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My 7 year old has uveitis that is associated with juvenile idiopathic arthritis (JIA). She was diagnosed 5 years ago, and has been using steroid eye drops, Timoptol, oral steroids, methotrexate and Humira. The inflammation is finally under control, but my ophthalmologist has said that even though we are starting to come off steroids (she's a steroid responder) her pressure may not return to normal, and they may need to insert a “drain.” My daughter was in the doctor’s office, so I couldn't ask too many questions. Can you please answer the questions below?

First, let me say that I am sorry that you and your child are going through while she is so young. I hope everything turns out well. Unfortunately, these cases can sometimes be quite difficult to manage, so routine follow-up with a pediatric glaucoma specialist will be of utmost importance. Given the fact that your daughter is so young and has so many years of life ahead of her, it is important to control the glaucoma as well as possible to preserve as much vision as possible. Let me try to answer your questions one at a time.

  • Is it a complicated operation? The operation itself is really not technically difficult from the surgeon's standpoint as long as the eye anatomy is relatively normal. I typically tell my patients that it takes an hour to 90 minutes in most cases. Some surgeries are more complex than others, but for the most part, if your daughter's only problem is JIA and uveitic glaucoma, the surgery should not be technically difficult.

  • Are there side effects? Absolutely. There is not a single medication or surgical procedure that does NOT have side effects. Any time we recommend a treatment or surgery, we discuss the risks, benefits, and alternatives of the treatment or surgery. Risks for the glaucoma drain or glaucoma valve include (but is not limited to) pain, bleeding, infection, double vision, pressure being too low after surgery which can cause some problems, pressure not being low enough after surgery, need for further surgery because the pressure is too low or too high, loss of vision, loss of the eye, or death (any surgery that involves anesthesia must include risk of death in the discussion even though it is incredibly low). Each of these risks is relatively low; however the risks are real. You need to have a full discussion with your eye doctor before agreeing to have the surgery. I suggest that you have your daughter step out of the room or make a separate appointment without your daughter to discuss the risks. In addition, you can also discuss alternative treatments or no treatments at all (although if the pressure is elevated that would likely mean loss of vision eventually). Again, you will need to have a full discussion with your doctor prior to the surgery.

  • Where does the fluid from this drain go? I tell my patients that the eye is like a baseball (the sclera) wrapped in saran wrap (the conjunctiva). During the surgery, we cut a hole in the conjunctiva and attach a small plate with a tube to the sclera at the top of the eye between the muscles. The tube is then tunneled into the front of the eye and we cover that with some tissue. We then sew the conjunctiva back and it heals over. The fluid travels from inside the eye, down the tube (drain), and onto the plate and is released on top of the eye (but under the conjunctiva). The body then reabsorbs the fluid naturally and the pressure goes down.

  • Will her eye look different after the surgery? Possibly. There is always a risk for the lid drooping slightly (ptosis) or being slightly fuller than the other side (there is a plate under the eyelid and on top of the eye). In addition, the tube is covered with a piece of tissue (either donor sclera or another material) and that tissue is white. You can often lift the lid and see that white piece of tissue covering the tube. Some doctors are now covering these with donor corneas. The advantage is that it is a clear piece of tissue and is less noticeable, but it does cost a bit more.

  • Will her vision be affected? If the pressure is not reduced and there is evidence of glaucoma, then yes her vision will likely continue to decline. If you chose to do the drain, there is a possibility of having double vision because the plate sits between the two muscles and does take up some space. Otherwise, the drain itself does not usually cause changes in vision. As mentioned previously, this surgery can cause the pressure to be too low or not low enough. Too low and the vision can be changed (and possibly require further surgery). Too high and you are back to needing further surgery or drops to get the pressure down to the target

I hope this helps. I know this can be a difficult time. I suggest that you take time to have a long discussion with your eye doctor regarding your child's risks, benefits, and alternatives. There will be risks, but it is important to be informed going into the surgery. No surgery is perfect and there is always a chance that a single surgery or treatment will not be enough; however, in most cases eye doctors can eventually control the pressure. I wish the best of luck to both of you.

Posted 06 May 2011

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