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]

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.

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.

• Aniridia

• Coat’s disease

• Dysplasia of retina

• Endophthalmitis

• Inflammatory cyclitic membrane

• Neurofibromatosis type 1

• Persistent hyperplastic primary vitreous

• Retinoblastoma

• Sturge weber syndrome

• Toxocariasis

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.

The diagnosis and management of buphthalmos is with an interprofessional 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.