New devices make strides in pediatric glaucoma

 

Take-Home

New devices for pediatric glaucoma surgery are becoming available that improve the ability to examine pediatric patients, perform surgeries more easily, and enhance treatment of difficult cases.

 

Dr. Freedman

By Lynda Charters; Reviewed by Sharon F. Freedman, MD

Durham, NC-Technologies for pediatric patients with glaucoma are helping to improve ophthalmologists’ ability to examine these young patients, perform selected surgeries, and treat difficult cases.

Still, such advances have been slow to progress over the years. There remains much room for the introduction of novel devices, according to Sharon F. Freedman, MD, who provided an overview of some of the many options.

New devices for measuring IOP

Dr. Freedman lauded rebound technology (Icare, Icare Finland) because there is no need to take patients to the operating room as often simply to check their IOP. Though both non-contact and rebound tonometry can be performed without topical anesthetic, rebound tonometry is more easily used to obtain a young child’s IOP in the office setting.

“Our studies [using rebound tonometry] with the Icare and the Icare ONE-not yet approved for commercial use in the United States-demonstrated in about two-thirds of cooperative children with known or suspected glaucoma that the tonometers measured IOP within 3 mm of the IOP measured with the gold-standard Goldmann applanation tonometer,” said Dr. Freedman, professor of ophthalmology and pediatrics, Duke Eye Center, Durham, NC.

“The Icare IOP measurements were usually higher than the Goldmann measurements by about 2 mm Hg, making rebound tonometry an excellent screening device,” she added.

 

 

An additional advantage of the Icare rebound tonometer, according to Dr. Freedman’s studies, is that it can be used as a clinical tool in the home setting by an adult family member to obtain IOP readings in pediatric patients with suspected glaucoma outside regular office hours.

Another tool (Icare PRO, Icare Finland) can be used with children in the supine position, but this device also is not yet approved for commercial use in the United States. It is Dr. Freedman’s hope that this instrument will be helpful for babies and in the operating room.

Surgical procedures

Angle surgeries-goniotomy and trabeculotomy, developed more than 50 years ago-still represent “pivotal developments” in the surgical care of pediatric patients with glaucoma, Dr. Freedman noted.

Goniotomy, first described in 1948, remains basically unchanged, which she explains is “a testament to the elegance of the procedure.”

Small modifications have been introduced over the years, such as use of a needle instead of a knife and use of an endoscopic approach in the presence of a cloudy cornea. The procedure also proven effective with uveitis-associated pediatric glaucoma, she added.

Regarding trabeculotomy, which was first reported in 1960, surgeons can use a standard trabeculotome to open 180° of the Schlemm’s canal, or can modify the technique to cannulate and complete a 360° trabeculotomy. This latter technique, first described using 6-0 Prolene suture, proves clinically very challenging in many cases.

“The illuminated microcatheter [iScience, iScience Interventional] has changed our approach somewhat in trabeculotomy,” Dr. Freedman said. “The illuminated microcatheter-originally developed for adult canaloplasty procedures-has made 360° trabeculotomy less technically challenging, expanding this procedure’s availability to more patients and more surgeons.”

The lighted tip of the microcatheter facilitates visualization of the catheter’s path in its travel around the circumference of Schlemm’s canal, as well as out of the canal in cases where it deviates into a collector channel.

 

 

The 360° trabeculotomy procedure is useful in patients with congenital glaucoma, as well as some cases of juvenile open-angle glaucoma and early-onset “aphakic” glaucoma.

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