Lecture: Pediatric Ophthalmology Questions & Answers: Part II

During this highly-interactive live webinar, questions related to strabismus, pediatric cataract, pediatric glaucoma and pediatric oculoplastics are discussed.

Lecturer: Dr. Daniel Neely, Pediatric Ophthalmologist and Professor of Ophthalmology | Indiana University School of Medicine, Indianapolis, USA

Transcript

DR NEELY: Welcome to part two of our pediatric ophthalmology question and answer seminar. I’m a pediatric ophthalmologist doing pediatrics and adult strabismus at Indiana University in the United States. I’m also a long time Orbis volunteer faculty member, most recently in Ethiopia. And I am also a consultant to Orbis, with our telemedicine and tele-education. And on that note, I’d like to make everyone aware that we’ve just recently launched a curriculum on phacoemulsification, which you can find in the Cybersight library, and this is similar to our other blended learning, multimedia products we’ve launched this past year, including the ophthalmic nursing, the pediatric ophthalmology and adult strabismus modules, and also the manual small incision cataract surgery modules that we have live there. So take a look at that, and I think you’ll find that to be very interesting. Our next product coming out will be the glaucoma modules. So today we’re going to do things maybe just a little bit different than we did last time. Last time I had all of your questions in advance, and we went through those, and I’m still going to work through that list of the previously submitted questions, but in addition to that, I’ll be monitoring the chat feed and the question and answers. Or, rather, the question and answers. Not the chat feed, but the question and answers. And I’ll alternate with one of the preprogrammed questions with a live question, if we have one. And again, this time we’ll stay as long as we have active questions. So starters here — I’ll go to the first leftover question from our last session, and then I’ll come into our question and answers. So you’ll see me hesitate at times, as I read through these submitted questions and find those that are appropriate for us to discuss. All right. So let me move on to sharing the screen here. And this is a question that came in — in I guess it was August, when we did this last. And the question was — this came from multiple sources. So you can see that a similar question came from Romania, India, and Saudi Arabia. And the questions were: Opinion on anisometropic amblyopia treatment in children 10 to 12 years of age? Amblyopia treatment in children over 12 years old? And is amblyopia treatment useful in adults? So you can see these are all relatively similar. Well, in general, when you’re talking about older children, particularly those that have never had treatment, I will always offer that to the families. You know, I think it’s good for everyone. Some of these kids will improve. Other times, they won’t improve, but at least you’ve given the family a shot at feeling like they had a chance to make some improvement. Because a lot of times, these families may feel guilty that it was discovered too late. So I think it’s always a good thing to try, because we always talk about 7 years of age being kind of the cutoff for amblyopia treatment, but we all see that there’s a lot of diversity. Some kids won’t improve after age 5. Other kids will continue to improve even when they’re in the 10 to 12 or older age range. So yes, I always give it a go. Now, sometimes if people have been through extensive treatment for years already, and I feel like they’ve already had a good shot at it, I don’t restart treatment or continue it in these older kids. But definitely give it a go if they’ve never had treatment before. And then there’s the question of adults. Adults… That’s a little bit more difficult. And I think that the evidence to suggest that they would improve is pretty limited. And personally I don’t treat amblyopia in adults. But if that’s something you want to try, there’s not much downside to it, other than just the inconvenience if it doesn’t work. A little summary slide of what we’re talking about. The bottom section here talks about neuromodulators. L-DOPA, levodopa, and other substances. These are medications that are thought to perhaps restore some plasticity to the neurologic system. And I have anecdotally had patients in my office who improved with L-DOPA therapy. And so for a while I had a lot of interest in that. And so these would be children who were refractory to ongoing treatment, or patching, or atropine. Or these could be kids that are older, and you’re wanting to start treatment and increase their chances of improving. Or it could even be adults with L-DOPA therapy. And again, while I’ve had some improvement, that hasn’t always been borne out, when you start to do large multicenter studies. There was actually a PEDIG study, the Pediatric Eye Disease Investigator Group, a few years ago, where they actually randomized some of these levodopa patients. So this group was — you can see it’s older kids. The participants there, they were 7 to 12 years of age, with residual amblyopia. Moderate to severe. They were 20/50 to 20/400. And they were given the levodopa oral therapy three times a day for about 16 weeks and monitored. The levodopa group did get better than the placebo group. But the difference was pretty small. So the levodopa group was improving by 5.2 letters, whereas the placebo group improved by 3.8. And when you break that down and look at it statistically, it just was not statistically significant. But there were no adverse side effects, as has been my clinical experience. So there are some reports of levodopa being helpful, and you may want to consider that. But just keep in mind that the scientific evidence for it is not quite there to fully endorse it. All right? All right. Let me open up our QA before we go to our next question here. All right. The first question this morning was from Dr. Ajmani. And what are the possible causes of sudden alternating esotropia in a 3-year-old boy? I saw this case in which the father said the boy developed alternating esotropia 2 hours back. So this is something we see not too uncommonly. It always causes a little bit of distress to not only the family, but to us as physicians, because people start thinking about the worst case scenarios, neurologically. I can tell you that I see this all the time. And it’s kind of this acquired non-refractive esotropia. And in the absence of anything abnormal, like papilledema or abduction deficits, or other neurologic signs, I usually don’t image these patients, unless there’s something else prompting me to be worried about a neurologic cause. You see this, and it’s usually just idiopathic. Sometimes there’s a familial history, and you’ll find some families where several people have had this acquired non-refractive esotropia. But most of the time, it’s just unexplained. And I think the key things here is: It doesn’t fall into that neat category of constant congenital strabismus, and it doesn’t fall into that acquired refractive esotropia. If they have any hyperopic refractive error, I will try glasses, but usually these are kids that might be +1s or +1.50s, and you don’t really expect that. Why does it happen so suddenly, I think, is a fair question. And I don’t know that I have the definitive answer to that. But it seems like sometimes there’s an event that just tips these kids over. They get sick. And they just start crossing. Other times, people will tell you that it’s intermittent at first and becomes constant. But I think when you have something acute like that, unless there’s a neurologic sign, what I would simply do is to monitor them. You can have cyclic esotropia also. But you would expect that to resolve and return. Those do usually become constant over time, so that would be a little bit different than this. So I think in this particular case, unless there was some other neurologic sign or papilledema or abduction deficit, I would just monitor the child and see them back in a couple weeks, and only do neuroimaging if there was something else that appeared to be going on. Okay. Let me go back to our next question. That’s been previously submitted. And this is about intermittent XT, which I think is a good question. Oops. Go back. Surgical criteria. What is your surgical criteria and upper age limit in intermittent divergent squint or exotropia? And this question comes from India. So number one, age limit. I really have no age limit, when it comes to intermittent exotropia. Clearly usually the patient population we see with this is aged 2 to 6. And that’s usually when it presents in my clinic, and a lot of times we’re making surgical decisions to treat kids before school starts. But frequently we’ll also see adults that have had this their whole life. Maybe they’re still intermittent, or maybe they’ve become manifest. It doesn’t really matter to me, because I think the results are the same. Well, I think the results are better if they’re intermittent. Those that have become constant XTs I think are harder to straighten out. I think they’re harder to keep straight. They tend to have very large angles, where you’re sometimes getting in to needing three muscles, four muscles, and they may or may not reacquire full sensory status. So their stereopsis may continue to be off afterwards. But how do I go about the intermittent XT patient? Well, regardless of age, I pretty much go about it the same way. In children, I don’t really care how far out someone drifts. Now, obviously, if they’re drifting out 5 prism diopters, that’s not really a surgical candidate. But people that are in this range of drifting 16 to 45 XT, that number doesn’t really matter so much in terms of my surgical decision. It tells me how much surgery I’m going to do, but it doesn’t tell me whether or not I should do surgery. That decision to me is guided by several things. One, how often does the family or the patient’s teacher see it happen. If they only see it when they’re tired, then there’s probably not any real reason to operate. But if they’re seeing it all throughout the day, no matter what the fatigue status is, well, then, that’s someone that is more likely to require surgery. Under what circumstances is it seen? Again, that’s kind of the fatigue/non-fatigue question. Who sees it? If it’s only the mother who sees it once in a while, that’s probably not — especially in someone that’s 2 or 3 or 4, that’s probably not a surgical candidate. But if everyone sees it, and other kids are pointing it out, other family members see it, teachers see it, again, that nudges you towards surgery. Are there symptoms? Well, a lot of times there are not symptoms. Especially in kids. But of course you see people — they’ll have light sensitivity. They’ll have squinting. They’ll complain about depth perception. They’ll complain about tripping. Sometimes they have symptoms of asthenopia or eye pain when they are reading. So you can definitely have symptoms. Adults complain frequently about driving. And they’ll alternate fixation, and the road will shift from one side to another. I hear that complaint a lot. Diplopia we don’t really hear much of. So that’s usually not an issue. Diplopia is usually pretty transient, when it happens. And sometimes it comes down to things like academic performance. People wanting to have exotropia fixed before kids get serious in the beginning of first grade or so. You know, a lot of times, even if you’re just doing things for cosmetic reasons, this becomes an issue at around age 5, when children start to tease each other. My criteria are a little bit different for adults. Adults are very sensitive about this issue sometimes, and yeah, maybe it only happens when they’re tired, but they feel like they’re struggling to keep their eyes straight all day, when they’re having conversations with people. And if someone is really struggling with it that much, I think it’s quite reasonable to do their surgery at a lower level than you would maybe for a 4-year-old child. So it’s pretty much everything other than the prism diopter measurement — goes into factoring when I do surgery. And I do not have an upper age limit, and I do not see problems with diplopia in adults having this surgery, unless you overcorrect them. As long as you leave them ortho or undercorrected, these people do fine. So no upper limits. All right? I’m going to go back to our live questions here. And I might do a couple here. Treatment of allergic conjunctivitis not responding well to tacrolimus. Allergic conjunctivitis is always a tough one, because a lot of the over-the-counter remedies are not really great. And even a lot of the prescription medicines I’ve been kind of underwhelmed with. Whether they’re once a day or twice a day. So sometimes what it takes with these — if I have severe — let’s just talk about seasonal conjunctivitis, not vernal and some of these other more difficult cases. But I’ll do a burst of topical steroids. Fluorometholone or prednisolone. And maybe do that for a couple weeks, while I’m also using a mast cell stabilizer. Whether that mast cell stabilizer is by itself or combined with an antihistamine. Because it generally takes a couple weeks for mast cell stabilizers to kick in. And so when you use a mast cell stabilizer, you have to caution a family: Look, you have to use this every day, as directed. It’s gonna take a couple weeks until you get the full effect. In the mean time, we’ll supplement with the steroid, but then I want you to stop the steroid and not continue it, unless you have my instructions to do so. And usually when I handle it that way, most people will be controlled. You know, the main problem with some of the mast cell stabilizers is that they have to be used a minimum of twice a day, and some of them have to be used four times a day. So it can be a challenge sometimes. There’s another question that I’m just going to acknowledge but not answer, because I don’t have a good answer for you. That previous question was from Dr. Manda. This question is from Dr. Dash. And Dr. Dash has a question. How effective is citicoline in the treatment of amblyopia? If yes, then how should it be prescribed? And frankly, I don’t have any experience using citicoline for amblyopia. Pretty much my amblyopia treatment has been restricted to occlusion patching, atropine penalization, which I’m a big fan of, if the patient has some hyperopia, and then supplementing some of that with the L-DOPA, as needed. But citicoline I don’t have any experience with, sorry. I can see if I can find an answer. Because now I’m curious. All right. So I’ll go back to our previously submitted questions, again. And I think this is a good one. This is one that comes up frequently when I travel, working overseas, as well as when I’m working with fellows in my institution. How do you calculate the intraocular lens power for a 3-year-old and a 5-year-old child? Well, yeah. Obviously when you’re talking intraocular lens powers in this age group, there’s going to be a variety of opinions. First of all, you have to decide: Can you put an intraocular lens in? And in an infant or someone with a small cornea, less than 10 millimeters, PHPV cases, nanophthalmos, you may not be able to do an intraocular lens. But in this age group, 3 to 5, presumably you have an eye that’s large enough. So then you have to decide what postoperative refractive error do I want there to be? And in a 3 to 5-year-old, there are two schools of thought. Some people would say you still target emmetropia, plano, just like you would in an adult, and that that will facilitate your amblyopia treatment, because even if they don’t have glasses, the eye is in focus. That is generally not how I do it. Nor is it how most pediatric ophthalmologists in the United States, at least, do it. You will find places overseas and Europe — some people I know target plano still. But generally the school of thought here that I prefer is leaving some residual hyperopia, so that as the patient grows and ages, that you’ll be closer to what their adult refractive error should be, so that you do not need to do an intraocular lens exchange. You do not need to do refractive surgery. You just have something that’s in the ballpark of what they would have needed if they were 20 years old. And I’ll show you a chart about how I come up with that. But that’s in the ideal circumstance. Targeting residual hyperopia. That’s when you have easy access to glasses. Maybe you have temporary access to a contact lens, if you’re not close enough. And assuming that you’re going to be able to keep that patient in glasses the whole time, while they’re growing, until they kind of emmetropize. When I do target residual hyperopia, I am going roughly on these guidelines. These are taken from what I think is the best book on pediatric cataract surgery, which is written by Ed Wilson and Rupal Trivedi, and it is the Atlas of Pediatric Cataract Surgery, I think it is. And a lot of our Cybersight library content in the pediatric ophthalmology module — the section that’s on pediatric cataract surgery has this table, and much of it’s taken from that text, which was first prepared with the help of Ed Wilson, along with my authorship. And I think that these — this table has not ever been presented as what you should do. And I think Ed Wilson would be quick to tell you: This is not a surgical guideline for strabismus. But I think these are good rough estimates of what I practice and target with my lens implantations. And I do lens implantations all the way down to infancy in some monocular cases. And then pretty much always in binocular cases, over age 1. For starters, I usually use the Holladay I formula. I think the Holladay I or perhaps the SRKT are pretty good formulas. The Hoffer Q, if you have a small eye in particular, may have some advantages, but as a general go-to, Holladay I is the formula that I use. And then what do I target? So in an infant, here let’s just say this is a three month old… Usually with an infant, if I’m putting in a unilateral IOL, I’ll go in this ballpark of +8. And you can see the intraocular lens power that’s usually required in an infant like that — it might be a +28 to a +32 to obtain that kind of hyperopic refractive error. Now, in an infant like that, if you’ve got +8, you’re gonna need to do something temporary to keep that eye in focus, if that’s their targeted refractive error, during their postop visits. So this is where you’re either gonna have to do glasses with a +8 on one side, which may not be a big deal, because a lot of these kids — they’re gonna be +4 in the other eye, +3 in the other eye. Or you might do a temporary contact lens, until that hyperopia has melted away. Which happens pretty fast. Because you can see here in, say, this 0.5, in a 6-month-old, I’ll be targeting something down here. Closer to a 6, 6.5. And in a 1-year-old, +5 is usually a pretty good target. So you see that the hyperopia is melting away quite quickly. And as you get in here to kind of our more common age and the age that this question refers to, the question was about a 3-year-old, if you’re doing cataract surgery, what do you target? And I think that this is a pretty good number. +3. They’ll be +3. You can do in the one eye or in both eyes — you can do glasses to equalize anisometropia, and within just a few years, their hyperopia is going to be gone, and you’re gonna be in the ballpark of plano. As they continue to grow. The second patient in this question was a 5-year-old. The 5-year-old is right here between our 4 and 6. And you can see in a 5-year-old, we might be targeting about +2. And then in an 8-year-old, +1. So really, by the time you’re getting to a teenager, or a 10, 11, 12-year-old, you’re pretty much just targeting like you would normally for an adult. Close to emmetropia. Maybe a little trace of hyperopia or a little myopia. But it’s basically emmetropia. And that’s generally how I do it. Now, if you want to see that chart, then again go to Cybersight Library. Find the full pediatric ophthalmology module. And then cataract is part 3 of that module, and that chart will be in there, as well as other guidelines. Things like where do you make a pars plana incision, if you’re doing a primary posterior capsulotomy. Ways to manage anterior capsule. All the things that are different about pediatric cataract surgery. Because clearly this is not just doing small eyes in small people. All right. So back to our previously submitted questions. I’m sorry. Let’s take a live question here. This is from my buddy, Dr. Fara. Dose of penalization on 4-year-old who has moderate amblyopia with retinoscopy of -6.50 in the right eye, and then the left eye is a -1.50. So we have anisometropic myopia in this case. With a best corrected — also has intermittent XT, and has a best corrected acuity of 6/24 in the right eye and 6/9 in the left eye. So at 4 years of age, with relatively dense amblyopia, the fact that it’s from myopia rather than hyperopia doesn’t make much difference, other than the fact that it takes them out of the atropine category. This is a good case where you would not respond to atropine. So that’s off the chart. So we’re talking about occlusion therapy. And for a patient like this, in a 4-year-old, I think you have to be relatively aggressive. They have dense amblyopia. And their plasticity period, where they’re gonna respond to treatment, is pretty minimal. It’s pretty short. It may be a year. It may be less. So, you know, I think this is one case where maybe trying full-time occlusion or close to it — maybe leave them unoccluded a couple hours a day, and start off by doing that for a month or two. I’d probably start doing it for a month and see them back, and see if you can get them jump started. Because otherwise, you might just be doing 4 hours a day, 6 hours a day, and they may respond, but it’s gonna be gradual, and you may lose some of that treatment time that you have, because they’re already 4 years of age. So I think one of two ways to go about this. Either start patching them 4 to 6 hours a day, and just do that consistently, until they get better vision, to where you could drop it down to 2 hours a day, and by better vision, to me that’s when they start to get in the 20/40, 20/50, 20/60 range. When they get into that range, then I might switch to 2 hours a day. So starting off, 4 to 6, and then tapering down, as they improve, or trying to jump start them with some full-time occlusion. All but one hour a day. And do that for a month, to get them jump started and see where they are. Now, if they haven’t been in glasses, I probably would just put them in glasses. With no patching. And see them back in about 4 weeks, and see how much better they are, just with the optical correction. So in general, that is what I will do. If people are not in optical correction yet, I will give them glasses, and then I will start patching at the next visit. Unless I think time is of the issue. Okay? All right. Back to our next previously submitted question. All right. This is a good one. Strategies and methods to follow various degrees of ectopia lentis. And this is from a physician in India. Well, I think the strategies and methods depend on how much ectopia lentis. And what do I mean by that? Well, if the lens is mild to moderately decentered, so you can see just a little bit of zonules at the edge of the pupil, for instance, undilated, so that lens is mild to moderately decentered, then most of those kids I will treat with just a very careful refraction. What do you expect to find? You expect to find moderate myopia. With moderate astigmatism along the axis — in plus cylinder — along the axis of displacement of the lens. So a lot of times you can manage those that way. Now, if you have moderate luxation of the lens, so now you’re seeing maybe a third of the pupil is filled with — it’s aphakic and filled with zonules, and then two thirds of the pupil is subluxated lens, let’s just go to the whiteboard here, so we can diagram that. Because I think these are the ones that we most commonly see. All right. Get all my stuff out of the way. Make some room. So most commonly, we’re going to see a pupil like this. The lens is here. And I’ve got zonules coming out. All right? This is a horrible drawing, because I’m doing it with the trackpad. Sorry about that. So the lens — this is all the lens. This looks like a third grader drew it. All right. So what do I do? You have two options in this kind of moderate subluxation. One, you can still refract through the lens. You’re gonna have more myopia, more astigmatism, and these are the refractions that start to look like -10, +5, stuff like that. Still kind of crummy vision. So a lot of times, refracting through the lens doesn’t work out very well. You do it, and then their acuity is still not good. So another option is: Keep them dilated. So make their pupil bigger. With atropine, twice a day. And now… The lens is there. Now you’ve got all this aphakic area here. And you may just do an aphakic spherical refraction through this zone, rather than refracting through the lens. So in someone who is not a surgical candidate, or is not ready for surgery, or can’t afford surgery, or maybe they have asymmetric luxation, and one eye is ready for surgery and one eye is not, this is something you can do just… So now, instead of giving them through the lens -10, +5, now you can refract them through the aphakic area, and maybe just give them +15 spherical lens. So that’s another great trick for managing these lens subluxations. Now, when you get more significant degrees of luxation, and the lens now is, say, the lens is now halfway across or more, these are the ones that… When you get that much subluxation, you can still do the aphakic refraction, and just leave the lens subluxated, but more commonly, this is when we’re removing the lens, and I like to do that with a vitrector. And that’s also a technique that you can find in the pediatric cataract surgery module. But a vitrector for removing subluxated lens is a great tool, and I tend to do that with… It’s not an intracapsular technique, because we open the capsule. But you make a small opening in the lens with a vitrector, put the vitrector inside the lens, and then, using aspiration only, you will go ahead and suck out the lens, until the bag is empty, and then turn the vitrector on, and take the bag out, and now they’re aphakic. Okay. So when I do that, I will usually then just do aphakic spectacles or aphakic contact lens. I am an investigator on the Artisan IOL, the iris claw lens, which at least in the US is still being implanted only under investigational studies. In Europe, it’s not investigational, and it’s done routinely. And this seems to be a pretty nice device for correcting these subluxated aphakic patients, whether it’s from subluxated lenses or trauma or complicated cataract surgery. People seem to do really well with this. So that would probably be the other good option. The third option, which is a suture-fixated IOL — I do that occasionally. I don’t like doing it in really young kids. I would not be a big fan of doing that bilaterally. You know, the thing with those, the thing with the suture-fixated lens, is that even if you use a heavier suture, like a 9-0 prolene, it’s not a matter of… Is it going to break? It’s a matter of… When is it going to break? So if you do a suture-fixated IOL in a child with a luxated lens, I think that everyone has to have a clear understanding that there are some significant risks with breakage, and it’s probably gonna have to be redone. Maybe you get ten years out of it. Maybe you don’t. But if you have a 6-year-old and that lens is gonna last 6 years, you talk about re-suture fixating a lens 6, 7, 8 times. I think that’s maybe not the best option, when aphakic glasses would probably not be the best thing, but they would work fine. Even if you can’t get contact lenses, the glasses work fine, as long as you can replace them. So suture-fixated IOL — lowest on my list there. All right. And let’s look at our question-answers here. I think this is from Vietnam. Dr. Anh. Do amblyopia treatments affect deviation when patients have strabismus combined with amblyopia? That’s a good question. Okay, so the question is: Does amblyopia treatment affect alignment when you have strabismic amblyopia? The answer is maybe. I don’t feel like I see a lot of variability in that. But I think it’s always best practice to treat the amblyopia first. For a couple reasons. Let’s go through a couple scenarios here. Congenital esotropia. So they’ve got 40 prism diopters of esotropia. And they have a fixation preference or amblyopia. If you treat their amblyopia before surgery, you can easily tell which eye they’re fixating with. It is very easy to guide your patching and get them equal or as close to equal as you can get. Once you straighten that infant’s eyes, though, it’s really difficult to tell which eye they’re fixating with. So you may not have a firm handle on their amblyopia treatment until they become verbal and you can test acuities. So for that reason, I think it’s important to do your amblyopia treatment first, and then do your surgery. Especially since the timing of surgery doesn’t seem to make a huge difference from a sensory standpoint. And also from an anesthesia standpoint, it’s probably more safety, as they get a little bit older. And I’ve not seen that change their strabismus deviations. If they have 40 XT, they’re gonna still have 40 XT. Where I think it could change your alignment measurements is in exotropia, or especially intermittent exotropia. So again, I think it’s important to maybe treat… If there is intermittent XT or constant XT, with amblyopia, then I would probably want to treat their amblyopia first, because that could affect… Maybe not so much their degree, how far out do they deviate, their prism measurements, but it’s probably going to affect whether or not they need surgery, in terms of intermittency. More dense amblyopia is gonna tend to be a more constant or frequent XT. Less dense amblyopia is probably gonna be less constant. With refractive esotropia, a lot of times I do these kind of concurrently. I’ll start their amblyopia treatment, and then if they have a manifest strabismus while they’re in the glasses, I’ll go ahead and book their surgery also. Because a lot of times these kids are a little bit older, and I think time is of the essence. A lot of these refractive ETs, they’re gonna be 3, 4, 5. It’s not uncommon to get them when they’re 5 years old and they’re doing some kind of a preschool exam. So you have a 5-year-old with refractive ET, and manifest strabismus. I think that once you get their eyes straight, that’s also going to facilitate their amblyopia treatment by having them be able to use the eyes at the same time. So yes, the bottom line here is: In general, treat the amblyopia first. Unless time is of the essence, and you feel like you need to do both concurrently, in particular with refractive ET. Okay. I’ll take another live question here, because it’s related. This is from Dr. Bengoa. And his question is: Can you tell us about the current patching protocol for amblyopia? Any available web source for stereopsis stimulations? So online sources for stimulating stereopsis… I don’t have any that I use. I know there are multiple ones out there, but I think the evidence to support online use of stereopsis software is soft. And so it’s not a part of my practice. You may want to check the PEDIG, Pediatric Eye Disease Investigator Group website. To see if they have anything listed. You know, in general, the results of stereopsis video games — and there was a recent PEDIG study on this — it was kind of a wash. It didn’t really seem to make much difference. So as far as patching protocols go, I tend to follow… I used to be a pretty aggressive patcher. Patching 6 to 8 to full-time hours every day. I do admit that I’ve decreased my patching intensity, following the PEDIG studies — at least for mild to moderate amblyopia. So the PEDIG study for mild to moderate amblyopia, and again, this is better than 20/60, I think, was the criteria — showed that 2 hours a day was equivalent to 4 to 6 hours a day. Or it was equivalent to 6 hours a day, I believe it was. So I did decrease my patching after that. But that’s not a uniform rule, because there are exceptions to this. If I have questions about compliance, I may recommend heavier doses of patching. If I think they’re doing half of what I give them. Conversely, you have to be careful about that. Because if you tell them 6 hours a day, and they just think that’s impossible, maybe they’ll do none. But if they’re willing to do 1 or 2 hours, then take that, and maybe you can increase it once you kind of get them on board. So for me, mild to moderate amblyopia is 2 hours a day. And you get into more severe amblyopia, 20/80 to 20/400, 20/200… This is when I really will try to get them to do all but 1 hour a day. The problem is, if they’re school-aged, they’re a 5-year-old, you’re not gonna be able to do that. And so a lot of times I find myself doing full-time after school. With these moderate to dense amblyopes. In infants, it’s a little bit different. So infant cataracts would be a prime example. Infant cataracts I will patch about 1 hour a day for every month old that they are. So a 4-month-old would patch 4 hours a day. And I cap that at half of all waking hours. So with infants, I’m kind of capping it anywhere from 2 to 6 hours a day, in general. But most commonly, I’m doing that again for infant cataract surgeries. All right? And let me go back to our previously submitted questions. And then we’ll come back to the live questions. All right. This one came in, and this is from Peru. Guidelines for the management of VKH, Vogt-Koyanagi-Harada disease, in children. And I have to admit, I don’t have much experience with this. But after the question came in, I did go through the literature to see what I could find, to at least give you some input on this. It’s not real common in the uveitic population in the United States. Okay? VKH is way more common in countries that have people of Asian descent. So it’s also not real common in pediatric age group. Most common in adults 20 to 50. Rare in children. Less than 1% of pediatric uveitis in general. How do these people present? Conjunctival hyperemia, anterior chamber cell and flare, serous retinal detachments and papillitis. I think those are the big hallmarks that you’re looking for, when you’re trying to decide: Does someone have VKH? If you have uveitis and a serous retinal detachment or papillitis, then be strongly suspicious. These patients can also get aseptic meningitis, deafness, poliosis is of course one of the classic hallmarks, which is the whitening of the eyelashes, and then skin vitiligo. So a lot of times this shows up more in people with more pigmentation. African descent, Asian descent. You can a lot of times see the vitiligo more easily. Basically no real tricks here, to answer your question. But it seemed to be that IV pulse steroids, methylprednisolone for several days, followed by oral prednisone for several months, was kind of the mainstay of treatment. If someone could not be controlled by oral prednisone, for a few months, then you start to look at systemic medications, other than prednisone. So I think at this point, you would want to involve a rheumatologist or an internal medicine specialist or a pediatrician, because you’re gonna have to start looking at things like methotrexate or the antitumor necrosis chemotherapy factors, just like with juvenile idiopathic arthritis. You’re gonna have to look at other systemic medications. So that’s my input, for what it’s worth. Let’s go back to our live questions. And what is your suggestion — this is from Dr. Anonymous — what is your suggestion for intermittent exotropia with high AC/A ratio? Intermittent exotropia with high AC/A ratio? I’m trying to think if I see this very often. Yeah, I see this in young kids, mostly. I’m thinking of when intermittent XT first starts. I see this in 3-year-olds. And what does this look like? Okay. So they’ll be manifest XT at distance. And then at near, totally ortho, or they have a phoria. What do I do? I try not to operate on these people. Especially with the young ones like that, when they’re 3. If I see a 3-year-old that has this, I’ll just monitor them. I don’t do anything. Just see them back in a few months and monitor. Wait ’til their near control starts to break down. Because this is safe. Even though they are manifest at distance. It doesn’t matter. Because they have good control at near. Therefore they’re not going to lose stereopsis. They are not going to get amblyopia. So you can wait on that forever. So don’t worry about it. Don’t let that affect your decision. Wait ’til they get older and wait ’til they decompensate. Because they will. They won’t stay this high AC/A ratio forever. What about an older child or an adult? Let’s think. Teenagers… So let’s just say an 8-year-old now, someone who’s in school. 8 years old to 18. Well, it’s a bit of a problem. I don’t worry about them as much as I do the kids who are of amblyopia-sensitive age, because what you worry about in these patients is that you might overcorrect them at near and give them diplopia at near or cause suppression at near. So that’s why I wouldn’t want to operate on a 3-year-old. Because all of a sudden you have something that’s not causing amblyopia to something that is. But in an 18-year-old or an 8-year-old, they’re not going to get amblyopia. So they may have some transient diplopia or permanent diplopia. But they won’t have their vision damaged by that. I prefer that they still break down a little bit. One thing you can do, whether it’s in children or adults, is do a patch occlusion test. If you’re examining them, and they’re manifest at distance, but they have a phoria at near, put a patch over one eye, and leave it on for about 10 minutes. Come back, and try and break them down. And if you can start to bring out a little more near deviation, then that makes it a little more reassuring when you want to do surgery. However, if they stay totally ortho at near, and you’re going to operate, or maybe they have a very small near deviation, I think you have to be a little bit cautious, and I would just back off my distance numbers. So say they’re 40 at distance, but they’re only 15 at near. I think you still want to do a pretty healthy dose to get their distance under control, but you might consider doing less surgery for their near deviation. And you might stick with lateral rectus recessions, rather than a recess/resect, where the strengthening in the medial could make them more ET at near. So patch occlusion to wear them down, or bring them back later in the day, when they’re tired, to see if you can diminish the high AC/A ratio. And if the high AC/A ratio doesn’t diminish, then maybe just being conservative on your surgical dose. That would be about all I do. I see one question live here that I’ll just answer now. And that is — because it has to do with something we just talked about a minute ago — and this is from Dr. Gordon. Why is the Artisan lens still on trial in the United States? Well, it’s still on trial because it has to go through FDA approval for use in pediatric age groups. All right. So just because it’s approved in Europe doesn’t make it automatically approved in the United States. And in the United States, there is a different approval process for using devices in adults or medications in adults, versus children. So it is still undergoing FDA trials I think for both adults and children. That study is being done simultaneously. You have to get certain numbers done, and then they have to be followed for a certain period of time to get the specular microscopy, et cetera. It just takes time. So they’ll be through the approval process within a couple years. But until then, it’s all being done under investigational device protocols. Which is fine. You don’t want to just start doing these things and find out that people are losing endothelial cells. So it’s available, but you just have to be in a study. And if you get one study eye done, you can have it done in the other eye that’s not part of the study. So that’s where it stands right now. All right. Back to our previously submitted questions. After VKH. This is a good one. What is your stepwise approach to infants with congenital glaucoma and cataract? Because we see this a lot. We see an infant that has both cataract and glaucoma. And specifically, to make it even more fun, their corneas are too cloudy for goniotomy. This is from Zimbabwe. So yeah, number one, corneas are too cloudy for goniotomy, so we can’t do that… I would say in general what do I do? Well, in general… In general, when I have cataract and glaucoma in a child, I prefer to do the lensectomy first. Now, that doesn’t necessarily apply to this question, because the cornea has been stated to be cloudy. But if I have a clear cornea, glaucoma, and a cataract, I will take the lens out first, and I’ll just do that by itself. Because some of these small eyes in infants or when you have an intumescent lens, so the lens is really thick, or if you have an abnormal eye, it’s got PHPV, or PFV, then by taking the lens out of there, you’re getting it away from this pupil, and you’re eliminating any element of pupillary block or crowding the angles, shallowing the anterior chamber, and a lot of times pressures will improve just by getting the lens out. Okay? So that’s what I generally prefer to do. However, as stated in this question, the cornea is cloudy. Well, if the cornea is too cloudy to do a goniotomy, it may or may not be too cloudy to do a lensectomy. Not always. I mean, goniotomy takes a really clear cornea, whereas lensectomy you could probably get through with a slightly cloudy cornea. So two options here. One, you could just scrape the epithelium. Because that’s generally where the cloudiness is, unless this is a scarred cornea. And if they can scrape it, and it’s clear enough to do a lensectomy, or if it’s just generally clear enough to do a lensectomy, I would still do that. Or then if it’s just super cloudy, trabeculotomy. I like trabeculotomies anyway, because even a mildly cloudy cornea in these infants — you get them under the microscope light, it’s really hard to see. For me, goniotomy is what I use in older kids who have glaucoma that clearly wasn’t as severe. They may have large clear corneas. So you see a 5-year-old with a clear cornea and glaucoma, goniotomy is a great first procedure for them. But when you have infants with glaucoma, with or without cataracts, a lot of times the cornea is really cloudy or it’s partially cloudy. And doing a goniotomy is difficult. So trabeculotomy, if you have to have one technique at your disposal, you can do on anyone. So I really like those. The only problem with trabeculotomy is that if you have an abnormal eye, like PHPV or one that’s really buphthalmic and stretched out, then finding Schlemm’s canal can be really tough. But if I had a cloudy cornea and a cataract and glaucoma, taking the cataract out right away is not really helpful, because the cornea is cloudy. So you’ve got to get the cornea clear. So I would do a trabeculotomy, get the cornea clear, keep them on oral and topical pressure lowering agents. As soon as the cornea cleared, I would reassess and go ahead and do your lensectomy at that point. Because you can probably do a better job with it. So both of those conditions, the cataract and the glaucoma, are amblyogenic. So get the cornea clear first, and then do the lensectomy. But do this all in a relatively compressed time period. Would I do them all at the same time? Probably not. That’s just… Each of these is complicated enough by itself. But doing them combined in an infant eye that’s soft and has been opened… You know, maybe you can do that. And maybe I would if there were anesthesia concerns or concerns that I wasn’t gonna get the patient back. But if I had good anesthesia and good access to the patient, I would do one at a time. Older kids… I might do endo laser, or even maybe a tube shunt implant, combined with cataract surgery, but not in an infant so much. All right. Okay. Our next question is from Syria. Dr. Humeda. And this is a good question about… This is from the live questions… This is about prism eating phenomenon. When do you see it, and how do you deal with it? So most commonly, we talk about people eating up prism. You give them a correcting prism, and they adapt to it, and you still measure more prism on top of that. At one time, I used to do a lot of prism adaptation for refractive esotropia. And so, for example, someone would come in with refractive or acquired non-refractive ET, measuring 30. And you would give them a prism for 30. Like a press-on prism for 30. Send them home for a few weeks, and have them come back. And then you would measure them, and now they’ve got 30 prism on, but you’re still measuring, say, another 15 or 20 of deviation. So now you up their prism another 15 or 20. So now they’ve got a 45 prism on. And they come back after a couple weeks, and even with that on, now they’re still measuring a residual 10. All right? Now, if they don’t eat it up, and they stabilize, then that is effective prism adaptation, and you would generally get slightly better results if you operate for that larger prism-adapted deviation. However, when they just keep eating it up like that, and it just keeps building and building, then you have a little bit of a dilemma as to what to do. Because they just keep eating it up. And in those cases, it gets a little confusing. And what I will do is generally operate for their largest non-prism-adapted deviation. But maybe factor it up a little bit. And usually you’re talking about the difference of 0.5 or 1 millimeter. These are not big differences. I don’t generally do prisms for exotropia. And I don’t generally do them with infantile esotropia. So usually it’s kind of this acquired non-refractive or refractive esotropia. You do see it with adults who are getting prisms postoperatively. They get partially corrected with surgery, and then you give them prisms, and then they come back, and they need a little bit more. So having Fresnel press-on prisms is nice for that, but admittedly, Fresnel press-on prisms cost about $50 US each, so we call it taking the prism for a test drive, before they go buy prism glasses. For us, at least, where prism eyeglasses might cost $400 US, doing a test drive with a $50 Fresnel may be reasonable. But I think for most of us in developing countries, A, you’re not gonna have access to Fresnel prisms to do trials with, so it’s kind of not even a factor, perhaps. If they stabilize with prism and eat it up, I’ll operate for that. Otherwise I’ll just kind of go a little more conservative. All right. Back to… We still have some previously submitted questions. So let me go back to those. This is one that comes up frequently when I give cataract lectures. What are the current indications for primary multifocal IOLs in pediatric cataract surgery? You know, this is something that just seems like it would be a great idea. This is from Tunisia. This question. It seems like… Yeah! Multifocal IOL is great for kids, because then they have this expanded depth of field, and it should help them with amblyopia and vision development. Well… It turns out it doesn’t really work that way. You know, when you’re doing a multifocal IOL — I’m not an adult cataract surgeon, but — when you do a multifocal IOL in an adult, it really needs to be precisely measured, and they really need to have an accurate postoperative outcome. Because you need to get their distance correction basically emmetropia with your IOL. And then they have the multifocal characteristics of the IOL to give them some range of near. If you’re gonna do that in a child who’s still growing, it’s not gonna work out. Because A, you don’t know what they’re going to be as an adult. So you can’t target that. All you could measure and target would be what they are right now. So going back to one of the earlier questions, a 3-year-old or a 5-year-old… All right. Let’s go with the 5-year-old. You’re gonna give them a multifocal IOL, and you’re gonna have to target emmetropia or something close to it. But that kid’s still growing. So if you can perfectly target emmetropia now, you may have a brief period where it’s working, but once they grow a little bit, now the distance is out of focus, so they need glasses for that, and also, you’ve lost any near benefit, because if that multifocal IOL was giving you 2 diopters of accommodative ability or near vision ability, well, now they’ve grown, and now it’s off. So now they don’t even have that. They have 2 diopters of range, but it’s somewhere in this intermediate range. It’s not at near anymore. So it just doesn’t work out. The other thing is: A multifocal IOL in a younger patient, where you’re still doing retinoscopy, it’s really difficult to see the reflex. This is like doing retinoscopy through a distorted lens or a subluxated lens or a lens that has irregular astigmatism. These are tough to retinoscope through, because you’re getting the multiple refractions from — no matter what kind of multifocal IOL it is. Okay? So in general, they’re just not a good option for those reasons. Could you use it in an older teenager? Yeah. If you were confident that they were no longer shifting on a refractive standpoint. And had seen that through a few office visits. Then I think that’s maybe one good application for a multifocal IOL, in someone who’s still a pediatric patient, technically. Okay? But I think you want to prove that the refractive error is not changing first. All right. Back to our live questions. And this is a good one. Because this is something that I like to do. This is from Dr. Manda, and it is: Do you encourage optic capture or just leave the optic in the bag in pediatric cataract surgery? Kind of depends on how the surgery is going and what I have to work with. Pediatric cataract surgery, if the bag is in good shape, and I can safely implant the lens completely in the bag, I do that. And I do not prolapse the optic through the posterior capsule. Okay? So when you talk about optic capture, there are different ways to do this. You can have the haptics, the haptics in the bag, and the lens in the bag. Right? Standard. That’s always my first choice. If you have the posterior capsule open, you have the option of prolapsing the optic through the posterior capsule and leaving the haptics in the bag. Now, why would you do that? Well, some people would like to do that because now when the lens cells migrate in to the visual axis, they cannot get on the back side of the IOL. They could get on the front side still. So I don’t think you really gain anything. Now, I do — when I do optic capture, it’s usually when I’m putting in a sulcus lens. So say I’ve had a complicated cataract surgery. It’s had an abnormal posterior capsule, like a posterior lentiglobus. Which would be very common, if the capsule blows out while you’re doing a surgery. Or you’re doing a young child, and you’ve done an anterior capsulotomy, and it just didn’t go very well. It’s too large or it’s got a radial extension. And I’m not confident in my ability to get it in the bag. Then I’ll do a sulcus lens, and if I’m doing a sulcus lens, I’m not gonna use a 1-piece monoblock lens. So I love the Alcon AcrySof lenses. But you wouldn’t be using an SN or an SA type lens. Right? That have the big thick solid haptics. You would want to use the one that has the thin three-piece haptics, or have a thin one-piece non-folding lens, or something similar, where you’re gonna put the haptics in the sulcus, and then you’re going to leave your anterior capsulotomy just small enough that the lens optic will go through… All right? So you’re pushing your lens optic through, and now the optic is in the bag. And so you are using your bag position calculations. That keeps the optic away from the iris. So you’re using sulcus fixation, but optic placement in the bag, behind the anterior capsule, so that you’re keeping the lens back in a more normal position. You’re not going to have problems with chafing on the iris back surface, and you’re also not going to have problems with pupillary block. So that would be my number two preference. And then if that’s just not possible, then I do complete sulcus placement. And a lot of times, that’s just the best thing to do, because you’re not wanting to disturb… You go back on a secondary IOL, and you’re not wanting to disturb the existing Soemmering’s ring in some cases. Back to our previously submitted questions. We’re past our time. I’m just gonna keep going, because I see we have a lot of live questions too. Let me see what we have left on the previously submitted questions here. All right. This is a general question. I think it’s a fair question. Any suggestions on how to increase cooperation when examining children with autism? This is from a doctor in the US. Well, I think that any time you’re dealing with a child with autism, you just have to bring your A game. Right? You’re doing the same thing you do with other kids to win their cooperation, but you just have to up it to the next level. You can’t… One thing with kids, with and without autism… You really can’t force them to do this stuff. You have to have them on your side. Unless they’re an infant that you can restrain, forget it. So what do I do? I specifically… I have a couple pointers here. You know, don’t just jump in and start your exam. Do anything but medical stuff at first with kids with autism or other kids that are just afraid. Talk to them about something non-medical. If you can engage them in conversation. I like to talk to kids about things like animals, food, dinosaurs, sharks, cartoon characters. All these things that kids think are cool. If you can identify something that they think is cool and start talking to them about that, then you incorporate that into your examination. And convince them that they want to look at what you want them to look at. If they’re non-verbal, then maybe I just make funny noises, or use light-up toys. These little LED light-up toys that blink and make noise are great. One thing with kids with autism specifically is: Be careful about making jokes or teasing them. Sometimes when you would tease around with them, they get mad or they get offended, or they get upset. And while I do that all the time with other kids, I find that I try not to do that with kids with autism. It ends up just getting them mad, rather than winning them over. So I always have… I’m famous for my little Tigger toy, which I like to do, because I can hold it in my mouth, while I’m doing prism measurements. So I’ll engage them when I’m doing things like motility or retinoscopy, and I can always put it there too. But I’ll try to get them to follow my toy. And if I’m doing retinoscopy or indirect ophthalmoscopy, if I’ve identified that they like dinosaurs or sharks, I’ll say: Hey, look in the light. Tell me if you can see the dinosaur. Just stuff like that. These are all just upping our game of what we normally do as pediatric ophthalmologists. All right. Live question. And this is: Earliest age for congenital cataract surgery in your practice. 0, 2, or 4 weeks? So earliest age for congenital cataract surgery. Depends on when you get them, right? I mean, it really boils down to that. I really like to have their surgery done at around a month, 6 weeks of age. Because that gives me time to get their surgery done on one or both eyes, and not only get their surgery done, but get them into optical correction, if they need it. Because it doesn’t do any good to take a cataract out and have them aphakic or out of focus. They’re still gonna be amblyopic and develop nystagmus if that’s the case. So you have to have the surgery done, and you have to have them optically corrected before 6 to 8 weeks of age, before nystagmus sets in. Okay? So for me, I do them as soon as I can. Usually you say… What’s a common scenario here? Red reflex gets picked up on pediatrician’s examination before they’re discharged from the hospital. So you’re seeing them. They’re about a week old. See them at a week old. Maybe schedule their surgery to be when they’re about 4 weeks old or 3 weeks old or 5 weeks old. I would say that that’s typical. Earliest age for me personally is… I’ve done an infant IOL on someone who was born 4 weeks premature, but then I did the surgery on their due date. I guess that’s technically zero. That was 18 years ago. He got an intraocular lens. I just saw the kid. He’s age 18 now. Saw him the other day. And he’s 20/60 in that unilateral infant IOL. So that’s one of those success stories for infant IOLs. Unilateral. And I still do infant IOLs, but not typically at that young age anymore, and typically not bilateral. And that’s based on the results of the infant aphakia treatment study. But sometimes it’s still indicated. All right? So that’s the answer there. Let me focus on our live questions here. Since we have everyone still online here. Another live question from Syria. Dr. Humeda again. How do you diagnose the dissociated horizontal deviation, DHDs? And do you use reverse prism test or not? So two things here. One is: Any kind of dissociated strabismus, whether it’s a dissociated vertical deviation or dissociated horizontal deviation. How do you diagnose them? Well, the simple answer to that, to just making the diagnosis, is: What happens in the other eye? Okay? So you see a patient, and they’ve got something going on vertically up or horizontally out. Which is usually what we see. Vertical or horizontal XT. All right. So you see that, and you go: Well, I wonder if that’s a deviation, a regular deviation, or is that a dissociated deviation? You’ve got to look at the other eye. So if this eye… If you’re doing cover testing, back and forth, back and forth, and this eye keeps going up, then this eye should be down. Right? So if you are going back and forth, and only this eye is going up, then that’s dissociated. If this eye is never hypotropic, then this is not a normal vertical deviation. This is a dissociated deviation. Same thing horizontally. You can be doing your cover testing. One eye always looks like it goes out. The other eye never goes out. All right? It’s just dun-dun. Dun-dun. Well, that’s a dissociated horizontal deviation. Do I do reversing tests? No, I don’t do reversing tests. I can just tell from the alternate cover test and the cover/uncover test. The problem is: How do you measure them? I don’t think these things measure very well. You can try to measure with a prism, and see what it takes for the eye not to refixate. So you get a vertical deviation. I’ll put a prism on when it’s deviated, and then force it to take up fixation, and see whether or not it still comes down. And that’s one way to estimate vertically or horizontally how much deviation you have. However, I don’t… A lot of times, I don’t bother to do that, because the surgical correction of DVD or DHD is not really measurement-based. So if I have a DVD, I’m either gonna do an anterior transposition of the inferior obliques, if there’s inferior oblique overaction, and that’s pretty much one size fits all, or I’m going to do a 5 or 8 millimeter superior rectus recession, if there’s no inferior oblique overaction. And how do I decide 5 or 8? Well, if the DVD is bilateral, then I do 8 on both sides. If the DVD is unilateral or highly asymmetric, I do 8 on the worst said and 5 on the less. Same thing with horizontal deviations. Usually if you have a DHD that’s XT, which is what we tend to see, then usually that’s just a maximum lateral rectus recession. It’s not something you measure and grade like you would for normal non-dissociated strabismus patterns. Now, you do have to be cautious, because you can have a combined DVD with a true hypertropia. And in that case, you are measuring — and say this is the hypotropic eye — you measure with your prisms until you no longer see that hypotropia, and all you’re seeing is the vertical dissociated strabismus. And then you have to kind of factor those two together. That’s really probably the only time I really bother to do prism measurements for dissociated strabismus, is when it’s combined with a true manifest hypertropia, and then I’ll write down some estimate of both kinds. But I just kind of estimate dissociated strabismus… It’s basically small, medium, or large. +1, +2, +3, +4. Okay? Everyone may not agree with that, and some people like to measure it, but I don’t think it’s clinically relevant, based on the treatments. Next live question. This is from Dr. Carasiova. And Dr. Carasiova’s question is: What formula or recommendations do you use for resection and recession amount calculation? Most of my training has been under people who trained with Marshall Parks, and so I would say in general my surgical dose calculations are derived from Marshall Parks tables. But those tables generally don’t go up into the higher numbers, so when you start getting into prism diopter measurements of 40 and 50 and 60, they don’t really go that high. So I will use some of the other tables that are out there. Von Noorden has published tables. Ken Wright has published tables. If you look at the Cybersight Library, again, at the pediatric ophthalmology and strabismus modules, there are I believe basic strabismus — which is module number 2, I think it is — advanced strabismus is number 4 — there are surgical dose tables, commonly accepted surgical dose tables there, and that’s what I’ll use. So if you need those straight up, that’s where you can look. All right? Next question is from Dr. Bengoa. How do you manage recurrent chalazia and blepharitis in children? Yeah, this is always kind of a pain. Clearly if someone has a big nasty chalazion, you want to do incision and curettage. But the question is: What do you do with the chronic ones, or prevent recurrences? And I would say that our protocol now — we’ve started doing a lot of flaxseed oil supplementation. That works by thinning out the meibomian secretions, so that people don’t get the blockages leading to blepharitis and chalazia. The dosing for the flaxseed supplementation I don’t have offhand. We have a little handout we give out in the office. But generally flaxseed either as the ground seed or as the oil is available in organic food stores, health food stores, or general markets, and people can take that a couple times a day as a supplement. That’s probably the biggest change, short of doing things that we’ve done for ages, with baby shampoo, lid scrubs twice a day, and a lot of times I’ll use erythromycin ointment after they do the scrub. So have them put erythromycin ointment on the lashes, on the lid margins. If someone has really bad blepharitis, I’ll use oral erythromycin also. The other similar medications — macrolides, Zithromax, I think, can also be helpful. Although I haven’t had great luck with that, topically. So that’s generally what I do. Next question from Dr. Aguela. We saw a 3-month-old baby last week with abnormal head posture and nystagmus. It was a jerk-type nystagmus on the same right side. No other signs. We advised them to simply come back in one month. Should we have done better? So a 3-month-old baby with a head posture and nystagmus… Jerk-type nystagmus. No. I don’t think there’s any… I don’t think there’s any urgency with a 3-month-old born with nystagmus? What’s it going to be from? Well, it’s not acquired. You’re not expecting this to be a neurologic lesion. So if the baby is otherwise normal, I don’t do imaging for a newborn baby with nystagmus. But I’m looking for… One, is there a family history of nystagmus? Because a lot of times these are familial. Just congenital motor nystagmus. I’m looking… As soon as I can get a close look at the iris, I’m looking for iris transillumination. Because people with albinism will have pinpoint iris defects. And then the third thing, especially in males, you can have just ocular albinism. So again, looking for iris transillumination defects. And it’s generally gonna be one of those things. And then optic nerve hypoplasia. You want to get a really good look at the optic nerves, to see if they are smaller than normal or perhaps less pink than normal. If you do find that, then that is someone that generally we would do neuroimaging with an MRI on, especially if it’s bilateral. If it’s unilateral, there’s some debate about whether or not imaging… You know, if they have head postures from nystagmus — it mentioned that they had a right head posture — in the short term, there’s really nothing to do. If that head posture is constant over time, or frequently manifest, particularly as they get closer to school age, then I’ll start talking to families about nystagmus null point surgeries. But I think first you want to make sure that the null point is not going to change. That there aren’t other ocular abnormalities accounting for this. Before you make your decision on null point surgery. And there’s plenty of time to do that. And the results aren’t perfect, so there’s no big hurry on this anyway. Okay. So I think you did the right thing. I would have done the same. Next question. Would you recommend — this is from Cambodia, from Dr. Fara — would you recommend ortho-K for your myopic cases? Orthokeratology? I’m not a big orthokeratology fan. I’m not owe opposed to it. I just don’t know that it really provides that sustained benefit that you want. Maybe I shouldn’t comment too much, because I just don’t have a lot of personal experience. But I would be curious if those… There’s no doubt that you can make some short-term changes in the curvature of the cornea, and maybe in a really young child, you could get some permanent changes, just like we see permanent changes from glaucoma. Right? That can change corneal characteristics. But after about… If you’re just using cornea glaucoma, for example, after about age 4, 5, you don’t see permanent changes in the corneal size. So why would I expect to see permanent changes in the cornea with orthokeratology in someone older than age 5? And I don’t think I would. I think as long as you’re doing it, you probably get changes, but as soon as you stop, I suspect it regresses quite a bit. So I’m not big on that. I think for me… Even low dose atropine… I’m kind of… The results of that… There’s some difference with low dose atropine, but it’s not like you’re taking someone who’s a -7 and making them a -1. You might impact their myopia by a diopter or two, from the studies I’ve seen, and whether or not it’s worth it — I think you have to come to that decision on your own. For me personally… It’s kind of a nonevent. I don’t think doing atropine for 5 years to save a diopter of myopia or so is probably worth it. But to some families it would be, and in those cases, it’s fine. Another anonymous question. Which antiglaucoma drugs are suitable for pediatric age group? Answer is all of them. I use all of the adult glaucoma drugs in the pediatric age group. But I do… The one that we should really make note of here is brimonidine or Alphagan. So this one is known for causing intense somnolence, CNS depression, in small or young children. So I would say anyone age 5 and under, it’s not an absolute contraindication. But I really try to avoid it, and if you do use it, you want to do it with punctal occlusion. But I’ve had several kids in that age group, up to 5, where they were on brimonidine, and the kids were so somnolent that the family couldn’t even wake them up for ten hours. So yeah, that’s problematic. Otherwise the other medications… So the beta blockers… You can use at half percent reduced dose or 0.25. That’s great. But I’ve not seen any problems with beta blockers. I’ve not seen any problems with carbonic anhydrase inhibitors, whether they were topical or oral. I’ve not seen any problems with iopidine or the other alpha agonists. The prostaglandin agents you can use. I’ve not been real impressed with them in children. Maybe they work on older kids, but in young kids, I think the effect is pretty negligible. I’ll use them as a supplement, but they’re not my go-to. So the answer is anything. But whenever you can use a lower dose, use it. Whenever you can use punctal occlusion, use it. And I’m just talking about temporary manual punctal occlusion for 4 or 5 minutes. Instil the drop. Wipe away the excess. But the big one is brimonidine, which is Alphagan in the United States. Probably try to avoid that one in the young kids. All right. Another question from Dr. Mustafa. And the question is: Your protocol for using Botox for strabismus. Generally when I use Botox for strabismus, it is most commonly in the setting of adult patients with acquired 6th nerve palsies. Probably 90% of the time when I use it, that’s what I’m using it for, and I’m using it during the first few months of the palsy, to try and prevent them from developing medial rectus contracture. And what I do is I give them 5 units into the medial rectus. Sometimes in the office, but frequently in the outpatient surgical center, with them just getting a mask induction for anesthesia. I used to do it with EMG guidance, and I kind of stopped doing that. I personally didn’t think it made a big difference, any more than I could get if I just have them a little sedated, and I grab the medial rectus with some heavily toothed forceps, and guide the needle in. Other times when I use Botox for strabismus would be to help augment a full tendon transposition, when I’m doing definitive correction for a 6th nerve palsy or maybe a partial 3rd nerve palsy. Then I’ll put it in whatever tight muscle there is, to help with my transposition. And then sometimes I will use it with acquired non-refractive strabismus in either children or adults. So the acquired non-refractive ETs in particular… If I don’t really know how it’s going to evolve, I’ve used it in those cases. But honestly, the times I’ve done that, I’ve had to eventually go back and do strabismus surgery. I haven’t seen quite the lasting permanent effects that some people report. I have tried a few times for infantile esotropia. Wasn’t terribly impressed. And frankly, those kids have to be under anesthesia anyway. I didn’t see much benefit to using Botox, which takes me 5 minutes under anesthesia, versus doing a bilateral medial rectus recession, which takes me 20 minutes under anesthesia. So it’s pretty limited, and mostly for adults with paralytic strabismus. Next question is from Dr. Olosoner. When is the best time to perform adjustment following adjustable strabismus surgery? Full disclaimer. I do not routinely do adjustables. I have done them in the past. I have not been too much in love with them. And so I stopped doing them, more or less. It’s very rare that I do an adjustable now. But the easiest time to adjust them is when you do it. But if you’re going to do it on the table, in the surgical room, then you have to do their surgery under light sedation. So this is propofol, perhaps. Which is expensive. And especially in an older person, you can do the surgery, especially if it’s on one muscle that’s easy to access, under propofol, and then they wake up really fast, and you can do the adjustment while they’re on the table. Okay? That’s easiest, honestly. If you have to do multiple muscles, or if you don’t have propofol, then you’re looking at doing the adjustment — next best, as far as I’m concerned — in the recovery room. So you let them wake up from their surgery, but they’re only out of surgery for say an hour. Say you do another case, and you go do the surgery. So they’re waking up from the surgery. They’re a little more alert, which is a concern. If you’re doing adjustments on people that are still gorped out from their anesthesia, I’m not sure how reliable that’s going to be. Also, if you’ve done a lot of surgery on them, multiple muscles, and their vision is all blurry, again, I’m not real sure how reliable their ability to fixate and give you input while you’re doing an uncomfortable adjustment on them is. So when I was doing adjustables, those are the two ways that I did them. And I didn’t really like either way. I didn’t feel like anyone benefited. I didn’t feel like it made my outcomes any better, and I felt like the patients weren’t necessarily able to give me really good input, because they were uncomfortable and they were sedated. The other way to do it is wait ’til everything wears off, and do it the next day in the office. That has the benefit of — now they don’t have anesthesia on board. Maybe they can see a little more clearly. The downside is they’re really uncomfortable when you adjust them in general. And the muscle starts to stick down where it was. And so making the adjustment is more difficult. And I haven’t done those, but I’ve assisted on those, 20 years ago, when I was a fellow, and I wasn’t too taken with that either. So for what it’s worth… That’s my input. Next question from Dr. Sedu. What is the best management of accommodative spasm with significant pseudomyopia in children? All right. This comes up once in a while. So accommodative spasm inducing myopia in children fortunately is not super common. But the times that I’ve had the management… What do you have to do? You have to break their accommodation. So usually that’s a matter of putting them on atropine. So I put them on atropine. You can start off by trying to do this just for a few days. A lot of times a few days is not sufficient, though, and you need to do this for weeks or even months. And in that case, you’re gonna want to give them a bifocal. All right? So you put them on atropine. You do an atropinized refraction, so that you can correct their distance deviation and then give them a near add, while you keep them on the atropine for several days or weeks. And once you’ve successfully broken the accommodative spasm, then go back to their non-cyclopleged eyewear. But be careful to double check that they didn’t have myopia that’s been offminused to begin with. So take a good look at your atropine refraction while you’re doing that, so that you can give them as low of a minus as possible. Okay? I think in kids that’s always a good idea, and this is one of the reasons why we do cycloplegic refractions in kids. Because they will either give you too much myopia, subjectively, or they’ll give you not enough hyperopia on their responses, subjectively. So cycloplegia is always important in kids. All right. Next question is from Syria again. Dr. Humeda. What do you do for exotropic dissociated horizontal deviation? If the patient has esotropia and an XO DHD… So this is an interesting situation. So they’re actually showing esotropia when you measure them on alternate cover testing. But they are developing an exotropia DHD at times. What do you do? All right. And I see this not commonly, but I think I’ve seen it a few times. Well, I think you kind of have to decide which of those two things is the problem. All right? What do I mean by that? I mean, if they have a large esotropia, and that’s the problem, or they have diplopia related to the esotropia, or cosmetically, the esotropia is a problem, then you fix that. If they have… If their concern is not the small to moderate esotropia they have, but the exotropia that shows up cosmetically with the DHD, if that’s their concern, then you do the lateral rectus recession just normally, like you would. And that’s usually the situation I see. They’re not so worried about the esotropia, and they’re not having diplopia, but they’ve got ET when you measure them. But they’re worried about the cosmetic XT from the DHD. That’s a lot of letters there. So usually I’m just doing normal surgery for their dissociated horizontal deviation. And that doesn’t seem to make the esotropia worse. So a lot of what you decide to do is the conversation you have with them about: Well, what’s the problem from their standpoint? And some of the add-on questions: Do you do less recession of the medial rectus muscle? I would still do whatever medial rectus recession you needed to control their symptoms. Okay? So if they are diplopic from the ET, you’re going to operate for that. And the other question was: Do you use Faden surgery for stroke dissociated horizontal deviation? And I will admit I don’t really use Faden’s — or posterior fixation sutures for either dissociated horizontal or vertical deviations. I know some people do, but I don’t have any personal experience to guide you on that. But I would think that that could be a consideration in this scenario that you’re suggesting. You do esotropic muscle surgery for the manifest ET, and perhaps a posterior fixation suture on the lateral for the DHD, if that’s showing up. I’m not confident that that would work. But I think that’s a possible scenario that some people would suggest. All right. Next question. Anonymous. Management on congenital 3rd nerve palsy. Yeah, well, these suck. There’s no good way to treat these. You know, whether it’s congenital 3rd nerve or acquired 3rd nerve, you have to deal with what you have. If you have a partial 3rd nerve, then there’s no fixed — there’s no set pattern for that. It could be anything, and you just have to do surgery that takes advantage of the muscles that are still working. Okay? If you have a total 3rd nerve palsy, usually — especially if it’s congenital — you can try recessing the lateral, but in my experience, just recessing the lateral in a total 3rd nerve doesn’t do anything, because the lateral is still pulling on the globe, and they’ll still be exotropic. So some people do extirpations of the lateral. And I’ve tried that. I haven’t been real impressed with that either. So you’re taking out a big piece of the lateral rectus and not hooking it back up to anything. The problem is: What’s left retracts, scars on to the posterior Tenon’s capsule, and it still pulls the eye XT. So I think for me, usually the best treatment for these complete 3rd nerve palsies is to fixate the lateral rectus to the lateral wall periosteum. And the concept here is: You put a non-absorbable suture in the lateral rectus. And you disinsert it, just like you would normal strabismus surgery. But then instead of fixating it back to the sclera, you go laterally inside the orbital rim, and you pass the needle through the periosteum, and you tie the lateral rectus to the periosteum. The concept here is: Now the lateral can contract all at once. But because it’s hooked to the periosteum, it’s not moving anything. Therefore it cannot pull on the globe or on the periorbital tissues and move the eye, and that’s gonna give you the best chance to center the eye. You’re gonna lose that abduction, but at least the eye will be centered now, so that there’s some single binocular vision that’s possible with the head posture. The only problem with that procedure is it’s very difficult to do. I do it not too infrequently, but having a curved needle that you can pass out in that space safely — it has to be a very short, tightly curved needle, a heavy needle, and having it be a non-absorbable suture, it’s tough to find even in countries with good resources — it’s tough to find that needle. And in countries with limited resources, finding a suitable needle has been really difficult for me. But something like a P2, supercurved, and stiff. And you can cut down through the conjunctiva. Like, you’ve done a limbal incision, and you cut down through the conjunctiva and the periorbital tissue to get to the periosteum, a little spatula-type retractor or Desmarres retractor can help with that, but it’s still very difficult to make that pass. The visualization is not good. The space for the needle between the eye, between the globe and the wall, is not good. So it’s technically a very challenging thing, but that’s the best thing to do. And then you can combine that with shortening and transposition of the superior oblique tendon. Just to shift it nasally by the medial rectus. This procedure is also described in the library modules in Cybersight, in the advanced strabismus section, which is module number 4 of the pediatric ophthalmology series. So take a look at that. It described how to do those two procedures. And the final thing you can do, which I’ll do sometimes, is just do great big resections or plications of the medial rectus. But the problem with using a dead muscle is you may get some initial correction to it, but it’s gonna stretch back out over time. But options are limited. All right. Next question from Dr. Mirkobic. Iris colobomas and refraction. So iris colobomas and refraction… Sometimes these can have irregular astigmatism, and some astigmatic refractive errors. In general, I try to ignore the coloboma. If that makes any sense. Because the coloboma is giving you access to part of the lens that you don’t normally refract through. So when you’re refracting someone with an iris coloboma or aniridia, or anything like that, concentrate on the center of the lens. The reflex in the center of the lens. And just neutralize that, rather than what’s going on in the periphery of the lens. That would be my comment on that. So center of the lens. Concentrate on that. Look for astigmatism or anisometropic refractive errors. Okay. Next question. From Dr. Humeda in Syria. High astigmatism with small error in the axis with glasses can cause anomalous head posture? Question. So the question is: Can high astigmatism with error axis cause anomalous head postures? What are other refractive reasons that cause anomalous head postures? So I do see some kids with refractive errors which seem to be causing anomalous head postures. It doesn’t completely make sense to me. So I see it. But I don’t quite understand it. Because if I have a refractive error that’s causing a head posture, when I turn my head, I’m still looking through that same visual axis. My iris didn’t move. So what’s different between my refractive error here or here or here? Unless the head posture is enough to block out the central visual axis in some way. Whether it’s with the nose or the eyelids, whereby you would get a pinhole effect induced from the external ocular structures. If their head posture goes away with a pinhole occluder, then I would say: Okay, that’s from the refractive error. But I don’t really understand how that happens otherwise. Because my visual axis is the same here, here, and here. I see it in some kids with Down syndrome that have funky refractive errors, and I’ve always thought… Well, maybe it’s just their latent nystagmus. So always look for nystagmus as the reason, rather than the refractive error. And it could be latent nystagmus. Or look when you’re doing indirect ophthalmoscopy. When you have them magnified like that, either with an indirect ophthalmoscope or at the slit lamp with a condensing lens, you can see fine nystagmus that you don’t perceive just normally. Just like sometimes people have strabismus that… They look okay. You do alternate cover testing, you don’t see the refixation, but then you do something like a Maddox rod, and you measure that they’ve got 4 degrees — or 4 prism diopters of strabismus. All right. Next question is from Dr. Bengoa. What’s your stepwise approach when you do cycloplegic refraction? Well, my population is mostly light-complected. We have some African-Americans and some immigrants that are dark-complected, but most of our patients are complected like me. So they’re very easy to cycloplege. Therefore what we do is we give an anesthetic drop, proparacaine. Two reasons. One: It burns less than cyclogyl. Cyclogyl burns like fire. Atropine doesn’t burn. But cyclogyl does. So we give an anesthetic drop first. And it also increases penetration of the cycloplegic. So it has two benefits. And then we generally use 1% cyclogyl. And they just get one dose and they go to the waiting room for 20 to 30 minutes, and then they get refracted. If I have someone who is very darkly complected, we may dose them twice. Or we may use 2% cyclogyl. If people still don’t dilate well, we may send them home with atropine to come back on another day. But I don’t routinely do atropine refractions, for two reasons. One, our population is not darkly pigmented enough to need it. Two, the onset — it takes about an hour before you can do refraction with atropine, and then it takes a day to wear off. So those are the main reasons why we don’t use atropine. But it’s clearly a better cycloplegic agent. Next question, from Dr. Celeste. How would you treat a 1-year-old child with 30 prism diopters of exotropia and an abducens nerve paresis from both sides? So 30 XT. And a bilateral 3rd nerve paresis? If you’re assuming that they have a total 3rd nerve palsy on both eyes or a partial 3rd nerve palsy on both eyes and 30 XT… Usually for 30 prism diopters… If I have… They’re saying a 6th nerve palsy. So if you have a 6th nerve palsy, an abducens nerve palsy, you’re actually gonna have esotropia, right? So the abducens — let me just break it down this way. Since it’s not clear from your question. If you have a 6th nerve palsy and 30 of esotropia on both sides, I would probably do a full tendon transposition of the superior and inferior rectus. On one eye. Because that will usually give me 30 prism diopters of correction. If I add a posterior fixation suture to that, that’ll give me another 10 prism diopters. So that would correct about 40 prism diopters of esotropia. If I have a true bilateral 6th nerve palsy, usually their deviations will be larger. It’ll be like 50 or 60, in which case I would just go straight to doing bilateral full tendon transpositions. And in this case, you may want to try… If it’s a child with a bilateral 6th nerve palsy, you may want to try Botox first, if that’s available. Now let’s flip this around. Let’s say you have bilateral 30 XT from 3rd nerve palsies. If they have bilateral 3rd nerve palsies, if you have muscles that are working, you work with those. So if there’s some medial rectus function still, then recess the medial. And resect the lateral. The problem gets to be when you… It’s just the total 3rd nerve palsies, where you have limited muscles to work with. That’s the problem. The partial ones you can still do. Recess and resect as needed. Next question. Dr. Bengoa. And just FYI, we’re coming up on two hours here, so I’m probably gonna cut this off after these next two questions that I have lined up right here. So that we’re about to wrap this up. Two questions. One from Dr. Bengoa, and then the next one from Dr. Humeda. Dr. Bengoa’s question is: How much plus do you add? Do you have any table? In cycloplegic refraction. So when you talk about how much plus do I add… So with cycloplegic refraction, I add, for me, for my working distance, I subtract 3 diopters, if that’s what you mean. If I’m giving plus to treat a high AC/A ratio, or a pseudophakic patient, I will usually use +2.50 or +3 diopters in those circumstances. And let’s say it’s a high AC/A ratio. Then I’ll decrease the plus as they start to outgrow the bifocal. But I’ll actually go straight to a 2.50 or 3 for both high AC/A ratio and for pseudophakia. In terms of working distance, if you have short arms, you have to subtract a little more working distance. All right. And then final question: Superior oblique palsy causes depression limitation in adduction? Or is it unnecessary? So superior oblique palsy. Does it cause depression limitation in adduction? The answer is no. I’m not surprised when I don’t see that. I think a lot of times whether or not you see limitation of the superior oblique with superior oblique palsies or what we call superior oblique palsies — it depends on whether or not it’s congenital or acquired. The congenital cases — really, I hate to call them superior oblique palsies. It’s more like the superior oblique tendon is too long. The muscle works fine. But the tendon is too long. So they get superior oblique. A little bit of underaction. You may not even see it on their exam. What we see is the inferior oblique overaction. They get +1, +2, +3. So that’s what we see. So no, I don’t mind if I don’t see superior oblique underaction. The acquired superior oblique palsies — that’s when I start to see a -1, -2 on superior oblique. But it’s never like a -3. It’s kind of interesting, how we just don’t see that. So I make a note of it when I see it, but not required to make the diagnosis. More likely to see that in cases of Brown syndrome, where the superior oblique underacts, because it’s too tight. All right. Let’s wrap that up for today. I appreciate everyone’s questions. We went through 31 questions live, and then I think we probably covered about 10 prerecorded, over a couple hours, so you guys did a great job with your attendance and your participation. And let us know if you like this format. We will keep doing it.

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November 5, 2018

2 comments

  1. yes sir . I liked this format a lot. Its of great help as there are always so many doubts when u actually start working as a strabismologist. Pls keep doing it sir.

    Thank you so much sir.

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