(December 15, 2008 - Insidermedicine) On a recent trip to Boston, we caught up with Dr. Janey Wiggs, MD, PhD, who is an Associate Professor of Ophthalmology, at Harvard Medical School and an Ophthalmologist at Massachusetts Eye and Ear Infirmary, specializing in Glaucoma and Genetic Eye Disease.
If I had a baby with chronic tearing
If someone has a newborn baby that is chronically tearing there are several types of diseases that can cause that. The first consideration is whether or not there is a problem with the tear system, or if there are other problems with the eye, among these, glaucoma. The first thing that should be done is that the baby should be brought to an ophthalmologist because it is only an ophthalmologist that is going to be able to differentiate between these different possibilities, and these two categories have very different consequences. The tearing problem from abnormalities in the tear ducts is actually very straightforward to take care of, and in fact most babies usually grow out of that as their tear ducts enlarge with growth.
The tearing that is due to changes in the eye secondary to congenital glaucoma is a much more serious problem and it is a problem that could cause permanent blindness if not treated relatively soon after the baby’s birth. It is very important to see an ophthalmologist as soon as possible. Most pediatricians who examine the babies right after the baby is born will be tuned into this, and will recognize that the baby should be seen by an ophthalmologist, but just so that the parents are aware as well, it is very important that that exam proceed swiftly.
What type of assessment should be expected?
When the ophthalmologist sees the baby there are several different tests that are going to be done to differentiate between these different possibilities. Examining an infant generally requires general anesthesia because babies are very difficult to examine; their eyes are very difficult to examine if they are awake and alert, although sometimes with newborns you can get away with it because they are still a little sleepy, and especially if they have just been fed you might be able to sneak in some measurements in the office, but most pediatric ophthalmologists , which would be the type of ophthalmologist that would see this baby would start by doing whatever they can in the office. The types of measurements that would be made are, first of all, the ophthalmologist will get a sense for whether the baby is using the eye: is the baby fixing and following, looking at objects (in newborns this can be tricky too because in a lot of newborns, they are really just developing their visual system so they may not pay a lot of attention to various objects). Generally you can get a sense of if the eye movements are normal, if the pupilary responses are normal, and that will help decide if the visual acuity or vision is actually being processed properly.
Also in the office, it is certainly possible to do an examination of the front part of the eye (called the anterior segment). In that type of exam, we can assess the quality or the cornea, determine whether the cornea is clear or cloudy, determine whether there are breaks in the corneal membrane which can occur if it is congenital glaucoma, and also get a sense of how much tearing there is and where the tears are going. We can determine whether the baby is photophobic if the light is really bothering them, and that can also be an important consideration.
If the baby is really cooperative, it may be possible to measure the intraocular pressure on the ovis, and that is going to be the one really important thing to differentiate between glaucoma from the lacrimal gland obstruction which can cause tearing because of the abnormal tear flow apparatus. This is done with an instrument that has a little transducer that measures the resistance to just pushing in the cornea a little bit. It may not be possible to do that in the office, and if the tear ducts look normal on visual inspection, then it will be necessary to take the baby to the operating room to do an exam under anesthesia. Under anesthesia the pressure in the eye can be measured to see if there is elevated intraocular pressure (which would be a sign that there is congenital glaucoma), the quality of the cornea can also be assessed, and the quality of the optic nerve can be assessed as well, to determine whether there has been any damage to the optic nerve. Also under anesthesia in the operating room, the tear drainage structures (called the lacrimal system) can be probed to determine whether there is any obstruction. That really can’t be done in the office setting. Once that is done, it will become readily apparent which one of these diagnoses it is, and then they each have very different courses of action.
What should be done after diagnosis?
The important thing if it is congenital glaucoma is to lower the intraocular pressure. This is not going to cure the disease, it is not going to take the disease away, it’s not like giving an antibiotic for an infection, or putting a cast on a leg if its broken. It is something that the patient is going to have to live with for the rest of their life. In adults, we would normally treat elevated intraocular pressure with medication or drops until the disease became so advanced that we needed to do a surgical procedure. In babies it is very often the case that the clinical course will go directly to surgery because of two reasons: firstly, it is very difficult for babies to use drops effectively for the rest of their lives (some of these drops aren’t even approved for use on children), secondly, because of the underlying problems that gave rise to the congenital glaucoma in the first place, surgery may be more effective than the medications. There are certain types of surgical procedures that are used only in children, and those can work very well for congenital glaucoma and the children can have good success and not need any additional therapy for a number of years.