Primary Congenital Glaucoma

Abstract

Primary congenital glaucoma is a rare, usually bilateral, aqueous outflow obstruction likely from developmental arrest of anterior chamber angle tissue (derived from neural crest cells). It presents in sporadic or familial patterns, and is usually autosomal recessive in familial cases. Causative genes include CYP1B1, LTBP2, and MYOC, and those in the ANGPT/TEK signaling pathway (i.e., TEK or TIE2). It commonly presents between 3 and 9 months of age and causes buphthalmos and blindness if not treated. The classic "triad" of presenting symptoms (photophobia, epiphora, and blepharospasm) relates to rapid ocular expansion of the infant eye under high pressure, causing corneal enlargement, and frequently also producing breaks in Descemet membrane (Haab striae) and resultant corneal edema and opacification. Associated signs include deep anterior chamber, buphthalmos, myopia, and optic nerve cupping. In extreme cases, the lens can dislocate. The primary treatment modality is surgical, with medications as adjunctive treatments. Visual loss can result from corneal scarring and/or optic nerve damage, but often also occurs due to amblyopia in unilateral or asymmetric cases. Vision in the better-seeing eye is at least 20/60 in most cases where glaucoma is stabilized. Aggressive early control of glaucoma and attention to refractive errors and amblyopia, as well as life-long follow-up of glaucoma, maximize visual outcome and quality of life in affected children.