Surgical topics, patching addressed during round table

In a gathering at the American Association for Pediatric Ophthalmolgy and Strabismus, OSN Editorial Board members discussed patching vs. atropine, optical correction options, surgical approaches, photodocumentation and more.

Atropine vs. patching

Robert S. Gold, MD: One year ago at our meeting, we discussed some of the experiences that we have had in our practices with atropine penalization vs. patching therapy for amblyopia. The amblyopia treatment studies are going fast and furious. Some of us are part of that, or doing clinical work in our own practices. Over the past year have you changed your practice patterns for patching vs. atropine, what are your preferences, and has any of the data changed the way you practice?

Kenneth Cheng, MD: Last year I was concerned about phototoxicity. I was concerned about worsening accommodative esotropia. I was concerned about blurring good vision in the good eye while the patients were in school. I’m still concerned about exactly the same things. The number of patients I have on atropine, or have started on atropine over the last year, I can tell you it’s exactly three out of thousands of children I’ve treated for amblyopia in that time.

My worries about parents asking about it, creating a big problem in my office — “What is this? What is the study? Why can’t I go on this instead of wearing the patch?” — have not materialized. A few people asked about it. Usually, they ask about “can it replace my child’s glasses” and other inappropriate things.

With most parents, I explain that I have concerns over the issue of atropine blurring vision in the good eye at school, and there is no way to reverse that, so why don’t they just wear the patch?

For the younger children, for the most part they don’t want to go through the effort of getting a second pair of glasses. They just prefer a patch.

Some of that may be because of my own personal bias. I’ve treated very few.

Naval Sondhi, MD: I share a lot of the reservations Dr. Cheng alludes to. My experience, however, has been different in that quite a few patients’ families have asked about it, they read about it, they get on the Internet and find out about the eye drops.

I still have the same discussion of patching vs. atropine. To me, patching remains the gold standard, but I have to admit that I’ve probably put more patients on atropine in the past year than ever before. The results have been a mixed bag, as with any kind of occlusive therapy, and at this point I’m not sure that one is better than the other in my practice, but I still try to sell the patching first.

Anthony P. Johnson, MD: I agree with Dr. Cheng. Some of my practice pattern is influenced by my own bias, and I feel strongly that the treatment of amblyopia has to be a commitment by the family. Even though I get three or four questions a month from concerned parents that have a legitimate question about whether or not that may be the better treatment for their child, when it’s completely discussed they prefer patching.

I also use that discussion as a stimulus for adjustment of the patching duration. But to specifically answer your question, over the past year, I have started one person on atropine drops.

Roberto Warman, MD: I’m the different one here. I’ve been using atropine for many years, so I feel comfortable with it. I don’t see any problems, and in Miami I certainly have not seen any problems with phototoxicity. Patients don’t complain in school, etc. So I’d like to relieve you all of the worry. That’s not a problem.

Now, in spite of that, I am a strong believer in patching. I agree with you all, and I use patching first. Most of the families, you convince them and they’ll go for it.

The problem comes later. The problem comes with stubborn children, or sometimes I don’t have a good grasp over their kids. You need help because they come back and back, and they’re just not gaining anything and the time is going to waste. They’re getting older.

I’ve got patients on atropine and a patch as much as possible in some cases, and the combination of them many times is what gets me out of problems. So I don’t have a safety issue, but I do agree that patching is my first choice.

Dr. Cheng:In Miami, do most of your families have prescription sunglasses also? I know that when I visit Miami the light is just so bright there (I compare it to Pittsburgh) that I’m surprised the children don’t mind having one eye dilated all day long.

Dr. Gold: I can comment on that. Being in Orlando, my experience over the past year, I have used atropine more, but I have used it in patients in whom there is absolute failure of patching. They absolutely will not patch no matter what I tell them, no matter how much I implore them to please patch their child. That’s when I’ve been using it.

I have seen no case of phototoxicity in the central Florida area since I have been using it, and I have used it more in the past year than I have in the 15 previous years of practice. Still not a lot, but it has certainly been in my armamentarium to be a little more flexible.

The results have been variable. I agree with the rest of the group that patching is the gold standard and still gets the results faster and more efficiently than atropine, as far as I can tell, but Dr. Warman, may disagree with that.

Dr. Warman: No, no. I use it a lot, and I’ve only had, throughout many years of using this, one time that I got stung with reverse amblyopia. This was a case where the child was so resistant that not only did I put him on atropine but I switched his +4 glass to a plano lens, and although I wrote and told them come back in a month, they showed up after 1 year of continuous use of the atropine. That got me a little grayer hair. I did reverse it back, but it took me a few months. That was the only case, but that was the most optical noncompliance that you can imagine.

Dr. Sondhi: I am using atropine more, as I said, but I use it in cases of severe amblyopia to initiate therapy where patching is extremely difficult, to get the child to a more acceptable acuity level and then switch over to patching, the reasons that Dr. Warman alluded to. In my career, I have seen four cases of occlusion amblyopia, and as it happens, all four came from atropine and spectacle lens manipulation. And those, I think, are the cases where the patients disappear, they continue to use the drops despite what you told them. That’s a risk you take when you use atropine therapy.

Scott E. Olitsky, MD: I use atropine a little more frequently than I did a year ago, and there are two places where I use it. One is for the child with moderate amblyopia where the parents are really struggling with a patch. Rather risk that patient never coming back, I have used atropine in those situations. The other is that I am using it more for maintenance. I’ve been very happy with its use on a once- or twice-a-week schedule for maintenance rather than patching.

But I share the concern that’s been expressed here over occlusion amblyopia with atropine. I have seen very few cases of occlusion amblyopia in patching, which is reversible, but I have seen a handful with atropine. Parents tend to go home, come back in a year and the eye is still patched, but they will use the atropine. So I think that’s a concern.

Dr. Cheng: I’m not averse to atropine, I just haven’t had many patients who really want to use it after hearing my speech about it. Again, not to be over-conservative, but when we say we haven’t seen any problems with phototoxicity, I’m not so sure we’re really going to know it. If you have a patient that’s a little subnormal, 20/30, 20/40, is that patient getting a contact lens examination of the macula? Is that patient getting a fluorescein angiogram? Is there maybe a little granularity of the macula? It’s a difficult potential. And then again, I don’t know if that patient may develop cataract at an earlier age. Those are things that really have not been proven out yet.

Dr. Gold: Those are obviously concerns that we all have, and in the studies so far, there have not been reported cases of that as of yet.

Dr. Sondhi: Dr. Warman, since you’re the one who has used atropine the longest here, what is the longest duration you’ve put a patient on atropine to treat amblyopia?

Dr. Warman:On and off for more than 2 years. Not continuously. Many times you see where you are, you try to wean them off and come back.

Dr. Sondhi: But if they’re not improving, or improving very slowly, do you keep them on it? I have patients that have been on it now for many months.

Dr. Warman: If they’re not improving, I go back and insist that patching is much more effective. I am a believer in patching more than in atropine, but I do use both simultaneously quite a bit, for short periods of time.

Dr. Sondhi: I am excited that a group like the Pediatric Eye Disease Investigator Group has a number of studies ongoing addressing different aspects of amblyopia therapy, in part-time, short-term, long-term and intermittent use of atropine and so forth. I’m sure a lot of these questions and concerns will be answered over the next few years.

How old to patch

Dr. Gold: One of the ongoing amblyopia treatment studies has to do with patching older children, over age 7 to age 18 years. I’d like to poll the panel today. How old are you patching children, and how do you determine when patching should be stopped, decreased, increased?

Dr. Olitsky: Well, I patch pretty much up to age 9. Now, I will treat a child that’s over age 9 who has never been treated before. We all know that many of those children can get better, and it’s difficult to turn to the family and tell them, “If only we had picked this up last year I would treat it, but not this year.” I treat them also because of the legal aspect as well.

Dr. Gold: If you have a 10- or 11-year-old child who comes in with 20/20 vision in the right eye and 20/100 in the left eye, who has never been treated before, what treatment option do you offer them at that point and how often do you follow them? What are your expectations, etc.?

Dr. Olitsky: I would talk to the parents about full-time occlusion, and I would see them back again in a couple of months.

Dr. Johnson: I do pretty much what Dr. Olitsky says. If someone has been diagnosed before age 9, I patch them until their ninth birthday. I check their vision carefully on their ninth birthday, stop the patching, continue with glasses if they’re anisometropic or amblyopic. Whatever the underlying reason is for their amblyopia, I would continue to neutralize that, recheck them after 3 months. If they lost ground, I would then go 6 months. If they’re stable after that, then I would see them on a yearly basis and continue to neutralize whatever is the underlying cause for their amblyopia.

If I see a patient for the first time that is over 9 years old, I would treat them very aggressively with full-time occlusion, recheck them in 2 months and leave it totally up to the family. Let them know that we may not see results. In the long run, I say, we may look back and know it was too late. I probably see four or five patients a year that fit that description, and about 80% of them actually do improve.

Dr. Warman: It’s important in those patients to see if they have anisometropia, or a bigger deviation for that matter, or not. Because the pure-anisometropia amblyope responds much better at that age, and that’s important. That’s often the patient that shows up for the first time at age 9 because they failed a screening in school. That’s encouraging, and those are the ones who are going to get a response.

Another thing is, I tell them from the beginning that it’s going to take a minimum of 3 months of full-time patching for me to know if it’s going to work or not, because I need two or three consecutive “no improvements” to stop. I’ll make them come back in a month because I know there is going to be some improvement, at least at near, and I want to use that as a stimulus to convince them to keep going. This works. That’s why I have them come back at 1 month.

But the kid has to know from the beginning that there will be 3 months of full-time patching and at least 1 year of a decreasing patching pattern because if not they’re going to be frustrated. These are tough kids. The ones that want to do it, they want to know when it will be over because of their age.

Dr. Sondhi: Probably similar to everybody else, I try to stop the patching a little sooner than 9 years of age in a child who has been under my treatment, has achieved the target visual acuity and has been stable there for a while. I try to wean them off sooner. If they start reversing, we go back obviously to part-time or full-time occlusion.

The older child, in my experience, is a different can of worms. I have great difficulty convincing those children and those families to do full-time occlusion for 3 months. I have yet to come across an 11- or 12-year-old child that will accept that and truly fit into that treatment regimen.

So we do the best we can. We emphasize it and see what they can give us, and depending on the result decide to pursue it or not.

Dr. Cheng: I’m not a full-time patcher because I have found very little compliance with full-time patching, and I do worry about strabismus. So given that, I probably tend to move slower. I’ll continue patching patients until the vision is equal in the two eyes, or until the parents give up. Often they will say, “We’re happy with 20/30, we’re happy with 20/25.”

The patient will maintain vision with a maintenance schedule of 2 hours a day patching for a few months, and then it’s time to stop. That may be as early as age 7, although most of the time the parents will want to continue on. However, when the children hit age 8 and we’re really not going anywhere for a few visits, then it’s time to stop.

To the question of whether I will patch a new patient who presents at an older age, just like everyone else, we’ve seen success stories with a 10-year-old, even an 11-year-old with anisometropia. So I will patch them, but it’s usually only effective in anisometropia.

Dr. Cheng: Several people have said they’ve seen penalization amblyopia from atropine, but none from patching. Does that suggest that atropine may be a more powerful detriment to the good eye than patching? Do you see what I’m saying? The reverse of that would be, gee, if it hurt the good eye maybe it can help the bad eye better.

Dr. Sondhi: That’s my impression. I think atropine in combination with optical penalization is a very strong amblyogenic factor, and those are the patients that can get away from you because of lack of follow-up. Generally, if people don’t follow-up they also don’t patch. But the drops are a lot easier to do.

Dr. Olitsky:That’s exactly true. It’s not necessarily the medication, it’s the fact that they will comply. The drops are easy, and if a little is good, a lot must be better. In other words, if they aren’t returning to your office, chances are they are not patching their child enough.

Dr. Sondhi: Dr. Warman talked about full-time occlusion. I can’t remember the last time I patched somebody full time. My rule of thumb is 80% or at least 2 waking hours that are free of patch, and I think that provides you the safety value not to run into occlusion amblyopia. It’s enough hours for a waking child to see if you’re going to get a therapeutic result or not. That’s my feeling.

Dr. Warman: I meant that I use full-time patching on those 10- and 11-year-olds. You’re not going to get reverse amblyopia at that age. These are patients that I just want to stress to their family, we are in a desperate situation. Actually, I direct the talk to the kid. “It’s up to you. You cannot be cheating here. If you want to do it, it’s going to work. If you don’t, let’s do it from the beginning. Let’s give up. It’s not the end of the world not to do it.” I do not use full-time patching at other ages.

Optical correction of AE

Dr. Gold: We’ve mentioned some concerns regarding accommodative esotropia. I want to discuss optical correction for accommodative esotropia (ET). We discussed in a previous round table whether or not progressive bifocals, or flat-top 35 bifocals, or executive bifocals, are appropriate treatment for accommodative esotropia with a high accommodative convergence:accommodation (AC/A) ratio.

In my practice I use progressive lenses commonly in children over age 3 with elevating optical centers to make them use that part of the bifocal, and I have been successful with that. Aesthetically, the parents like it, and the children seem to tolerate it well. Is anyone else doing that?

Dr. Warman: I don’t do it in young kids. When they are approaching preteen and I cannot wean them off the bifocal rapidly, I will switch them to a progressive and try to wean them that way. I like the idea, but I’m just a little worried if we haven’t determined if there’s stereopsis.

Dr. Johnson: I never used a progressive lens for accommodative ET with a high AC/A ratio until about 6 or 7 years ago, and it was merely because of insistence by a mom. When she discovered that my real reluctance was because I was protecting her pocketbook, she told me to let her worry about her pocketbook, that she wanted to give this a try for her daughter. And it worked beautifully.

Since then, I have relaxed on that quite a bit. I’m still sensitive that it costs quite a bit more, but I think it works equally effectively. They have to be fit differently. We have all seen the flat-top, probably more times than not, being fit too low by an optician who is not used to doing this, especially if they’re not fit in our optical shops. When they’re fit with a progressive, unless you really mark the lens in the lensometer yourself, you don’t know what the segment is, and they truly have to be fit at least 1.5 mm to 2 mm higher than even the aggressive optician wants to fit them.

The patients do not complain of spectacle blur with that, and I think that they are treated effectively. It’s even more physiologic, if you think about it, because there’s the intermediate range. That patient that has the high EA ratio doesn’t just switch binocularity to an AT at near just at any one distance. It happens over a range of distances. As the target at which they’re looking gets nearer, it only makes sense from a physiologic standpoint that it would work.

Dr. Cheng: Since I’ve learned that people are using progressive lenses, I’ve been more agreeable to the idea when asked by parents. I’ve placed some children as young as 7 and up. In them, it has worked out just fine. However, I only place those children in progressives if they prove to me that they already have good stereopsis with high levels of stereoacuity. But I’ve had no problems.

I do have an interesting older patient that I’ve seen over the past year. She’s 14 or 15 now, and she didn’t start with me, but she came in as a recent patient. She changed her glasses before leaving her previous ophthalmologist and moving a year ago, and they put the segment too high on one side, it was a progressive or a transitional bifocal. One side was much higher than the other, and that’s forced her to really use only one eye for reading, which became easier. She clearly had a near esotropia which the parents and she didn’t notice.

She was comfortable and fine with these glasses on, and when I pointed this out to them, the mother was excited because she had terrible stereopsis, although her previous record showed that she had good stereopsis with an appropriate bifocal. I changed her glasses, and then I started getting phone calls about terrible headaches and asthenopia. I induced the headaches and the asthenopia since I changed the actual power of the prescription during reading. Because now using the bifocal she actually had an esophoria that she was controlling, and because she was controlling her esophoria and she was a voracious reader, she developed problems with asthenopia. She actually preferred the glasses where she was mono-fixating.

So the take-home message was that we must be careful and make sure the glasses are fit appropriately. It’s hard enough to get even bifocals with a flat-top placed to the right height in young children that are squirming around and have glasses that are bent and cockeyed, or one segment or one lens is tilted and higher than the other one by a quarter of an inch. So I remain careful about placing patients in transitional lenses.

Dr. Sondhi: I guess I’m the only one here that has not tried progressive lenses, simply because that’s the way I was taught. My concern in the past has always been the fitting of those lenses. Physiologically I agree, it makes sense that they would do equally well, maybe better, in progressive lenses. This panel has convinced me today to go back home and try those progressive lenses in the future.

Dr. Warman: Do you make the add a +3 like any other, or with a progressive do you go to +3.50 with the idea that you get the add a little higher?

Dr. Johnson: It does make sense. That’s part of the art of dealing with progressives. With some of the frames now, when you edge the lens you may get rid of the full power of the add. The stock lens may come with the label +3.50 but they may only effectively get +3 out of it. So there’s nothing wrong with going higher.

Dr. Cheng: The patients who have relatively poor stereopsis, do they do just as well with a transitional? Do you feel they really use it as much as the true bifocal fixator?

Dr. Gold: I have not found any problems at all, even in the patients who have lower stereopsis. They seem to tolerate it well. I have not found any difficulties.

Tear duct surgery

Dr. Gold: Let us discuss the timing of tear duct surgery and the different procedures that we have available now for tear duct surgery in children. What is the timing you use for initial probing procedures in congenital nasolacrimal duct obstruction.

Dr. Sondhi: That’s dictated by when we get the patient. More often than not, we’re not the people who decide when the patient should see us. In an ideal world, my preference is to see them at 6 months and do the primary probing procedure somewhere between 6 and 9 months of age.

Dr. Gold: Do you do probings in the office or under general anesthesia?

Dr. Sondhi: I give that option to the family. Under the age of 1 year, the family can decide after they weigh the pros and cons of both procedures. I had switched from being in the operating room under general anesthesia 100% of the time about 5 years ago to almost 100% in the office. Over the past 2 years I am slowly going back toward the operating room again. I thought initially that my success rate in the office was going to be better. As it turns out, it’s still good, but not as good as I thought it was going to be. Typically, when I present the numbers, at least in my hands, I find more patients opt to go to the operating room for the primary procedure.

Dr. Cheng: I do my first probings after 8 months of age. I started seeing more and more 6-month-olds for whom I would schedule a probe surgery, and the mom would call me up at 7.5, 8 months of age, and it got better. So I stopped probing until after 8 months now, and I’ve had few cancellations.

I still probe entirely in the operating room. To me the concept of office probing was really directed toward those who probe when the children are very small and easy to use routine anesthesia on.

Dr. Olitsky: I only probe in the operating room, and every once in a while I’m reminded why I do that. I generally encourage parents to wait until they’re a year old, although I discuss the option of probing a little earlier when they’re 7 or 8 or 9 months, and the fact that they may still get better. I let the parents guide me in that decision. Before that age, I suggest to parents that they wait until 9 months before probing.

Dr. Johnson: I suggest to the parents that between age 8 months and a year they have a probing done. After a year, or after a previous failure with probing, I recommend putting in a copper tube. All these procedures are done with general anesthesia.

Dr. Warman: Just about the last time I probed in the operating room was in my residency 17 years ago. Actually I was trained to go to the operating room. It was my partner who convinced me to switch. When I started practice, I started to probe around 6, 7 months of age in the office.

I am a strong believer in office probing. I have nothing against going to the operating room. My comment to those that do it, in general, is they have just not given it enough of a chance to see how easy it is in the office.

We get a lot of people without insurance, which is a big dilemma in Miami. They cannot be taken to the operating room. It would cost $3,000 or $4,000 to put them to sleep in the hospital. Because of that and for one or another reason, I expanded my probings in the office.

I prefer to do it between 6 and 9 months of age, but I probe up to 18 months of age in the office without a problem. I don’t like doing the 18-month-old. I know the kid is bothered more by it. My staff doesn’t like holding the kids. That’s not the ideal situation, but I will probe 18-month-olds in the office. My success rate is lower in those, I must admit. Maybe it goes down to 80% to 85%, but up to a year of age, I have not noticed any increase in problems.

Once I go to the operating room, I always put a tube in. I agree with Dr. Johnson. I’m not going to waste the patient’s time and anesthesia and not put a tube in.

We have a very static situation with our population, and we know pretty much all the patients. The number of dacryocystorhinostomies (DCRs) in our area in south Florida in the past 30 years from congenital nasolacrimal duct obstructions, from failed treatments, can be counted on one hand. It’s an incredibly low number. Although I don’t have scientific data to prove it, I’m convinced that if you are aggressive and probe earlier, and in your office you can probe earlier because you’re not concerned with anesthesia, you will decrease those long-term complications. That’s why I’m such a strong believer in probing in the office.

I have never had a patient afraid of coming back to the office after being probed. So I don’t believe there is psychological trauma under these conditions. I have had multiple parents ask me to reprobe a second time before going to the OR, and they stay in the room when I do it. I give them the option, and they usually want to be there. I have had many parents bring their next sibling, and they object to me waiting until 6 or 7 months as I did the first time. They force me to go earlier because of the good experience they had before.

So that is one of the things I am the strongest proponent of, office probing.

Dr. Gold: Two hundred fifty miles up north in Orlando the air must be different, because I do my initial probings between 6 and 12 months of age, and I do all of mine in the OR, and which will segue now into the next question.

A 2-year-old child comes into your office with a congenital nasolacrimal duct obstruction. They’ve been told by the pediatrician for the past 2 years that it’s going to go away, and it has not. What procedure do you do?

Dr. Johnson: From my own experience, the success with just a probing is between 90% and 95%. But after age 1 year I have seen the success of probing drop off. Not dramatically, but as they get older and the bony and cartilage structures start to mature, then the success of just probing drops. So I want to do anything that we can do to decrease the chances of having to go back to the operating room.

So in the case of this 2-year-old, I would primarily do a probing with a tube stent.

Dr. Cheng: It depends on the operative finding. If I find that I can feel a clear pocket upon passing the 0 size probe, and if I find that I don’t feel any stenosis of the duct with passage of a number 1 size probe, then I won’t feel a need to go ahead and put in the silicone tube stent primarily.

If it’s at all questionable, however, because the patient is 2, and I don’t want to come back again, I will use a stent. The stent I’ve been using rather than a Crawford is the monocanalicular stent, because I find I can use those in the office 100% of the time without going back to the operating room.

Dr. Sondhi: I’m somewhere between the two. Like Dr. Cheng, I would base my choice on my findings in the operating room. A definite stenosis that is easily overcome with a probe, a decent size probe that will pass easily, I may not insert a tube. I will routinely irrigate these ducts after I probe them, and if the solution passes freely, I may not pass the tube. In case of doubt, at that age I will go toward putting a tube in.

I do not use the Crawford tube or the monocanalicular stent. I do use the Ritleng bicanalicular stent. I’ve been very comfortable with that from the time I started using it, and I remove them in the office from the eye side, not from the nasal side, and it takes just a short time to take it out. I’ve never had one that I’ve had to leave any pieces behind.

Dr. Warman: If I go to the operating room they will get intubated under general anesthesia, and I will go forward and put in a Crawford tube. Once I’m there I don’t want to waste time.

I’m not worried about taking the tube out because we tie the tube with 6-0 Vicryl to each other. We don’t make a knot with the silicone, and then I pass the sutures to the appositive nostril, and most of the time either it falls on its own or it takes 3 seconds to take it out in the office.

Usually, if I take it out electrically I will take it out around 4 to 6 months after. It depends on how much tearing they have with it. Most of them don’t. I don’t see much of a morbidity in putting the tube in, other than a few extra minutes. It takes me a little longer because I’m teaching the residents, but other than that, you can put a tube in very fast.

In today’s atmosphere of cost containment I may ask you to try something. I just tie the tube ends with two surgeon’s knots, single-throw knots, and then stretch the tube. The size of the knot pretty much comes to the same diameter as the rest of the tube. It comes out just as easily, so you don’t need to use a 6-0 Vicryl and the cost of all of that.

Dr. Johnson: I’d like to ask the panel, if you do put in Crawford or Ritleng tubing, how much difficulty you have with it prolapsing superiorly?

Dr. Sondhi: I have no study on this, but I think the incidence of extrusion, if I can use that term for what you’re describing, seems to be slightly higher with the Ritleng tube than I remember it with the Crawford tube system. I think that has to do with the diameter of the tube.

I’ve also found that when they do extrude, in most of those cases I have not had to go back and re-intubate them. Even a day or 2, or 5, of intubation has probably done the job. From a physiological standpoint it shouldn’t require more than 7 to 14 days. All you’re doing is keeping the tubes in there long enough for epithelialization to occur, for the crack to heal, and so forth. The rest of the time is for our comfort, not necessarily for the patient’s benefit.

So to answer your question, the extrusion rate is probably in the 5% range or less.

Dr. Johnson: The reason I asked is because of that extrusion problem, 8 or 9 years ago I started using a technique where the tubing was tied over a 3-mm silicone sponge. As you tie it, you can adjust the tension nicely. It’s tied with multiple knots. You can adjust it with perfect control over the tension, and the incidence of extrusion is really minuscule.

Dr. Sondhi: There’s another technique I’ve learned where you actually put a knot in and it comes and settles in the lacrimal sac, and those tubes cannot be pulled out. The problem with those is they’re a bit harder to take out in the office. You can, but it takes longer.

Dr. Gold: I would like to get the panel’s feeling regarding balloon dacryoplasty, whether they do it, what their indications are.

Dr. Sondhi: I reserve that as a last resort procedure from the conservative surgery standpoint. When I mean conservative, I mean nonincisional surgery. I do not use it as a primary procedure. I will always do a probing and probably a probe and tube at least once before I consider doing a balloon dacryoplasty. I probably do that just a few times a year.

To comment on what was said earlier, it’s been years since I’ve done a DCR. Between the different systems and methods that we have now, DCRs should be a rare occurrence.

Dr. Warman: I agree about the balloon. The last time I used one was on a self-paying patient, and the parents almost had a heart attack when they got the bill. It’s a very expensive piece of equipment in the operating room. I don’t know if it’s worth the benefit. I’m sure there are special indications, recalcitrant situations where you should use it, but that’s my main problem.

Dr. Gold: I did not perform the balloon dacryoplasty until recently. Because of my own curiosity to see what procedure would be best, I have started to do this procedure more frequently, and what Dr. Warman brought up is concerning to me. The equipment for the balloon dacryoplasty is extremely expensive. Each one of the balloons costs $250, and the pneumometer costs about $60. There are some ambulatory surgical facilities that cannot afford to purchase this equipment because the reimbursement for the procedure does not warrant it. There are hospitals that will purchase the equipment. I have spoken to the company in this regard and have gotten nowhere.

There are many physicians around the country doing this procedure, and frankly I feel it’s a good procedure. I will use it in certain circumstances, such as in those people that have failed a probing and when anatomically it makes sense to do. But it is a concern of mine as we aim to treat our patients in the best way, as well as to be fiscally responsible, to make sure that we’re doing the best treatment possible.

Dr. Cheng: I do very few of these. There are papers with, I think, good science in them that report high success rates for the use of balloons in recalcitrant cases and first-time probing. But I still don’t understand the pathophysiology of why it should work long-term, and because of that I have done only a few.

If we look at the cost of probing, the reimbursement rate to the ophthalmologist for probing in the operating room is so poor, personally, I lose money every time I take a patient to the operating room. There’s no question about it, because of the time involved in filling out the hospital chart, waiting for the patient to go under general anesthesia. Certainly in that respect, office probing would make much more sense than probing under general anesthesia. But I probe under general anesthesia for numerous reasons that have already been stated. I think that’s a larger issue that needs to be addressed with payers, reimbursing physicians who are taking care of children.

Dr. Olitsky: I started doing these balloons when the apparatus first came out, and I wasn’t convinced that regarding my patients it would really help. Some of the reports showed it to be useful in the treatment of the older child with tear duct obstruction. I might argue that those patients might do just as well with a probing. I’m not convinced it’s needed there.

If a child has failed probing I generally refer them to the plastic surgeon, and some of the surgeons will use that device.

Dr. Johnson: If we think of the mechanism that this employs, it doesn’t seem to be a lot different from silicone tube intubation. There are many of our colleagues who may not be comfortable with silicone tube intubation, and if you’re not comfortable with the silicone tube, this device may make sense.

But it’s a good point that Dr. Gold makes about the fiscal responsibility that we have as clients of outpatient departments. Even though they are trying to attract our business, take good care of our patients and do the best they can, sooner or later they’ll dictate that the expense of an appliance like this is so great that they can’t afford it, and then they’ll tell us we must take that procedure elsewhere.

And as we get our comfort level up, and we like to go to one or two facilities, we don’t like to be told, “Well, sorry, you have to take this one procedure to some place else.”

Dr. Sondhi: From a physiological standpoint, I’m not sure what I’m dilating. There are no sutures there, no muscular sphincter, so I’m always wondering if the beneficial therapeutic effect is simply one of a slightly larger probe going through the system one more time.

Dr. Gold: Obviously, it’s another part of our armamentarium that is there if we need it. I think you have enough information.

Dr. Johnson: It sounds like I employ the tubing more than some others. Ken mentioned a while ago using the monocanalicular device. I have used that a few times, especially if there is heavy stenosis, and I think it’s a beautiful way to do it.

A senior medical student has just spent some time with me, and he was interested in doing a retrospective review. Part of his data-gathering has looked at all the patients that I have done Crawford tubing on between 1997 and 2001, so a 5-year period. There were three patients of 175 during that time that had over 1 year follow-up, three patients that wound up failing with the Crawford tubing and having that repeated. That’s a very small percentage. But that doesn’t mean this is the only way to do it. There are other ways. Including, perhaps, even the balloon.

Dr. Warman: I’m so comfortable with Crawford tubes, that that’s why I didn’t switch to the Ritleng. I know it’s difficult, but I just happen to be good with it. They train the residents, and they’re taught to retrieve it, and you need practice. But for those that are not good at it, they don’t have to use a balloon. The Ritleng tube, I’ve been told, basically comes out on its own.

Dr. Sondhi: More often than not, it will not come out. You have to go fish for it, just like Crawford tubes.

I think it’s a comfort level. Once you figure it out and get good with it, it comes out quickly every time, it works well with both systems. But if you’re not comfortable with it, that can be different. When I’m teaching residents, I find that the trauma to the tissues is greater with the Crawford tube and the Crawford hook than with the Ritleng, and that’s the reason I switched to it.

Equipment for photodocumentation

Dr. Gold: Let’s talk about ophthalmic equipment and costs. The RetCam (Massie Research Laboratories) is a piece of equipment that costs, I believe, in the neighborhood of $65,000. Of the six of us in this room, who has a RetCam? (Show of hands.) So 50% of us have access to a RetCam, three out of six. Dr. Sondhi at the Indiana University, Dr. Cheng at the University of Pittsburgh, and Dr. Olitsky at Children’s Mercy Hospital in Kansas City.

What are your indications for use, and how many times a year do you use it?

Dr. Olitsky: Up until 6 months ago I didn’t have a RetCam, and I don’t find a lot of clinical use for it. I think it is a useful teaching tool. To share pictures with colleagues of patients reporting to the operating room, you can use it there.

The biggest single use, unfortunately, we use it for is shaken baby images. The attorneys want it, and that was probably the biggest push to acquire a RetCam.

Dr. Gold: In the 6 months that you’ve been there, in how many shaken baby cases has it been used, have pictures been taken for?

Dr. Olitsky: Well, unfortunately, I’d have to tell you two and sometimes more times a week. So it’s frequently.

The quality of the photographs is excellent, but many of these children are sedated or intubated somewhere.

Dr. Cheng: In the operating room we have the Nidek system, and the division at Children’s Hospital in Pittsburgh that takes care of child of abuse, they bought a RetCam, so I have access to both.

I have not been successful at getting high-quality images with the Nidek without taking much of my own time to get them. Much of that may be due to my error rather than the camera.

The RetCam is somewhat easier to use, but in my hands it is still quite cumbersome, and unfortunately I don’t find it to have a lot of clinical value.

However, I think that as image acquisition systems improve, they will become valuable for things like retinopathy of prematurity, and, unfortunately, to document our findings on shaken babies. The pen and paper is still documenting things very well.

Dr. Sondhi: I have access to RetCams when I need them. One in the operating room at the Children’s Hospital and the other is used primarily for nonaccidental trauma cases in the NICU at the other hospital. For the nonaccidental trauma cases, a couple of the nurses, as well as the neonatologists and the intensivists, have been trained to use the camera. They just dilate the pupils, take a photograph of the fundus and send it over the computer, and one of us can look at it and let them know whether we see hemorrhages that are consistent with nonaccidental trauma. So that helps save some hospital trips.

Is that cost-effective? I’m not sure. I don’t think so.

I do find photodocumentation of certain optic nerve conditions, retina conditions to be helpful. My pictures and drawings may be great, my handwriting may be great, but people’s interpretation of what I drew or wrote 10 years from now may be different. Photographs don’t tend to change that much with time. But I share Ken’s views that at the cost they are available now, it is not cost-effective.

Dr. Gold: All of us in this room see cases of nonaccidental trauma and shaken baby syndrome. Do you think that in the legal investigations of this condition, the pen is going to become less trusted than the picture?

I don’t now how many RetCams have been sold in the United States, but obviously there are more pediatric ophthalmologists that are going to see babies in the PICU for nonaccidental trauma rule-outs than there are RetCams. Are there going to be problems in the legal aspects of these cases without photo documentation?

Dr. Cheng: I don’t think so. I think if you are an expert witness and you’re providing timely documentation of your findings, I don’t think that that can be challenged. Unless they challenge your veracity as an examiner, and that could equally be challenged as to the chain of evidence on a photograph. I don’t think it’s any different.

Naval, what you said is very intriguing, that the nurse at the NICU will e-mail the photograph or the RetCam to you so you don’t have to be there. That seems tricky to me, whether that would hold up legally. Have the nurses and the neonatologists in that NICU been able to provide you with high quality images so that you don’t actually have to go?

Dr. Sondhi: I will just use a screener to begin with while my partners cover the hospital and see those patients. I’ve had the opportunity to see some of those pictures come through. They’re of sufficient quality. It’s not hard to know whether there’s a hemorrhage or not.

Famous words, “A picture is worth a thousand words.” I agree with Ken. I think if you have done your job right and you document it, unless your credibility with the jury or the judge is in question, there should not be a difference.

However, if you hold up a photograph or image with multiple hemorrhages in front of a jury or a judge and say, “This is what I saw,” you have powerful evidence in your hand. I don’t do as much with nonaccidental trauma as others on this panel, but it’s been my experience that whenever the suspects in those cases have been presented with photographic images up front, and informed that these almost certainly represent nonaccidental trauma, they have broken down and admitted to that, and the cases have not had to go to trial.

Dr. Johnson:I see quite a number of these, as the only pediatric ophthalmologist in our area, and as much as I am not fond of getting involved in these, I feel an obligation to. I agree with Ken, that the standard of care and the standard of documentation is still a well-written note. In many situations, photography may not be available, and you simply need to put that in your note. If it is available, it’s a great enhancement.

But if you document, you have to document very carefully. You’ve reviewed the lab, you have examined the patient, they have retinal hemorrhages in all layers of the retina from the posterior pole to the peripheral retina, you know there are too many to count, preretinal hemorrhages, vitreous hemorrhage — for some of these things, a photograph that’s not of great quality may not show as well as your description. That’s still the standard of documentation.

Dr. Olitsky: I agree with that. I think most of the time the question isn’t whether the hemorrhages where there. The question is how they occurred. I suspect that the picture has most of its usefulness in front of a jury and not convincing them that the hemorrhages where there, but when it comes time to decide whether there was a harm to this child, those pictures are very powerful.

Dr. Gold: I’m sure that not all of us have been involved in jury trials where we’ve had to testify. In the last 6 months, I’ve had to testify twice. Being on the stand, looking and saying what you see in a very definitive manner, this is also a very effective tool. You’re taking an oath when you go up on the stand, and you have to tell what you saw. None of us likes to be involved in those cases, but your expert testimony is an obligation to say what you have seen.

Dr. Warman: I’ve been up to the PICU at night with the best intention of taking pictures. I’ve gotten my Kowa camera, and then the patient is comatose, the eye is full of ointment by the time they ask you to see it, and you cannot get the ointment off to get your picture. But that doesn’t degrade your exam. You can get in through your indirect, you make your note, and I’ve written photographs attempted, and they weren’t successful, and I’ve gone to court with that.

Dr. Olitsky: That’s the point. It’s not that one is better than the other. It’s a matter of getting as much information as you have, as much as you can present, to make a stronger case.

Dr. Gold:And I think the conclusion is that while some imaging devices may be very good tools, the pediatric ophthalmologist and his or her examination is still the best tool.

For Your Information:

• Robert S. Gold, MD, can be reached at 225 W. State Rd. 434, Suite 111, Longwood, FL 32750; (407) 767-6411; fax: (407) 767-8160; e-mail: rsgeye@aol.com.
• Roberto Warman, MD, is an associate professor at Bascom Palmer Eye Institute and Miami Children’s Hospital. He can be reached at 3200 S.W. 60 Court, Suite 103, Miami, FL 33155-4072; (305) 662-8390; fax: (305) 661-7862; e-mail: rwarman@eyes4kids.com.
• Anthony P. Johnson, MD, FACS, can be reached at 131 Commonwealth Drive, Suite 390, Greenville, SC 29615; (864) 458-7956; fax: (864) 458-8390.
• Kenneth Cheng, MD, can be reached at 1000 Stonewood Drive, Suite 310, Wexford, PA 15090; (724) 934-3333; fax: (724) 934-3371; e-mail: kpchengmd@stargate.net.
• Naval Sondhi, MD, is a clinical professor at Indiana University. He can be reached at Midwest Eye Institute, 201 Pennsylvania Parkway, Indianapolis, IN 46280; (317) 817-1333; fax: (317) 817-1331.
• Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospital, Department of Ophthalmology, 2401 Gilham Road, Kansas City, MO 64108; (816) 983-6730; fax: (816) 855-1793; e-mail: seolitsky@cmh.edu.