anestesia puede
interferir con la exactitud de la lecturas . La succinilcolina puede
incrementar la presin intraocular debido a la despolarizacin inicial
y contractura de los musculos extraoculares antes de la parlisis
muscular, mientras que el halotano pude reducir la presin. Una
presion relativamente baja bajo anestesia en un apciente con las
manifestaciones clinicas apropiadas no elimina el diagstico de
glaucoma. La presion intraocular para infantes menores de 10 aos
es de 10-15mm Hg. En casos unilaterales o cados donde un ojo ha
sido tratado exitosamente, la comparacin de las presiones
intraoculares puede ser muy til.
Durante el examen bajo anestesia , el diametro corneal exacto debe
ser medido asi como debe examinarse la cornea por la presencia de
edema corneal y estrias de Haab.

El examen del nervio ptico es mejoer evaluado bajo anestesia,

espcialmente cuando existe edema corneal. Bajo anestesia , se
pueden tomar fotografias del nervio ptico para ayudar a
documentar la progresin del glaucoma. El ultrasonido puede ser
realizado bajo anestesia . El modo A del ultrasonido provee la
medicin de la longitud axial que puede ser seguido para

monitorear el glaucoma. Un longitud axial incrementada indica

buftalmos progresivo.
Le ultrasonido modo B se indica si una cornea opaca impide la
visualizacin de la retina y el polo posterior para descaratar un
tumor. La refraccin bajo ciclopegia es tambin de gran utilidad
para monitorear cambios en la longitud axial e identificar
ansimoetropia.
Trauma
Si se sospecha una herida abierta en un globo ocular