Visual acuity outcomes in pediatric glaucomas

Monica R. Khitri, MD, Monte D. Mills, MD, Gui-Shuang Ying, PhD, Stefanie L. Davidson, MD,
and Graham E. Quinn, MD
PURPOSE

To evaluate and compare the visual acuity prognosis in the various pediatric glaucoma
subtypes and to determine risk factors for vision loss.

METHODS

The medical records of pediatric glaucoma patients from 2000 to 2010 at Childrens
Hospital of Philadelphia were retrospectively reviewed. Visual acuities, surgeries, glaucoma subtype, and etiology of vision impairment were recorded. Univariate and multivariate analyses were performed to determine the risk factors for visual impairment.

RESULTS

A total of 133 eyes (36.8% primary congenital glaucoma, 28.6% aphakic glaucoma, 12.0%
glaucoma associated with anterior segment dysgenesis, 12.0% Sturge-Weber glaucoma) of
88 patients were included. At last follow-up (median length, 5 years), 46.6% eyes achieved
excellent ($20/70) visual acuity. Of the glaucoma subtypes, primary congenital glaucoma
conferred the best visual prognosis, with 69.4% eyes with excellent ($20/70) visual acuity
at final follow-up. Factors most associated with visual impairment (\20/200) were unilateral disease, multiple surgeries, poor vision at diagnosis, and other ocular comorbidities.
The most common primary etiology for vision impairment was amblyopia (54.9%).

CONCLUSIONS

Patients with glaucoma early in life appear to have a better visual acuity prognosis than previously reported, with those with primary congenital glaucoma faring better than other
glaucoma subtypes. Recognition of risk factors for visual impairment can better guide
clinical management and counseling of patients. ( J AAPOS 2012;16:376-381)

ediatric glaucoma is a challenging condition to

treat and is commonly associated with extensive vision impairment. The etiology of patients vision
impairment is often multifactorial, including amblyopia,
optic nerve damage, and other ocular comorbidities.1-3
Recent classification schemes of childhood glaucomas
have focused on distinguishing the various pediatric
glaucomas by etiology, thereby assisting in the selection
of treatment choices specific to the given condition.4 For
instance, primary congenital glaucoma often is treated
with anterior segment angle surgery such as goniotomy or
trabeculotomy as the first-line management strategy,
whereas secondary glaucomas, such as those associated
with anterior segment dysgenesis and aphakic glaucoma,
may be initially managed medically. A better understanding
of how the visual prognosis compares between the various
pediatric glaucoma subtypes would aid not only in counseling parents at the time of diagnosis but also in tailoring
treatment plans to address better an individual patients
greatest risk factor for vision impairment. The purpose of

Author affiliations: Department of Ophthalmology, Childrens Hospital of Philadelphia,

Scheie Eye Institute, Philadelphia, Pennsylvania
Submitted February 16, 2012.
Revision accepted May 1, 2012.
Correspondence: Monica R. Khitri, MD, Philadelphia VA Medical Center, 3900
Woodland Ave., Philadelphia, PA 19104 (email: monica.ralli@gmail.com).
Copyright 2012 by the American Association for Pediatric Ophthalmology and
Strabismus.
1091-8531/$36.00
http://dx.doi.org/10.1016/j.jaapos.2012.05.007

376

this study was to determine the relationship among the various subtypes of pediatric glaucoma and their visual outcomes and to identify the factors that most affected visual
prognosis.

Methods
The medical records of all patients with pediatric glaucoma
treated between 2000 and 2010 at Childrens Hospital of Philadelphia were retrospectively reviewed. Institutional review board
approval was obtained for data review and analysis, and the study
conformed to the requirements of the Health Insurance Portability and Accountability Act. Eligible patients were identified
through queries of the medical billing record. Exclusion criteria
for the study included age .14 years at time of diagnosis, glaucoma related to trauma, and diagnosis and/or initial management
of glaucoma made at another hospital.
The following data were collected: type and laterality of glaucoma, age at diagnosis, ages at all surgeries, types of surgeries undertaken, visual acuities, and associated ocular and systemic
comorbidities. Visual acuities were measured using fixation or
Teller grating acuity cards for nonverbal children and Lea symbols, HOTV, and Snellen letters progressively for verbal children
as cooperation allowed. For those patients with subnormal final
visual acuities (\20/70) the primary etiology for the poor vision
also was determined. The cause of vision impairment in glaucomatous eyes can be multifactorial; however, we determined the single most important contributing factor for each eyes loss of vision
on the basis of the physical examination (ie, presence of optic
nerve pallor and/or cupping, retinal degeneration) and history

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Khitri et al

Table 1. Characteristics of study subjects with pediatric glaucoma

(N 5 133 eyes)
Age at diagnosis (yrs)
Mean (SD)
Median (min, max)
Type of glaucoma, n (%)
Primary congenital glaucomaa
Aphakic glaucomab
Glaucoma associated with anterior segment
dysgenesisc
Sturge-Weber glaucoma
Uveitic glaucomad
Aniridia associated glaucomae
Otherf
Ocular comorbidities at diagnosis, n (%)
Cloudy cornea
Aphakia
Anterior segment dysgenesis
Enlarged cornea
Uveitis
Aniridia
Nystagmus
Strabismus
Retinal degeneration/injury
ROP
Cataract
Pseudophakia
Systemic comorbidities at diagnosis, n (%)
Developmental delay
Chromosomal abnormality
Prematurity
Juvenile idiopathic arthritis
Sickle cell disease
Vision at diagnosis, n (%)
Excellent (20/20 to 20/70, CSM)
Good (\20/70 to 20/200, CUSM)
Fair (\20/200 to 20/800, CUSUM, CSUM)
Poor (\20/800 to light perception, UCSUM,
UCUSUM)
No light perception
Age at last follow-up, years
Mean (SD)
Median (min, max)
Years of follow-up since diagnosis
Mean (SD)
Median (min, max)

2.11 (3.35)
0.36 (0.0, 13.8)
49 (36.8)
38 (28.6)
16 (12.0)
16 (12.0)
5 (3.76)
4 (3.01)
5 (3.76)
53 (39.9)
38 (28.6)
16 (12.0)
5 (3.76)
5 (3.76)
4 (3.01)
4 (3.01)
2 (1.50)
1 (0.75)
1 (0.75)
1 (0.75)
1 (0.75)
9 (10.2)
5 (5.7)
5 (5.7)
4 (4.6)
2 (2.3)
35 (26.3)
73 (54.9)
3 (2.26)
20 (15.0)
2 (1.50)
9.24 (6.87)
7.05 (1.28, 34.3)
7.14 (6.18)
4.95 (0.29, 27.9)

CSM, central-steady-maintained; CSUM, central-steady-unmaintained;

CUSM, central-unsteady-maintained; CUSUM, central-unsteadyunmaintained; ROP, retinopathy of prematurity; UCSUM, uncentralsteady-unmaintained; UCUSUM, uncentral-unsteady-unmaintained.
a
Newborn primary congenital glaucoma, infantile primary congenital
glaucoma, or late-recognized primary congenital glaucoma.4
b
Infantile aphakic open-angle glaucoma.4
c
Sclerocornea, Peters anomaly, iridotrabecular dysgenesis (iris
hypoplasia) syndrome, or Axenfeld-Reiger syndrome.4
d
Open-angle glaucoma associated with chronic uveitis.
e
Congenital aniridic glaucoma or acquired aniridic glaucoma.
f
Angle-closure glaucoma secondary to retinopathy of prematurity,
glaucoma associated with congenital ocular melanosis, or juvenile
open-angle glaucoma.

(compliance with patching regimens, changes in visual acuity over

time). IOP measurements were not investigated in this study,
given the variability of these measurements with patient cooperation in this age group.

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377

Table 2. Management in pediatric glaucoma (N 5 133 eyes)

Surgical management, n (%)
No
Yes
Age at initial surgery, yra
Mean (SD)
Median (min, max)
Age at most recent surgery, yra
Mean (SD)
Median (min, max)
Initial surgery performed, n (%)a
Angle surgery
Filtering surgery
Cyclophotocoagulation
Peripheral iridectomy
Other
Most recent surgery performed, n (%)a
Angle surgery
Filtering surgery
Cyclophotocoagulation
Revision of filtering surgery for failure
Revision of filtering surgery for malpositioned
tube
Other
Total number of surgeries per eyea
1
2
3
4
5
6
7
8
10-12
Mean (SD)
Median

9 (6.77)
124 (93.2)
2.41 (4.19)
0.55 (0.01, 19.8)
4.03 (4.80)
1.62 (0.01, 28.3)
89 (66.9)
20 (15.0)
11 (8.30)
2 (1.5)
2 (1.5)
44 (33.1)
38 (28.6)
21 (15.8)
8 (6.0)
6 (4.5)
7 (5.3)
46 (37.1%)
37 (29.8%)
14 (11.3%)
13 (10.5%)
3 (2.4%)
4 (3.2%)
3 (2.4%)
2 (1.6%)
2 (1.6%)
2.35 (2.01)
2

Restricted to those that received surgery management.

Patients were clinically managed by 1 of 3 pediatric ophthalmologists (MDM, SLD, GEQ). The surgeries were classified as angle
surgery (goniotomy, trabeculotomy), filtering surgery (trabeculectomy, placement of an aqueous drainage device), revision of filtering bleb, cyclophotocoagulation, peripheral iridectomy or
iridotomy, or other (anterior chamber washout, synechiolysis, revision of tube shunt for malposition). The aqueous drainage devices used were the Ahmed glaucoma valve implant (New World
Medical Inc, Rancho Cucamonga, CA), the Baerveldt implant
(Advanced Medical Optics, Santa Ana, CA), and the Molteno implant (Ophthalmic Ltd, Dunedin, New Zealand). The Ahmed
valve implant was placed in a single procedure. The Baerveldt
and the Molteno implants were placed in a staged process with
a 4- to 6-week interval between the plate placement and the tube
introduction. For the purposes of this study, these two-staged procedures were counted as one surgery; the date recorded was that of
the second procedure given that the IOP-lowering effect of the
surgery would not occur until after the second procedure. Besides
surgery, patients often were on topical or systemic glaucoma medications during the course of their treatment.

Statistical Analysis
The patients ocular characteristics at diagnosis and characteristics of surgical management were summarized by mean, SD,

378

Khitri et al

and median for factors measured in a continuous scale, and by

proportions for the categorical factors.
For the statistical analysis of visual outcomes at diagnosis and at
last follow-up, visual acuities were categorized into 5 groups: (1)
excellent (20/20 to 20/70, central-steady-maintained); (2) good
(\20/70 to 20/200, central-unsteady-maintained); (3) fair (\20/
200 to 20/800 central-unsteady-unmaintained, central-steadyunmaintained); (4) poor (\20/800 to light perception, uncentralsteady-unmaintained, uncentral-unsteady-unmaintained), and
(5) no light perception. The percentage of eyes in each category
was calculated and compared among the different types of
glaucoma.
To examine the risk factors for vision impairment, we defined vision impairment to be a final visual acuity \20/200.
We used univariate and multivariate analysis of risk factors, including sex, age at diagnosis, age at surgery, laterality of glaucoma, type of glaucoma, type of glaucoma surgery, visual acuity
at diagnosis, number of surgeries, and years of follow-up after
diagnosis. The factors were first analyzed by the use of univariate analysis, followed by the multivariate analysis including the
risk factors with P \ 0.10 from univariate analysis. The multivariate analyses were simplified by stepwise selection to keep
the statistically significant risk factors with 2-sided P \ 0.05.
The associations of risk factors with vision impairment were
assessed by odds ratio with 95% confidence intervals from
the logistic regression models, with the inter-eye correlation
accounted for by using the generalized estimating equations.5
All the statistical analyses were performed in SAS v9.2 (SAS
Institute Inc, Cary, NC).

Results
A total of 133 eyes of 88 children (50 females [56.8%])
with glaucoma were eligible and included; 24 patients
were excluded for insufficient data resultant from significant treatment periods at other hospitals, 3 for age
.14 years at diagnosis and 2 for history of trauma.
The ocular and systemic presenting characteristics of
the patients at diagnosis are given in Table 1. Fortyfive (51.1%) patients had bilateral glaucoma. The median age at diagnosis was 0.36 years (range, 0-14 years).
The median age for each glaucoma group was as follows: 2.53 years (range, 0.07-12.2 years) for aphakic,
0.30 years (range, 0.00-2.89 years) for primary congenital glaucoma, 0.02 years (range, 0.00-5.93 years) for
Sturge-Weber glaucoma, 0.29 years (range, 0.00-13.8
years) for glaucoma associated with anterior segment
dysgenesis, and 5.50 years (range, 0.14-10.5 years) for
others. The most commonly encountered types of glaucoma were primary congenital glaucoma (36.8%) and
aphakic glaucoma (28.6%). Many of the patients presented with other ocular comorbidities, both related
and unrelated to their diagnosis of glaucoma. The
most common ocular comorbidity was corneal opacification (39.9%) followed by aphakia postcataract extraction
(28.6%). Notably, the vast majority of the eyes (81.2%)
had excellent or good vision at time of diagnosis, with

Volume 16 Number 4 / August 2012

Table 3. Final visual outcomes in pediatric glaucoma (N 5 133
eyes)
Visual outcomes

n (%)

Visual acuity at last follow-up

Excellent (20/20 to 20/70, CSM)
Good (\20/70 to 20/200, CUSM)
Fair (\20/200 to 20/800, CUSUM, CSUM)
Poor (\20/800 to LP, UCUSUM, UCSUM)
NLP
Functional visual outcome at last follow-upa
Good vision in both eyes
Good vision in one eye
Good vision in neither eye
Primary etiology of vision lossb
Amblyopia
Glaucoma
Retinal disease
Corneal opacification
Cataract
Other optic neuropathy

62 (46.6)
18 (13.5)
12 (9.02)
35 (26.3)
6 (4.51)
23 (35.9)
31 (48.5)
10 (15.6)
39 (54.9)
18 (25.4)
10 (14.1)
2 (2.82)
1 (1.41)
1 (1.41)

CSM, central-steady-maintained; CSUM, central-steady-unmaintained;

CUSM, central-unsteady-maintained; CUSUM, central-unsteadyunmaintained; UCSUM, uncentral-steady-unmaintained; UCUSUM,
uncentral-unsteady-unmaintained.
a
Among those who had data for both eyes (n 5 64 patients). Vision
impairment is defined as visual acuity \20/200.
b
Restricted to those with less than excellent vision at last follow-up
(n 5 71 patients).

only 2 eyes (1.5%) presenting with visual acuity of no

light perception.
In regard to the therapeutic management of these patients, only 9 (6.77%) were managed medically on antiglaucomatous medications without a need for surgery
(Table 2). Of those eyes requiring surgery, 78 of 124
(62.9%) required more than one surgery to control their
IOP. Seven eyes (5.3%) required more than 6 surgeries
during the course of this study to control their glaucoma;
each of these eyes had undergone multiple sessions of endoscopic cyclophotocoagulation. The most common initial surgery performed was an angle surgery (89 eyes
[66.9%]) followed by filtering surgery in 20 eyes
(15.0%). When angle surgery was performed, it was always the initial procedure for that particular eye or had
been preceded by a previous angle surgery. Patients
who had filtering surgery, particularly a glaucoma tube
shunt procedure, often underwent bleb revision should
encapsulation have been a cause for failure. Also listed
in Table 2 is the last procedure performed for the glaucomatous eyes during the time period studied. Rarely, patients required anterior vitrectomies (isolated from other
simultaneous glaucoma procedures), anterior chamber
washouts for hyphemas, revisions of tube shunts for hypotony, and synechiolysisall included in the other
surgical category in Table 2.
The median follow-up period was 4.95 years (range, 0.328 years), with only 6 eyes (4.5%) having less than 1 year of
follow-up. The final visual outcomes for the eyes are presented in Table 3. As seen, 80 eyes (60.1%) with glaucoma

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Khitri et al

379

Table 4. Multivariate analysis of risk factors associated with vision impairment at last follow-up
Risk factors
Laterality of glaucoma
Bilateral
Unilateral
Vision at diagnosis
Good ($20/200)
Poor (\20/200)
Glaucoma diagnosis
Aphakic glaucoma
Primary congenital glaucoma
Sturge-Weber glaucoma
Glaucoma associated with anterior
segment dysgenesis
Aniridia associated glaucoma, uveitic
glaucoma, other
No. surgeries
\2
2
.2

No. eyes

No. eyes with vision

impairment, n (%)a

Odds ratio (95% CI)

90
43

26 (28.9)
27 (62.8)

1.00
5.46 (1.83-14.0)

108
25

72 (33.3)
15 (68.0)

1.00
4.68 (1.28-17.1)

38
49
16
16

19 (50.0)
11 (22.5)
5 (31.3)
10 (62.5)

1.00
0.25 (0.07-0.87)
0.07 (0.01-0.40)
1.60 (0.34-7.60)

0.03
0.003
0.56

14

8 (57.1)

0.64 (0.14-2.84)

0.19

55
37
41

12 (21.8)
12 (32.4)
29 (70.7)

1.00
3.30 (0.98-11.1)
32.3 (7.82-133)

P value
0.002
0.02
0.01

\0.0001
0.053
\0.0001

Vision impairment is defined as visual acuity \20/200.

Table 5. Agreement of visual acuity at diagnosis with visual acuity

at final follow-up
Visual acuity at final follow-up
Visual acuity at diagnosis

NLP

Poor

Fair

NLP
1
1
0
Poor
2
9
2
Fair
0
1
1
Good
3
20
6
Excellent
0
4
3
Percent of agreement 5 45/133 5 33.8%
Weighted kappa (95% CI) 5 0.23 (0.16-0.35)

Good

Excellent

0
2
0
11
5

0
5
1
33
23

NLP, no light perception.

had at least 20/200 vision (excellent and good vision as

tabulated), whereas 53 (39.9%) had visual acuity \20/
200, 6 eyes of which had visual acuity of no light perception.
In looking at the patients functional visual outcome or their
vision using both eyes, there were 64 patients with reliably
recorded visual acuities for both eyes, including all 45 of
the bilateral glaucoma patients. In these patients with
available bilateral visual acuity data, 54 (84%) had at least
one eye with good or excellent vision. The primary etiology
for the patients vision impairment (for those without
excellent final visual acuity) also was evaluated, and amblyopia was the most common contributing factor to vision
loss (54.9%) followed by glaucomatous optic atrophy
(25.4%).
Factors associated with vision impairment from multivariate analysis are shown in Table 4. Eyes with unilateral
glaucoma were 5 times more likely to have vision impairment than eyes where the glaucoma was bilateral. Poor
vision at diagnosis was significantly associated with an increased risk of vision impairment at final follow-up (P 5
0.02). As shown in Table 5, of the 133 eyes, 45 (34%) had

Journal of AAPOS

visual acuity at final follow-up that was in the same visual

acuity category at presentation. Further, final visual acuities
in 92 eyes (70%) were the same or differed by only one category from the presenting visual acuity category.
The type of glaucoma also was shown to significantly influence the final visual outcome (Table 4). Eyes with primary congenital glaucoma and Sturge-Weber glaucoma
were less likely to have vision impairment than those with
other glaucoma diagnoses (P 5 0.01). Although newborn,
infantile, and late-recognized primary congenital glaucoma may confer different disease courses, age of disease
diagnosis did not appear to affect final visual prognosis in
the small subset of primary congenital glaucoma patients
studied (P 5 0.47): visual acuities of $20/200 at final visit
were achieved in 75% patients diagnosed before 6 months
of age (n 5 35 patients) and in 86% patients diagnosed at
age $6 months (n 5 14 patients). Finally, eyes that required more surgeries were more likely to be associated
with poor visual outcomes. Sex, age at diagnosis and age
at surgery, type of surgery, and years of follow-up were
all not significantly associated with vision impairment
(P . 0.05).
The distributions of visual acuity at final follow-up by
type of glaucoma diagnosis are presented in Figure 1.
Nearly twice as many eyes with primary congenital glaucoma (34 of 49 [69.4%]) achieved excellent vision at final
follow-up than the other glaucoma diagnoses (15 of 38
with aphakic glaucoma [39.5%]; 6 of 16 with SturgeWeber glaucoma [37.5%]; 5 of 16 with glaucoma associated with anterior segment dysgenesis [31.3%]; P 5
0.02). Despite the differences in final visual acuity distribution among the various glaucoma subtypes, the most common etiology for vision impairment at final follow-up
remained the same: amblyopia (Figure 2). Among eyes
that achieved a final visual acuity less than excellent,

380

Khitri et al

FIG 1. Visual acuity at final follow-up grouped by pediatric glaucoma

subtype (P 5 0.02): excellent (20/20 to 20/70, central-steadymaintained); good (\20/70 to 20/200, central-unsteady-maintained);
fair (\20/200 to 20/800, central-unsteady-maintained, central-steadyunmaintained); poor (\20/800 to light perception, uncentralunsteady-unmaintained, uncentral-steady-unmaintained); and no light
perception (NLP).

amblyopia accounted for vision loss in 60% of those with

primary congenital glaucoma, 69.6% of those with aphakic
glaucoma, 60% of those with Sturge-Weber glaucoma, and
54.6% of those with glaucoma associated with anterior
segment dysgenesis.

Discussion
In our pediatric patients with glaucoma, we found that at
least 60% of the glaucomatous eyes achieved good vision
(ie, $20/200) at final follow-up, and nearly one-half
(46.6%) of the eyes achieved a visual acuity of $20/70,
vision sufficient to qualify for a motor vehicle driving license in most states. Considering the patients vision
with both eyes open (functional visual outcome), more
than 84% of patients who could be tested in each eye had
at least one eye with final visual acuity of $20/200. These
results suggest outcomes better than those reported by earlier case series, which have reported good visual outcomes
in 29% to 41% of patients.6-9 The slightly greater
incidence of excellent vision in this study suggests that
progress that has been made during the last several years
in the medical and surgical management of pediatric
glaucoma, as others have suggested.3,10
We decided to group the various glaucoma subtypes in
a slightly different schematic than that reported by Yeung
and Walton4 to better reflect the specific subtypes most
commonly seen at our institution. Patients with primary
congenital glaucoma were all grouped together for the
purposes of this study despite the potential variability in
genotype because genetic testing was not routinely available. It became apparent that primary congenital glaucoma and Sturge-Weber glaucoma conferred a better

Volume 16 Number 4 / August 2012

FIG 2. Primary etiology for vision impairment in patients with worse

than excellent (\20/70) vision at final follow-up according to glaucoma subtype (P 5 0.20).

visual prognosis than the other subtypes studied. Specifically, only 22.5% and 31.3% of these groups, respectively,
had eyes with final visual acuities \20/200. Eyes with
other causes of glaucoma with additional concomitant ocular abnormalities (aphakia, anterior segment dysgenesis,
uveitis, aniridia, and other) have other additional factors
contributing to their poor visual outcome besides
glaucoma.
Poor vision at diagnosis appeared to portend a poor
visual prognosis. This correlation underscores the importance of early diagnosis to improved visual outcomesin
our study, patients who had already sustained considerable
vision loss by the time of presentation likely already suffered from amblyopia and/or glaucomatous optic neuropathy. Thus, the goal of effective treatment of pediatric
glaucoma may not be to improve patients vision but to
preserve the vision they present with at diagnosis.
IOP control in pediatric glaucoma is possible with
current surgical techniques and medications. The British
Infantile and Childhood Glaucoma (BIG) Eye study demonstrated that IOP control in pediatric glaucoma is successful in 94% of patients.11 However, good IOP control
does not necessarily predict a good visual outcome. Amblyopia proved to be the single most important factor contributing to poor visual outcome in our study. This finding is
similar to visual acuity outcomes associated with other pediatric ocular conditions, such as congenital cataracts.12-14
Successful management of pediatric glaucoma cannot
focus exclusively on IOP control but must also ensure
adequate amblyopia therapy.
Patients with unilateral glaucoma fared worse than
those with bilateral glaucoma, just as in their counterparts with congenital cataracts. In multivariate analysis,

Journal of AAPOS

Volume 16 Number 4 / August 2012

Sturge-Weber glaucoma and primary congenital glaucoma
were associated with a lower risk of vision impairment than
other types of glaucoma. However, nearly twice as many
eyes with primary congenital glaucoma achieved excellent
vision compared with those with Sturge-Weber glaucoma.
This apparently contradictory result is most likely because
Sturge-Weber glaucoma is much more frequently unilateral than is primary congenital glaucoma, and unilaterality
itself confers a 5-fold greater risk for vision loss, presumably related to amblyopia.
Patients who required multiple surgeries fared worse
than those who required fewer surgeries. Final visual acuity
may be related to the number of surgeries by the severity of
the disease (more severe disease causing more vision loss
and requiring more surgery) or through amblyopia because
each surgery is associated with a certain amount of postoperative recovery time, which may represent time lost to
patching therapy.
This study is limited by the difficulty of measuring visual
acuity in the subject population. Visual acuity measurements in nonverbal children are less precise than recognition acuity measurements, and over- or underestimates of
acuity are possible. We used a standardized method to convert fixation acuity observations to recognition acuity testing equivalents. This potential imprecision would mostly
affect the initial acuity data because 75.9% of final acuity
data was measured by recognition acuity. This study is
also limited by the variability in treatment courses, patient
compliance, and follow-up inherent to any large retrospective study. This study highlights the importance of not only
the early recognition and aggressive control of elevated
IOP but also the recognition and treatment of amblyopia,

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Khitri et al

381

which is a common cause of vision loss in patients with

childhood glaucoma.
References
1. Kipp MA. Childhood glaucoma. Pediatr Clin North Am 2003;50:
89-104.
2. Aponte EP, Diehl N, Mohney BG. Incidence and clinical characteristics of childhood glaucoma. Arch Ophthalmol 2010;128:478-82.
3. Biglan AW. Glaucoma in children: Are we making progress. J AAPOS
2006;10:7-21.
4. Yeung HH, Walton DS. Clinical classification of childhood glaucomas. Arch Ophthalmol 2010;128:680-84.
5. Liang KY, Zeger SL. Regression analysis for correlated data. Annu
Rev Pub Health 1993;14:43-68.
6. Kargi SH, Koc F, Biglan AW, Davis JS. Visual acuity in children with
glaucoma. Ophthalmology 2006;113:229-38.
7. Haas J. Principles and problems of therapy in congenital glaucoma.
Invest Ophthalmol 1968;7:140-46.
8. Haas JS. End results of treatment. Trans Am Acad Ophthalmol
Otolaryngol 1955;59:333-41.
9. Robin AL, Quigley HA, Pollack IP, et al. An analysis of visual acuity,
visual fields, and disk cupping in childhood glaucoma. Am J Ophthalmol
1979;88:847-58.
10. Bussieres JF, Therrien R, Hamel P, Barret P, Prot-Labarthe S. Retrospective cohort study of 163 pediatric glaucoma patients. Can J
Ophthalmol 2009;44:323-7.
11. Papadopoulos M, Cable N, Rahi J, Khaw PT, the BIG Eye Study
Investigators. The British Infantile and Childhood Glaucoma (BIG)
eye study. Invest Ophthalmol Vis Sci 2007;48:4100-106.
12. Birch E, Stager DR, Wright W. Grating acuity development after
early surgery for congenital unilateral cataract. Arch Ophthalmol
1986;104:1783-7.
13. Thompson DA, Moller H, Russell-Eggitt I, et al. Visual acuity in
unilateral cataract. Br J Ophthalmol 1996;80:794-8.
14. Lewis TL, Maurer D, Brent HP. Development of grating acuity in
children treated for unilateral or bilateral congenital cataracts. Invest
Ophthalmol Vis Sci 1995;36:2080-95.