NHMRC Glaucoma Guidelines - ANZGIG

NHMRC GUIDELINES FOR THE SCREENING, PROGNOSIS, DIAGNOSIS, MANAGEMENT AND PREVENTION OF GLAUCOMA
Chapter 9 – Medication
Table 9.7: Treatment of glaucoma in children
Medication
class
Beta-blockers
Carbonic
anhydrase
inhibitors
Prostaglandin
analogues
Alpha 2
-agonists
Information on use in children
Beta-blockers are often used as first choice treatment for glaucoma in children
(Moore & Nischal 2007). Beta-blockers should be avoided in premature and small infants
as these agents can cause bradycardia, bronchospasm and hypoglcaemia. In general,
beta-blockers should be used at the lowest concentration and dose possible.
Dorzolamide is reported to be a better choice for children than brinzolamide because its
topical use causes less burning, stinging, and itching (Coppens, Stalmans, Zeven et al 2009).
The use of topical and systemic carbonic anhydrase inhibitors has been associated with
causing metabolic acidosis in infants, which can present as failure to thrive. Therefore infants
on these medications should be observed to ensure they are feeding well and gaining weight.
Despite this potential side effect, topical carbonic anhydrase inhibitors are often used as first
or second choice treatment in young children (Moore & Nischal 2007).
Systemic treatment with acetazolamide is usually last choice, and is used in situations when
glaucoma remains unsatisfactorily controlled with other topical medications or in an attempt
to avoid/delay surgical intervention and prevent further glaucomatous optic neuropathy.
This is based on the increased risk of side effects associated with systemic carbonic anhydrase
inhibitor therapy (Coppens et al 2009).
While prostaglandin analogues substantially reduce IOP in adults, there is some evidence
to suggest that they may not be as effective in reducing IOP in many paediatric glaucomas.
Prostaglandin analogues are usually used as second choice therapy in children but
administration as first choice therapy is acceptable as these agents are often effective in
these settings and are well tolerated with the added convenience of once daily administration
(Moore & Nischal 2007).
Alpha 2
-agonists are contraindicated in children less than two years of age and should only
be used with caution in children younger than seven years of age as children are particularly
sensitive to the central nervous system depressant effects of these medications. Several case
reports of somnolence, respiratory depression and hypotony have been reported after use in
children (Coppens et al 2009). Apraclonidine and brimonidine are usually used as second or
third choice agents in the management of glaucoma in children and are useful as short-term
adjunct therapy pre- and post-surgery (Moore & Nischal 2007). The use of apraclonidine is
usually limited to short-term therapy, while brimonidine may be used long-term (AMH 2009).
Evidence Statements
• Evidence supports using beta-blockers in infants and children where necessary.
• Evidence suggests using beta-blockers with caution in premature and small infants, as bradycardia,
bronchospasm and hypoglycemia have been reported.
• Evidence indicates caution when using topical and systemic carbonic anhydrase inhibitors in children,
in situations where glaucoma is resistant to other treatment and/or prior to surgery.
Women wishing to conceive
Women with childbearing potential, who have glaucoma, should be encouraged to discuss their
reproductive plans with a health care provider prior to becoming pregnant. This allows treatment
choices to be planned appropriately, optimising benefits for the mother and minimising risks for
the foetus by managing and potentially reducing medication exposure during critical early stages
of foetal development. An appropriate treatment plan will depend on the degree of the patient’s
glaucomatous damage, the level of her IOP and personal preferences. It may be appropriate to
offer primary surgical intervention to women with glaucoma who wish to conceive.
National Health and Medical Research Council 131