Pediatric experts discuss new legislation, advocacy and tear duct obstructions

Five Ocular Surgery News editorial board members met during the American Association of Pediatric Ophthalmology and Strabismus meeting in April in Washington, D.C. Part 1 of 2.

Robert S. Gold, MD: Let us begin by discussing what is going on in the legislative arena. As a preface, during this meeting, 75 pediatric ophthalmologists went up to Capitol Hill April 3 to discuss with their legislators, both senators and congressmen, some of the legislation that is in front of Congress. The two most important, from a general ophthalmologist standpoint, have to do with Medicare cuts and from a pediatric ophthalmic standpoint, the Vision Care for Kids Act that has passed the House and will lead to screenings of children to identify vision problems. The third has to do with optometrists and their scope of surgical practice.

Why don’t we first talk about the Vision Care for Kids Act and your thought process as kids are trying to be identified for vision problems at a young age. We will start with Scott.

Scott E. Olitsky, MD: The bill actually came from one of the senators in Missouri, and it is an important issue, not only because, as I think we all know, vision screening is an important topic, but some of the critics of vision screening vs. mandatory exams and the access to care in this bill will provide funding for the care of the children who failed insufficient screening programs. And I think that not only will it further impress upon people how important vision screening is but also will hopefully silence some of those critics who would rather see mandatory exam laws passed.

Round Table Participants Robert S. Gold Moderator Kenneth P. Cheng Scott E. Olitsky Rudolph S. Wagner Roberto Warman

Dr. Gold: It should be noted that this piece of legislation, which passed the House I believe unanimously and is in the Senate now, was a bill that got all aspects of the eye care community as well as pediatric community together for the first time, I believe, ever, including the American Academy of Ophthalmology, AAPOS, and the American Academy of Pediatrics and the American Academy of Optometry, as well as other vision care consortiums. So it is something that is supported and identifies the children who need comprehensive eye exams rather than mandating every child to have a comprehensive eye exam before a certain age.

Kenneth P. Cheng, MD: Everything you said is 100% correct. And the biggest issue really is that this puts something on the table that provides for programs to support the concept that screenings are a much more efficient utilization of resources than mandatory exams. Mandatory exams are a tremendous waste of our resources of money and manpower. And, unfortunately, mandatory exams have passed in several states because it certainly sounds good on the surface to ensure that every child has their eyes examined, except the funding to do that just is not available, and the manpower to do it is not available. And that does not touch upon the flip side of the coin of unfortunate, unnecessary treatment when mandatory exam programs are in place.

Roberto Warman, MD: I agree completely. My worry is the other side. At least in my area in Miami, the pediatricians do not want to do the Head Start screenings, and they send or try to send all the patients to the tertiary care pediatric ophthalmologists, which over the phone the secretary is very difficult to discern what can come in and what cannot. And we get inundated with things that we really should not be doing. The screenings should be done by others, and I think one of our problems is that we have been working for 20 years looking for a perfect photo screener, and if we keep on waiting for the perfect one, we are just going to get inundated with these exams. We need to understand and agree that we are not going to get a perfect photo screener. … But we need to start somewhere and we need to start putting our stamp as an association behind one or another system relatively soon, even if we continue improving, so we can really do the screenings effectively. Because what is going to happen is that the specialists are going to get inundated with screenings and we cannot handle them.

Rudolph S. Wagner, MD: I have two points on this issue. First off, what Roberto said about the vision screening, that is a really important point. In New Jersey, and I suspect nationally, there is increased use of a code for vision screening, not by ophthalmologists but by pediatricians.

Dr. Gold: The code is 99174. It is not reimbursed for them and there are no relative value units (RVUs) at the moment for that. But this has to go through Centers for Medicare and Medicaid Services. It has to go through all of those political and governmental avenues. The hope is in the near future that that code will be given an RVU, so that pediatricians can get reimbursed for those services and hopefully, with one of the technologies that is out there that they are comfortable with and that has proven to be a good screening unit, especially in preverbal children, will be then able to get the right children to us at younger ages. Right now it does not have an RVU and we cannot tell when that is going to happen, but hopefully it will get one.

Scott E. Olitsky, MD, (left) and Kenneth P. Cheng, MD, discuss their approaches to treating infants and children who have tear duct obstructions. Images: Wolkoff L, OSN

Dr. Wagner: Anecdotally, I have had pediatricians tell me that they are getting reimbursed for this using either a SureSight Vision Screener (Welch Allyn) or the Enfant Pediatric Vision Testing System (Diopsys).

Dr. Gold: In the Diopsys unit, they can bill for a visual evoked potential (VEP) test, which is reimbursable. Now that is concerning. What the other units do, whether it is the SureSight, Power Refractor II (Plusoptix) or PediaVision machines, basically they are refractometers. They are autorefractors. And these units, hopefully, will be able to, as they get more and more sensitive and specific, pinpoint with a low false positive rate these children who need to be referred instead of what Roberto said, that they are not then over-referred. In some of the units that you have mentioned, the over-referral rate is astronomical, as Roberto has seen also in his practice. So that is part of the concern as the technology improves.

Dr. Cheng: The reimbursement for that vision screening code, it is carrier-specific and region-specific and there are some areas and some local carriers that will pay nominal amounts for that vision screening code; however, those are truly nominal amounts. From what I have heard, they are $5 or $10. On a large reimbursement, maybe $15, where clearly it does pay to do it.

I think what ultimately needs to happen is, as legislation is passed to adopt or to spur on the effort for vision screening, is to have better education for vision screening. Hopefully screening for eye disease in young children will take on the same sort of political favor as screening for breast cancer does. So for example, even though mammography is a screening test and typically private insurance carriers will not pay for screenings, they pay for mammography because it is politically correct. And hopefully, vision screening in children will take on the same position.

Dr. Wagner: One other thing about vision screening vs. mandated complete eye examination. In New Jersey, a bill passed that was supported heavily by optometrists in which they are doing a pilot study on third- or fourth-graders. They are going to go to four areas in the state where they are going to select kids for mandatory eye examinations, and these children will also have learning evaluations. The premise is that they are going to find many kids who were classified as having learning disabilities who merely needed good care for their eyes, either with glasses or whatever treatment was necessary. Therefore, it would justify mandated eye examinations on all children in those age groups.

Dr. Gold: And the sky is the limit. There are states that have passed mandatory comprehensive eye examinations prior to even getting into school, so this is something that will continue, and I am sure we will discuss it further.

To add a few comments about my experience on the Hill, it was wonderful. I was able to meet with the legislative assistants for health care from both of my senators, Mel Martinez and Bill Nelson. And that was done with a group of four of us from Florida. They were positive meetings. My best meeting was with the legislative assistant to John Mica, who is my representative. He was very engaging. He was very respectful. He listened wonderfully, and I actually felt that he understood what I was saying and actually would speak positively about what is going on in eye care and what is happening on the Hill. So I had a wonderful experience. I look forward to doing it again.

I will tell you it is quite a feeling of awe to sit in the office of someone who is in the Congress of the United States and looking around in the office and seeing the pictures and seeing the plaques, and whether it is pictures with the president or pictures with other members of Congress, it really makes you feel that you are an American. It really was quite an experience.

Need for advocacy

Dr. Cheng: I think it is a tremendous thing that the leadership of AAPOS dedicated one afternoon of this meeting to legislative issues, that they arranged for their membership to become active in advocacy. And I think that as the reality of scope of practice issues hits all of ophthalmology, as the reality of Medicare cuts hits, that ophthalmologists are going to need to become more active in areas of advocacy, both on the state level and national level in order for our profession to survive for patients.

Dr. Warman: I have concerns about our specialty’s ability to survive. And we need an advocacy to do something so pediatric ophthalmology gets better reimbursed, not from the greedy point of view that we need a little bit more. I want to make that very clear. We are not getting enough ophthalmologists interested in pediatric ophthalmology. It is very difficult to get into the specialty. I do not know how many of you deal with teaching programs, but once they are in, they want to go and do retina and they want to go and do refractive surgery. And 10 years down the line, we are going to be in a horrendous crisis. Not only don’t we have people who want to screen ROP, which is one issue we dealt with last year. We will not have enough people to deal with the diseases, and we know that the general ophthalmologists just do not have the interest and the time to do it. We need to get them into pediatric ophthalmology. I do not know what we are going to have to do, but I would like my grandchildren to be treated by a pediatric ophthalmologist some day in this country. I am very worried about this.

Dr. Wagner: That is a big issue. I understand that many fellowship positions in the past few years were not filled. There are many issues that account for this, including lower reimbursement or a lack of mentors. There are many reasons why people choose particular specialties. But I think you are right, and I think this legislative session shows that maybe pediatric ophthalmology is trying to do something to set itself apart. It is important that people begin to recognize this. Perhaps the residents in ophthalmology will recognize it too.

Dr. Cheng: I was actually surprised to learn that the young membership of AAPOS, have decreased this year as opposed to previous years and that there are quality fellowships that are going unfilled. And it is a surprise to me because as Medicare reimbursements are dropping, as cataract surgery is becoming less lucrative, if you really think about it, the percentage of decrease of a general ophthalmologist’s income has been larger than the percentage decrease for a pediatric ophthalmologist. In other words, I think that we are doing better compared to our colleagues now than we did previously.

Dr. Gold: I think we have to be advocates for our own profession. And I think our society is trying to do that, but it has not been all together successful yet.

Dr. Warman: Half of the available fellowships are staying empty. We could train many more people without increasing the programs right now. And for whatever it is, those who are coming out are absolutely not enough. The demand is tremendous out there, and in certain areas I can tell you it is very difficult to recruit. It is in most of pediatric specialties. This is not only pediatric ophthalmology.

Dr. Cheng: I think the larger problem is on the geriatric end. As all the baby boomers are growing older, the number of physicians to care for the elderly is going to be way short, and it is going to require a whole new practice mechanism in order to meet the demand.

Dr. Wagner: The other thing is, it might be a reflection of the interests of the people who are being attracted to ophthalmology. There may be fewer patient care-oriented and more technically oriented residents who become enamored with the new technology in ophthalmology.

Tear duct obstructions

Dr. Gold: Shifting gears, I would like to go through with each of the editorial board members your armamentarium and schedule for treating infants and children who have tear duct obstructions. Scott, why don’t we start with you?

Dr. Olitsky: I would generally put off surgical treatment until 1 year and have parents use massage and keep the child as clean as possible. Generally, I suggest waiting until 1 year because I do my probings in the operating room. So if a child is very symptomatic or if they are having another procedure done in the operating room before a year of age, I will offer a procedure before then as well. For about the last year and a half now, I have switched from primary probings to intubating with silicone tubing in all my patients who go to the operating room.

Dr. Gold: What is your primary procedure of choice in those children?

Dr. Olitsky: I use a Ritleng monocanalicular tube because I find it easier to insert and easy to remove in the office several months later. And from some of the reports we have seen, it seems to increase the success rate to 96% to 97%, and the tube costs less than $100. I think if you can decrease the potential need for another surgery, another trip to the operating room, then it seems to me to be well worth it.

Dr. Cheng: My routine is to wait until the kids are 8 to 9 months of age before doing a probing. Before that, it is conservative management with topical antibiotics as needed. After 8 months of age, if the patients are significantly symptomatic and the parents are getting tired of it, I will schedule a probe and irrigation procedure under general anesthesia in the operating room. Unlike Scott, I find very little need for silicone intubation. I also advise parents that I am perfectly comfortable waiting until the children are 1 year if they want to try to avoid the anesthesia, but I do not like to go too much past 1 year of age before probing, as the success rate of simple probing alone probably decreases when the problem persists significantly past 1 year of age.

Dr. Gold: Rudy?

Rudolph S. Wagner, MD, spoke about at the declining number of pediatric ophthalmologists entering the field during a round table discussion at AAPOS this year.

Dr. Wagner: I have a similar approach to Ken’s. I tend not to probe too early. I would like to wait until they are around 12 or 13 months of age, if there is no clinical improvement in symptoms they have been having for a while. Sometimes I will probe them a little earlier, particularly when they have had episodes of more purulent discharge or where it is more of a concern to the parents and to the family.

When I decide to do the procedure, usually if they are less than 1 year of age, I will just do as the primary procedure, the dilatation, probing and irrigation that has been done classically for years. The change for me is that when I probe these kids at about 12 or 13 months of age, I often do a Lacricath balloon catheter dilatation at the time of their initial procedure. I do not use silicone tubes initially. I have reserved them for the cases that were treatment failures.

Dr. Gold: Roberto?

Dr. Warman: Well, I am the only one who does things differently because I do probings in the office. It does not mean it is better or worse, but the moment you do probings in the office, it starts sooner. So even though the child may get better on their own, if they have significant symptoms, it is easier to probe at 6 to 8 months and I will probe earlier.

I probe babies up to 1.5 years sometimes because they do not have insurance, and it is terribly expensive to take them to the OR, at least in Miami. And I do not like to do them, but I will do them older. But if I have a patient who fights too much, even for a regular exam and, they are 12, 14 months old, I agree, let us just go to the OR and not fight it in the office.

I do most of my probings in the office, and if the patients arrive at a reasonable age to me, it is really a minority that I have to take up to the operating room. So when I do go to the operating room, that means I will go twice many times. And I do many. I probably do four or five probings in the office a week. I could not afford to go that often to the operating room and take that much time from my office.

If I go to the operating room, once I am there, the reason it takes a little extra time is because I have residents and I am teaching them, but if I have to put the tubes in myself, with rare exceptions, the extra time is so little that once I am in the operating room, even if it only improves 6% or whatever the recurrence rate, to me it is worth it not to go back out.

I like my silicone Crawford tubes because I am good at them, and so I have not switched. Lacricath is very expensive and that has been the main reason I backed out from it, but not because it does not work. But I still do my bicanalicular silicone intubation, but I tie the tube with Vicryl so I do not have to go back in the operating room to take them off ever. They either fall off or I take them off in the office.

Dr. Gold: When I see these patients — and often the pediatricians take their time to send the patients to us, despite educating the pediatricians over 20 years in my area — I often will not see them until close to 1 year of age. When I see children at a younger age, between 6 and 12 months of age, with the initial conservative treatment, I will offer the parents, at their decision, the timing of the probing procedure. I do all of mine under general anesthesia. I will initially, usually up to 18 months of age, do a standard probing and irrigation procedure. In my hands, they are extremely successful, probably in the 95% range. In my population, I have not had to do more anesthesia time for that.

When they do fail or if they are older than 18 months to 2 years of age, it is sort of a gray zone in my practice to try to judge what procedure to do at that time. But if they fail a procedure and particularly if they are older than the age of 2, I will do a different procedure. My procedure of choice is the Lacricath, and I found that it works very well and I don’t personally have to worry about a tube. I use Crawford tubes and I find that the patients do pull these tubes out, maybe more frequently than is reported, but maybe I just get the phone calls at midnight or 2 a.m. when that happens.

And I make a judgment in the operating room as to what procedure to do. I do not say I am going to go in doing a Lacricath or I do not go in saying I am going to be doing a Crawford tube or other tube procedure. If the obstruction is such that it is in the inferior or superior canalicular system, the Lacricath does not work, so you have to do something different, and in that case, I will put in some type of stent. I have found that the Lacricath works well, and if it is a bilateral procedure, the bilateral simultaneous Lacricath works very well and cuts the operating room time several minutes.

Dr. Cheng: I would comment that in patients that I have seen who have failed probing, I think it is oftentimes due to the position of the inferior turbinate. And I make a special point of looking at the inferior turbinate on every case to make sure that I see adequate space underneath the turbinate, that I can easily find my probe underneath it with metal-on-metal contact. And I would say that, and this is just a rough estimate, maybe on 10% or 15% of patients, I will perform an infracture of the inferior turbinate.

Roberto Warman, MD, said he does not see a large incidence of mucocoeles requiring endoscopy in a round table discussion held during AAPOS.

Dr. Warman: I also infracture an inferior turbinate. One other comment that you hear is about mucocoeles and endoscopies. I do not see that. My patients get better or they do not get better, and I have to put a tube. That is fine. But I do not get those horrendous cases that need endoscopy. Do you all see those?

Dr. Olitsky: That is a great question. I have been told about the need to do endoscopy and the need for an ENT surgeon to come in, and I also have found that has not been my experience. Most of the time, I just probe and they do well.

Dr. Wagner: I have seen mucocoeles in the nursery. In all my years of practice, I have seen two cases where there probably was an extension of a mucocoele into the nasal cavity causing respiratory distress. One of the situations was diagnosed when an ear, nose and throat specialist took a look in the nose and saw something there. Together we used nasal endoscopy, and I probed from above. Now, the interesting thing about it was that you could actually visualize the probe coming through the mucocoele in the nose when we did the procedure. Then once I got through the cyst decompressed, he was able to marsupialize and remove the remainder of the tissue. At the distal end of the nasolacrimal duct you had this dilated cystic structure that was just filling up with mucous and had no place to go. So you had obstruction both distally and proximally causing this. But that was the only indication when I found it useful to use the endoscopy. It probably could have been done without it because I would have done the probing procedure anyway. It would have popped, and I would never have known what I had seen in there.

I like what Bob said about varying the procedure depending on what you find in the operating room. You do not know what you are going to find. The monocanalicular tube might be useful in these situations, where I have had very tight obstructions. I got through it with a probe and then tried to put a tube through, and the tube pulled off the Crawford stent. Now, what I did one time that was successful was to go back in with a Lacricath and dilate the duct, then I went in with another Crawford tube and it went right through. So that was kind of interesting because it showed me that there is some dilatation benefit effect. It might be easier to use the monocanalicular tube in a situation like that because you only have one tube to pass through the duct.

Dr. Gold: I want to echo what you said about the inferior turbinate area. If I try to put a Crawford tube in and something like that happens, where the probe comes off the tube, that to me is an indication of narrow inferior turbinate opening. And that is when I make the decision to infracture the turbinate in that situation.

Dr. Warman: But that is not where the obstruction is. When they break, it is up in the proximal part because there is something that is breaking it down farther.

Dr. Gold: That is certainly one area, but I have also found coming around the corner that it has cheese-wired off at that point as well.

Dr. Cheng: One thing on the mucocoeles; I think that if you look carefully enough and actually put an endoscope in everything that has a true mucocoele, you will actually find the little nasal cyst that Rudy is talking about in 100% of the cases. And I think that in those patients, it is valuable to make sure that you put a large hole inside that little cyst because the failures in those patients are because there is extra epithelial tissue there to close up again. In patients who have mucocoeles, if they are tiny babies and they present at birth, I will probe those patients without anesthesia on the hospital floor if they are admitted for cellulitis or in the office if they come into the office. But if we electively go to the operating room, I will take out the endoscope, look at the cyst, and then put in a very small forceps or a small biopsy forceps and marsupialize or take out part of the cyst wall. I will frequently put silicone tubes in those patients also to prevent closure of the distal end of the nasolacrimal duct.

Dr. Olitsky: I think, at least in my mind, the question is not so much whether or not they exist. The question is whether or not you need an ENT person or somebody else to come in and look. It is important to make sure you are through, but I generally do that by touching metal-on-metal and move it along the probe on both sides and aspirate to make sure I have gone through a potential cyst. The potential problem is you go down and you think you have touched metal on metal and there is a membrane in the way.

Dr. Gold: And I also think that there are many of our members who are comfortable with endoscopy, and in those cases, and I think Ken mentioned the point, that you really have to marsupialize some of these because they will flap right back. And whether it is having an ENT come in with you to do that because they are very comfortable, or you have learned the technique of doing endoscopy, I think it is a good part of another type of our surgical armamentarium to feel comfortable in getting rid of these.

Dr. Cheng: It is a very simple technique to learn. It is not difficult. With a small, straight, rigid endoscope, you just look inside the nose. That is it. It is not a hard thing to do.

Dr. Warman: One more question on the same topic. I would like to see what you feel because of the situation in my practice and the senior partners in retired practice, we really have a close follow-up of most of our patients. And the few that would hold somewhere else, we are in close contact with those other people. And our experience in all these years is that patients with congenital nasolacrimal duct obstruction who get treated one way or another, but they get treated appropriately, it is extremely rare the patient who needs to go for a bilateral dacryocystorhinostomy (DCR). We really cure almost everybody. But maybe with one handful in 20 years of patients who may need a DCR. Is that your experience?

Dr. Cheng: Absolutely. In 17 years of practice, I have not referred one patient for a DCR.

Dr. Gold: In 21 years of practice, two patients.

Dr. Wagner: In 22 years of practice, I have referred one for a DCR.

Dr. Olitsky: Certainly, less than a handful.

Dr. Cheng: That is excluding the patients with congenital anomalies and things like that.

Dr. Warman: So the corollary to that and the reason I ask is it is not because we probe very early or because we probe very late, because we probe in the office and we may not be able to be as efficient, or we probe and it is just not this disease. The literature on DCR is outdated and not sustainable.

Dr. Gold: That is a very good point. And here is another example of five of us that practice and do things differently, and it is very successful whenever we do. And so there are a lot of different ways to do things, and a lot of them are successful.

A note from the editors:

Look for part two of this round table in the June 25 issue of OSN. The editorial board members discuss treating amblyopia in older children and the functional and social benefits of strabismus surgery.

For more information:

• Kenneth P. Cheng, MD, can be reached at 1000 Stonewood Drive, Suite 310, Wexford, PA 15090; 724-934-3333; e-mail: kpc123@verizon.net. Dr. Cheng has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• 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. Dr. Gold is a paid consultant for Quest Medical, producers of the LacriCath and is on the Medical Advisory Board for Pediavision (PlusOptix).
• Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108; 816-234-3000; fax; 816-346-1375; e-mail: seolitsky@cmh.edu. Dr. Olitsky has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
• Rudolph S. Wagner, MD, can be reached at Children’s Eye Care Center, 495 N. 13th St., Newark, NJ 07107; 973-485-3186; fax: 973-497-5674; e-mail: wagdoc@comcast.net. Dr. Wagner has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
• Roberto Warman, MD, can be reached at Miami Children’s Hospital, 3200 SW 60th Court, Suite 103, Miami, FL 33155-4072; 305-662-8390; fax: 305-661-7862; e-mail: rwarman@eyes4kids.com.