NINE-YEAR-OLD Hajra visited the paediatric ophthalmology department at our hospital with complaints of decreased vision. An examination revealed that her visual loss was significant and irreversible in both eyes. All that could be done at this stage was to prevent further loss of vision by surgery.

Hajra is one of the many unfortunate children whose vision has been compromised because of the injudicious use of over-the-counter steroid eye drops. These potent topical anti-inflammatory medicines are frequently prescribed for ocular irritation, including seasonal allergy, owing to their remarkable healing properties. They are prescribed by salesmen at pharmacies, relatives, quacks, sometimes even unwary general practitioners, who are ignorant of these medicines’ potential for raising intraocular pressure, leading to glaucoma and irreversible blindness.

At our hospital, we see around five patients every week with vision loss that stems from steroid-induced glaucoma. This response, though also seen in adults, is most commonly seen in the paediatric patient population. Our GPs should always counsel patients to see an ophthalmologist if an eye pathology persists beyond a week. Pharmaceutical companies should also mention the side-effects of these medicines on their packaging.

World Glaucoma Week, held every year in the third week of March, aims to raise awareness about this eye condition. Although various platforms are actively engaged in educating people about adult glaucoma, public knowledge regarding paediatric glaucoma is scarce. A significant proportion of glaucoma patients in Pakistan are children — from every age group.

A significant ratio of glaucoma patients in Pakistan are children.

Glaucoma is also (though rarely) diagnosed in neonates. Congenital glaucoma is a sight-threatening condition which presents with light aversion, watering and an unusually large diameter of the cornea or a bluish/cloudy cornea at birth. It is the outcome of genetic mutation and is sometimes linked with other ocular and systemic conditions. Left untreated, it can cause permanent corneal scarring and irreparable damage to the optic nerve. Examination at birth by an ophthalmologist is recommended for every child to rule out any eye abnormalities. The earlier the condition is diagnosed, the greater the chances of preserving vision.

Ocular trauma is another factor that can raise pressure inside the eye and lead to silent visual loss, sometimes over many years. Eye surgery in the early years of life for congenital cataract can also lead to glaucoma in a small proportion of children. Treatment options for glaucoma include instilling eye drops to relieve pressure inside the eyes. Regrettably, many cases of paediatric glaucoma are not controlled by topical medicines alone and patients frequently need surgery, with lifelong monitoring. The positive outlook is that with timely diagnosis and initiation of treatment, progressive visual loss from glaucoma can be halted.

Symptoms of adult glaucoma include blind spots anywhere in the visual field, the perception of reduced peripheral vision during driving, and in advanced cases, tunnel vision with only a central island of remaining vision. Some patients also have sudden pain in the eye due to the acute rise of intraocular pressure, which needs emergency management. The challenge with adult glaucoma diagnosis is that in a significant majority, it is detected at a routine eye examination, without the patient noticing any changes in vision. It is therefore referred to as the “silent thief of sight”, as eye damage is slow but can be irreparable even before noticeable visual loss sets in.

Early detection of glaucoma is possible at a routine eye examination by assessing vision, checking intraocular pressure by a simple test and having a look at the back of the eye to check for signs of optic nerve damage. If clinical features suggest the presence of glaucoma, the ophthalmologist can order a few investigations to confirm the diagnosis, assess severity of the disease and monitor its progression. These tests require specialised equipment, but none are invasive and all can be done in the clinic.

Irrespective of whether one is a child or an adult, an annual eye examination by an ophthalmologist is recommended to detect early signs of glaucoma and intervene before it is too late. Over the years, a number of well-equipped eye care centres have been established in all major cities in Pakistan, with referral centres in many villages and smaller cities; for instance, the Al Shifa Trust Eye Hospital in Rawalpindi and the LRBT Trust Eye Hospital in Karachi and Lahore. Despite the exorbitant costs incurred in specialised eye care, such set-ups provide free to low-cost eye services to patients from all socioeconomic strata. Cost concerns, then should not delay a visit.

The writer works as a paediatric ophthalmologist at Al Shifa Trust Eye Hospital, Rawalpindi.

Published in Dawn, March 12th, 2023