Lecture: Pediatric Ophthalmology Questions & Answers: Part III

During this highly-interactive live webinar, the full hour will be dedicated to answering your questions about strabismus, pediatric cataract, pediatric glaucoma and pediatric oculoplastics.

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

Transcript

DR NEELY: Well, greetings, everybody. I’m Dr. Daniel Neely, a pediatric ophthalmologist at Indiana University in the United States and also a longtime Orbis volunteer, treating all aspects of pediatric ophthalmology, as well as adult strabismus. This is a continuation of our question and answer series in pediatric ophthalmology. And some of you have been very gracious to submit questions in advance, and I’ll start off with those. And give those prioritization. But I also want our other participants — we want you to submit your questions live. And I will intermix the previously submitted questions along with the questions that we receive live, and we’ll try to cover as much ground as we can during this next hour. If at any point in time there are difficulties with audio or video, please just send that as a question to me, and let us know, and we’ll address things. And during this, I will be going back and forth between talking to you like this, and then at times we’ll be looking at PowerPoint slides, and other times I’ll bring up articles or videos. And we’ll also be looking at the Cybersight website. So there will be a little bit of manipulation as we go on here. For starters, here, I’ll go to the screen share and bring up the PowerPoint. And you should be seeing that right now. This is the strabismus and pediatric ophthalmology question and answer session, and I am Dr. Daniel Neely. So going to one of our first questions here, this is an interesting question, and it’s been a very hot topic on all the discussion boards recently. And this is a question that came from at least a couple countries. Qatar and India. And the question was about the use of atropine and progressive myopia in children. And I think there’s a lot of misunderstanding and misinformation about this. And so I wanted to talk about this, so that we understand what this can do and cannot do. Now, this interest in this is not new. It’s been there for decades. But really just a few years ago, here, let me actually switch out of this for a minute… I’ll go straight to the PowerPoint, so it’s less cluttered here. Here we go. All right, so I think you have just the PowerPoint now. So these ATOM studies — this was atropine for treatment of childhood myopia. These were published just within the last five years. They largely are studies that were done in Asian populations. This particular set of studies is from Singapore. And they seem to be very well done. And there were kind of two phases with this. ATOM1, which looked at atropine versus placebo, and I think also Cyclogyl was included in that. Cyclopentolate. And the summary of that was that they were given either the placebo or the atropine for a couple years, and then the medication was stopped, and there was a one-year washout period. So 400 children treated for two years with atropine versus placebo, and then a washout period. Well, with 1% atropine, it was quite obvious that the amount of myopic progression — here you see -0.28 over the two years in the atropine group — was significantly less than the placebo group, where they progressed by over 1 diopter of myopia. So during the treatment phase, there was definitely a very significant difference. Then there was this washout year. And in this washout year, the medication was stopped. And the patients were monitored for one year. And what you saw was there was a rebound. Okay? So as soon as the atropine was finished, all of a sudden then the next year there was over a 1 diopter myopic shift that happened in the ones who had been on atropine. And then there was continued myopic shift in the group that was placebo, of course. They were continuing to get normal myopia. So at the end of the three years, what was the net effect of two years of treatment and one year of washout? The net effect was basically this here at the bottom. The treated group progressed by 1.4 diopters of myopia, whereas the placebo group was 1.5, 1.6. So if you just treated someone for two years and stopped, there’s basically not going to be much difference at all. Okay? But that wasn’t the point of this study. The point of this study was that while they were being treated, there was a significant difference. Phase two, this ATOM2 study, again… 400 kids in Singapore. And I think the amount of myopia included in this study was anywhere from I think -1 to -6. It was in that kind of moderate range. Not high myopes, and not super low myopes. And again, this was kind of looking at different atropine concentrations. So there was 0.5 atropine, 0.1% atropine, and 0.01% atropine. And the results of this were very interesting. Same kind of thing. Treated for two years and then a one-year washout. And what you saw was at the end of two years, the 0.5% progressed the least. So the strongest dose of atropine progressed the least, 0.3. The middle dose of atropine progressed slightly more. 0.38. And then the lowest dose of atropine progressed slightly more than that. So 0.3 diopters versus 0.5 diopters. But the really interesting — and you can kind of say… Okay. Well, that makes sense. A weaker dose was less effective. But an interesting thing happened during the rebound washout period. And during the washout period of one year, those that were on the higher dose rebounded the most. That were on the medium dose rebounded a medium amount. And those that were on the lowest dose rebounded the least. All right? So then you have to look at: What was the net effect of gain during treatment and then rebound. Well, after three years, these are the amounts of myopic progression. So 0.5%, just over 1 diopter of myopic progression. The 0.1% progressed about 1 diopter. And then the lowest dose, when you accounted for the rebound, progressed the least. All right? So the rebound was less than the treatment gain. And that’s where you see a lot of people using this 0.1% concentration. I’m sorry, 0.01% concentration. And then they did another interesting thing from that study. And that was: Those that had rapid progression, defined as more than half a diopter per year, during the washout phase, were restarted on the low dose atropine. The 0.01%. And they did that for two more years. All right? So that was phase III. And at the end of this 5-year clinical trial, they then looked at what was the net effect. All right? So the ones that continued to be treated with the 0.01% atropine daily, they had a 1.38 diopter progression of their myopia at the end of five years. And that was less than those treated with 0.1% and 0.5%. And presumably less than the placebo groups or non-treated groups. So the article for this… There are different articles out there. And there are different studies out there. But this is certainly one of the largest. Going back to my desktop here… I’ll move this toolbar out of the way so I can see. So this is that result. And this is in the American Academy of Ophthalmology 2015. And that was the five-year clinical trial. So the conclusion: Over five years, atropine 0.1%… Was more effective in slowing myopia progression with less visual side effects, compared to higher doses of atropine. So if you’re going to treat — first of all, I’ll just say that I have personally not had many people want to do this. And so I don’t have a large cohort of people that I have treated. Because… Why is that? Well, two reasons. One, I don’t have a significant Asian population, so there’s less of a call for it. But two, you have to look at this and say… Okay. You’re going in this for the long haul. These studies are two years, three years, and they don’t account for what happens when you finish the treatment. I think to really know what happens and how much benefit there is, you’re going to have to treat these patients all throughout their period of myopic progression. So for most kids, that’s a 10-year window, from about age 8 to 18. All right? Are you going to commit to treating them with atropine, low dose or high dose, whatever it’s going to be, for 10 years? Or are you only going to treat them for 2 years or 3 years or 5 years? And then anticipate that there’s going to be some progression? Even when they are effectively treated, the other thing to keep in mind is… This doesn’t stop myopia. It merely retards the progression. So maybe it cuts down the amount of myopic progression 20%. Maybe it cuts it down 40%. Maybe it’s 50%. But there’s no evidence that it’s going to be any greater than that. It’s probably somewhere less than 50%. And we don’t have a lot of information on the high myopes, the pathologic myopes, which are the ones that really get into trouble. Not just these… I don’t want to wear glasses or contacts… But these are the kids that are -10, -20, and at risk for retinal detachment. We don’t have a lot of evidence as to whether that improves their ocular health. Yes, there’s a lot of interest in atropine treatment for myopia. But you have to understand the pros and cons. I should mention in terms of side effects… At least with the 0.01% low dose atropine, side effects were pretty minimal. Yes, you can get some pupillary dilation. But there doesn’t seem to be a lot of accommodative impairment. And that’s the big thing that you’ll want to watch for, if you are treating these kids. Are they having accommodative impairment? So this low dose atropine is an effective tool, if you do have families that are very interested and are in it for the long haul, multiple years. I think this is a reasonable thing to do. But let’s all keep in mind that I think the jury is still out on this, because we don’t have long-term follow-up during the treatment. We don’t have long-term follow-up after the treatment is completed. All right? So take that to your patients and discuss that. I’m going to go back to the PowerPoint slides here. And so far I do see that we have a couple questions that have been submitted online. I’m going to do one more of the preprogrammed questions, and then I will start maybe alternating with some of these questions that are being submitted live. So feel free to continue submitting questions. All right. And back to the PowerPoint. All right. This is an interesting question. This comes from Nigeria. And this is something that we all struggle with. This is: Pediatric cataract surgery capsulotomies. And when I think about pediatric cataract surgery and how it differs from adults versus children, really to me it breaks down into not just that we don’t need phaco for 99% of pediatric cataracts. Almost all of these we’re doing with aspiration only. Whether you do aspiration with an IA handpiece, a Simcoe, even, or an automated IA handpiece, or you’re using a vitrector, I don’t think it really matters. But what does matter is what do we do with lens implants, and what do we do with the anterior and posterior capsulotomy? This person did not specify whether or not their question had to do with anterior or posterior capsulotomy, but I can break it down for you. For me, the dividing age, when I decide how to do a cataract surgery, is right around 5. Why 5? Children 6 and older are usually pretty cooperative. So in terms of the posterior capsule, I can usually feel like I can leave it intact, just like I would for an adult. And if I need to do something later on, they can usually sit at a YAG laser. It doesn’t mean the YAG laser is going to be easy for a posterior capsulotomy, but they can usually do it. Occasionally you have to take them back and do a surgical capsulotomy. So some people will actually do primary posterior capsulotomies to even older ages than 6. They might go 7, 8, 9, even. But for me, my cutoff is right around there. Other times in older kids, I might open the posterior capsule. Posterior lentiglobus, posterior cataracts, PHPV, in someone who’s older who hasn’t been operated. But in someone older than 5, I’ll leave the posterior capsule intact and for the anterior capsule I’ll do a manual tear exactly the same as an adult. Bent tip, needle, Utrata forceps. In that age group, 5 and older, the anterior capsule is more elastic than an adult, but you can usually tear it with a fair degree of safety and control. Age 5 and under, I usually will open the posterior capsule. And that’s one thing that we’ll talk about here with this question. Different posterior capsulotomy techniques. Relative to the anterior capsule, though, I think it doesn’t really matter how you do that. If you’re really good with tearing anterior capsulotomies, and you want to tear it manually, I think that’s fine. For me, once they get less than age 3, I struggle to control that manual tear capsulotomy. And I will switch to a vitrector technique to open the anterior capsule. And I will show you that in just a second. Between 3 and 5, I will usually tear it, but sometimes I’ll do it with a vitrector. And I don’t really have a rule as to how I decide. A lot of times it depends on what the cataract looks like to me, and how opaque it is, and other factors. So 3 and 5 is kind of a gray zone between manual tear and vitrector capsulotomy. But I think the big thing, the important thing, is that in the under age 5 group, it’s the posterior capsule. You have to open the posterior capsule, because it’s going to become opaque in a short period of time, and if you don’t have the posterior capsule out of there, these kids are too young to sit at a YAG laser. The posterior capsule opacification is too dense. They are also going to opacify so quickly that it’s going to be amblyogenic. So you might as well open at the time of the surgery, regardless of whether you’re putting a lens implant in or not. So let’s look at a couple techniques here, with both the anterior and posterior capsule. I’m gonna switch back out of the slides and go to some videos here for a moment. And first let’s look at an anterior capsulotomy. I think it’s this one. Let’s see what we’ve got here. Yeah. All right. So here is… This is a 1-year-old or less. So what I’m doing is I’m not — this is a posterior lentiglobus-type cataract. It’s not a very dense cataract, but you can see the opacity back here. The big thing is that the refractive error is very funky, because of the bowing of the posterior capsule. But it gives us a nice visualization to see this vitrector technique. I decided I don’t want to tear an anterior capsulotomy. I want to use the vitrector. You can do this different ways. This is with an anterior chamber maintainer. Here I’m putting in a 20 gauge anterior chamber maintainer for the anterior and posterior capsule. And the nice thing about the anterior chamber maintainer is it frees up both hands, if you want to have both hands on the vitrectomy handpiece or want to stabilize the eye with a forceps. Cut rates can be anywhere from 50 cuts per minute up to 2,000. Generally I will run the cutter as fast as possible if it will engage the capsule. Pause for a second. You see what we’ve done is we’ve turned the vitrector port down. It is facing the anterior capsule. And you use the minimum amount to vacuum that it takes to engage the capsule and take little bites out of it. In this particular case, I have started more or less in the middle, and I’m enlarging it, until I get to my desired size of roughly 5 millimeters. And while I’m doing that, I’m trying not to engage the underlying lens material too much. I really just want to take the capsule and superficial lens material. If you step on the vacuum too much, you will pull right into the lens and cut through the backside. The other way to do this is to basically cut a circle with your vitrector, and then go back and finish the inside portions. Like you’re cutting a donut or a circle, and then you go back and finish. But let’s continue with this. Again, just enough suction. And you can see that this ends up being scalloped a little bit. Back up just a touch. Even though this is taking cuts, and there’s a little bit of scalloping here, what happens is that the points of this roll under, and you end up with something that looks smooth and circular, although the edge is a bit scrolled. Now, is this as strong as a manual tear? No. It’s a little bit less. But this has no radial extensions. This tends to be back towards the middle. So it’s relatively strong. All right. So once you have that… Then since you already have a vitrector in the eye, you’re welcome to just switch over to aspiration only. Turn your cutter off. And go ahead and remove your lens material. Okay? So it makes the vitrector a very nice multipurpose instrument for pediatric cataract surgery. Now, you see I’ve done the subincisional cortex first, because that’s the most difficult area. It’s nice to get it out while you still have all this lens material holding the posterior capsule back. If I’m going to turn the cutter on, like I did just there, I’m doing it in a safe space, up in the pupillary axis. All right? A little cutting there. Get some of that dense lens material. And just keep aspirating, aspirating. Just like you would with an adult. Out in the periphery, you engage, you pull it back to the middle, where you can safely aspirate it. Okay? So nice example of using the vitrector to do an anterior capsulotomy, and remove the lens material in a child under age 5. Over age 5, I would just use — personally, for me, I would just use an automated IA handpiece. All right. So that’s one video. Let’s now look at the posterior. Get out of that. Let’s look… What are we gonna do now? Now we need to do a posterior capsulotomy, right? So… What do you do? You put your lens in. Okay. There we go. Now… Put your lens in. I like these lenses, these Alcon single piece lenses. I think any lens that goes in folded, so you can do small incision, and any lens which opens slowly… I mean, look at this. The haptics are still on the optic. That allows you to position this lens in a small eye, with a less than perfect capsulotomy, very safely. You’re not stressing the edges. Okay, so your lens is in. Now, you could… We’re closing right here. But let me roll back just a touch. I’m gonna stop right there. Okay. Let’s say your lens is in. Now we need to deal with the posterior capsule. One of two ways. We could have opened the posterior capsule with a vitrector before we injected the lens. And that’s fine. If you do that, you have the downside of having to inject the lens with the posterior capsule open, and sometimes it can snag on that opening, or you can stress that posterior capsule opening. And you can get an extension of the posterior capsule opening. So a lot of people do that and are comfortable doing that. I’m not comfortable doing that. I will sometimes at this point… Once this lens is in… Take my vitrector and reach in underneath the lens. So you can see here how the lens is displaced inferiorly a little bit. That allows you to get under this anterior capsular edge, and the edge of the lens implant, and you could stick your vitrector back here right now and open up this posterior capsule, and then come out and close up and be done. That’s very appealing. If you do that, it’s easier for those of us who don’t like going through the pars plana. But you just need to be sure that you don’t pull vitreous with you back around that lens and back to the wound. So you need to be very meticulous about being sure that there’s no vitreous. And if there is, getting it cleaned up, so we don’t have a displaced lens, we don’t have a vitreous wick, and we don’t have an irregular pupil. But that’s easier. The other way is… A little more complex. But I think it has some advantages, if you’re willing to try it. And this is the pars plana approach. Pars plicata. The advantage of this — you can take it down at the limbus. That’s fine. I try to leave the limbus intact, but 20, 30% of these kids have glaucoma and maybe need glaucoma surgery later. But here I’ve taken the conjunctiva down, done a little cautery, and I’m gonna go in with this MVR blade. In this child, it’s probably 2.5 or 3 millimeters from the limbus, and I’m gonna make a pars plana incision. This is a 20-gauge vitrector. This particular step I think some of the smaller vitrectors do have an advantage. The 23s and the 25s. But honestly, even though this is a large instrument, and we’re just going through a sclerotomy without trocars, I’ve been very lucky in 22 years and have had very few complications doing that. I do think it’s a safe maneuver. You want to get that posterior capsule open right away. So that you have fluid that’s flowing from the infusion, back to that vitrector. Now, your lens is stable. You haven’t displaced it. You are able to easily judge how big you want your posterior capsulotomy to be. And when you pull out, if there’s any vitreous that follows the instrument, you can just clean it up, and it’s not going to cause any leakage. It’s not going to cause any displacement of your lens. It’s not going to cause any distortion of the pupil. So that’s a bit more uncomfortable, and maybe a bit more challenging. It takes a little more time. Versus going from the front. But those are the arguments for going through the back, rather than the front. Personally, I think either technique is good, as long as you do it with nice technique and pay attention to what you’re doing. And I’d rather have you do it in the front, and open the posterior capsule than just not open the posterior capsule at all. In these young kids, if you’re not going to open the posterior capsule, you pretty much might as well not do the cataract surgery. Now, what if you don’t have a vitrector, though? Because a lot of us don’t have access to a good vitrector. Does that mean you can’t do pediatric cataract surgery in younger kids? The answer is no. Are you a bit more challenged? The answer is yes. But let me show you one more video, before we go on, because I think this is a technique that we’re going to look at next that really is applicable to any situation. All right? And I’m gonna go back to my desktop here. Close the one we just looked at. Wait. I know where it is. Okay. I just forgot. Let’s do that. We’re going to step into Cybersight here for a minute. All of this material that we’re talking about today — everything I’m going to tell you is available for your future review on Cybersight. If you open up your homepage — here’s my homepage. I have four consults that I need to respond to. I have 18 that are in progress. You guys are keeping me busy. I’ve got 1200 that I’ve answered. So keep those coming. Please send consults. Just a plug for consults. I think this is the greatest thing that we do, are these free consults, where you can ask a subspecialist a question. And these questions are going… If you have a patient consultation that you submit, it is going to someone who’s a specialist and is probably a world-renowned ophthalmologist. So please take advantage of that. And I think it’s just an incredible teaching tool. Yes, it’s great for patient information to get you advice on your patients, but it’s also just an absolutely tremendous teaching tool. All right. But aside from consults… What else do we have? Well, the library. And the courses. So if you go to the library, you can see all the videos. You can see all the old lectures. If you go to the courses, we’re talking about pediatric ophthalmology and adult strabismus today… And you go to this catalog of courses, and let’s go to the pediatric ophthalmology section. This one in particular right here. Fundamentals of pediatric ophthalmology and strabismus, full course. If you open that… This takes you into what I consider to be the core curriculum for pediatric ophthalmology and strabismus. These are the things that, when I go out on Orbis programs, I am teaching. These are the things that, when I have fellows, and we’ve trained over 100 fellows at my institution in pediatric ophthalmology. This is the stuff that I want them to know, before they leave. All right? And so here we’re talking about cataract in particular right now. I’m gonna open this up to show you a particular video. In this cataract course. And you’ll see that — look. We have anatomy and physiology of cataracts, preoperative approach to cataract surgery, types of IOLs, how do you make the lens calculations, cataract surgery techniques, like we’re talking about right now. Both anterior and posterior techniques. And then postoperative management. I want to show you this particular cataract surgery technique, which is here in part one. And here — same stuff we’re talking about. Posterior capsule, IOL, anterior capsule. This video demonstration… These are just really great videos. This is the one I want. All right. So Dr. Shakankiry from Egypt. This lady is fantastic. So this technique — she will use a vitrector, but I think this technique is adaptable to even not doing vitrector. That’s not what I wanted. Come back. Here. I thought that was gonna be full screen. All right. And I’ve adapted her technique, I’ve switched to what she’s going to do, which is bimanual. Here she’s going to tear it. She’s not using a vitrector. She’s really good with this. She can tear a manual capsulotomy on an infant, no problem. So I think this is personal choice right here, based on your comfort level. A lot of times — I’ll just point out something — a lot of times you get these nuclear cataracts. That’s roughly about the size you want your anterior capsulotomy to be, whether you’re cutting it with a vitrector or tearing it like she’s doing. She’s using a vitreoretinal forceps here, rather than Utratas. Hydrodelineation, hydrodissection, stirring the nucleus there to loosen it up. That’s a nice move there I’ve adapted. This is another thing I’ve adapted from her, this bimanual technique. Rather than using an anterior chamber maintainer or a Simcoe, she has an aspiration cannula and an infusion cannula. She currently has the aspiration in the left hand, and the infusion is over here in the right hand. Assuming this is 12:00. And I really like this instrument that she has here. It’s flat, it has diamond dust on it, and it really grabs the cortical material. And because this is bimanual, if she gets subincisional material, she can just switch hands, and get stuff that was posing a problem. Let’s see if she switches hands here or not. I don’t remember. Looks like it’s probably all gonna come. Okay. But say that hadn’t come out of there. She could have just switched left hand to right hand and reached right across there. So you could just put your lens implant in now. You could open the posterior capsule now. And do a vitrectomy or not. A little viscoelastic. All right. She is doing a primary posterior capsulotomy, manual technique. And this is why I’m saying you don’t need a vitrector, necessarily. Or you don’t need a good vitrector to do this. Any vitrector can finish the case that she’s going to do here. But she’s going to open the posterior capsule with this needle. Put a little viscoelastic behind it. And then tear it manually. And I think we’re all kind of afraid to do that. But I’ve tried it. With a little bit of practice, it is not as scary as you’d think. You’re gonna open it anyway. So you can’t make this too bad. And yes, she’s very good. She’s got great technique. But I think we can all do this. If we can tear an anterior capsule, we can tear a posterior capsule. It behaves a little differently, because it’s thinner, but it also is less elastic. It doesn’t want to run as much. All right, so there… Now you could… She’s opened the posterior capsule. If you didn’t have a vitrector at all, I would just go ahead and put your lens implant in now. I wouldn’t mess with vitreous face. I’d try to leave it intact. If you get vitreous prolapse, that’s really where you’re going to need the vitrector. But what she’s doing here — she’s gone in with the vitrector, and she’s clearing out the vitreous face. No one really knows what’s the best thing to do with the vitreous in these kids. Most of us do this, where we take some of the vitreous, but some people will leave the vitreous intact. I think my main concern is getting the posterior capsule open, and making sure we don’t get vitreous coming forward — that would need to be dealt with. But here she’s doing a little bit of vitrectomy. And now next is going to put the lens implant in, with the posterior capsule open. So yeah, it can be done. And she does a lot. I think she does something like 300 pediatric cataracts a year. Maybe more. So I think she’s very skilled. But I think all of us can do this. If we are patient, and keep at it. There’s nothing that’s too radically different from doing adult cataract surgery with this technique. The differences are minor. And you have to be careful. Yes, it’s more difficult, but I think any ophthalmic surgeon who does adult cataract surgery could learn to do this technique. Injecting the lens. This for me — this is the step that I’m uncomfortable with. Which is why I still tend to do mine posteriorly. But look at this. It’s just a beautiful implantation. And again, look at the advantage of having this slowly opening lens, where you can kind of manipulate it into position. If you had a one-piece lens, admittedly, this would be more difficult. If I had a one-piece lens or a three-piece lens, I probably would put the haptics in the sulcus, and then do optic capture. I think that’s what I would probably do. But you don’t want to do that with these one-piece lenses. These one-piece lenses — you want to put them in the bag. All right, so I’m gonna stop there. But that’s really an interesting and impressive technique. To deal with anterior and posterior capsules. So we’re gonna go back. Oh, let me go to our questions here. And we’ll see what we have here. All right. First question is about alternate patching. Does it have a place in the treatment of anisometropic amblyopia? Alternate patching for amblyopia. And I think for any kind of amblyopia, let’s talk about alternate patching, regardless of the cause. You could have anisometropic amblyopia, you could have bilateral amblyopia — that’s where I most commonly see this question. From someone who’s a high hyperope. Should I do alternate patching? For me, the answer is no. If I have anisometropic amblyopia, the more farsighted eye is going to be the amblyopic eye, so I’m gonna patch the other eye exclusively. 2 hours, 4 hours, 6 hours — whatever that is going to be. Bilateral amblyopia, from bilateral high hyperopia, or from bilateral cataracts, because they can have bilateral amblyopia, bilateral high hyperopia and bilateral cataracts — there’s no advantage to patching, alternate patching. I restrict the patching to whichever eye is the worst of the two. Whichever eye is the better of the two, the patient is automatically going to use that eye to its full potential. And it will improve to its full potential on its own, once you’ve corrected the refractive error issues. If they’re already preferring their right eye, making them patch the left eye does not make the right eye get better faster. I don’t think there’s any evidence of that. Nor does it make it get better to a better degree. It is going to improve to whatever degree it is physiologically and neurologically able to. If visual acuities are equal in the two eyes, and someone had a bilateral amblyopia from high hyperopia or pseudophakia, again, there’s no advantage to alternate patching. They will both — if the vision is equal, they will both improve spontaneously, at the pace that they can. All right? So for me, alternate patching has almost zero place in the treatment of amblyopia. That may not be an opinion shared by everyone in the world. But to me, it doesn’t make sense, and I don’t think that there is any significant literature to support its use. About the only time I would use alternate patching is occasionally for intermittent exotropia. There are some studies to indicate that people’s control will improve with alternate patching. I will admit that I have tried it many times, over the last couple decades, and I have uniformly been disappointed. And I no longer do it. I don’t really think it makes any difference. If I’m doing it, it is not with much expectation of significant improvement. It is more because the family doesn’t want surgery. All right? Another question here… Only… Okay. There’s a question here that reads only for strabismic amblyopia. And it’s not from the same person. If you could clarify that, Donatella, I would be happy to answer that. But I’m going to move on from that one. Let’s do another spontaneous one here. This question here is what IOL power to implant in a unilateral cataract in a four-year-old, if one eye is 25 diopters and the cataract eye is 30 diopters? So presumably we’re talking about a unilateral cataract, and when you look at the lens calculations, one eye, the non-cataract eye, comes to a 25 for emmetropia. And the cataract eye comes to a 30 for emmetropia. All right. Perhaps more importantly, as to what the lens calculation for the non-surgical eye is, I would probably be looking at the refractive error, to best answer this question. Because if the non-surgical eye has low to moderate hyperopia, I’m probably going to do what I always do, regardless of what the number is. And for a 4-year-old, I want them to still be hyperopic. A little bit. A couple diopters, perhaps. 2 diopters. Maybe no more than 3 diopters. Somewhere in that vicinity. Why am I targeting that as my postsurgical refraction? Because they are going to grow a little bit more. They’re going to become less hyperopic, as they get into those preteen years. And so I’m trying to anticipate that. If the non-surgical eye is myopic, though, well, I’m probably going to be targeting something closer to whatever it is. It’s not ideal, because you know that your surgical eye is then gonna end up myopic as well. But I want the two eyes to be somewhat close to each other. Now, when we do adult cataract surgery, we talk about having refractive error anisometropia of less than 2 diopters. Adults don’t tolerate more than 2 diopters of difference from one eye to other, typically. Children do, though. And I think as long as you get them within 4 diopters of each other, they’re probably fine. So if one eye is myopic, I would target something to get close to that. Now, an interesting thing about hyperopic targets. In the past, I have targeted larger amounts of residual hyperopia in younger children. Recently at the AAPOS meeting in San Diego, Wilson’s group had an interesting paper that said after the age of 7 there wasn’t much of a significant shift in their cataract surgery patients. So normally in a 7-year-old, I might have left them 1 to 2 diopters hyperopic, but looking at his data, it was suggested in a 7 or 8-year-old you might want to be targeting closer to just emmetropia. Because they’re not gonna change very much after age 7 or 8. So I think that’s something to keep in mind. In these younger age groups, when you start getting down into 6 months old, 1 year old, 2 year old, it is really hard to accurately predict what lens implant to give these kids. And it’s one of the downsides of infant IOLs. You don’t really know how much myopic shift there’s going to be. Even if you know what their parents are. You also don’t know if they’re going to have glaucoma, which is going to cause more myopic shift or not. It’s really difficulty accurately predict those lens implants. So the answer to your question: In a 4-year-old with these calculation numbers, I probably would first of all — in your target postoperative refractive error… In that box on your A scan, I would put the target of being a +3, probably. Okay? Now, other people do this calculation differently. I was in Tanzania recently, and the school of thought there was: They put emmetropia in that lens calculation box, and then they reduce the lens power by 20% or 30%, depending on the age of the patient. And I have less experience with that, but it’s a way to achieve the same goal. You’re anticipating some growth, and so they’re not giving — like in this case, they wouldn’t give a 30-diopter lens. They would give something that might be 20% less than that. So that’s a 24. So that’s one way in your particular case to answer that. Reduce it by about 20%, perhaps. Then we have another question about… How to manage persistent fetal vasculature. All right? Well, the way to manage persistent fetal vasculature is pretty much what we just did with those cataract surgeries. Especially the ones that you saw with the vitrector. Basically persistent fetal vasculature — you need to open the posterior capsule and remove the anterior vitreous, so that that dense opacity that’s right behind the lens in that anterior portion of the stalk can be removed with a vitrector. You do not need to remove the entire stalk. You do not need to go posterior. But you do need to just sever that traction that’s on the posterior capsule centrally. We do that for a couple reasons. One, to clear the visual axis. Two, you need to get the traction off the ciliary processes. Because in persistent fetal vasculature, that dense central scar tissue pulls the ciliary processes in, and they can even end up meeting in the middle, and eventually, while you can get glaucoma in these eyes, you can also just get eyes that shut down and they become phthisical. So we make sure to get rid of the traction on the ciliary processes. The only other difference with PFV is: Do you put a lens implant in these eyes or not? It depends on how severe the PFV is. By that, I mostly mean: How distorted are the ciliary processes? But the corneal diameter. The corneal horizontal white to white needs to be 10 millimeters or more, in order to accept an intraocular lens. All right? Smaller than that — it’s probably just not going to fit. So now let me go back to some of the previously submitted questions. That people sent in advance. I don’t want to disadvantage them. So I’m going to go back to the PowerPoint here for a moment. Talked about capsulotomy. How to evaluate a child with strabismus. I appreciate this question, but the scope of this question is pretty extensive, and it’s not something that we really have time for. This is a whole lecture in itself. If you look in the library, we have covered this webinar before. Kind of the introduction to pediatric ophthalmology, fundamentals of strabismus. You can find this material, though. Let me go back to the desktop here for a moment. I want to go back to Cybersight here. All right. Where can you find this material? Here’s pediatric cataract. Get this tool bar out of my way. All right. So we were talking about library… Okay. If you want to see some of these old webinars, you can find — the lectures are here. All right? All the old webinars are listed there. And you can filter them and find the ones on pediatric ophthalmology. But what I’m interested in right now is going back to… The courses. So I’m going back to the courses. And that same section that I was referencing before, with the comprehensive training section on pediatric ophthalmology… So here we are. Pediatric ophthalmology. Fundamentals of pediatric ophthalmology, full course. I can find it there. Or you can see it’s been broken out separately here also. Evaluation of the pediatric patient and adult strabismus. All right. So if you want to know how to evaluate a child with strabismus, go to this module 1, and look at these first couple sections here. Visual acuity testing, motor and sensory, measuring the deviation, measuring motility, how do you write that down. There was another question that was submitted earlier, about refractive errors in children. Well, again, that’s a big topic. The question about refractive errors was: Prescribing guidelines. Well, that’s a whole lecture in itself too. But here you can find it right here. Guidelines on prescribing glasses, magnitude of refractive error. Suggestions for prescribing for myopia. Suggestions for prescribing for farsightedness, hyperopia. Astigmatism guidelines. Anisometropia guidelines. And then guidelines specific to when there is esotropia strabismus, when there is exotropia strabismus, and guidelines for bifocals. So I can’t really go into that second question either, but you will find answers to both those questions right here on the Cybersight courses. Fundamentals of pediatric ophthalmology. All right? I’m gonna go back to the live questions here. Next question is how to go about a traumatic cataract with a B scan showing vitreous hemorrhage in a 3-year-old. Should we do cataract surgery and not primary posterior capsulotomy? That’s a good question. Traumatic cataract in a 3-year-old, if you have vitreous hemorrhage… In a 3-year-old, the question is: How long can you wait until you clear the visual axis? I don’t think you want to wait one month or two months to clear the visual axis. You need to get this eye cleared up earlier. And I think what I would do here is… I would do the lensectomy. I would probably do this with the vitrector. I would do a vitrectorrhexis, and I would remove the lens material, and I think I would go ahead and open the posterior capsule from the front. Once I had the posterior capsule open, I probably would do a little bit of an anterior vitrectomy and see how much of that blood came out. Maybe you can accelerate having that blood resolve by having that posterior capsule open and removing some of the anterior blood, at least. I think the big thing here that you have to be careful about is you don’t want to be sticking the vitrector back into the central vitreous or posterior vitreous from the front. And if I had someone, a retina specialist, that I could utilize to clear out the vitreous hemorrhage, I would probably let them handle that part. That’s frequently difficult for us to come by, I know. And so that may not be an option for you. But I think that trying to get that visual axis clear, one way or another, from the front, by doing a lensectomy, an anterior vitrectomy, at the very least, whether or not to put a lens implant in at that time might be optional. You might just wait for the hemorrhage to resolve. But I don’t see a reason not to put a lens implant in, even if you’re going to refer them to a retina specialist. That way, they’ll have a nice clear view. If you let them do the lensectomy, they’re gonna take everything and you won’t have anything to work with. Better you take the cataract out and put the lens implant in and have them do the vitrectomy, if needed. The other thing here is you want a very careful B scan and be quite convinced that you don’t have a retinal detachment with this vitreous hemorrhage. Okay? Next question is an amblyopia question. Cause of the crowding phenomenon. Well… That’s a good question. I don’t know that I know… Can adequately explain the precise physiology of it. But what is the crowding phenomenon? This is when you’re testing someone with amblyopia, and you give them a single letter at a time, and they test really well. They do 20/30. Or 6/18 or whatever. So they test really well, but then you test them with a full line of optotypes, and they test worse. They’re 2 or 3 lines worse on the eye chart. And you notice that maybe they only get the first letter and the last letter. These are classic examples of the crowding phenomenon. So this is why, when we do vision screenings and we test acuities in the office, we always give full lines, to compensate for this crowding phenomenon. If you’re going to give a single optotype at a time, it should have those crowding bars, top and bottom, left and right. All right? I’m gonna take a few more live questions, and then I’m going to draw this to an end within just a few minutes, because I have another obligation here coming up. Next question is about active vision therapy for amblyopia. What is it and how useful is it? We don’t know. Okay? Any kind of vision therapy, whether it’s exercises for the muscles or whether it’s visual stimulation inducing… There’s a lot of interest in that. I think people put a lot of hope in that. But the fact is: We don’t really have any solid medical literature that these things make any big difference. You will find definite camps of thought. Some people are super intense believers. Others are complete disbelievers. The truth is probably somewhere in the middle. There probably is some use, but I think we just really don’t know. As far as eye exercises, I will use convergence exercises for convergence insufficiency. I will use convergence exercises sometimes for intermittent exotropia. That is about the extent of how I utilize vision therapy. To me, vision therapy is wearing an occluding patch for amblyopia. Vision therapy is using atropine for amblyopia. To me, that’s vision therapy. There have been studies. I think that the PEDIG group did studies to see if using handheld devices or performing tasks while being patched for amblyopia — if that made any difference. And if there was any difference, it was pretty negligible. So that was not supportive of activities or vision therapy. Okay? Yeah. This question came up in advance. This is another spontaneous question here. But it also came up in advance. I don’t know if it’s the same person. Question was: Indication for tomography in children. Is it avoided or prohibited? CAT scanning, computed tomography, involves radiation. There have been studies that came out within the last few years that showed that there was a higher incidence of, I think, carcinomas and other complications in young children who were receiving radiation from CAT scans. As a result of those findings, there has been a big backlash against CT scanning children. Now, I think we have to take that information… Is it prohibited? No. It’s not prohibited. I think if you only have a CT scanner available to you, and you don’t have an MRI scanner, I think you still need to use that CT scanner, when you have someone who needs neuroimaging. Right? I mean… That’s better than not… If you suspect someone has a tumor, get a CT scan, right? If you have someone who you suspect has a complicated skull or orbital fracture, get a CT scan. However, if you have both a CT scan and an MRI scan, and you can get the same information then the recommendation is: The MRI scan would be preferable, because of the lack of radiation. That’s what this recommendation boils down to. So yes, we are trying to limit radiation exposure in the younger children in particular. Just like we are trying to limit multiple general anesthetics in the younger children, because we know that there are some issues, long-term, in terms of safety. All right? So not an absolute contraindication. It is a relative contraindication. And you use what you have available. All right? Next question. What is your experience with putting intraocular lenses in infants less than 6 months? And what are your parameters to implant or not? My experience… I’ve been putting intraocular lens implants in infants under 6 months since I started practice 22 years ago. My experience has generally been favorable. All right? They do okay. And I’ve had some very good outcomes, and I’ve had some very bad outcomes, but I don’t think it’s any different than the ones when I did the lens implant in secondarily later. I have put lens implants in babies that were premature, and the surgery was done on their due date. So they were basically zero weeks adjusted gestational age. And their visual acuity came out fantastic, 18 years later. And the infant aphakia treatment study showed us that. The visual results with infant IOLs — visual results were fine. They were equivalent to leaving the kids aphakic and treating them with a contact lens. The reason that, in the US, at least, people have backed off doing infant IOLs in this age group is that the rate of surgical complications was higher. The rate of repeat surgeries was higher. So the current… This is for unilateral. Okay? The current thought tends to be: Holding off on infant IOLs, and doing secondary IOLs later. But the fact of the matter is: If you don’t have contact lenses available to you, then doing a unilateral cataract surgery and not putting in a lens implant, you’re guaranteed to have a horrible visual result. So I think we have to do this on a case by case basis. Do you have contact lenses available? Is the family going to come back for follow-up? Do we think they’re reliable? If they lose the contact lens, can they get another one? You know, sometimes it’s not clearly a lens implant is better or worse than aphakia and a contact lens and secondary lens implant later. There was only this difference in the complication rate. And I think you have to do what’s going to work for your patient and your situation. So far, my comments have been having to do with unilateral cataracts. I think it’s a different animal when you have a bilateral cataract. As long as you can get aphakic glasses. We know that the complication rate with bilateral lensectomy and aphakic glasses is really low. These people do really well if you can keep them in their correction and get them new glasses as they need them. They will have perfect vision. So would I want to put bilateral IOLs in a 6 month old or a 2 month old or a 1 month old? Probably not. I wouldn’t. But you may have circumstances that the family is not going to be able to get aphakic glasses, and maybe that’s all you have to do. But my suggestion for aphakic bilateral is to… I’m sorry. For cataracts that are bilateral is not to do IOLs in the infant group. Do secondary implants later. All right. I’m going to do two more spontaneous questions. And then I’m going to draw us to an end, I think. This question is: When, say, a 5-year-old orthotropic child, so we have a child with straight eyes, needs +6 glasses after cycloplegic refraction, do you give it all at once or in steps? Do you add a cycloplegic for a couple of weeks for adjustment? So we have a child, their eyes are straight, but they have a + 6 refractive error. What do I do with that child? Do I give them + 6? No. If they were esotropic, I would. But if they have straight eyes, I would take 2 diopters off of that. The child is still going to do 2 diopters of normal accommodation. That’s for comfort. But yet we’re getting them out of this high hyperopic zone, by correcting 4 diopters of it. So now effectively in the glasses they’re gonna be a 2 diopter hyperope. So that should protect them from developing bilateral amblyopia. It should protect them from developing refractive esotropia. But they should be comfortable because you’re letting them do a little normal accommodation. If they didn’t tolerate the glasses, if they couldn’t stand it and they wouldn’t wear them, then I might do it in steps or I might put them on a temporary cycloplegic, so that they were blurry, unless they were wearing the glasses. And if I do that, I’ll do atropine for a few days and then stop it. And that sometimes will work. But generally no. I just give them what I think they should have. Whether it’s the full plus for an esotropic child or reduced plus for a child with straight eyes, and go with that. Next question. ’til what age do you practice occlusion therapy for anisometropic amblyopia? And what is your experience with the results? So asymmetric refractive errors. At what age? ’til they don’t need it anymore. That’s a sarcastic error, but it’s true. If you find that child when they are 2 years old and they are amblyopic, I will treat them until their acuities are equal or close to being equal. If they’re in the correcting glasses, you should then be able to stop it. You will only need to continue treatment if they’re not improving or if they’re not wearing glasses. But usually if I see a child with anisometropic amblyopia, I usually give them the glasses only, and I don’t start the amblyopia treatment other than the glasses. I see them back in two months and I see if they’re improving. If they’re improving, I will continue with the glasses only. If they’re not improving or they stop improving, then I add the patching until I get the result I want. Or until multiple visits have shown me that they’re going to be refractory. Once multiple visits have shown that I have the result that I want, or that they’re not going to improve anymore, that’s when I stop it. Now, for a new patient that comes in, that’s older, say you have a patient that comes in, and they’re 10 years old. If they’ve never been treated, I will treat them for the amblyopia still. I will prescribe patching or atropine, along with the glasses. But if they have a history of being treated for several years, I’m not gonna go back and try treatment. All right? A lot of times we talk about age 7 as being the cutoff. But everyone is different. Some people will not respond after age 5. Some people will continue to respond until after age 10. So if someone has not had a course of treatment, I think it’s reasonable to try. Okay? All right. I’m going to need to draw us to an end there. So that I can fulfill my other obligation. I appreciate everyone that submitted questions in advance. And thank you very much for the live questions. Please do continue sending those. We will catalog any questions that have not been answered, and when we do our next session, I will start off with those. Again, thank you for your attention, and I look forward to talking to you again in the future. Good day.

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April 15, 2019

One comment

  1. Thanks so much for the answers to the questions. I am happy the session was recorded. I missed the live session but was able to understand the recorded version

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