# Childhood Uveitic Glaucoma: Complex Management in a Fragile Population
## 6 Conclusions and Special Considerations for Children  
Childhood uveitic glaucoma is a potentially blinding condition. Clinical management is challenging for ophthalmologists and requires a multidisciplinary approach. Children have a long life expectancy, so a prompt diagnosis is extremely important, as well as a proper IOP-lowering therapy, in order to reduce disease progression and preserve vision for life. Unfortunately, there is a lack of evidence from RCTs in the pediatric population [59] and especially in children with uveitic glaucoma. Most of the data for UG in the pediatric population were collected from retrospective studies with small sample sizes. In this review, we aimed to summarize the best available evidence that could be useful for ophthalmologists, pediatricians, rheumatologists and other specialists. A crucial topic is how to define the pediatric population and how to manage different age groups. The International Conference on Harmonisation/Committee for Medicinal Products for Human Use (ICH/CHMP) guidelines define five subgroups in the pediatric population for clinical trials (Table 5). This heterogeneous definition makes it difficult to provide general results in clinical trials that could be valid for different ages. Medical therapy is usually the first line of treatment in glaucoma, but we should remember that children are more prone to systemic side effects than adults because of their smaller body mass and blood volume and the immaturity of the brain-blood barrier [65]. Any effort to decrease the systemic absorption of topical treatments is crucial in these young patients. Training parents and caregivers to occlude the lacrimal duct for 2-3 min after eye drop instillation could be useful in long-term medical management. Furthermore, poor compliance with therapy may be more common in the pediatric population, and the resulting suboptimal IOP control increases the risk of poor visual outcomes in glaucoma. Fixed combinations, possibly in preservative-free formulation, could be a good choice to reduce the number of daily administrations and improve tolerability and compliance. Currently, none of the fixed anti-gluacoma combinations is licensed for children [65]. Anterior chamber implants could be a new therapeutic strategy to overcome compliance issues in children, preventing ocular surface disease induced by topical therapy and preserving healthy conjunctiva for future surgeries. Durysta(r) (AbbVie, an Allergan company) is a Bimatoprost anterior chamber implant, the only Sustained Release (SR) approved by the Food and Drug Administration (FDA) available for glaucoma treatment in 2022. Two phase 1 studies (Clinicaltrial.gov identifiers: NCT04060758, NCT05333419) are recruiting patients to evaluate the safety, tolerability and effective dose of an SR Latanoprost implant. A phase 1 study (NCT04360174), two phase 2 studies (NCT02371746 NCT05335122), and two phase 3 studies (NCT03868124 NCT03519386) are trying to assess the efficacy of an intraocular Travoprost implant in glaucoma patients. Unfortunately, none of these new \begin{table}
\begin{tabular}{l l} \hline
**Pediatric Subgroup** & **Age** \\ \hline Preterm newborn infants & \textless{}37 gestation week \\ \hline Term newborn infants & 0–27 days \\ \hline Infants and toddlers & 28 days–23 months \\ \hline Children & 2–11 years \\ \hline Adolescents & 12 to 16–18 years (depending on region) \\ \hline \end{tabular}
\end{table} 
Table 5: Pediatric population subgroups according to the International Conference on Harmonisation/Committee for Medicinal Products for Human Use (ICH/CHMP). devices has been licensed for children yet, and new clinical trials are needed to assess safety and efficacy in the pediatric population. A valid therapeutic option for UG could be Rho Kinases Inhibitors (RKIs), such as Netarsudil and Ripasudil, a new pharmacological option in glaucoma treatment. RKIs increase aqueous outflow through the trabecular meshwork, reducing IOP by about 20-25% in adults in monotherapy.