# Childhood Uveitic Glaucoma: Complex Management in a Fragile Population
## 4 Medical Management  
Correct management of the systemic disease underlying the uveitis is crucial to minimize the recurrence of intraocular inflammation and becomes pivotal in preserving visual function in these patients. The use of systemic steroids and/or immunosuppressive medication in pediatric patients requires multidisciplinary collaboration and careful follow-up to monitor possible side effects. Revising the whole medical management for the systemic disease related to uveitis is beyond the scope of this paper; Table 2 outlines the most relevant therapeutic options in the pediatric population [57]. The medical management of UG in children is complex, and the clinician should consider the etiology, the patient's age at presentation and general health and be aware of the known efficacy and safety profiles of each drug. All the IOP-lowering agents are indicated in UG in adults, except for prostaglandin analogs during active inflammation and pilocarpine, whose mitotic effect may increase the risk of posterior synechiae [58]. Nowadays, there is a lack of RCTs regarding the treatment of childhood uveitis glaucoma. [PERSON] et al. [59] identified only five RCTs [60; 61; 62; 63; 64] evaluating the efficacy of topical IOP-lowering drugs in patients younger than 18 with glaucoma and ocular hypertension (Table 3). \begin{table}
\begin{tabular}{l} \hline Glucocorticoids \\ \hline Methotrexate \\ \hline Anti-TNF-alpha monoclonal antibody therapy (adalimumab, infliximab) \\ \hline Anti-interleukin 6 receptor antibody therapy (tocilizumab) \\ \hline A CTLA-4-IgG fusion protein (abatacept) \\ \hline Anti-CD20 monoclonal antibody therapy (rituximab) \\ \hline Janus kinase inhibitors (tofacitinib) \\ \hline \end{tabular}
\end{table} 
Table 2: Medical options in pediatric uveitis. However, most patients were diagnosed with PCG and JOAG, and secondary glaucoma other than UG was included. Therefore, no specific conclusions for medical therapy of UG can be drawn from the primary RCTs on pediatric glaucoma. Even if most glaucoma eye drops are not licensed for children, they currently have an off-label use in pediatric glaucoma, with a good safety profile [65]. Beta-blockers (BBs) and carbonic anhydrase Inhibitors (CAIs) are considered first-line options in UG [58]. Topical BBs decrease aqueous production, reducing IOP by approximately 20-25% in adults and up to 36% in children [59]. Effectiveness in IOP lowering is similar among the different beta-blockers agents. Timolol and Betaxolol are available in eye drops, in 0.25% and 0.50% concentrations, with twice daily administration. Timolol is also available in a 0.25% or 0.50% gel with a single-day indication. BBs are primarily prescribed for pediatric glaucoma, but a careful anamnesis is pivotal to prevent systemic side effects in children at risk of hypotension, bradycardia, bronchospasm, and apnoea [65]. In the previously reported RCTs, one patient developed bradycardia, and another had pneumonia as a severe side effect after timolol administration. Cardioselective B1 blockers, such as Betaxolol, are less likely to cause respiratory side effects. CAIs, such as Dorzolamide or Brinzolamide, decrease aqueous production and reduce the IOP by approximately 20% in adults and 23% in children [59]. CAIs eye drops three times a day in monotherapy seem more effective in children than in adults [59]. Therefore, Dorzolamide or Brinzolamide could be an excellent pharmacological choice in young patients. However, a history of allergy to sulfonamides should be excluded before CAIs prescription because of the possible cross-reactivity between the two classes of drugs. Corneal edema, superficial punctate keratitis and stinging have been reported as side effects. Systemic adverse events observed in oral administration, such as renal failure, metabolic acidosis or aplastic anemia, are uncommon in topical treatment [65].