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Round table: Ophthalmologists debate use of IOLs vs. contacts in aphakic infants
OSN Pediatrics/Strabismus Section Members also consider topical antibiotics, best measure of IOP and eye care for patients on Sabril.
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Robert S. Gold, MD: One of the more popular round table topics is use of topical antibiotics and pediatric conjunctivitis.
Rudolph S. Wagner, MD: Most of the conjunctivitis that we see is primarily treated by primary care physicians or pediatricians; by the time these cases get to us, they are cases that may have been misdiagnosed or they are something out of the ordinary. But, to address the topic of a selection of an antibiotic for what I feel is bacterial conjunctivitis, I use a newer-generation topical fluoroquinolone.
Gold: In today’s managed care market and Medicaid market, you give that patient a prescription for fluoroquinolone and the phone call comes from the pharmacy that it is not covered by the plan. This happens to me every single day. What do you do?
Roberto Warman, MD: Initially, in most cases, I use Polytrim (polymyxin B/trimethoprim sulfate, Allergan) or its generic. With emergence of new resistance, it probably has better coverage. And the generic will be covered, essentially, by everybody. But bacterial conjunctivitis is a self-limited disease anyway, and many cases are actually viral, so you are treating a superficial infection just to clear the discharge a little to make the family happy.
Roundtable Participants
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Moderator
- Robert S. Gold
- R.V. Paul Chan
- Kenneth P. Cheng
- Anthony P. Johnson
- Scott E. Olitsky
- Erin D. Stahl
- Rudolph S. Wagner
- Roberto Warman
- M. Edward Wilson
Scott E. Olitsky, MD: I tend not to treat most of these children. Dr. Wagner’s point is good: Many of these children have already seen a pediatrician before coming to us and they may have something else that I do end up treating, but if that child comes to me first, I generally do not treat him. Issues with resistance are becoming a much larger problem, not just in our field but in all of medicine. I try to restrain myself from prescribing antibiotics, even though the parents may want their child to have a prescription. I usually try to explain why it is not necessary.
M. Edward Wilson, MD: What about the tear duct obstruction that becomes purulent?
Anthony P. Johnson, MD: I usually use TobraDex (tobramycin/dexamethasone, Alcon) or the generic equivalent if there is a lot of sticky discharge and the child’s lashes are stuck together. I use it three times a day for a 3-day interval just for the discharge. I tell the parents that this is not going to solve the underlying problem.
Kenneth P. Cheng, MD: If the medication administration is under my direction, then I will frequently use something with a steroid added because I think the patient’s eye gets quieter quicker and the patient feels better quicker. If someone else is directing the medication administration, then I would use tobramycin. The coverage is good in most cases, and that gives me alternatives when resistance develops, because resistance will develop. But is giving tobramycin for 3 days long enough? I have advised using it for 5 to 7 days, even after the discharge clears, to reduce the likelihood of resistance.
Gold: I advise two or three times a day until there is no discharge for 2 days, but I don’t know if that is long enough either.
Wagner: I think most cases of nasolacrimal discharge are not infections and most do not really need an antibiotic, but when parents are concerned, I go through the routine, telling them to keep it clean and to use erythromycin ointment if it is really purulent for a few days. The reason I do not like to tell them to use TobraDex is because pediatricians generally discourage from using topical steroids.
Wilson: I am usually quick to probe the nasolacrimal duct obstruction in the office, so I do not run into the long-standing purulence situation as much. However, any of the antibiotics are probably going to be effective for this. When the discharge turns purulent, I think it is a good idea to treat the discharge while also having the patient use massage or observe, because it sends the discharge back to the baseline stickiness that is nonpurulent.
IOLs in infants
Gold: IOLs in infants: We have an expert here to talk about that. What is going on in that realm?
Wilson: In the first 6 months of life, it is very clear these days that more children are left aphakic and treated with a contact lens rather than an IOL, especially unilaterally. With that said, though, you have to make decisions based on an individual patient’s needs. If I have a Medicaid family and a unilateral cataract, and I am certain that they are not going to manage a contact lens well, then I am going to see severe amblyopia from uncorrected aphakia if I do not insert an IOL. The Infant Aphakia Treatment Study 1-year outcome showed that both of those treatments are safe. People are concerned that there were more returns to the operating room on the IOL side, but I would point out that the vision was equal and that both arms of the study were viable. In the article, we recommended caution implanting in the first few months of life until the final 5-year results are out. I think that was the right thing to say in the article, but the individual needs of the patient have to drive that decision. For the best parents who can manage anything in the first 6 months, I am leaving the infant aphakic and putting on a contact lens at the end of the surgery with no patch or shield. The parents can start the drops right away. I want to finish the surgery very atraumatically and fit a contact lens on the table. For those who need an implant, it can also be done safely in these early months of life. After the first birthday, I pretty much implant everyone who has a normal capsular bag.
Olitsky: In developing countries, what is your opinion on balancing the fact that contact lenses may not be available but return trips to the operating room multiple times may also not be an option?
Wilson: What I have advised is to implant those children as soon as they are identified, but to place the lens in the sulcus. That probably works well in the United States, too, but people have a bias against sulcus implantation. If you do not have high-quality viscoelastics but you do have a vitrector handpiece, in the developing world it makes sense to do the surgery as though you were leaving the patient aphakic. Then put the lens, which may be a PMMA lens in that setting, in the sulcus, which allows the capsular remnants to seal, making return trips to the operating room unnecessary. Later in childhood, it is easier to exchange that lens. That would reduce returns to the operating room even in the United States, but we have this bias for in-the-bag implantation.
The reason there were more returns to the operating room in the Infant Aphakia Treatment Study was that, in the early months, the lens epithelial cells grow fast, and no matter how well you clean the capsular bag, there is going to be some lens material made. Although the anterior rhexis and the posterior rhexis seal very well to each other, the capsule does not seal to acrylic as well as it seals to itself, so the Soemmering’s ring material does not stay sequestered. But, as I said earlier, you can allow it to seal if you put the lens in the sulcus. This recommendation applies to any setting in which high-quality viscoelastics are not available, soft, foldable lenses that can easily be placed in a child’s capsular bag are not available and the available microscopes do not provide the best visualization. So, fewer mistakes are made with the lens inadvertently going into the vitreous cavity. That probably works better in such a setting.
R.V. Paul Chan, MD: What is your opinion regarding timing of when to operate in terms of functional outcomes and anesthesia risk?
Wilson: I think the data published by Eileen Birch and others is compelling in that in a unilateral cataract you probably lose no potential prognosis by waiting until after 30 days of age. We like to operate unilateral cases, that is, visually significant cataract at birth, after 30 days but before the end of the sixth week. Bilateral cases probably have a little bit more time, but I try to operate all of them within that time frame. Our anesthesia team is much happier if we can wait in a term infant to 30 days or slightly beyond, in which case the infant is sent home the same day. If they are younger than 30 days or if they are premature, we keep them overnight for observation and apnea monitoring. For partial cataract cases, it may not be necessary to operate that early.
Cheng: Replacing the lens purposely in the sulcus is a really interesting idea. In these young kids, though, I worry a little bit about getting a thick enough Soemmering’s ring to anteriorly displace the lens and getting iris chafe.
Wilson: I have not seen it to be a problem. In the developing world, they do not get those cataracts done that early for the most part. I have done that in my own patients on occasion, and I have not seen iris chafing. You can try to prevent that by using a lens that will capture. You put the lens in the sulcus and then capture the optic through both the anterior and posterior rhexes. The Soemmering’s ring will form around the lens and will not push the lens forward as much. But I have not seen iris chafing. I prefer in-the-bag implantation whenever possible, but there really is not any evidence that an IOL that is made to go in the sulcus is not appropriate.
Warman: Your recommendation in the Infant Aphakia Treatment Study is to increase patching month by month up to 50% of the day. If I do surgery at 1 month of age and I put in a contact right away, 2 hours a day of patching is more than enough in most cases. How did you come up with your recommendation?
Wilson: At the time we wrote the protocol for the study, the steering committee looked at all of the available literature, and we came up with the best consensus we could. We decided 1 hour per day per month of age, working our way up to 8 hours, and then settling on half the waking hours. Many of these kids come in somewhat late, and the amblyopia is already pretty bad. So even though 2 hours a day may be sufficient for anisometropia that is mild to moderate amblyopia, for deprivation amblyopia, that is just not going to be adequate long term.
Wagner: About this critical period of visual development, for the micro-preemies in the neonatal intensive care unit, I tend to think that I have 30 days or 6 weeks after they reach what would be their normal gestational age. I wonder if that is a reasonable way to think about it.
Wilson: So you start the clock when they hit term?
Wagner: Not necessarily term, but when I feel they are approaching at least that developmental stage when they respond like full-term infants.
Wilson: If the child is a preemie, I give them credit for half of that time. So if my aim is to operate between 4 and 6 weeks and they are born 4 weeks early, I will give them 2 extra weeks. There is certainly something different about being outside the womb vs. inside the womb, and they probably will get sensory nystagmus a little earlier. But you do have extra time. I settled on a compromise where I give them credit for half of their prematurity. That is just my system. I do not have hard science on that.
Measuring IOP
Gold: How are you measuring IOP in your pediatric patients?
Erin D. Stahl, MD: Both Dr. Olitsky and I use the Icare tonometer routinely. I use it more and more in the clinic, and my technicians are all comfortable using it in small infants and combative kids; you can often distract them long enough to be able to get an Icare reading.
Gold: There is no perfect instrument to measure IOP in children. With the Icare I can measure pressures on a 1-day-old infant without a problem in the office. I find it to be superior to a Tono-Pen (Reichert), which personally I have never been able to get used to.
Warman: My understanding is that the new one will be able to work with the patient supine.
Olitsky: We have a fairly large pediatric glaucoma practice, and I can say the Icare completely changed the dynamics of our practice with a kind of trickle-down effect. It virtually eliminated the need for examinations under anesthesia (EUAs). In our operating room, the EUA was generally booked as an “EUA possible surgery,” so there would be an extra amount of time blocked for every patient. Now, not only do those children not need EUAs any longer, but also we have more time to get other patients into the operating room. The only child who I cannot get a pressure for is the one who is already screaming when I walk in the room.
Johnson: We have had two Icare tonometers for the past year that are primarily used by my partners who see adults, because I do not routinely check pressure on kids unless there is a clinical need to. But the point that Dr. Olitsky made about eliminating a lot of the EUAs and the cost savings of that really is revolutionizing how to measure pressure in young kids.
Examining patients on Sabril
Gold: Let’s talk about our approach to children who are on Sabril (vigabatrin, Lundbeck) for intractable seizures.
Warman: The question is, how do we examine patients taking Sabril? The bottom line is that it is a fantastic medication for patients who really need it, so we have to support the use of Sabril.
Having said that, it is extremely cumbersome for the neurologist, who must examine the patient every 3 months. It is a problem for us to dilate these patients every 3 months and then do what? We never find anything in the periphery. You look for the optic atrophy, but you really find nothing. They are all essentially negative exams. However, if the child has cortical blindness or no potential for significant vision, then the neurologist can skip the need for an exam every 3 months. That is new. Realistically, we should be doing the evaluation once a year, but that is not what we are faced with.
One test that does work is the electroretinogram. We do not do an ERG every 3 months, but in many children we do the ERG once a year. We have a big discussion and document it on the chart with the family.
Johnson: I am interested in Dr. Warman’s comments because I feel helpless. I see these patients all the time, and I know that the neurologists are very selective. They only use Sabril when they absolutely have to. And some of these parents are just so unbelievably grateful for this medication. The confusing part for me is when you fill out the form it has a place for all of these diagnostic studies, but the only one that can possibly be done on a child is an ERG.
Olitsky: We as physicians and parents are put in the middle here because we know that we are not really doing anything with these examinations. I also explain to parents that we are not talking about these children going completely blind. We are talking about changes in peripheral vision. Most parents recognize that they would not make a change in their management regardless of what the ERG would show, so we therefore do not do it on these patients.
Johnson: Has anyone seen a patient whose peripheral field was becoming constricted?
Cheng: Robert C. Sergott, MD, who is in charge of the long-term follow-up of these patients, came out with preliminary 2-year data that did not show anybody had vision loss yet at that point.
Stahl: What age group?
Cheng: It was all comers, including adults.