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A look back: 20 years in pediatric ophthalmology
As part of our celebration of the 20-year anniversary of Ocular Surgery News, our Section Editors look at how far we have come. This month, Robert S. Gold, MD, on pediatrics/strabismus.
Pediatric ophthalmology has made great strides in the past 20 years, since Ocular Surgery News began publication. There have been advances in pediatric cataract surgery, strabismus surgery, treatment of retinal conditions, dispensing and other areas that affect children’s eyes.
Twenty years ago, congenital cataracts were treated with cataract extraction in combination with epikeratophakia, or patients used an extended-wear soft contact lens or rigid gas permeable (RGP) lens. Today, pediatric cataracts and even congenital cataracts are being treated with extraction plus an IOL or a silicone extended-wear contact lens. Piggyback lenses are being implanted, with the plan to explant one lens 4 to 5 years later.
Adjustable sutures in strabismus surgery were in their infancy 20 years ago and have since evolved into a common procedure in both adult strabismus cases and selected cases in children.
Twenty years ago, botulinum toxin was in the early stages of ophthalmic use for injection into extraocular muscles in the treatment of strabismus. Its use has decreased since that time, but it is still used in specific cosmetic situations today.
Retinal conditions
The treatment of retinal conditions are at the forefront when it comes to changes and innovations in pediatric ophthalmology. Twenty years ago, retinoblastoma was treated primarily with enucleation. External beam radiation, plaque radiotherapy and cryotherapy, which were then newly developed technologies, were also being used. Today, in addition to all of these treatments, chemotherapy is used, and enucleation is the last resort for large tumors only.
Screening for retinopathy of prematurity has evolved over the course of 20 years. Screening criteria have become more well-defined, and treatment for threshold disease has moved from cryotherapy to laser treatment today, with specific criteria generated by the extensive studies that have been conducted.
Twenty years ago, the treatment for accommodative esotropia with a high AC/A ratio was with an executive or flat-top bifocal. Today, bifocal technology has allowed the use of progressive lenses to treat this condition.
Community awareness
We also see today a greater awareness for early diagnosis and treatment of amblyopia and strabismus conditions. Primary-care physicians are gathering more information regarding family history and are referring patients for eye exams at a very young age to rule out problems. Preschools and elementary schools have vision screenings at regular intervals to find problems in students.
Communities have photoscreening devices to help detect refractive errors and strabismus abnormalities in children. Preventive eye care has come a long way over the past 20 years and will certainly continue to evolve.
Dispensing practices
Contact lens dispensing has also changed. Twenty years ago, RGP and soft daily-wear lenses were widely dispensed. Today, children are being fit with lenses at younger and younger ages. The lenses being dispensed are daily-wear spherical, toric soft lenses and one-day disposable lenses.
Finally, 20 years ago few pediatric ophthalmologists (or general ophthalmologists, for that matter) dispensed glasses in their offices. Today, more than 50% of pediatric ophthalmologists dispense, and we are able to offer great optical products and convenience to our patients and families.
As our practices become more comprehensive, more offices will dispense spectacles to their patients so that the consumer will be provided with the complete eye care package and one-stop shopping.
Controversies ahead?
I look forward to the next 20 years in pediatric ophthalmology. We know that cataract surgery and IOL technology will continue to evolve. The role of refractive surgery in the pediatric population is a controversial issue today and will certainly be in the years to come. Will more teenagers desire refractive procedures with the informed consent of their parents? Will surgeons starting performing LASIK on younger and younger patients?
Research in refractive surgery for severe anisometropia at an early age to prevent or better manage amblyopia is beginning, and this procedure may become more widely used. But will it ever have a permanent place in the treatment of anisometropic amblyopia?
I have loved my 15 years in pediatric ophthalmology. It is wonderful to help children see, to straighten their crossed eyes, to educate their parents and most of all to see children of all ages smile.