Buphthalmos


Article Author:
Kaberi Feroze


Article Editor:
Bhupendra Patel


Editors In Chief:
Jasleen Jhajj
Cliff Caudill


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/13/2019 4:05:28 PM

Introduction

The word buphthalmos originates from the Greek word "ox-eyed." Congenital enlargement of the eye was recognized as early as 400 BC by Hippocrates, and later by Celsus and Galen in the first and second centuries AD respectively, but it was not related to increased intraocular pressure.[1]It was just after the 19th century, with the invention of the ophthalmoscope and tonometer, and with precise anatomical dissection, that this condition was related to raised intraocular pressure (IOP). At present, the term "buphthalmos" is used to describe the visible enlargement of the eyeball detected at birth or soon after, due to any uncontrolled glaucoma in early childhood.

Etiology

Buphthalmos occurs most frequently due to primary congenital glaucoma. Other conditions which can cause raised IOP in early childhood, for example, Sturge-Weber syndrome, neurofibromatosis, aniridia, etc can also cause buphthalmos.

Epidemiology

Many studies have put the average prevalence of buphthalmos at 1 in 30,000 births.[2] Studies among the Slovak Romani population and studies conducted in South India and Saudi Arabia show a significantly higher prevalence of primary congenital glaucoma. In Saudi Arabia and the Romani population of Slovakia, primary congenital glaucoma is the most frequent cause of childhood blindness. The highest reported prevalence is in Slovakia (1:1250 live births), followed by Saudi Arabia (1:2500 live births).[3]

Pathophysiology

Extensive growth of the human eye occurs in the first 5 years of life with the greatest increase in axial length seen in the first 4 years. High intraocular pressure causes an increase in axial length as well as an increase in the corneal diameter. This increase in the size of the eyeball in congenital glaucoma occurs due to the extreme softness and elasticity of the infantile eyeball. Increase in the size of the eyeball can cause axial myopia and increase in corneal diameter can cause thinning of cornea and breaks in the Descemet's membrane. These breaks in the Descemet's membrane are called Haab's striae, which is a classical finding in patients with buphthalmos. A reduction in the number of endothelial cells in the cornea has also been reported. Severe congenital glaucoma has been associated with corneal haze, and studies report a correlation between corneal haze and other factors which determine the severity of the disease, for example, increased intraocular pressure, CD ratio, and corneal diameter.

History and Physical

The most common cause of buphthalmos is primary congenital glaucoma (onset at birth) or primary infantile glaucoma (onset after birth to 3 years). Buphthalmos is usually not seen in glaucoma with onset after the age of 3 years. That is why juvenile onset (3 years to teenage years) glaucoma is not associated with buphthalmos.[4]

The classical symptoms of congenital and infantile glaucomas include tearing, photophobia, and irritability. The parents may notice a hazy cornea or an increase in the size of the cornea. On examination, clinicians notice that there is increased corneal diameter, deep anterior chamber, and an increase in the size of the globe. Corneal examination reveals the presence of corneal edema, with ruptures of Descemet's membrane known as Haab's striae. The intraocular pressure is elevated, and there may be optic disc cupping.

Other conditions causing buphthalmos:

  • Aniridia: Characterized by complete or partial iris hypoplasia. Inheritance is autosomal dominant. Angle-closure is thought to be the cause of the glaucoma
  • Neurofibromatosis type 1: Characterized by multiple neurofibromas, cafe au lait spots, iris Lisch nodules, and axillary/ inguinal freckling. Inheritance is autosomal dominant. Glaucoma is thought to be due to developmental anomalies of the anterior chamber angle.
  • Sturge-Weber syndrome: Characterized by nevus flammeus of the face and meningeal angiomas. Glaucoma and associated angle anomalies are seen in 60% of cases. Angle developmental anomalies and raised episcleral venous pressure are the proposed causes of glaucoma.[5]

Evaluation

The mainstay of evaluation of Buphthalmos patients is Examination under anesthesia. The following examinations should be done:

  • Refraction using streak retinoscope
  • Corneal Examination
  1. Measurement of corneal diameter using calipers may show an increase. A corneal diameter greater than 12 mm is considered abnormal.
  2. Corneal edema may be seen due to raised intraocular pressure.
  3. Breaks in the Descemet's membrane or Haab's striae may be seen, which are typically horizontal or parallel to the limbus.[6]
  • Examination of the anterior segment may reveal other underlying causes of Buphthalmos like Aniridia and Lisch nodules of neurofibromatosis.
  • Measurement of intraocular pressure in the first few minutes of anesthesia to avoid falsely low readings.
  • Gonioscopy with a direct gonioscope may demonstrate anterior insertion of iris onto the trabecular meshwork, the "Loch Ness monster" phenomenon (vascular loops in the angle) and "Lister’s morning mist" (fine, fluffy tissue on the peripheral iris).
  • Ophthalmoscopy may demonstrate the presence of optic disc cupping. It is interesting to note that optic disc cupping may be reversed with appropriate treatment in many cases of primary congenital glaucoma.
  • Ultrasound biomicroscopy may be done in cases of an opaque cornea to evaluate the anterior segment structures.
  • Clinical genetics consultation may be advised.

Treatment / Management

The main aim of treatment is to reduce IOP to prevent progressive corneal opacification and glaucomatous optic atrophy and thereby preserve existing vision.[7] The most definitive treatment of Buphthalmos is surgical. Medical management is indicated to control the IOP to clear the cornea during surgery.

Medical Treatment

Medical therapy can be instituted with topical Beta blockers, Carbonic anhydrase inhibitors or Prostaglandin analogs.

Surgical Treatment

Goniotomy: In this procedure, openings are created in the trabecular meshwork, thus reducing resistance to outflow.

Trabeculectomy: The trabecular meshwork is incised by cannulating Schlemm's canal with a probe.

Trabeculectomy: A section of the trabecular meshwork and Schlemm's canal is removed underneath a partial thickness scleral flap, thus creating a fistula draining aqueous to the subconjunctival space.

Combined trabeculectomy and trabeculectomy: Involves removal of a block of sclera after performing trabeculectomy

Glaucoma drainage implants

Cyclodestructive procedures

In the postoperative period, the surgeon should correct any refractive errors and also manage amblyopia, if any. Lifelong monitoring of IOP is indicated in these patients.

Pearls and Other Issues

Although buphthalmos is not a very common condition, it may be associated with significant visual loss. Many children require low vision aids and visual rehabilitation even after successful control of IOP.[8] Once considered a condition with a bleak prognosis, this condition can now be managed reasonably well with the modern surgical procedures.

Enhancing Healthcare Team Outcomes

The diagnosis and management of buphthalmos is with a multidisciplinary team that includes a pediatrician, nurse practitioner, primary caregiver and an internist. The main aim of treatment is to reduce IOP to prevent progressive corneal opacification and glaucomatous optic atrophy and thereby preserve existing vision.[7] The most definitive treatment of Buphthalmos is surgical. Medical management is indicated to control the IOP to clear the cornea during surgery.

Outlook

Over the years, the prognosis of children with buphthalmos has slightly improved. However, despite treatment, many children require low vision aids and visual rehabilitation.[8] Once considered a condition with a bleak prognosis, this condition can now be managed reasonably well with the modern surgical procedures.


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Buphthalmos - Questions

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A 2-month-old baby is brought to the ophthalmologist with complaints of inability to look at light and watering from both eyes. The ophthalmologist notices that the corneal diameter looks larger than normal for that age. Which among the following examinations will help to arrive at a definitive diagnosis of the child’s ocular condition?



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A 10-month-old baby boy is brought to the ophthalmologist with complaints of tearing, irritability, and photophobia. On examination, the ophthalmologist notices corneal edema and a large cornea. Examination under anesthesia shows a raised intraocular pressure. Which of the following corneal signs may be seen in this patient?



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Which among the following would be the best treatment option for a child with buphthalmos and a hazy cornea?



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Which of the following is a reported finding in patients with buphthalmos on gonioscopy?



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Which of the following investigations could be of help in assessing the integrity of the anterior segment in a patient with buphthalmos and hazy cornea?



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Buphthalmos - References

References

[Epidemiology and clinical characteristics of primary congenital glaucoma]., Aziz A,Fakhoury O,Matonti F,Pieri E,Denis D,, Journal francais d'ophtalmologie, 2015 Dec     [PubMed]
Unilateral congenital buphthalmos., Vasileiadis GT,Frangouli O,, BMJ case reports, 2015 Jun 3     [PubMed]
Primary congenital glaucoma outcomes: lessons from 23 years of follow-up., Zagora SL,Funnell CL,Martin FJ,Smith JE,Hing S,Billson FA,Veillard AS,Jamieson RV,Grigg JR,, American journal of ophthalmology, 2015 Apr     [PubMed]
Primary Congenital Glaucoma, Abu-Amero KK,Edward DP,,, 1993     [PubMed]
Corneal changes assessed using confocal microscopy in patients with unilateral buphthalmos., Mahelková G,Filous A,Odehnal M,Cendelín J,, Investigative ophthalmology & visual science, 2013 Jun 10     [PubMed]
Buphthalmos development in adult: case report., Alves M,Malki LT,Rocha EM,, Arquivos brasileiros de oftalmologia, 2012 Oct     [PubMed]
Medical and surgical outcomes in childhood glaucoma: a population-based study., Aponte EP,Diehl N,Mohney BG,, Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus, 2011 Jun     [PubMed]
Buphthalmos: early glaucoma history., Mark HH,, Acta ophthalmologica, 2011 Sep     [PubMed]

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