Reversible cupping and persistent vessel narrowing after glaucoma surgery in childhood glaucoma: a quantitative fundus photograph study

Purpose To investigate postoperative changes in peripapillary retinal vessel caliber and optic disc structure in childhood glaucoma. Design Prospective, comparative cohort study with a 2-year follow-up. Methods This study included 24 glaucomatous eyes (primary congenital or juvenile open-angle glaucoma) and 24 age-matched normal control eyes. Quantitative parameters, including vessel diameters (standardized to the vertical disc diameter), cup-to-disc ratios (CDR), rim widths, and β-zone parapapillary atrophy (PPA) morphology, were measured from standardized optic disc-centered fundus photographs using image analysis software (ImageJ). Results Preoperatively, glaucomatous eyes demonstrated attenuated peripapillary vessel diameters, with the superior temporal vessels being significantly narrower than those in controls ( P < 0.05). Postoperatively, despite successful IOP reduction (32.11 ± 8.36 to 14.30 ± 2.55 mmHg, P < 0.001), a paradoxical further narrowing of major peripapillary veins and arteries were observed which remained abnormally narrow compared to controls ( P < 0.001). Although the mean vertical CDR change was not significant, 16.67% (4/24) of patients exhibited notable cup reversal. This reversal was strongly correlated with inferior rim widening ( R 2 = 0.84, P < 0.001). Preoperative disc hemorrhage and a higher β-zone PPA Regularity Index were independent predictors of cup reversal. Conclusion Successful surgery unmasks a dichotomous remodeling response: a limited, biomechanical optic cup reversal in a subset of patients, linked to rim widening and an increase in PPA regularity, coexists with a persistent and paradoxical narrowing of the large retinal vessels. This indicates that vascular alterations may constitute a maladaptive or irreversible component of glaucomatous damage in children, distinct from the partially reversible connective tissue changes.