Pediatric experts tackle issues of amblyopia in older children, benefits of strabismus surgery

In part 2 of this round table, five members of the OSN Pediatrics/Strabismus Section discuss patching of patients and getting approvals from insurance companies, among other topics.

Robert S. Gold, MD: A 10-year-old child comes in to your office with anisometropic amblyopia of one eye. The amblyopic eye is 20/80; the other eye is 20/20. He has never seen an eye doctor before, has never been treated by anyone before. What do you do with that child?

Kenneth P. Cheng, MD: I think that treating that child is definitely worthwhile. At age 10, even though they are 10, especially if they have never seen the correct optical correction, putting on the optical correction alone and re-checking the vision after the correction has been on for a little while will probably yield an improvement in vision. But, of course, I do not keep the patient around for a few hours or have them come back right after they get glasses, but on all those patients, I will suggest that they do a little bit of patching just to save a visit, and I will have that patient patch for 3 or 4 hours a day and have them come back in 2 months. And almost assuredly, you will get some improvement in vision.

Rudolph S. Wagner, MD: The way that you presented that case, I would handle it exactly the way Ken did. I think many times you like those kinds of cases because you have a good therapeutic option. You can intervene with a pair of glasses. Many times, just from the optical correction, you are going to get an improvement.

I guess the question comes down to, what is your baseline or how far are you going to go? If you get them to 20/40 with or without patching, are you going to continue to pursue that? And the older they get, I would say the less likely I am to pursue it. I do not know if there is an exact cutoff when I am going to stop, but I guess at a point where I see that there is stabilization. But I think in the case you are describing, with anisometropia of 20/80 to begin with, you will get a pretty good result no matter their age.

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

Roberto Warman, MD: I have one comment that I would like to make. This patient was photophobic, as many of them are. I would try it, particularly in light of the new Pediatric Eye Disease Investigator Group studies, which indicate that there is nothing to lose by trying, even with somebody who has a small deviation. It can make a big difference even if they are only a microtropia, but the success rate will be much less and we do not know about the sustained improvement of their vision. I do not know when you stop trying. I never attempted doing it on a 20-year-old, but at some time we need to decide. I think we can bring the vision down, but what are we gaining? Is it going to stay down or not? Or is it that we just want to know what their potential is in the future if anything happens? So yes, maybe I will do a 20-year-old, or at least I will try and see.

Dr. Gold: Let me pose another question. A child comes back, 2 or 3 months later, does not wear the glasses, does not do any patching. What do you do at that point? If the child is 10 years old, has an amblyopic eye that has a risk, if he has any trauma to the good eye, where do you go from here with your discussion with the parents?

Scott E. Olitsky, MD: Some of it depends on the degree of anisometropia. If there is a place to use atropine in that specific child, I would try that. If there is not, or if we try atropine and it does not work, I would discuss with the parent that they try patching. At some point, you have to say this is not going to happen, and in that case where patching is not happening and atropine is not appropriate or has not worked, I would have that discussion with the parent and then put that child in safety glasses.

Dr. Wagner: I agree. I think it is always a question like Roberto said. If you know you can get some useful vision, you will feel better about the fact that if they ever did have an injury to their better seeing eye, they are going to at least pick up something. And I agree with Scott, it is a good idea to be wearing glasses anyway, just for the protective component with a polycarbonate lens.

Dr. Gold: Ken, how old of a child would you treat?

Dr. Cheng: I do not have an upper limit. If somebody is willing to try treatment, I will always give it as an option, especially if they have never been treated before. And if somebody has a history of being treated before and horrible compliance and whatnot, it is still a worthwhile effort. If somebody has been treated before and has had a poor result, if they have not tried it for years, if it has at least been tried before, I am less optimistic. But as long as someone is willing to give the treatment a try, I do not have an upper limit. I do not picture many teenagers, or 13- or 14- or 15-year-olds certainly, being willing to tolerate wearing a patch, and certainly they are not going to tolerate using atropine and not being able to read in school. So that is the practical limit of it.

Dr. Gold: Let me state the question another way. What is the oldest child you have treated, and what is the oldest child you have gotten a positive result from the treatment?

Dr. Olitsky: The oldest person I have treated or discussed treatment with is a 30-some-year-old truck driver who wanted his commercial driver’s license. He needed 20/40 or better vision in a 20/60 eye. We discussed it. It meant a big salary increase for him. He opted not to do it, but I had that discussion with him. As for the oldest child, probably 14 or 15 years old. As with Ken, I would offer it to anybody regardless of age. The practicality of it is once you get into that age group, it is going to be a tough sell for them.

Dr. Warman: I think what needs to be stressed is that the days of telling the patient, “There’s nothing to do,” are gone because we get those patients from optometrists, sometimes from other ophthalmologists, where they say, “There’s nothing to do,” even at much younger ages. I think the message that has to go out is that at least we need to be able to offer the patient and the family the option because we get surprises. We get very good surprises.

Dr. Wagner: I think that you are absolutely correct, and I think the problem is when people who do not do a lot of what we do get this information, they tend to consider all amblyopia as the same and might conclude that in every 14-year-old you should try the treatment. We are not saying that. We are saying that we know there are some cases in which it might work based on their refractive error, their initial acuity and their previous history of treatment. I do offer it to all people who have never been treated before, sometimes just to show them that when they put the patch on, the child really can tolerate it. At least they can be assured that they did all that could be done, and they will not go back in 20 years and say, “We never tried” or “We never had the opportunity” or “They never offered it to us.” We all know that in certain cases treatment is not going to work, but it may be worthwhile for that reason.

Dr. Cheng: And it is worthwhile pointing out that if I have somebody who comes in and the vision is truly horrible, 20/200, 20/400, and especially if they have had some attempt at treatment in the past that did not go well or whatnot, I will tell that parent point-blank that the best we hope to get with this eye is 20/100 or 20/80 and it would be an improvement, but in all practicality, you are always going to use the normal eye to a greater degree. That kind of lets them off the hook if the child is older. And so they do not feel so guilty about not trying the patch or trying it, seeing that it is truly miserable and quitting after a week because they have to have that out, because there are people who will feel guilty with, “I can’t, I refuse to let this not get better,” and they will be dogmatic about the patch for months when, if you have little hope for it to truly do a lot, you have to give them an out.

Dr. Wagner: Speaking of extreme examples, I saw there was a paper published recently using Dermabond (2-octyl cyanoacrylate, Ethicon) to supplement eye patches and leaving the patch on for a week. We have all seen patients where we say, “Gee, I could have used that in that particular case.” This measure gives you an idea how difficult it can be to patch in certain cases.

Dr. Warman: Particularly on the simple initial ametrope. The family needs to understand the patient’s brain is malleable enough. We need to taper very slowly. This is not one where you want to taper that fast. And whatever mechanism you want to do, you probably need to do some support for quite a while, at least I would say 1 year. I do not have data to say how much, but I know that if I get them down from 20/80 to 20/40 and they are very happy, we need to be on top of them for a long period of time or they will slip back.

Dr. Gold: Let me present a little different scenario, and this can also help segue into some of the benefits of surgery for some of these older patients.

So you have this same 10-year-old who, again for some unknown reason has never been seen by an eye care practitioner whatsoever, comes in with a sensory strabismus. Let us say they come in with a sensory exotropia of 30 äD. They have been walking around like this and no one has identified them, which in this day and age would be extremely unusual, but no one has identified them. And they come in with a vision of 20/100 or 20/200 in the amblyopic eye, and let us say they have minimal anisometropia. Where do you go from there in a patient like that?

Dr. Warman: I do not think the treatment is going to work, but you could always argue by the same token what about post-amblyopia where the sensory disease. I guess based on what is coming out in the data, I will probably try. But I think it is different. There you have to have a direct talk with the child and say, “Look, I need you to find a time where you’re going to put a patch all day long, no matter what, at least for a couple of weeks, 3 weeks in a row.” It will be on vacation time probably because they are not in school. You need to ask if they are really willing to do it – and not cheat – because you need to know if it is going to work or not. A little patching is not going to work here at all. It has to be very aggressive patching, and I do not know that I am going to get anybody who really wants to cooperate with that. So I think it is a lost case.

Dr. Gold: Ken, do you have any comments about that?

Dr. Cheng: What was his reason for the decrease in vision?

Dr. Gold: I did not give a reason. This has been around for a while, probably since a long-standing strabismus.

Dr. Cheng: I would agree with Roberto that I do not think that patient is likely to get much in vision. I would not be quite so dogmatic with them in demanding that the patient wear a patch the entire day. I think that an effort for 6 or 8 hours would probably be enough to show some improvement, if it was going to improve. I think few patients at that age are going to be willing to do it. If the strabismus is cosmetically objectionable, I would offer the patient strabismus surgery.

Dr. Olitsky: I would attempt to treat the patient’s amblyopia, and I think I would do what Roberto suggests. I would have a discussion with this family and the child that I want compliance for a relatively short period of time, but with full-time occlusion. And typically, I might see this patient back over a couple of months, but in this case, I would probably see him back in a few weeks with the thought that if there was any hope, after a few weeks of compliant full-time occlusion you should see some improvement.

Dr. Wagner: I agree with Scott. If he eventually did go to surgery, I might tell them that you might notice a change in your visual field when we complete the operation. In other words, the patient may have been more aware of things in the periphery prior to surgery.

Functional, social benefits of strabismus surgery

Dr. Gold: Let us segue into the benefits of the strabismus surgery in both children and adults, the functional benefits as well as the social benefits of this. And with insurance companies becoming much more scrutinizing about what we are doing, especially in older patients, why don’t we discuss some of your indications and how you go about verifying that, not only to the patient, but if you are called up by an insurance company for pre-authorization of these surgeries.

Dr. Olitsky: I think it is important that we as strabismus specialists help educate other physicians and eye care professionals. These patients can be helped, even when their vision may not be helped. I am sure we all hear too often parents and older patients say, “I was told that I can’t be helped.” And what that might mean is that they would not gain binocular vision in an eye that does not see, but these patients can be helped greatly from a social standpoint, and I think there is enough evidence in the literature now that supports that objectively. Fortunately, in the area of the country where I am, this is not a big issue, as far as insurance is concerned, but I think that literature is available to us. In my clinic, the forbidden word is “cosmetic.” We never use that word. This is not cosmetic surgery, and I think we should all get away from using that term because it denotes a surgery for something that we are not providing for these patients when we straighten their eyes.

Dr. Cheng: I would agree with Scott, and I think that it is a societal perception and a matter of degree. For example, you can use an analogy of if a patient lost an eye entirely due to some accident or trauma and their eye needed to be enucleated, their insurance company would pay for a prosthesis because the deformity is bad enough, and I think that to a patient who has a very large-angle esotropia or exotropia and they are bothered by it, that patient may be bothered just as much as somebody who is missing an eye entirely. Again, it is well-pointed out in the psychological studies that have been done on these patients, and clearly this is a significant disability for them to have this. So it should be considered a functional procedure in that regard.

I think that it is always valuable to let patients know that they are there for a reason. They do not need to feel guilty that it is cosmetic in nature or something, and that it is worth trying to address the insurance company in that manner.

Is it necessarily successful? No, unfortunately not. And I do not have any grand scheme or tricks other than that I try to bring out in the patient history whether they really are bothered with it. Many of these patients will not have diplopia. Certainly many of the exotropes will note image jump; they will notice a change in their vision as they switch back and forth from right eye to left eye. So these are patients who have good vision in both eyes and those are actually the ones who are almost easier to sell to the insurance company, but if they are not actually complaining of diplopia, diplopia is the key word for some insurance companies. I will document, “No sensation of diplopia,” but I will also include a caveat right next to that, “Patient experiences symptomatic image jump,” and that is usually enough to get it approved.

Dr. Wagner: I like what Scott said. It really is not cosmetic surgery because it is really reconstructive. The eye is not “normal” because the position and function of the eye is not normal, so you are trying to reconstruct something that should be brought back to normal if possible.

Now, I think what happens is that the insurance companies use certain triggers to reject a claim. I have not had problems in children prior to strabismus surgery not being approved even with very poor vision or loss of vision in their eye. But I have had problems getting some adults approved. In some cases, if you explain the goal of the proposed surgery reasonably well, the patient can become proactive in their own argument with the insurance carrier.

Dr. Warman: Although insurance is a big issue, I still think that our biggest issue is that ophthalmologists do not help their adult patients understand that they should see somebody for deviations. Not that ophthalmologists do not know, but they are too busy in their practice and they dismiss the issues of deviations. I think we need to re-educate our fellow ophthalmologists that this is important for their adult patients. This is independent of insurance. At least let them know that there is somebody out there who knows how to fix this, and that it is worthwhile doing. And we do not do a great job with that.

Dr. Gold: Thank you all for taking part in this discussion.

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.
• 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.
• 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.
• 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.
• 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.