Primary Open Angle Glaucoma in 8y/o

My question concerns my 8 y/o son with POAG diagnosis. Diagnosis in Dec '06, followed by a regime of drops. Pressures seemed to be controlled ou. OS IOP at onset was ~40 mmHg, OD ~ 25mmHg. Post trtmnt with Alphagan P BID ou, Azopt BID os pressures were ~15 ou. Last week os iop spiked to 50 (od ~ 16). Diamox , timoptic xe, travatan were added ( Azopt stopped). All exams show clear corneas, open angles, normal vf, corrected vision 20/20 od, 20/30 os, c/d ratio slightly worse in os (can't recall what they were)---otherwise healthy kid. Next step would presumably be surgery. I would like to exhaust all other options before sx. Could the unilateral nature of this be indicative of some sort of something (venous flow problem)? In the abscence of any systemic issues (sturge-weber, others typically seen with glauc)) or other ocular issues are there other avenues to diagnose and/or rule out. Would an MRI or MRA tell us anything? Could there be some sort of -oma lurking in there somewhere? We are recieving excellent care and advice form our OD and Ophthalmologist, but would like to get additional input.
Any resources or advice you can offer is appreciated

[Forum-OD-MP]

'Could the unilateral nature of this be indicative of some sort of something (venous flow problem)'

probably not.  glaucoma is always described as 'bilateral but asymmetric', meaning that almost every glaucoma patient has one eye with higher pressures.  this phenomenon is poorly understood by the profession.

'Would an MRI or MRA tell us anything?'

unlikely to, no.

'Could there be some sort of -oma lurking in there somewhere?'

highly, high;y unlikely b/c both eyes have high pressure.  a tumor would be pretty obvious and have a lot of other signs/symptoms, and would be really unlikely to affect the iop in BOTH eyes.  this is much, much more likely to be POAG than anything else.

surgery is probably your best option IMO.  most glaucoma surgeries are laser-based and not so bad, and the alternative is 75+ years of expensive eyedrops and trying to be compliant.  very difficult to achieve, even in patients/parents with the best of intentions.

[aimee37]

Thanks for the quick reply.  your assessment aligns with other the opinions of other resources. It was also reassuring to hear of laser options , as the thought of managing (from a parent point of view) an 8 y/o with a bleb was not a comforting one.

surgery is probably your best option IMO.
  not sure what IMO is?  

thanks for your input.

[aimee37]

imo (in my opinion)  ....got it

[aimee37]

IMO = "in my opinion"

and a bleb is pretty much a last resort.  no way your 8 year old gets a bleb as a 1st option.  he's going to get SLT or ALT:

http://www.glaucoma.org/treating/surgery.html?section=152

its relatively painless and highly likely to work well.  i have an 8 year old and i guarantee that if my 8 year old had high iop/glaucoma, laser would be my 1st choice.

[aimee37]

Thanks again.

[aimee37]

this in in f/u to ? re surgical options.  You state that SLT or ALT  would be first option...what type of pressure reduction on average would one expect from  LT vs trabeculoplasty (conj flap)?  we are realisticaly looking at a reduction of 20-30 units!  The kid has pressures of 50 at times!  IOP is 30 now being treated with an arsenal of gtts.   My instincts tell me that there is an underlying systemic issue...nothing to back it up, just having a hard time coming to terms with that high of pressure, unilaterally, in an 8 y/o.  thanks again for your opinion

[aimee37]

dont know if you can get 30 mmHg out of SLT.  but worth a shot.  at the very least it would greatly reduce the "arsenal" of meds.

unlikely IMO to be an "underlying" systemic condition.