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Round table: How pediatric ophthalmologists contend with adult strabismus

In this round table conducted at the 2012 AAPOS meeting, members of the OSN Pediatrics/Strabismus Section also discussed patient expectations and LASIK in children.

Issue: May 25, 2012

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Robert S. Gold, MD: Does anyone have any caveats for their preoperative or postoperative management of strabismus?

Kenneth P. Cheng, MD: The most important thing when I am dealing with adult patients is to make sure they have realistic expectations. I go through great pains to let people know what is realistic. People are accustomed to everything being perfect, but in adults with strabismus, particularly patients with thyroid disease or paralytic strabismus, things cannot be perfect. We can certainly make these patients much better, but you cannot make them perfect, and they need to know that. Even for patients with fourth nerve palsy, I go through great pains because every once in a while there is a problem. That goes a long way toward postoperative satisfaction.

Rudolph S. Wagner, MD: I think the expectations are very important, particularly in adult patients. One of the things that I do, especially in adults, is ask them what they notice about their eyes and then bear in mind what it is they perceive is their biggest problem.

M. Edward Wilson, MD: On the other hand, we do not want to set the expectations for adult strabismus patients too low. We know the majority of adult strabismus patients will regain some form of fusion. They probably will functionally see better. If they have double vision, we can get most of them relief from it. If they do not have double vision, we can probably restore some degree of binocularity. But I tell them that I am going to do my best to achieve the goal. It is possible that their response to the surgery, based on our nomograms, will not be average. When they heal from the first surgery, we can make a conclusion as to whether we are done or whether a second surgery is needed.

The patient needs to recognize that I am working toward a goal. It might take one trip. It might take two trips. But it is achieving the goal that is important. The good thing about eye muscle surgery is that we do not burn any bridges. We are not doing anything that cannot be added to or subtracted from. The bad part is that sometimes, based on their response to the initial surgery, we need to touch up things. So you set that up so that the patient is not surprised if a second surgery is needed, but I certainly would not downplay our ability to get to the goal.

Dr. Gold: Many of these patients have already had one surgery, so their expectations for being happy with the second surgery are high. That is part of the discussion that you have to have with them, that a certain percentage of the time, you actually may need a third surgery to meet those expectations. Yes, 90% of the time we can meet that expectation on the second surgery, but 10% may need a third surgery. That is part of the discussion to have.

Anthony P. Johnson, MD: I err more on the side of describing overcorrection. The couple of really unhappy patients who I have had have been overcorrected. Especially with kids — for example, a child who now has crossed eyes after overcorrection and whose parents have never seen the child with exotropia — I tell the parents that one is no better than the other or no worse than the other, but it is still not what we are shooting for. So I emphasize that to make sure they understand that overcorrection is a possibility.

Dr. Gold: When you are talking to families about their children, it is almost a similar discussion as with adults with strabismus. The parents feel that you are going to operate on their child and that their eyes are going to be perfect. But that discussion needs to go greatly deeper, whether it is more surgery, undercorrection, overcorrection, patching, bifocals — those are all things that need to be in the preoperative discussion. Because if they are not and there is a surprise, then they are not going to be very happy.

Dr. Johnson: I take the focus off of whether or not we did just the right amount of surgery or chose just the right procedure, and emphasize that what we are really relying on is for the fusional mechanism to have a chance to control the alignment and hold the alignment for the long term.

Dr. Wilson: Rarely do we do the wrong surgery or the wrong amount of surgery; we have some pretty well-calculated nomograms. But if the patient’s response is different, we are not going to leave him with a less-than-satisfactory result. We are going to continue to work until we reach that goal. And then, hopefully, the patient’s fusional mechanisms will hold long term.

Erin D. Stahl, MD: I tell parents, “There’s a problem between the brain and the eyes. And that’s not something that I can fix. But I can react to it by mechanically straightening the eyes, and then the brain and the eyes have to work together to hold them straight. It’s not something I can control.” That is my way of telling parents, “This is what the average child needs to fix this, but each child is unique.”

Dr. Cheng: It is valuable for parents to have that discussion to prepare them when a small-angle esotropia develops after 9 months or a year, which is a common occurrence after the child’s eyes had been straight following surgery. They understand better when you say, “We would have hoped that the brain would have started using both eyes together, but it hasn’t quite happened, and we’d like to still give the brain the opportunity to start using both eyes together.” Whether the angle is an acceptable small angle or an unacceptable one, the parents are prepared for the news and possibly for the need to perform further surgery.

Postoperative medication

Dr. Gold: What do you do postoperatively medication-wise? Are you using drops or ointments?

Scott E. Olitsky, MD: At the end of the procedure, I put Betadine (povidone-iodine, Alcon) in the operative eye and topical antibiotic ointment. But I do not send patients home afterward with anything.

Dr. Stahl: I do the same. But this year, I have changed from using 10% Betadine on the face to 5% before and after, because we had some chemical conjunctivitis that was pretty impressive and a couple cases of epithelial sloughing.

Dr. Cheng: I do not use any postoperative medications at all. I prep before the case with 5% Betadine, and it goes in the eye before the case, but not after.

Dr. Johnson: On adults I use a non-steroidal afterward for a few days, just for analgesia. I do not use postoperative antibiotics.

Dr. Wagner: Particularly on reoperations or a case in which I expect inflammation, I will use a combination of steroid and antibiotic postoperatively, but not in every case.

Roberto Warman, MD: I still use medication for 3 days postop. At the end of the case we use Betadine.

Preoperative marking

Dr. Stahl: Based on a recent paper about surgical mistakes, I have increased my preoperative marking on the patient’s forehead to be much more specific about which surgery in which eye in which muscle I am doing. For example, I put a dot over the muscle, and then I put either “ET” or “XT” on the forehead.

Dr. Gold: One of the things that we have instituted in the last several months in our operating room is not only the marking, but also a white board. I write in large print the procedure that I am planning on doing in the operating room. We read it when the patient is ready for surgery.

Dr. Wilson: I do not specifically mark every muscle on the patients who have more complicated deviations because the plan may not be set in stone, but we certainly do our “timeout” and mark the eye or eyes that are being operated. I have a surgical plan sheet that has all of the patient’s strabismus measurements and any other information I have available, and I keep that within view. I usually tape it right behind me. I print it out from the electronic record, and I am constantly looking at it. As I make any incision, I constantly check that sheet, looking at the deviation and the pattern, for example. Then you can change a plan as needed, but that patient’s specific information is constantly in view. And at the conclusion of the case, before you say, “I’m done,” check the paper and make sure you have done everything you set out to do.

LASIK in children

Dr. Gold: When is it appropriate for a child with accommodative esotropia to have LASIK?

Dr. Stahl: Pediatric refractive surgery is for those cases that cannot be treated by anything else. And for accommodative esotropia, most of those kids do just fine in their glasses and contact lenses. They see well, and their eyes are straight. In my mind, they are very good candidates for laser refractive surgery when they are mature, meaning their refraction is not changing, whether that is 18 or 21 years old. When they stop growing, when their refraction is stable, I think they are great candidates. And if they were straight with their glasses and contact lenses, they will most likely be straight after refractive surgery. If you do it earlier, you would just be chasing a moving target. You cannot guarantee that they will have a stable refractive outcome, and they may not be straight after they are done growing. So I do not really see any good reason for it.

Dr. Warman: What level of hyperopia are you comfortable with in a 20-year-old, without doing heroic, aggressive damage to the cornea to get a good result?

Dr. Stahl: Somewhere between +4 D and +6 D. I am not comfortable going as high as +6 D, but some people are. And it depends on what type of laser you have, what the cornea looks like, what the keratometry looks like. There are a lot of factors to consider.

Dr. Gold: And how old? You wait until the patient is 18 years of age and older before you consider it?

Dr. Stahl: At 18 years they are signing their own consent and making their own decision. Medicolegally, there are some good reasons to wait until this time. But if you put that issue aside, it is when their refraction stops changing. In some people, especially girls, that is younger than 18. Also, the lasers are FDA approved for patients older than 18.

Dr. Wagner: That is a great point about waiting until that age if you are going to even consider it, especially for accommodative problems. The hard part is identifying when the refractive error will stabilize. That is a very common question that parents ask. Patients ask, “Can I get out of glasses?” and “Am I going to get better?” I used to tell people, “Yes, your hyperopia is going to reduce.” But it does not in all cases. It is very difficult to predict. The only way to know is to follow them for a long enough period of time.

Dr. Cheng: When I am talking with general ophthalmologists or with refractive surgeons, I tell them to shy away from refractive surgery on strabismic patients, because if a patient really is not adequately evaluated beforehand, then all of the nuances of the strabismus may not be discovered. As a strabismologist, Dr. Stahl is fully aware and capable of how to take care of the patient afterward in case the patient’s condition decompensates into esotropia, and she would have appropriately warned the patient of all those risks. But the more typical refractive surgeon is not in that same position. So I would maintain my position that, in general, refractive surgery needs to be approached very cautiously on a patient with a history of strabismus. Unless it is well-defined and well-evaluated, it needs to be approached carefully.

Dr. Gold: There is not a week that goes by in my practice that I do not see a patient who has undergone refractive surgery but the underlying strabismus problem had not been identified, and they come in pretty unhappy with sometimes strange double vision symptoms that are hard to treat.

Dr. Stahl: I think the note to the refractive surgeon is to say, “If your patient has a history of strabismus, have them evaluated by a strabismologist first.” Then the refractive surgeon can have that ammunition to say whether or not surgery has been recommended.

The patient can then make a decision knowing that their alignment may decompensate. They probably had surgery in the past. They may have been diplopic in the past. They know the risk they are taking. I think you are going to have the really unhappy patient when the refractive surgeon either has not elicited that history or has ignored it, done the surgery, and the patient had no idea that that was part of the expectation.

Dr. Johnson: I have had a couple of patients who had decompensated with their probably small phoria because of monovision. In a study of 12 such patients, seven of them actually improved just by neutralizing the anisometropia that was created by the monovision. We have to be careful in the comprehensive care of these folks, because monovision is so mainstream, whether it is with contact lenses or with IOLs or with refractive surgery.

References:

For more information:

• Kenneth P. Cheng, MD, can be reached at 1000 Stonewood Drive, Suite 310, Wexford, PA 15090; 724-934-3333; email: kpchengmd@me.com.
• Robert S. Gold, MD, can be reached at 790 Concourse Parkway South, Suite 200, Maitland, FL 32751; 407-767-6411; email: rsgeye@gmail.com.
• Anthony P. Johnson, MD, can be reached at Jervey Eye Group, 601 Halton Road, Greenville, SC 29607; 864-458-7956; 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; 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; 816-234-3000; email: edstahl@cmh.edu.
• Rudolph S. Wagner, MD, can be reached at Doctors Office Center, Suite 6100, P.O. Box 1709, Newark, NJ 07101; 973-972-2065; email: 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; email: rwarman@eyes4kids.com.
• M. Edward Wilson, MD, can be reached at Albert Florens Storm Eye Institute, 167 Ashley Ave., Charleston, SC 29425; 843-792-1414; email: wilsonme@musc.edu. 
• Disclosure: The round table participants have no relevant financial disclosures.