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Issues in pediatric ophthalmology include vision screening, ROP risk management
Robert S. Gold, MD, reviews developments in pediatric ophthalmology over the past year.
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Vision screening
Vision screening has emerged as a salient topic in pediatric ophthalmology in the past year, especially as ophthalmologists face such obstacles as waning industry support and a lack of new technology production. Technology companies are still hesitant to show support when the source of funding for new technology is questionable.
There has always been resistance, even in the pediatric ophthalmic community, to photoscreening because it is not reimbursable. Some believe physicians should be reimbursed for their services while others think screening should be considered a public health project and should not be reimbursed. The next step is for state and federal governments to provide funding for the screenings. If the government intervened by providing funding or reimbursement, the industry would produce more new technology, which would be both profitable and beneficial to the ophthalmic community.
| Robert S. Gold |
Rather than working together, the optometric and ophthalmic communities have been at different ends of the spectrum on the topic of vision screening. For example, the American Optometric Association is in support of mandating comprehensive eye exams for all children by the age of 5 years. Within the past few months, the AOA has begun to introduce its InfantSee program to have all children up to 1 year of age have mandated comprehensive eye exams. The American Academy of Ophthalmology believes this is a fiscally irresponsible situation, and I think most ophthalmologists would agree with that.
Ophthalmologists and optometrists in Massachusetts, however, are working together. Their combined efforts have led to the approval of a Massachusetts bill requiring vision screening within the 12 months prior to kindergarten. This involved tremendous cooperation between the two groups and will aid a large segment of the population. There are also mandatory screenings in several other states.
Vision screening equipment
In addition to the controversy over reimbursement, another highly debated topic is over the type of equipment that should be used in vision screening. The Medical Technology and Innovations PhotoScreener from the 1990s takes a picture of the eye and sends it to the screener for review, but it now has limited availability.
There are some promising newer technologies, including the Enfant Pediatric Vision Testing System (Diopsys Inc.), a visual evoked potential unit that is being used in limited areas around the country. It was introduced at the 2004 meeting of the American Association for Pediatric Ophthalmology and Strabismus. Another company called WaveTec Vision Systems is in the investigational phases with a next-generation screening unit that interfaces pediatric ophthalmology with wavefront technology. The EyeDx photoscreening system has also received positive press in its ease of use and accuracy.
Screening studies
Several screening projects, such as the Vision in Preschoolers (VIP) study funded by the National Eye Institute (NEI), have been successful. The VIP study was developed to assess vision screening for preschoolers because screening methods vary greatly nationwide. It is currently in phase 3 to evaluate the accuracy of mass screenings by the general public.
Another NEI-funded project that has recently launched is the Infant Aphakia Treatment Study, in which infants less than 7 months old are randomized to receive either a contact lens or an IOL at the time of cataract surgery. The purpose of the study is to determine which method of correcting infants after unilateral cataract surgery leads to a better visual outcome. Investigators will grade visual acuity at 12 months of age to evaluate myopic shift, complications, follow-up operations, incidence of strabismus and parenting stress, which is something that occurs with any pediatric ophthalmic care.
Pediatric ophthalmology trends
New issues are surfacing in pediatric ophthalmology regarding the management of pediatric patients after refractive surgery. For example, we are seeing patients with double vision after refractive surgical procedures who can be extremely difficult to treat. There will be increasing need for refractive surgery in younger children because it will become indicated for more than just anisometropic amblyopia in the future. Also, changing and evolving treatment for retinoblastoma is an important topic.
One of the most interesting recent issues in pediatric ophthalmology involves the medical and legal aspects of retinopathy of prematurity (ROP). It is the No. 1 pediatric ophthalmic medicolegal issue. I am looking forward to speaking about the practice management of ROP at the first-ever pediatric ophthalmology session during the AAO Subspecialty Day on Oct. 15.
In our offices, an important development in ROP is risk management. We have a database tracking system in my office to find patients who have missed an appointment. It has become almost necessary to have a person in the office who is dedicated to managing the clerical and technical duties of ROP work as well as help with screening. I typically have 20 to 30 patient charts on my desk every week to review and determine whether we need to track them down. The office sends letters and makes phone calls, and in rare cases, we must contact the Department of Children and Family Services when we cannot find a patient. They must be tracked because it is common that patients get lost to follow-up. Often, when a patient is transferred from one hospital to another, the doctor forgets to re-consult the pediatric ophthalmologist.
An imaging unit that has made an impact on medicolegal issues in pediatric ophthalmology is the RetCam Digital Imaging System, which produces wide-field pictures for ROP detection. One of the main indications for the RetCam is taking pictures for documentation of shaken-baby syndrome. Medicolegally, it is a useful piece of equipment because I am routinely consulted to rule out non-accidental trauma. My partner and I are consulted at least twice a week, on average, and approximately 10% of those cases show evidence of retinal hemorrhages. Although it is an expensive piece of equipment, the RetCam can help save time because the ophthalmologist is no longer needed when there is picture documentation in these cases. The system is also useful for documenting ROP stages, especially when referring cases to a retina specialist.
For Your Information:
- Robert S. Gold, MD, can be reached at 225 W. State Road 434, Suite 111, Longwood, FL 32750; 407-767-6411; fax: 407- 767-8160; e-mail: rsgeye@aol.com.