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Round table: Eye pain, IOP and retinal hemorrhage in children
OSN Pediatrics/Strabismus Board members discuss managing eye pain, IOP measurement and retinal hemorrhage.
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Robert S. Gold, MD: Let’s talk about eye pain. Besides the complete exam, as we all would do, what else are you discussing with the family? What else are you looking for?
Anthony P. Johnson, MD: The buzzword, for the mom especially, is “pain.” Pain always gets mom’s attention. Ultimately I do not want the mom to think that I am dismissing her concern, so I do a complete evaluation. If the exam is normal, I tell the parents that there are very few things that cause real eye pain. I take extra time to explain this because, even though they may be hearing good news, I want them to be satisfied that their concern has not been dismissed.
I tell them that they may hear the complaint again the same day, but they can be reassured that everything else is OK. It may be a headache or itching/burning or any number of things that might be called “pain,” but if the symptoms are not associated with redness, injury or discharge, it is pretty certain that there may be a complaint but that it does not require treatment. Usually the parents are satisfied with that.
Scott E. Olitsky, MD: The one thing I always specifically ask about is whether the child has pain when he first wakes up in the morning. That history is consistent with recurrent erosion, which we may miss. That is one thing that I think about asking those patients.
Kenneth P. Cheng, MD: I would add that, in the scenario of a normal exam, that is, no redness, tearing, blinking or any signs of a surface-type problem, I ask the parents about sinus trouble. That would be another cause of pain behind the eye that is sometimes missed. It is not necessarily that the nose is runny because it may just be thoroughly locked in with thick mucous. But, again, it is one of those vexing problems to me in which usually you do not find anything, so I reassure the parents.
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
Gold: With our newer technologies, would you try to measure IOP in a child complaining of eye pain?
Erin D. Stahl, MD: We have been using the Icare tonometer for so long that most of my technicians use it automatically to check pressure in patients with eye pain. You would hate to think that you did the whole exam and missed a pressure high enough to cause pain. Certainly there would be other signs, but I check IOP just to reassure parents more than anything else.
M. Edward Wilson, MD: Checking pressure is certainly easier with the Icare because you do not have to put in a topical anesthetic, so we do it more often, but typically high pressure is not going to cause pain. If it is really high, they might get nausea and vomiting before they would really get pain. As Tony mentioned, there is an interpretation of what the child means by “pain,” and it is a wide range.
R.V. Paul Chan, MD: Yes, I would agree. I have a lot of kids who have retinal issues and who have neovascular glaucoma. Often, they do not have any pain at all and will be blind in that eye for whatever reason. The pain issue is interesting because a lot of them just will not have pain, even though their IOP is very high.
Checking IOP
Gold: Talking more about checking pressure in children, I am curious as to how and when you do it, and just in general checking pressures in the pediatric population, because with our new technology, it is becoming easier.
Chan: I have a question for those of you who do retinopathy of prematurity exams. Oftentimes, you will see a clouded cornea or the neonatologist may be concerned about some haze and worry about glaucoma. Do you check that child’s IOP in the neonatal intensive care unit (NICU) even though the baby is in the age range in which it is maybe normal to have a hazy cornea? As a retina specialist, this is a dilemma that we face, whether or not the pediatric ophthalmologists will come in and check the IOP.
Gold: Sometimes you have a cloudy cornea — the cloudy, hazy media when a baby is born — but if I have any concerns whatsoever during my examination, I will use an Icare tonometer in the NICU to check a pressure. It happens very rarely. Most of the time, the neonatologist will prepare me by saying “cloudy cornea” or “hazy media,” and I know to carry my Icare tonometer at that time to the NICU. In rare cases, if I see a patient in the NICU who looks very suspicious, I will go back and check the pressure. But the Icare is certainly the standard.
Wilson: But in the NICU, they are lying down, and we do not have the Icare Pro yet.
Gold: We sit them up.
Wilson: In that setting, the Tono-Pen (Reichert) is usually included in the in-patient consult pack that our residents and fellows take up, so in that exam, you have topical anesthetic drops and the Tono-Pen seems more practical. The Icare seems more practical when you do not really want to put in a topical anesthetic.
Olitsky: I question how many of those children you are going to see with that kind of mild haze and a normal size eye. For many of these children, you are going to put in a lid speculum and they are going to cry. You are going to potentially get an artificially high pressure anyway, so when I see those children, I generally do not check the pressure if the other things do not fit.
Gold: It is very rare that I have to do that in the NICU.
Roberto Warman, MD: For the general readership or other ophthalmologists, if you do not see a reason to check the pressure on a young kid, do not check it. All the time we get these referrals, particularly from optometrists, because they check a pressure and it is borderline or it is slightly high. Then we do extensive work-up, and we have to prove that there is nothing going on there when the pressure did not really need to be checked to begin with. So, that rule does not change just because the Icare is available. Yes, it is easy and reliable, but I still think that you check a pressure in a child when you have a suspicion, not as an automatic routine.
Gold: Is there a minimum age when you start checking pressures on routine exam?
Warman: No.
Cheng: I start measuring IOP when the kids are 16, unless there is some other cause, anisomyopia, for example.
Wilson: I see a lot of aphakic and pseudophakic children. In these eyes with early surgery for cataracts, you know the children are at lifelong risk. With the Icare tonometer, now the expectation is that you attempt to check the IOP in these children at every visit. I do not think we did that before because we just felt like we were not going to get it. Now we are getting the measurement more successfully, and we are training our staff to check IOP in that high-risk group at every visit. At least you make that good attempt.
Olitsky: The other high-risk group that our technicians check automatically is patients with any history of uveitis.
Rudolph S. Wagner, MD: By having the ability to check it with the Icare more easily, as you are saying, you are probably avoiding a lot of the examinations under anesthesia that might have been done previously just for measuring pressure in many cases.
Wilson: I think you are right. Our routine in the office, and I think most people do this, is if we get an abnormal pressure, then we tend to try to verify with another device. That is just being cautious. If I get an abnormal pressure with the Icare, I tend to want to confirm with a Tono-Pen or with applanation or vice versa. All those devices seem to be more reliable when the pressure reading is normal, so a normal probably means normal, but an abnormal needs to be verified.
Chan: Along with what Rudy said, I think that it has saved a lot of children who we operate on from having to go back to the operating room for an exam under anesthesia to check IOP because it can be done in the office now. It is much easier because checking their pressure postoperatively is critical.
Stahl: Something we have come across, with some of our vision plans, is that to get reimbursed for some visits, there must be an IOP check at every visit. It is one of the things that our optometry colleagues in our office fight against because it is really not indicated. It is an interesting quarrel that we are in the midst of.
Retinal hemorrhage
Gold: All of us have seen non-accidental trauma patients, but I would like to open the floor for discussion about other causes of retinal hemorrhages in a 3-month-old.
Chan: If we have ruled out non-accidental trauma, other causes could be a number of things. You would always look at the blood count to make sure there is no thrombocytopenia, or something to that effect. One thing I worry about in a 3-month-old would be incontinentia pigmenti, which is often asymmetric or unilateral. In terms of just ruling things out, I utilize imaging very frequently, so I would have a low threshold for obtaining fluorescein angiography, fundus photographs or optical coherence tomography in these children. These tests give me a lot of information to determine whether there is a lot of peripheral ischemia or some other pathology that is not so apparent on indirect ophthalmoscopy. In non-accidental trauma, there can be significant peripheral ischemia. Also, it would be unusual to have retinal hemorrhages from birth trauma still present at 3 months.
Wagner: At one of the NICUs where I cover, they do a lot of cooling therapy, and that has been associated with retinal hemorrhages. I have seen a few that had a little more extensive hemorrhaging than you would expect just from birth trauma. They do disappear too, usually uneventfully, but it is something that has been reported and I have seen it.
Warman: We have the same protocol for the cooling patients, and I have not seen one. How many do you think you have seen, and what is your denominator?
Wagner: Over the course of the year, maybe I have seen it in 2 out of 10. I had one the other day, and the hemorrhaging was pretty extensive.
Warman: I think that right now you just happen to have two. I have had to do this already for about 2 or 3 years, and I have not seen one hemorrhage.
Wagner: The other thing that comes up is the event that caused them to need the cooling therapy, whether that was some sort of anoxic event or something that might be in itself associated with hemorrhaging, too.
Chan: To have retinal hemorrhages at 3 months of age is unusual, so I think that you have to investigate, or at least think about other things that could cause that. Infection can also be an issue, but you also have to look at whether or not there are any inflammatory changes or uveitis. Is it unilateral or bilateral? These are all the things you need to consider, but to have persistent diffuse retinal hemorrhages at 3 months of age is not so common.
Johnson: In the normal 3-month-old with a normal birth history, if we see retinal hemorrhages in our office, that is a huge red flag. If the child is already in the hospital, there is a reason. As burdensome as it is, it is really important to document exactly what you see. How far out do the retinal hemorrhages go? How many retinal hemorrhages are there? Can you count them? What layers of the retina are involved? Those things always come up in court, and the only defense strategy is to discredit your testimony and to discredit your documentation. We have to be very specific in what we document.
Another thing: There is a difference between legal controversy and medical controversy. It sounds silly to everyone around this table, but if we said that I have a subconjunctival hemorrhage and I also have a hangnail on my big toe, how do you know that those two are not related? So without doing this prospective study, you cannot prove that those are not related, but we know as scientists that there is no correlation. In the courtroom, if that question is raised, then it becomes a reason for at least some sort of an empirical study to prove that those relationships do not exist. That is why we have all the studies on seizures and whether they are associated with retinal hemorrhages, on CPR and whether that is associated with retinal hemorrhages, and on documented cases of accidental severe head trauma and whether those are associated with retinal hemorrhages. All of those studies document that you do not see the kind of retinal hemorrhages in those patients that you do in children with inflicted head trauma.
Chan: That is one reason I have a very low threshold for doing photodocumentation. I am following a patient now whom I first saw as an outpatient after the hemorrhages had started to resolve, but the child was first seen in the hospital and non-accidental trauma was suspected. When you compare the two images, the hemorrhages look much better now, and to have the digital image there from the previous exam is very useful.