Pediatric ophthalmology has seen major innovations over past 25 years

As OSN celebrates its 25-year anniversary, a panel of pediatric ophthalmologists looks back at some of the most important breakthroughs in the subspecialty.

Issue: July 1, 2007

A note from the editors:

Ocular Surgery News convened a round table discussion at the American Association for Pediatric Ophthalmology and Strabismus meeting held in April. Led by OSN Pediatrics/Strabismus Section Editor Robert S. Gold, MD, the discussion touched on the most influential innovations that have taken place in pediatric ophthalmology in the past 25 years.

Robert S. Gold

Robert S. Gold, MD: Ocular Surgery News is celebrating its 25th anniversary this year and is devoting some of its coverage to identify the top 10 most influential ophthalmic technologies. I would like to get your thoughts, as pediatric ophthalmologists, as to what you feel are the most influential ophthalmic technologies from a pediatric ophthalmic standpoint.

Scott E. Olitsky, MD: I think that, looking back, one that comes to mind first is the introduction of the modern vitrector, which has allowed us to develop better cataract techniques for children. I know there was a time when it was debatable whether or not removing unilateral cataracts in children was a worthwhile endeavor because results were so horrible.

Now we are arguing about the best way to get to the best visual acuity and potentially good binocular vision. A lot of that has come from the state-of-the-art technology that we have. I think some of that started with the first vitrectomy that allowed us to do some of the modern surgeries on these babies.

Kenneth P. Cheng, MD: I think Dr. Olitsky has hit the nail on the head with that. I am actually old enough to remember the first vitrectors, and clearly, the advent of better instrumentation has been revolutionary and completely changed cataract surgery in children as it has in adults. Similarly, the use of IOLs is not that old in children. It has become a common practice now, where 25 years ago it was on the cutting edge of things. And improvements of lenses that have been made over the years have changed things. Now we are talking about implanting lenses in babies.

Kenneth P. Cheng

Other technological improvements have been made in surgical instruments, especially for intraocular surgery. The finer forceps that we have now have certainly made things a lot easier. The use of hooks to dilate the pupil in the small-pupil cases that we face frequently in children has changed things dramatically.

Lasers have also certainly changed pediatric ophthalmology. The portable diode laser that is used to perform laser treatment for retinopathy of prematurity (ROP) has changed things. Going back a step, 25 years ago we were not even treating ROP. There is the groundbreaking work from Earl A. Palmer, MD, the use of cryotherapy and then replaced by laser, that changed things. The use of YAG laser to open up the posterior capsule in children has changed the paradigm for how we think about managing pediatric cataracts.

Anthony P. Johnson, MD, FACS: There are several diagnostic modalities I think that have either come about or have been made available for pediatric use. Then, too, some of the neurological imaging technology and high-resolution MRI, MRA, MRV studies have provided much better information on children. A lot of the outpatient hospital departments are placing the intensivists in charge of soliciting these studies, which has increased their availability, although with a lot of emphasis on doing them safely, and this has been helpful for me.

Anthony P. Johnson

There are other diagnostic exams that have been around for a while that we are not sure what to do with yet in pediatric ophthalmology, but at least hopefully they will provide us with other tools.

Optical coherence tomography (OCT) comes to mind, especially for retinal disease and occasionally for some of the children glaucoma suspects who are too young to reliably do visual fields. You can have CT information about their optic nerves and use that to follow any of their clinical changes.

And also, we are hearing about genetic testing. It has changed unbelievably, in fact, so quickly that if it were not for the pediatric geneticists in our area, I would be completely lost. I have completely turned that over to them. I feel like that is an area that is only going to continue to explode in terms of giving us molecular diagnoses and the ability to manage patients differently.

Retinoblastoma

Dr. Gold: One of the things that I would like to mention has to do with the specific disease process of retinoblastoma. It always comes to mind how, over the years, we are now identifying better, and how we are able to treat better, retinoblastoma without losing the eye in many cases, whether it be with plaque radiotherapies, laser therapies or medical therapies. Many eyes are being saved, and again genetic testing with regard to retinoblastoma is now coming to fruition.

Also, there is no question that we have the beginnings of refractive surgery in children. And there are papers that are currently being presented in that regard. It is an evolving part of pediatric ophthalmology. It is being used in those cases that are refractory to patching therapy and anisometropic. But it is still something that will evolve over the years for a while to come. There are many pioneers in the pediatric field that are making it possible. Does anyone else want to comment?

Dr. Cheng: An additional topic where advances have clearly been made are the use of systemic immunomodulators for juvenile rheumatoid arthritis. In the chronic uveitis patients, it is dramatically easier to manage those patients now than it had been when I started in practice. Additionally, the treatment of infants with infantile glaucoma and aphakic glaucoma has changed dramatically since I started practice 20 years ago. The use of mitomycin-C has changed things significantly, and techniques have improved with more use of trabeculotomy. It is a whole different practice now than 25 years ago.

In the area of practice management, the way we work as pediatric ophthalmologists has changed dramatically. With the advent of surgery centers, and the increased efficiency of doing surgery faster with less downtime has changed the way we work. The need to see more patients as we have been challenged economically has changed the way we work. These are all things that make practices different from 25 years ago.

Pediatric refractive surgery

Scott E. Olitsky

Dr. Olitsky: I think the other thing with regard to refractive surgery is we will see a lot of discussion about lowering the age for surgery. The emergence of younger children with parents who are concerned about contact lenses, eye care safety and efficacy has shown that refractive surgery age is certainly going to drop as time goes on.

Dr. Johnson: I have moms come in who occasionally will ask about it and be disappointed when the U.S. Food and Drug Administration guidelines for refractive surgery still limit the surgery to age 18 years and above, or to the surgeon’s preference, because they often comment that this would be a nice graduation gift.

But one of the technologies along those lines that I actually until recently had no experience with is wavefront analysis. It has been something that the refractive surgeons have been using for a long time.

I initially did not really see a lot of utility for the pediatric age group, but just the objective measurement and looking for higher-order aberrations in the child who potentially may have early subluxation and some off-axis astigmatism. It is valuable for anything that is a little bit unusual if you are wondering whether or not there is something that you are missing because their corrected visual acuity is not what you expect. And I have actually seen a couple of patients with higher-order aberrations that are not corrected by spherocylindrical correction. In fact, in some of those cases I think they would potentially – depending upon your index of suspicion – otherwise wind up with an MRI or some other search for a neurological explanation, which actually could be eliminated by something as simple as this 5-minute test.

Dr. Cheng: Then what do you do about it?

Dr. Johnson: It saves you other diagnostic difficulties but often, as you have suggested in your question, it is not correctable. It keeps you from looking further to explain it and wonder if there is an optic nerve tumor or some other kind of tumor.

Dr. Gold: One of the things that is interesting about the possibilities of something like OCT in the pediatric community is that, when you have a child who has unexplained amblyopia, it may be a test to be able to look at the optic nerve and the macular area to determine whether or not that is a possibility in diagnosis. So there is some excitement there.

Also exciting are the many vision screening instruments attempting to identify pre-verbal children at risk. While I believe there is not one instrument that is the end-all, an attempt is being made to screen as many children as possible with some of this instrumentation to try to identify those at high risk for amblyopia. Although it is not perfect, at least we are trying.

For more information:

Kenneth P. Cheng, MD, can be reached at 1000 Stonewood Drive, Suite 310, Wexford, PA 15090; 724-934-3333; fax: 724-934-3371; 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.

Anthony P. Johnson, MD, FACS, can be reached at 601 Halton Road, Greenville, SC 29607; 864-458-7956; fax: 864-458-8390; e-mail: apj@jervey.com.

Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108; 816-983-6777; fax: 816-855-1793; e-mail: seolitsky@cmh.edu.