Round table: Vision screenings vs. mandatory exams, MRI vs. CT

In the third excerpt from a round table held during the AAPOS meeting, members of the OSN Pediatrics/Strabismus Section also discuss propranolol treatment for capillary hemangiomas.

Robert S. Gold

Kenneth P. Cheng

Robert S. Gold, MD: I want to get some comments from the members of this round table on the continuing saga of vision screening vs. mandatory eye exams. Congress passed the Vision Care for Kids Act, which authorized $65 million over a 5-year period of time to bridge the gap in eye care. It is supported by the American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus, the American Academy of Pediatrics and even the American Optometric Association. So the question that I have — is there still the controversy of vision screenings vs. mandatory exams and their cost? I want to get your comments on where we stand today and where we are going tomorrow.

Kenneth P. Cheng, MD: As far as I am concerned, there is no controversy. Mandatory examinations just don’t make sense from a system wide health care perspective as there is excessive spending for very little potential gain compared with vision screening. Everything says that the amount of added health care dollars spent on mandatory examinations just does not make sense compared with vision screenings.

Rudolph S. Wagner, MD: Well said. I agree. I don’t think you can justify any program where the yield of the percentages of those who will be identified as having visual problems that need treatment will be very low compared to the expenditures that would be needed.

Scott E. Olitsky

Rudolph S. Wagner

Scott E. Olitsky, MD: I agree. I think a recent article showed a relatively small number of children who have some predisposing factor for amblyopia just cannot justify in most of our communities the expense of a mandatory exam to identify them when screening does a good job of that.

Dr. Gold: Let me go to the next step. There was a presentation at the AAPOS meeting regarding referrals from school nurses to eye care practitioners for eye pain, red eyes, infections. I thought maybe it would be a good idea to comment on this, that the School Nursing Association says that children should go to see their optometrist. Now the question then is, as pediatric ophthalmologists, who should be advocates for this type of medical eye care in certain emergent situations? What is your feeling as to that situation?

Dr. Wagner: I think school nurses should know better. They come from a medical training system, and I think that they should keep the best interests of their students in mind. Children need to be treated by medical professionals who deal with these problems regularly. I am not surprised, however. Referral patterns may happen because of, I don’t want to call it lobbying, but educational efforts by the optometrists to get to the nurses and other health care professionals, such as occupational therapists, to establish those kinds of relationships. It is a difficult problem to overcome.

Dr. Gold: Do you want to comment on that, Scott?

Dr. Olitsky: Yes. I will answer that question with a question. To what other subspecialty medicine service do school nurses make direct referrals? They probably don’t send children to a cardiologist or a GI specialist. A patient is best served by seeing his pediatrician who knows that patient well and then can make the appropriate referral. We are removing the patient from their medical home by doing this, and I agree with Rudy. They are not serving the patients well, and I think the school nurses should know better.

Dr. Cheng: I think that was very well said, and I think that in many cases and in certain states, those sorts of recommendations from the school nurse may very well be referring the patient to an eye care provider or an optometrist who does not have the scope of practice licensure to treat the conditions that the child may have. So it would be inappropriate.

Capillary hemangiomas

Dr. Gold: Recently, there has been discussion about various treatment options for capillary hemangiomas: our tried and true treatments of injection with steroids, oral prednisone and recently with propranolol. I wanted to know some of your experiences and some of your opinions on this treatment. How would you treat this and when, if at all, would you use the propranolol treatment, and under what auspices would you do it?

Dr. Olitsky: I don’t have any direct experience. I have talked to some people who seem to be very impressed by it. I am fortunate where I am that we have pediatric dermatologists who treat this with oral corticosteroids, and so we no longer, by and large, inject these patients. But I am looking forward to hearing other people’s experience because I think both we and our dermatologists are very interested in seeing what is happening.

Dr. Wagner: Most of the evidence that I have that it works is from the article that was published in The New England Journal of Medicine in June 2008. The images they show in this article are quite remarkable and clearly show systemic propranolol improving these hemangiomas. The only clinical experience I have is a single patient treated by an oculoplastic surgeon from our institution. Both of us noted that it worked quite well as far as reducing the size of the hemangioma. There are some issues about rebound following cessation of therapy, but I don’t know if anyone has a great deal of clinical experience in the use of propranolol for this condition.

Dr. Gold: And there does not seem to be a protocol for it. We have one patient in our practice who was actually sent to us by a pediatric hem/onc doctor and was on it orally for a capillary hemangioma, and we saw the child after it had been put on. It did not appear to be responding as rapidly as what we have seen in some of the others, but it seems to be responding.

In my years of practice, I have been more of an oral steroid proponent than an injection. Not that I am afraid to stick a needle in the lid, but I am afraid to stick a needle in the lid without the proper controls. I like to have the pupil dilated and look inside and make sure that there is no vascular occlusion if I do that. But I think it is something that obviously is getting some attention, and I think we will see where it goes. Do you have any comments about that?

Dr. Cheng: I stopped injecting these lesions when the case reports came out regarding the injections having a potential, albeit low chance, of causing blindness. Even under control, and if you see a vascular occlusion in the operating room, there is still not much you can do about it. So I stopped injecting these lesions at that point. I have been an oral steroid treater for a long time, and it works well for the majority of patients. The propranolol issue, I think, is very exciting, but I have no experience with it.

Dr. Gold: And I will agree with your comments about that. Once you hear the complication of a central retinal artery occlusion, it scared me, and that is why I have really been an oral proponent. We will see how things go down and report further in Ocular Surgery News.

CT vs. MRI

Dr. Gold: One more subject: indications for CT vs. MRI in children. Scott, why don’t you make some comments?

Dr. Olitsky: I think the issue has really come up now because of the reports of lifelong risk of radiation-induced tumors in children and the risk being higher the younger the age that you are performing some of these scans, specifically CT scans. So I think we have made a real effort to limit those scans, and that might mean an MRI scan instead of a CT scan when possible. Better yet, we should try to avoid scanning these patients when the information does not really help you. Where I see this happen quite frequently is the child who comes in with a swollen eyelid who has a scan done before we are ever asked to see them, and we probably could have saved that patient the radiation. For example, clear-cut preseptal cellulitis — the patient needs to be put on antibiotics, and that scan really did not need to be done.

Every time you are about to order that scan, ask yourself, “Do I need the information? What am I going to do with it?” I think that is where you start to eliminate some of these.

Dr. Wagner: I agree. Just think about what you are doing. Do we really need the scans? Is it going to add information? I think a good example are orbital dermoids, which are located in their typical superotemporal location. How many times have you seen a suspected dermoid in this location turn out to be something that a scan would have changed your management? Some people routinely get scans when they should rely on their physical exam.

Dr. Gold: Specific indications for neuroimaging in a child younger than 6 months of age — I think it is a very confusing subject. People will see a child, let’s say with nystagmus, and some of our colleagues will scan every nystagmus patient. So the question is, what would be some conditions that you would absolutely scan?

Dr. Wagner: Since you mentioned nystagmus, I get nervous when I see a dissociated nystagmus. This can be the presenting sign of a chiasmal glioma. I am less concerned about symmetric, in-phase nystagmus, which I can explain from other clinical findings.

Dr. Olitsky: I think papilledema. I image every child who comes in with what I consider might be papilledema.

Dr. Cheng: I start imaging infants who cannot see for unexplained reasons — if there is no retina reason, there is no optic nerve reason when they are beyond 6 or 7 months of age.

Dr. Gold: When I see clinically a patient with optic nerve hyperplasia, I will scan them, for many reasons, in addition to looking at the corpus callosum and septum pellucidum, and I also, of course, get certain other consultations neurologically and endocrinologically. But that would be one on my list.

Dr. Olitsky: So we have named four, and probably only one of those needs a CT scan, the patient with optic nerve edema if you cannot get the MRI right away. The other ones can wait until the MRI is available in most cases.

Dr. Gold: Any other conditions that you can think of off the top of your head that you see, let’s just say within the first year of life, that you would scan?

Dr. Cheng: The only spot where CT is better than MRI is if the MRI is unavailable, or if you are worried about bony erosion of a tumor within the orbit or a tumor within a sinus.

Dr. Wagner: Or even an orbital fracture.

Dr. Cheng: It is just for bony imaging. But that MRI, even with bony changes, is still very good. I get very few CT scans now.

Dr. Olitsky: I think it may not be just us. We have to educate some of our colleagues that the child with the swollen eyelid may not need the CT scan if there is no other sign of orbital problem.

Reference:

• Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taïeb A. Propranolol for severe hemangiomas of infancy. N Engl J Med. 2008;358(24):2649-2651.

• 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, 1 Clara Maass Drive, Belleville, NJ 07109; 973-751-1702; fax: 908-665-8482; e-mail: wagdoc@comcast.net.