Juvenile Glaucoma in Africa

In EnglishIt is sad to see a very young person going needlessly blind. This is a case of bilateral advanced stage juvenile glaucoma in young 16 y.o. lady. She had bilateral deepest cupping of 1,0 and 6/60 vision in one eye and finger counts at 3 m in the other. Her intraocular pressures were, as it is common here and especially in young persons, – slightly below 50 mm Hg in one eye and 55 mm Hg in the other eye.

The problem of glaucoma in Africa is described nicely and in details elsewhere: https://www.iapb.org/blog/my-challenges-managing-glaucoma-sub-saharan-africa, https://www.ncbi.nlm.nih.gov/pubmed/19225348. My few cents will be like this (in order of relevance):

  1. Lack of early recognition among the patients
  2. Lack of IOP and disks screening among even trained mid-level ophthalmic staff
  3. Poverty, leading to huge delays to a hospital visit
  4. Poverty, leading to inability to buy medications for chronic disease
  5. Unavailability of fency eye drops (only timolol is available in most of rural places, and it’s value in IOP 50 mm Hg is from limited to none)
  6. Lack of follow-ups, leading to unnecessary failure of trabeculectomies

Each of those makes majority of patients with glaucoma present in advanced stages (rarely amenable to medications).

I opted bilateral trabeculectomy with 5-fluorouracil in this case (however, in ideal circumstances I would preferr mitomycin – it is stated to be more effective in studies). She underwent uneventful surgeries for both eyes (one week apart). Right eye (the worse eye), however, showed persistent leakage from fornix-based bleb, and had to be sutured additionally after a week postop. Both eyes dropped the IOPs to mid teens, and the girl’s parents were counselled properly on very important follow-ups during next few months. Failure of trabeculectomy is common first 6 months after the surgery.

Right eye: Bleb additionally sutured to close leakage. I acknowledge, that this is not the ideal way to close leaking bleb, and will release this sutures upon ten days.

Left eye: fornix based diffuse bleb

P.S. I am still not sure on what is the best practice in trabeculectomy in african population regarding the tenon’s capsule. It can be either excised a little, or just undermined, or even sutured to the limbus below the conjunctiva. There were no RCTs on that, and that’s quite important: I feel the chances are higher for the bleb to become cystic if tenon’s was excessively excised.