Round table: Pediatric panel stresses importance of patient history

In this third excerpt from a round table conducted at the 2011 AAPOS meeting, members of the OSN Pediatrics/Strabismus Section address ways to prevent double vision after refractive surgery and what to do after over-correcting for intermittent exotropia.

Robert S. Gold

Erin D. Stahl

Robert S. Gold, MD: We have all seen patients who come in after LASIK or refractive surgery with double vision. What tips do you have for refractive surgeons that will help them prevent postoperative diplopia?

Obtain history

Erin D. Stahl, MD: As an adult refractive surgeon as well as a pediatric ophthalmologist, I see both sides. I encourage all LASIK surgeons to perform a thorough ocular history and to ask all their patients about a history of strabismus surgery. Many people know that they had surgery when they were young, but they do not know what it was for. Whether it is the technician or the doctor performing the exam, we pursue that history and pin down exactly what the condition was as a child. Then we pursue checking for alignment as part of a comprehensive LASIK exam and elicit any complaints of diplopia preoperatively. A thorough session with the patient follows to determine what issues or recurrences may arise.

Kenneth P. Cheng, MD: I tend to be pretty conservative, so personally I think that patients who have a history of strabismus and childhood strabismus should just pass and not have refractive surgery done. Why even open up Pandora’s box? But if somebody is not going to take that advice, then I would plead that the surgeon not turn the patient into a monovision patient. I have seen numerous patients who have had problems with strabismus after laser surgery, and they have been turned into monovision patients, which breaks down their fusional abilities. They lose control of it, and they have problems.

Kenneth P. Cheng

Roberto Warman

The big warning sign, if there is any history of strabismus, is hyperopia. Just do not do refractive surgery on the patient who is a hyperope. Do not correct them because when they are under-corrected, they are going to start accommodating again, and then they are going to get their accommodating esotropia back, so those cases are a problem.

Dr. Stahl: We certainly operate on people who have a history of strabismus, and again, it is a conversation with the patient to address it. For a patient who does well in contact lenses and who is being treated for the same refractive error, there is no reason to think that they are not going to do well with LASIK surgery. I do agree with avoiding monovision, and sometimes we will put these patients in an extensive contact lens trial first. If somebody really wants to be spectacle-free and that is why they are having surgery, put them in a monovision trial with exactly the same offset that you are going to use in the surgery and see how they do. Just make sure that they understand we can reverse monovision.

Roberto Warman, MD: Up to how many diopters of hyperopia do you feel comfortable correcting with refractive surgery and feel confident that you get the full correction without problems?

Dr. Stahl: As far as refractive surgery and hyperopia, we are pretty conservative about how high we treat. We look very carefully at the keratometry, and somewhere between 3 D and 5 D is our comfort range. It is definitely an issue, though. Those people really do want to get out of their glasses and want their eyes to be straight too, so we make sure they understand the ramifications. But it seems like a lot of those people are in contact lenses, and if we are putting exactly the same prescription on their eye, they should do well.

Dr. Gold: The question that I still cannot answer is this: If you eliminate the hyperopia, what is going to happen to the strabismus? Empirically, it should go away, but I cannot guarantee it.

Dr. Stahl: Generally, if patients’ eyes are straight with their current prescription, they will be straight after surgery. But long term, I cannot guarantee.

Dr. Gold: We also do not know if they will have double vision afterward, so that is another issue.

Scott E. Olitsky, MD: The best thing to do is a careful history. If there is a history of strabismus or diplopia, think about referral to somebody who does a lot of strabismus. If there is an outcome the patient does not like, it is better to have that referral in place, even though we may tell the patient the exact same thing that the refractive surgeon does.

Scott E. Olitsky

Anthony P. Johnson

Correcting intermittent exotropia

Dr. Gold: You have an intermittent exotropia patient whom you have operated on. What do you tell the family about over-correcting and patching?

Dr. Olitsky: I talk to every family beforehand because it saves a phone call, perhaps the next day, so every parent knows the eyes are likely to cross and they are going to be diplopic. If I am comfortable with a relatively small over-correction, I do not do anything differently. I see the patient back in 2 months. If the over-correction is larger, I might see them back earlier, in several weeks, to make sure they are getting better. If not, then I might do something different to check the refractive error to make sure there is not another component to it.

Anthony P. Johnson, MD: That is consistent with what I do. I have had a couple of occasions of a +3 D or +4 D hyperope that is intermittently exotropic and have really delayed doing surgery for it, but eventually it is obvious that they need surgery. And one or two of those with an over-correction wound up in glasses. I try to make a big deal to the parents that this is a possibility because it is potentially very upsetting to convert an intermittent exotrope into someone who is in glasses all the time for this situation of a secondary intermittent esotropia or accommodated esotropia that is constant. That is pretty hard for them to accept unless they have heard about that ahead of time.

Dr. Warman: There is the occasional patient who is usually 15 D, 20 D esotropic afterward. And, even though you warned them, everybody is very stressed about it. For the first couple of weeks, I do not do anything. Usually it improves. But if it persists, I do start patching a couple of hours a day, and I have salvaged others later on. My threshold is about 1 month, and then I put them on Fresnel prisms. There have been a couple of cases that I have had to re-operate.

• Kenneth P. Cheng, MD, can be reached at 1000 Stonewood Drive, Suite 310, Wexford, PA 15090; 724-934-3333; email: kpc123@verizon.net.
• Robert S. Gold, MD, can be reached at 790 Concourse Parkway South, Suite 200, Maitland, FL 32751; 407-767-6411; fax: 407- 767-8160; email: rsgeye@aol.com.
• Anthony P. Johnson, MD, FACS, can be reached at Jervey Eye Group, 601 Halton Road, Greenville, SC 29607; 864-458-7956; fax: 864-458-8390; email: apj@jervey.com.
• Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO 64108; 816-234-3000; fax; 816-346-1375; email: seolitsky@cmh.edu.
• Erin D. Stahl, MD, can be reached at Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108; email: edstahl@cmh.edu.
• 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; email: rwarman@eyes4kids.com.
• Disclosures: No products or companies are mentioned that would require financial disclosure.