Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Childhood Glaucoma

Childhood glaucoma is a group of rare but severe disorders with raised intraocular pressure (IOP); primary congenital glaucoma (PCG) causes 5% to 18% of childhood blindness [S9]. The burden is heaviest in low- and middle-income countries, where delayed diagnosis, limited treatment and poor follow-up worsen outcomes [S1] [S12]. Treatment is mainly surgical and lifelong [S1] [S9].

Key points - Signs include buphthalmos or progressive myopic shift, Haab striae, corneal oedema, increased corneal diameter, raised IOP and optic disc cupping (narrative review) [S9]. - Angle surgery (goniotomy, trabeculotomy) is first line; trabeculectomy and drainage devices are second line; cyclodestruction is reserved for eyes with limited visual potential [S9] [S12]. - 360-degree circumferential trabeculotomy may give greater surgical success than conventional trabeculotomy (moderate certainty) [S2]. - After surgery, rigid gas-permeable contact lenses improved visual acuity more than spectacles in an RCT [S11]; amblyopia and refractive care matter as much as IOP [S3] [S11]. - No high-quality clinical practice guideline specific to childhood glaucoma exists [S4].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Enlarged or cloudy cornea, buphthalmos, rising myopia in an infant or child [S9]. Any of these needs an urgent eye examination.
• Children on topical steroids: young age, family history of glaucoma, vernal keratoconjunctivitis and uveitis are risk factors for a high steroid response [S10].
• Corneal changes on netarsudil: reticular epithelial oedema occurred in 15.9% of treated eyes [S8].

Recognise it: types and risk

• The Childhood Glaucoma Research Network classifies primary glaucoma (PCG and juvenile open-angle glaucoma) and secondary glaucoma (with non-acquired ocular anomalies, systemic disease, acquired conditions, or after cataract surgery) [S9].
• PCG prevalence is 1 in 10 000 to 68 000 in Western countries [S9]; in India and the Middle East the disease often presents with severe corneal oedema and megalocornea [S12].
• Genetics: CYP1B1 variants were found in 5% to 86% of PCG depending on population; MYOC variants in up to 36% of juvenile open-angle glaucoma [S6].
• Guidelines consistently recommend eye screening for children and additional screening for those at high risk [S4].

Confirm it

• Examination findings to record: IOP, corneal diameter and clarity, Haab striae, refraction, cup-disc ratio and asymmetry of at least 0.2 [S9].
• Genetic testing practices vary and there are no widely accepted testing guidelines [S6].

Manage it

Before acting on this section, check the national and local guidelines, product information and regulatory approvals that apply where you practise. See the medical disclaimer.

Tier A (primary care / no specialist)

• Recognise the signs above and refer the child the same day [EIC expert opinion].
• Avoid prolonged topical steroid use without eye review in at-risk children [S10].

Tier B (general eye clinic)

• Confirm raised IOP and corneal signs and refer to a paediatric glaucoma surgeon [S9] [EIC expert opinion].
• Medication is often used before surgery [S9]; one guideline listed topical beta-blockers or carbonic anhydrase inhibitors, on low to moderate quality evidence or expert opinion [S4]. Dosing for children is not covered by these sources; follow paediatric formularies.
• Correct refractive error and treat amblyopia after surgery; optical correction was needed in 66% of PCG eyes long term [S3].

Tier C (specialist centre)

1. Angle surgery. Goniotomy and trabeculotomy are first-line operations [S9] [S12]. Microcatheter-assisted 360-degree trabeculotomy gave lower IOP at 12 months (MD -1.77 mmHg) and higher success (RR 1.54) than conventional trabeculotomy [S2].
2. Combined trabeculotomy-trabeculectomy (CTT). CTT and trabeculotomy showed little to no difference in IOP or success at 1 year (very low certainty) [S2], but CTT is described as showing superior long-term success in Indian children (narrative review) [S12]. Caregiver quality of life improved after CTT [S5].
3. Cyclophotocoagulation. Transscleral and endoscopic cyclophotocoagulation both lowered IOP (from 31.2 to 20.8 mmHg and from 32.9 to 22.6 mmHg), with multiple sessions often needed [S7].
4. Netarsudil may be an adjunct in refractory cases on maximal drops, with careful corneal examination; evidence is retrospective [S8].
5. Optical rehabilitation. Rigid gas-permeable lenses gave 0.19 logMAR more improvement than spectacles at 1 year, and better stereoacuity [S11].
6. Long-term care. Lifelong monitoring is needed because surgical success can decline over time [S12]. Surgical success was associated with better final acuity and stereoacuity [S3].

Refer when

Pitfalls

• Treating only the IOP and neglecting refraction and amblyopia [S3] [S11].
• Losing children to follow-up: inadequate follow-up worsens outcomes in developing countries [S1].
• Ignoring caregiver burden, which is high and worse with longer and more severe disease [S5].
• Missing steroid-induced pressure rise in children [S10].

Evidence notes

• Thin evidence. The search sheet held mostly narrative reviews; trials are few and small, and no high-quality guideline exists [S2] [S4]. Clinical signs and the treatment sequence rest on narrative reviews [S9] [S12].
• The Cochrane finding of no difference between CTT and trabeculotomy conflicts with the Indian review's preference for CTT [S2] [S12].
• Not covered by these sources: examination under anaesthesia technique, drug doses for children, drainage device outcomes in children, and glaucoma after childhood cataract surgery.

Related articles

• Paediatric cataract
• Glaucoma Drainage Devices
• Tonometry: Goldmann, rebound and home monitoring

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.