Examination under anesthesia can supply important information about the childhood patient. In addition to tonometry, corneal measurements, gonioscopy, and ophthalmoscopy should be performed in the operating room and carefully documented. Intraocular pressures recorded under general anesthesia are usually lower than those obtained in the office because of the effects of the anesthetic agents. If available in the operating room, pachymetry to quantify corneal edema and A-scan ultrasound to determine axial distention often are useful. Primary congenital glaucoma almost always is managed surgically.
Medical therapy is used only as a temporizing measure prior to surgery.
The primary surgical techniques are designed to eliminate the resistance to aqueous outflow created by the structural abnormalities in the anterior chamber angle. This may be accomplished through an internal approach with goniotomy or through an external approach with trabeculotomy. Goniotomy is a technique in which abnormal tissue is incised under direct visualization with the aid of a goniolens. This presumably relieves the compressive traction on the anterior uvea on the trabecular meshwork, which eliminates any resistance imposed by incompletely developed inner trabecular meshwork. In trabeculotomy, the Schlemm canal is identified by external dissection, and the trabecular meshwork is incised by passing a probe into the canal and, then, rotating it into the anterior chamber.