During this highly-interactive live webinar, the full hour is dedicated to answering 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
DR NEELY: Well, welcome, everybody. This is a new item for us today. Today we’re pioneering a little question and answer session. So you’ll get to spend a little quality time here with me. What we’ve done is we’ve solicited your questions in advance, and have asked you to send those in. And I’ve gone through those, and I’m Dr. Daniel Neely. I’m a professor of pediatric ophthalmology at Indiana University. I’ve also been Orbis volunteer faculty for 15 years, and I help with the Cybersight telemedicine program. That’s my background. I practice pediatric ophthalmology full-time, and I’ve been to at least 20 countries all around the world, so we have these questions that have been submitted in advance. And I’ll start by going through those. We’ll also be taking questions online, through the chat system. So I’ll monitor that. If there’s something that I can touch on, while we’re doing this, and that might fit in with some of the other questions, I’ll answer it live. If we have time at the end, I’ll go to the chat questions also. If we just have too much to get through, and we don’t get to the chat questions, we’ll save those, and we’ll do another one of these, and we’ll start off with those. So what we’ll do is… I’ve gone through and I’ve tried to include as many diverse countries around the world as I could. And I also tried to consolidate — some of the questions were similar, so sometimes you’ll see there are several questions on the same topic. And let’s just dig right in. I’ll also be using a white board today. We’ll start off by going to a PowerPoint, just so you can see the questions. So I’m gonna share my screen, and let’s get into my PowerPoint. Here we go. All right, so you should be able to see my PowerPoint. This is our very first question. This one comes from South Africa. And the question was: What’s the best time for cataract surgery? Well… It’s a bit of an open-ended question. But let’s say we’re mostly talking about infants here. And the optimal time for cataract surgery is as soon as possible. Because you need to have these kids seeing as quickly as possible, before nystagmus develops. Once nystagmus develops in the eyes, which is around a couple months of age, it’s really hard to get good visual acuity results, of course. So as soon as possible. But also, when it can be done safely. You know, a lot of the places we work in around the world — pediatric anesthesia is very difficult. And so you always have to take that into consideration, when you’re working with these infants. You need to be sure that you can get the kids asleep safely. You may need to consider doing both eyes at the same time. And for me, the optimum timing for this is, if it’s a bilateral cataract, you have a little more time. So somewhere in the ballpark of 4 to 8 weeks after birth. And if they have a unilateral cataract, trying to get this done by 4 to 6 weeks after birth. And of course, there’s always some factors there, with prematurity. One thing to remember here, though, is we’re not just talking about having the surgery done by this time. We need to be talking about being able to have the eyes optically corrected. So they need to have an intraocular lens. They need to have glasses. They need to have a contact lens. Something like that has to be going on, in order to have this eye rehabilitated. I’m gonna put in a little plug right now. Many of you have maybe seen some of these older Orbis manuals. So here’s the one that I helped write. With Ed Wellson and others. And this is the pediatric cataracts in childhood. And the nice thing about this — at the time, just black and white. But of course, you can see it’s step by step on how to do vitrector or IA cataract in an infant. And it has things here like intraocular lens calculation, targets for infants, and so forth. Pars plana measurements. Well, in the last year, we’ve completely redone that system, and now if you go to the Cybersight… Let me go back to my share here. If you go back to the Cybersight library, what you’ll find is that these pediatric cataract books that we used to print are now interactive modules. So the pediatric cataract module happens to be a three part module. One is evaluation and management. Two is the step-by-step surgery, which we had in the printed manual, and there’s a third section, which deals with technical aspects. And this is part of a larger series that you should be aware of, which is a full course on pediatric ophthalmology and strabismus. Since that’s mostly what we’re talking about today. This goes step wise through evaluating the strabismus patient, basic strabismus. What we’re talking about right now is pediatric cataract. Module 4 is advanced strabismus, superior oblique, vertical muscles, inferior oblique, and module 5 is pediatric glaucoma, and module 6 is retinoblastoma. These seem to be the subjects that are highest in demand when I go out on programs. You have to register for these, but they’re free. They’re really nice. These are slick. They’re interactive, they have pop-ups on them, videos built into them, there are quizzes you can take, and there are supplemental materials. If you want to download a PDF of this old manual, you can still do that. It’s not just from me. It’s from many authors. And I think you can find that that’s a comprehensive source of information that everyone will benefit from. That will be my one plug for the day. So that’s my short answer to the optimum timing. I’m going to go back to the next question now. And this question is: Too young or too old for strabismus surgery. When is the right time? Can patients be too old for it? And that question is from a physician in Nigeria. Second part of this, I think, which is related, is from a physician in South Africa again. At what age should congenital non-accommodative squint be corrected? Too young or too old for strabismus surgery? You know, I don’t think there’s really… Again, there’s not really an answer for that. I operate on kids with strabismus that might be as young as six months for congenital esotropia. But really the answer is whenever. If you have stable measurements, and you have a healthy patient, you do the surgery as soon as you safely can with anesthesia. And so we’re talking about infantile strabismus right here. So my target with a congenital esotropia is somewhere between six months and two years. There is some evidence that after two years, results aren’t quite as impressive. But it’s hard to find a lot of support for doing ultra-early surgery, under six months, and certainly you start to get into anesthesia concerns there. But even between six months and a year, you have anesthesia concerns. So I think you do it whenever it’s reproducible and it’s safe. And there really is no upper limit. I do a lot of adult strabismus surgery as I get older, and I operate on people that might be in their 90s. So it really depends on… Is it bothering the patient? Is it bothering the patient, and are they healthy enough to undergo it? This is a pretty benign surgery, so if they’re having problems, and they want it fixed, fine. If they have 30XT and they don’t care, there’s no sense in doing the surgery, right? So… Again, there’s no convincing evidence that this ultra-early surgery is of benefit. So I think… With all these things, again, everything that I tell you — some of it I will show you research studies to support it. But other times, I’m just giving you my anecdotal experience, having done this for 20 years now. And people may disagree with what I say. There’s no right or wrong answer with any of this. I think that’s another thing everyone needs to keep in mind. There’s more than one way to do this stuff. And as long as you do it well and you do it reproducibly and do it safely, that’s all you’ve got to do. Right? All right. And then it gets down to techniques and opinions. Take it all in and choose what’s gonna be right for your situation. All right, so let’s go to our next question. This is about congenital glaucoma. And this comes from a physician in India. What is the change in corneal diameter and axial length in post-trabeculotomy congenital glaucoma patients? So when we talk about congenital glaucoma, we have a process where pressure builds up in the eye, and the eyes get larger. Well, buphthalmos tends to occur up until age three, four, maybe five sometimes. But usually if a child that’s five years old has elevated intraocular pressure, unless it’s really high, they’re not usually getting axial length changes anymore at that point. So the younger they are, the easier the eye gets larger and wider and buphthalmic. The same is true in terms of reversal with these surgeries. If you get the surgery done, get the pressure down, you will see dramatic changes in optic nerve cupping. You may have a 0.8 cup, and all of a sudden it shrinks down to just like 0.3 or less. And you see that routinely in infants, when you’re able to see through the cornea before the surgery and after. And axial length changes and corneal diameter changes — they reverse less. There’s no question about that. But you can see the corneal diameter go down by half a millimeter, when you get the pressure down. You might see the axial length go down by a half or 1 millimeter. But you don’t see these dramatic changes like you do in the optic nerve. So again, the answer to that is that it’s… Somewhere around age 3 to 5, and you’re gonna see less of a change in the axial length, in corneal diameter, but you’re gonna see more change in the optic nerve head. As that regression occurs. Another cataract question. This is an important one, because this comes down to the topic of intraocular lenses. What about unilateral cataract, in a 5 month old, when the parents are unable to use a contact lens? And that’s from Egypt. Second question is: Intraocular lens contraindicated in pediatric patients? And that’s from India. Now, this question comes up when I started in practice… 20 years ago… We were just starting to put intraocular lenses into infants. And I’ve put lenses into infants that were premature, it was on their due date, and they did really well. And their vision might have ended up 20/40, 20/50. Now, 18 years later, I’m still seeing these kids. But you see other kids that get an intraocular lens as an infant, and it’s a disaster, and you’ve got to take it out. They get membranes. So there’s a lot of variability here. And again, there’s no right or wrong answer. I do think we saw a little bit of backlash on intraocular lenses after the infant aphakia treatment study. So we’re gonna talk just a second about the infant aphakia treatment study, so everyone understands what the implications of this study were. All right? So before the study went on, people were putting intraocular lenses in. Some were really committed to it. After the study, it seemed like most of the US surgeons started to back off on unilateral intraocular lenses. And I think that’s a keyword right there, unilateral. So let’s go to a little summary here of the infant aphakia treatment study. And we’re gonna talk about its implications. Okay? So the infant aphakia treatment study randomized 114 infants, and these were infants. They were between 4 weeks and 7 months. So this study, right off the bat, does not apply to a 1-year-old or a 2-year-old or a 4-year-old or a 6-year-old. This study applied to infants. This age group is completely different than infants who are one year older than this. Other take-home lesson here: These were unilateral cataracts. These were not bilateral cataracts. Again, that’s a different animal. And your criteria are different for that. They were randomized to intraocular lens or aphakic contact lens. One key point about this: The ones that were randomized to the aphakic contact lens, the study gave them the contact lenses. All right? These people lose these all the time. So if you’re in a situation where someone is gonna lose an aphakic contact lens, and can’t afford to replace it, right off the bat, that’s not a good solution for them. Right off the bat, they might be way better off with an intraocular lens, because they’re never gonna be able to replace that contact lens. And here in the United States, those contact lenses are at least $100 US. This study followed them until age 5. So they were old enough that they got visual acuity outcomes on most of them. It wasn’t just grading acuities, et cetera. What did that study show? At age 4.5 or 5, there was absolutely no difference in the visual acuity outcomes. Zero difference. They were not statistically different. So the visual acuity results between a contact lens and an intraocular lens were the same. About half the patients in each group had a visual acuity better than 20/200. Now, honestly, the big factor that decides what the visual acuity is is how early the surgery is done and how well the parents comply with the patching. It probably has a lot less to do with whether it’s a contact lens or an intraocular lens. And you can see that that was borne out here. The method of aphakic correction didn’t really seem to matter. But what was the take-home here? The intraocular lens group had more complications and required more surgeries, and many of these were in the very first postoperative year. So that’s the finding that caused a little bit of backslide on people being aggressive with intraocular lenses, unilateral intraocular lenses, in infants, in the United States. We still do it in some cases. But we’re more likely to leave them aphakic and use a contact lens temporarily, until they can get a sulcus lens, or a lens with optic capture in the bag later. The other argument sometimes for intraocular lenses is that it protects against glaucoma. Well, that doesn’t seem to be true. In both groups, a third of the eyes developed glaucoma or were glaucoma suspects. I think that that concept of intraocular lenses protecting against glaucoma came from a time when they were only being put into normal-sized eyes or larger eyes, and if you had a smaller eye, you didn’t get a contact lens, so you have PHPV, microphthalmia, well, those are the ones that are more likely to get glaucoma. So I think the chance of developing glaucoma has less to do with whether there’s an intraocular lens and more to do with the underlying size or developmental status of that eye. So let’s talk about this just a little bit more. So that’s what the infant aphakia treatment study showed. Now, what do I think the role is for intraocular lens in infants? If, again, they can’t get or maintain or handle a contact lens, that kid is gonna be way better off with an intraocular lens, regardless of what age they are, than they would be a contact lens. Okay? If follow-up is an issue — sometimes that is an argument for intraocular lenses. However, we have to keep in mind that if that child is less than 5 to 8 years of age, you probably always want to be doing a primary posterior capsulotomy. You just take the lens out and put an intraocular lens in, in a 3-year-old, and then six months later they have a posterior capsule opacification, you might as well have not even done the cataract surgery. So you need to be versed in the technique of opening the posterior capsule with one of the various techniques. And again, those techniques are discussed in the pediatric cataract surgery module, and the pediatric cataract lecture that I have given a few times, which is cataloged on Cybersight. So take a look at those, because that’s critical, to open a posterior capsule in a child less than 5 to 8 years of age. All right? Bilateral cases… You know, a one-year-old with bilateral cataracts, and you’re doing cataract surgery… For me, that’s kind of where I’m sometimes uncertain. Should I do bilateral intraocular lenses, or just do aphakic glasses? Because glasses are relatively expensive. They’re relatively available. And bilateral cataracts of any age always do well with aphakic glasses. So a lot of times in these bilateral cases, I’ll do that as a temporary measure in infants, or in one-year-olds, and then do secondary IOLs later. In a two-year-old, now you start to get into an area where I’m quite comfortable going ahead and doing a lens implant bilaterally, in a two-year-old. So two on up, I think intraocular lenses are definitely the way to go. Under two and under one… You’ve kind of got to take the big picture into consideration and do what’s right for that particular patient. Okay? Again, there’s no right or wrong answer. And we actually have some more intraocular lens questions coming up in just a bit. But let’s go back to our next question here. Strabismus and amblyopia question. This comes from one of my new friends in Syria. Is amblyopia common in infantile esotropia? Generally it is less common. It definitely occurs less than 50% of the time, when you have congenital esotropia. But it does occur. Maybe it’s around 30% or less in my clinical experience. Do you treat it before strabismus surgery? Well, the answer to that is yes. And we’ll talk about that. Is patching two hours daily recommended for the best result? So infantile esotropia — yes, they do get amblyopia. And how do you detect that in a six month old or a one year old? Mostly we’re looking at fixation preference, right? You can’t test their vision. Most of us don’t have Teller cards and all these fancy research tools. We’re looking at fixation preference. If they’re alternating, you don’t need to do alternate patching. I just monitor them, I repeat their surgical measurements until it’s stable, and once they come back two or three visits in a row with 35ET, time to go. They go to surgery. So I like to see a couple visits in a row with the same measurement. Now, if you’re not gonna have follow-up on these, then you take one measurement, and you do the surgery. It is hard to do alternate cover on these infants, but it’s not impossible. I like to use a loose prism, rather than a prism bar on infants. If you cannot do… And honestly, you’re not gonna be able to get distance fixation, to get distance measurements, usually. So I’m usually holding a toy. I’ve got my little Tigger toy right over here somewhere. Let me see if I can grab him. Anyone who’s worked with me has seen Tigger. We’ve got about 100 of them. And usually you can get kids to look at that. I like Tigger. He’s got a tail. That tail is very important. It goes right there. Now the kid is looking at you, looking at the toy. You’ve got a few seconds to get this done. You get the toy in your mouth, you hold the prism up, you do your cover testing, you’re done. All right? Just confirm that it’s about 30, 35. This stuff is kind of ballpark at this age. Gene Helveston, my mentor, basically said these come in small, medium, and large. And he’s right. You’re not measuring down to 0.25 millimeters when you’re doing recession for congenital esotropia. You’re ballparking this stuff to get them straight so they can have good sensory status. A quick cover test at near, get your measurements, and once they’re stable, you go to surgery and you get them fixed up. The second part of the question had to do with: Do you treat the amblyopia before you do the surgery? Yes. If they have a fixation preference, I will start patching. And I’ll patch with the goal of trying to get them alternating. That doesn’t always happen. Sometimes they have pretty strong fixation preferences. But if they won’t alternate, I like to at least see that they’ll hold the non-preferred eye for a second or two, before they switch back. So you’re trying to get some semblance of getting them to use the non-preferred eye. Why do we do this before surgery? Why not do it after surgery? Just get the surgery done and that will work on some amblyopia? Well, the reason is: A, we know there’s not a huge hurry between six months and two years. It’s kind of soft on sensory outcomes. You want to get them lined up as soon as you can, but it’s not like it’s night and day between doing it at six months or doing it at a year or two. So you have a little time here. Once you straighten their eyes, it is really hard in a one-year-old to tell which eye they’re fixating with. Yes, you can do base down prism tests, and other prism tests, but it can be tough to tell if they’re straight. I mean, if they still have strabismus, you can usually tell which eye they’re fixating with, but even then, it’s a bit of a chore. If they have 40ET, it’s pretty easy to tell which eye they’re using. So it’s easier to manage the amblyopia management in advance, when you can see which eye they’re fixating with. So I like to do a little bit of that first. And then of course you have to continue afterward, and just do the best you can, until you can tell what their acuities are. All right? And then the third part of that question from Syria was: Do you patch two hours a day? How many hours a day do you know to patch? For amblyopia? We’ve all kind of come into this two hours a day mindset. I see it here in my practice. I think I do it too. I’m just patching everyone two hours a day. The amblyopia treatment study in 2003 said it was equal to six hours a day. And I think we kind of have to keep in mind a few factors here, and not just automatically do that. We need to take it one step further and think about the other factors. And so we actually are gonna talk about the amblyopia treatment study, where the two hours a day came down from. But let me go back to my next slide here. And this next slide has a little bit more information about what we just talked about. And the thing to keep in mind here is that younger children — this third bullet point and then two small bullet points — younger children are more sensitive to patching. Their neurologic system is immature. They’re way more responsive to patching than a five-year-old. We see that every day. So you may only have to patch one hour a day in a three month old. In the infant aphakia treatment study, the amblyopia treatment guidelines were patching one hour a day per month of age. So if you had a four month old, they wouldn’t be patched any more than four hours a day. And if you had a six month old, they wouldn’t be patched any more than six hours a day, and I think it kind of maxed out at half of all waking hours. So we’re not generally patching all day long. We’re not generally patching even eight hours a day. But it’s somewhere in that one to six hours, depending on the age, and how dense you think the amblyopia is. Again, you kind of have to use a little judgment here. The patching… The patching — where this two hours a day came from was one of the amblyopia treatment studies. I participated in many of these, and I did participate in this one. And this is from the pediatric eye disease investigative group. And I consider this group’s studies to be of the highest quality. They are… This and the infant aphakia treatment study are gold standards for how randomized studies should be done, multicenter basis, monitored, both private practice and academic practice, large sample sizes, I trust the results of these studies implicitly. All right? This study — I forget which one this was. I don’t know if it’s ATS3 or whatever, but this was the one that said part-time patching, 2 hours daily, was as rapid and effective as part-time patching 6 hours daily. A few caveats here. This was for moderate amblyopia. This was for children with 20/40 to 20/80 vision. This does not apply to dense amblyopia. Now, we had a couple hundred patients, more than 200 patients in the study, and there was a mixture of strabismic and anisometropic kinds of amblyopia. They all had to be seven years of age and younger. So from a practical standpoint, there weren’t any six month olds or one-year-olds, and I don’t think there were any two-year-olds in the study, because none of them could do acuity testing. There were some three-year-olds, but most of these patients were four, five, six, seven. So after this came out, I have to admit, most of my patching now is about two hours daily, but that does not apply to infants. It does not apply to dense amblyopia, and it does not apply to older children or adults. The next question that I have — this is a strabismus surgery question. We’ll shake it up a little bit here. And this is a good one. This is a common question. The first one is from Romania. Strabismus surgery keys. And there wasn’t much more explanation to that. But I think when we talk about strabismus surgery, there’s the technique, and we don’t have time to go through the technique. That’s a whole lecture in itself. But then there are surgical guidelines. The surgical dose response. That’s the question I get from fellows and residents. Everyone wants to know: How much surgery should I do? And a second question from Egypt says just that. How do you determine the correct amount of muscle recession after strabismus measurements? What do I do? The books have multiple sources of tables. And there are all the textbooks in the back usually have these charts. And I’m aware of three or four of these charts. And they’re roughly similar. What do I use? These guidelines are probably 50 years old now. Right? These are from Marshall Parks, modified by one of his fellows and one of my mentors during residency, Dr. David Stager. And these are good. I use these pretty exclusively, except in the larger angles of deviation. I draw from some other tables to get some of the larger deviations. Let me tell you first how you use these. So let’s just start over here. Exotropia — you’re gonna recess both laterals. So for me, 20 prism diopters is a 5 millimeter recession. 30 is a 7 millimeter recession. And then as you get above that, that’s where I kind of go on to some other tables. Oops. Let me go back. So you do that same thing to both sides. Conversely, if you need to do bilateral resections, for residual exotropia, which — I don’t do this too often, but these are the same guidelines. You’re gonna resect about 4, 5, 6 millimeters, depending on the numbers. If you do a recess/resect, you’re gonna pick one from each of these two columns. So if I’m doing a unilateral recess/resect, I’m gonna pick a lateral rectus recession and pick the same category of medial rectus resection. So 20XT, I’m gonna recess the lateral 5 millimeters and resect the medial 4 millimeters. Same thing with esotropia. We have the same thing. Mostly we’re doing medial rectus recessions. I pretty much use these exact numbers. And you can see these go up pretty large. I don’t do 7 millimeter recessions. I will occasionally do 6.5. You have to be careful as you get into these larger numbers. You get some late slippages and overcorrections. So you can see what these numbers are here. You always have to take into consideration some other things, though. Those numbers to me are for primary surgery. You’re doing the very first surgery. If someone has already had a medial rectus recession, and now I’m going to do a lateral rectus resection, I don’t do a full surgical dose. I usually back off a little bit on the resection. Because you’re working with weakened medials now. So those are some of the things you’re taking into consideration. One of the things I’ve gotten into recently — I might go to the whiteboard and talk about this — is I’ve become a big fan of… Instead of doing resections and taking a piece of the muscle out, I’ve become a big fan of doing plications. We haven’t talked about this too much on any of our lectures in the past. So let’s just… Let me switch to my whiteboard here for a minute, and I’m hopefully gonna have a video of this soon. I’ve been saying that for about a year. But David Plager, who is one of my senior partners, kind of got me started on these a couple of years ago. I’m not sure who turned him onto it, but it’s become a big part of our practice. And let me see if I can get my whiteboard up here. Of course it’s… Okay, it’s connecting here. Let’s just see. Okay, we got it. So you should be able to see my whiteboard now. Lawrence, message me if you don’t see that. But it looks like it’s up.
>> Yeah, we got it.
DR NEELY: You got it? Okay. So let’s just talk about a recession. If you’re doing a recession, there’s our cornea, and then we’ve got our muscle. We’re gonna talk about resections, sorry. So a normal resection — we’re gonna resect 6 millimeters. We’re going to put our vicryl suture here. And then we’re going to basically cut this out, and pull everything forward. Right? Well, what I don’t like about that is that you’re cutting right in front of your suture, and of course, this can sometimes be under a lot of strain, because you’re tightening this up. So sometimes you can get this suture kind of slipping forward towards the cut end right here. So there’s some opportunity for things like slipped muscles, lost muscles, and there’s also opportunity for bleeding. What I’ve gone to here recently is a plication or a tuck. So we’re talking about… You’ve got your muscle. And you’re still gonna put your suture back here. But now instead of cutting this section out, what we’re going to do is just… We’re gonna bypass this. What do I mean by that? It means we’re gonna take our suture, our double armed 6-0 vicryl suture, and pass the needle through the sclera here and pass this one through the sclera right here. What happens then? Once you’ve passed your needles through there and you start to pull this forward, and make your iPad do something crazy… What happens is… Now this fold gets formed. So the muscle… I’m gonna exaggerate a fold here. So this is the section in front of the suture. And our suture is here. And here. And there. It comes around. And there. So we’ve got this fold right here, that we’ve created. And you need to make sure that this space right here is tight. That that muscle is completely folded up against it. And I think that’s the critical step here. You want that… You’re taking that muscle. And you’re folding it. And you want… As that muscle folds, you want those two halves of the muscle way up against each other, and you want that vicryl super tight right there. Now, what happens is… It looks bad at first. You’ve got this big lump of tissue from this fold. But it disappears. It absolutely disappears. After about two to four to six weeks. It’s flat. All right? So it maybe takes a little bit longer to heal, or it’s a little bit lumpy bumpy. I wouldn’t say it takes longer to heal, because resections are always more inflamed. But it looks lumpy bumpy for a bit. You never are cutting the muscle. They are never at risk of losing the muscle, unless you lacerate it with the needle, and I use the same surgical dose response tables. I don’t change my numbers at all, and I think the results have been fantastic. And again, we’ve been doing that for at least a couple years, and most of my partners have switched over to that. Not a new technique, but just a resurgence of something that’s been around for a long time. As a teacher and a busy strabismus surgeon, I do it all the time, and I advocate that you try that sometime. Again, you have to keep those folds up tight. It takes a good assistant, because they need to lift up… You need a skinny hook underneath there, because you need to be able to slide the hook out, once you tie that loop. So we use some Helveston hooks, which have small to no knobs on the end. A non-knobbed or very skinny hook that you can slide out after you tie. Your assistant also has to hold that fold up at the right tension and move it around back and forth, because they need to not undo the knot that you’re tightening, and they need to lay the fold where you can get your knots down on top. So let’s go back to our next question. Let me make sure I covered all the answers to that one. And I’ll keep going here. I want to get to as many of the questions as we can. So strabismus measurements. Again, these numbers… If you go to that pediatric ophthalmology module that I talked about in the strabismus section, you’ll find these numbers. Okay? So Cybersight, library, courses, pediatric, fundamentals of pediatric ophthalmology, full course series. Go to the basic and advanced strabismus modules there. You’ll find those. Those are great modules. Again, surgery videos, interactive, the whole works. All right. Next question. Which strabismus cases are at risk for diplopia after surgery? And that comes from the country of Burundi. And this one is related, I think. If a patient with intermittent XT complains of diplopia with neutralizing prism, are they at risk of postop diplopia? This is a common concern. I get this question a lot, either through the Cybersight consults, which I think are one of the most valuable things at your disposal, by the way. Cybersight consults, pairing you up with a mentor who can analyze your case and give you feedback from a world expert. And it’s free! We all should take more advantage of that, and do more Cybersight consults, okay? Be sure when you do strabismus consults to give some indication of what the motility is like. And the measurements. At least measurements in the primary position. If you have photos, that’s nice. And sometimes you can just do the whole case with photos. But it’s nice to have at least some of your interpretation of the motility and the measurement, as well as a few position photos. So the diplopia — I honestly don’t worry a whole lot about diplopia. That sounds cavalier, but I’ve been doing this 20 years, and I can think of two people who had intractable diplopia after their surgery. Neither one of them wanted their surgery reversed. They both said that they were so happy that their eyes were straight, that the second image didn’t really bother them. Okay? I take that back. I think I’ve seen one unhappy patient with intractable diplopia who had been a congenital ET and got moved out of her area of suppression, and was just generally unhappy. But I think she was gonna be unhappy kind of no matter what happened. So yeah, it doesn’t seem to be a big deal. Certainly in kids it’s not a big deal. Kids, the younger they are, they just suppress. They get amblyopia instead of diplopia. So you’ve got to deal with that. Teenagers and young adults — if they’ve had strabismus for a long time, they’re pretty good at suppressing secondary images, unless you just really bump people out of their suppression scotoma. But what usually happens is they have diplopia for a bit, and it goes away or it doesn’t bother them anymore. People that are bothered by diplopia are people that had normal eyes as children. They had normal eyes, and then something happens, and they get strabismus, and they have diplopia. They get diplopia. Now you operate on them, and it’s not perfect. And they still have diplopia. Those are the ones that are a headache for me. I mean, they still have diplopia. We need to do more surgery, we need to do prisms, but someone who’s walking around, a 40XT, or 30ET, I don’t know. I just don’t see it that much. I like to do a subjective prism test, which is one of the questions there. Someone has got an intermittent 30XT, and you hold the prism there. For intermittent deviations, I don’t buy a lot of that, because they’re intermittent, and sometimes it takes them a long time to kind of adapt. So the intermittent deviations — I don’t usually go by that. The constant deviations — I’ll try to get some idea of what they can tolerate in a prism. So if they have 30ET, I’ll hold the prism — I’ll let them — I like to do this. I like to take the prism bar and let the patient hold it, and slide it up and down and see what they like. Whether it’s hypertropia or esotropia or exotropia. I like to subjectively let them play with that prism and see what they like, and I write that number down. And then I see what they become diplopic with separately on my exam, and I write down those numbers. That doesn’t mean that’s the number I’m gonna target, but if they have 50ET and they’re diplopic if I give them more than 30 prism, I’m probably gonna back off just a little bit, and kind of try to leave them maybe a little bit undercorrected. So not everyone may agree with that, but I’ve done 10,000 strabismus surgeries, and diplopia after surgery… They didn’t have diplopia before surgery, diplopia after surgery is not a big deal. If they do have diplopia because they had a bad result, you just fix it with prism or a reoperation. Reoperations happen. This is just part of what we do as strabismus surgeons. I think that’s something to keep in mind. Everyone is not gonna turn out perfect. It doesn’t matter if you do adjustable or fixed sutures. I’ve done both, and I’m a fixed suture person. But some people are the exact opposite. When I counsel patients about strabismus surgery, I tell them: Look, you’ve got about an 80% chance that what we do today you’re gonna be happy with, and you never have surgery again. And you’ve got about a 20% chance that you’re gonna need a reoperation. You’re gonna need a touchup at some point. Either what we do — we’re not gonna be happy with it in six to eight weeks, or it’s gonna change as you get older. I think as long as people have those expectations, postoperative diplopia is not a big deal. So you do take it into consideration, but I don’t let that prevent me from operating on people. And they are happy and they do fine. So let’s keep going with some more questions. And we’re getting down to about ten minutes left. I’m undoubtedly going to have some left over. So if I don’t get to your question, A, I apologize, and B, we’ll just do it the next time. I’ll start from where we left off, and we’ll just keep adding to this list. I kind of like this format, and I’m happy to do this as much as we want. So if you like this format, let us know. If you don’t like this format, also let us know. We’ll deal with that too. Okay. Question from Austria. Surgery for Brown syndrome. I think it’s a good one, because this comes up a lot when I do Cybersight consults. This and Duane syndrome. And maybe DVD are some of the most common questions that I get. So I think we should talk about this. A couple things to keep in mind about Brown syndrome. One, most of these people are actually okay. Most of these people are okay. They have head postures. I’ll come back to this slide. But most of these people are okay. They have head postures, and they’ll be like this, and turning. But they generally don’t have a lot of diplopia. Unless in the primary position, they’re just flat-out off. They’ve got a manifest hypertropia. But most of the time, they don’t. Most of the time, they’re pretty decent-ish in primary, or they have a little head posture to neutralize it. When they go to the side, you see this big deviation. Certainly up and to the side, they’re out of wack. But that’s not a problem. Kids are short. They’re looking up at their parents all the time. That’s where Brown syndrome looks terrible. You take that, but you don’t necessarily make decisions based on what the parents are telling you. I like to see what they’re doing as they get a little bit older, school age, what’s their head posture doing, or are they getting amblyopia from the Brown syndrome? Less common, but it can happen. So let’s revisit a couple facts here, from studies, about Brown syndrome. That can help us make these decisions. One thing to keep in mind is that 85% of these improve spontaneously to some degree. Now, it doesn’t mean — by age 5 to 7 years. That doesn’t mean it goes away 100%, but it does mean that they get better. Okay? So go slow on deciding about surgery. Unless it’s really severe. If they have amblyopia or a horrible head posture or diplopia that they can describe to you, okay. They need surgery. But otherwise, give it a little bit of time. See how it shakes out as they get closer to school age. One of the frequent treatments for Brown syndrome is a tenotomy. An unguarded tenotomy. That means we’re just gonna cut across the superior oblique. A couple points to keep in mind here. The closer you cut the superior oblique to the trochlea, the more effect you’re going to get. If you just disinsert it from the sclera temporally, you’re gonna get a little bit of effect. If you cut it nasal, just nasal to the superior rectus, you’re gonna get more effect. And if you cut it next to the trochlea, you’re gonna get a huge effect. I usually go just along the nasal border of the superior rectus. But if you look at these unguarded tenotomies, so you just cut the tendon, let it go, 50% to 85% of those are reported to lead to secondary surgeries for overcorrections, as time goes on. That’s a pretty high overcorrection rate. So Ken Wright certainly popularized the concept of a silicone band spacer. Others have used suture spacers. And these are what we call guarded tenotomies. So I’ll draw a little picture on that in just a minute. But before I get to those, my usual approach is to monitor the vision, monitor the alignment and head posture, wait until as close to school age as possible, manage the amblyopia if needed, and if they need surgery, I usually try one of the guarded tenotomies with the silicone spacer, usually a retinal band, and if that does not work, I do a free tenotomy. I go back and take the spacers out. Spacers are an interesting thing, and people have questions about that, so let’s go to the whiteboard here for a second. And it’s coming. Maybe it’s coming. Come on! All right. I think I’ve just got to find the window here. Let’s stop that. It seems to be a struggle. All right. So I’m not gonna do it. Let’s do this. Let me do… Let me stop the share here. I can use the other whiteboard instead of the iPad one. It’s just easier to draw on that. I’ve got it all jacked up. There we go. Now we’re out of that loop. Just in time. All right, let’s go back… Let me try one more time. See if I can get that whiteboard out of there. See what happens. Please play background music. Here we go… Now we’ve got closed captioning going on. That’s cool. But I still don’t see my whiteboard. So somehow I’ve messed that up. I’m gonna just bypass that. Oh, wait. That looked like it. No, I don’t want to sync. Just had my iPad. All right. Know when to say when. All right. We’ll talk about… If you go to the strabismus modules, again, on the Cybersight learn… The fundamentals of ophthalmology, pediatric ophthalmology, it shows you exactly how to do a spacer. Let’s cover a couple more questions before we wrap this up on the top of the hour here. We’re going pretty long here. As a matter of fact, I’m gonna make this our last question. In pediatric glaucoma, which drops are effective and safe in the 0 to 3-month age group? Okay, this is when we… This is from Nigeria. All right, so congenital glaucoma — we usually are getting these kids when they’re a few months old, hopefully. 0 to 3 months is a great time to get ahold of them. And which drops are okay to use? It looks like our connection is a little unstable, so hopefully you can still hear me. I’m gonna put up the… Just in case it’s choppy, let’s put this up. So glaucoma drops in infants. So what do I do? I try to operate on them as early as I can. So as soon as I see them, I’m trying to take them to surgery that same week or the next week. As a temporizing measure, I will try and use 0.5% timolol. Beta blockers usually come in 1%. If I can get the Betoptic timolol, 0.5%, I will do that. You can also have pharmacies dilute that and make it for you. If you do use regular Timoptic, even with 0.5%, I think it’s a good idea to have the parents do punctal occlusion. Put the drop in, wipe away the excess, occlude the punctum for several minutes, so you don’t get a lot of systemic absorption. But I’ve never had any problems using a beta blocker in an infant. Dorzolamide, carbonic anhydrase inhibitor drops, they work fine. They burn, eyes get red, but they work okay. Prostaglandin analogs — Xalatan, et cetera, I’m not impressed with them. I use them sometimes in older kids, but they don’t seem to do much in young kids. The reason I thought this was a good question in particular is because Alphagan, which is brimonidine you should pretty much never use. Certainly not in infants, but even in kids that are 5 years of age, or even on the smaller size, they get profound CNS depression to the point where they’re comatose, almost. You can’t wake them up, and it lasts for several hours. That’s a no-no. Stay away from brimonidine. All right, I’ll go back. And I’m just realizing now that I probably didn’t have that shared. But here we go. So we’re at the top of the hour. There are a lot of questions. And I’ve got 14 new ones that have come in during this webinar. So next time we do this, I will start off where I left off in the question queue, for those of you that submitted them this past month. And then I will go through, and I’ll start at the end of that — I’ll add on the questions that came in today. I appreciate everyone being with us for the hour. This is recorded. It will be on the Cybersight library. And again, one last time: Go ahead and look at the library. A lot of things have changed in the last year or two. That whole fundamentals of pediatric ophthalmology six-module series is there. There’s a similar interactive series with videos and pop-ups and reference material on manual small incision cataract surgery, we’ve just done one on ophthalmic nursing, so share that with your OR staff. That’s a great one. And currently we’re working on a phaco module, which we should have out before the end of this year, and getting ready to start on a glaucoma — fundamentals of glaucoma series. And we’re just gonna keep working through all of the subspecialties ’til we have all of these. But these are great multimedia blended learning modules that you can do in small packets, and are really the core of what you need to know to take care of these. It’s not exhaustive, but it’s the kind of stuff — if you were doing a fellowship in pediatric ophthalmology, this is what you would be talking about. If you were doing a fellowship on glaucoma, that’s what’s gonna be in that module. So check frequently, see what’s new, and until the next webinar, I’ll say goodbye. And I’ll see you then.