This article is more than 5 years old. Information may no longer be current.
Round table: Pediatric ophthalmologists debate merits of patching for intermittent exotropia
Click Here to Manage Email Alerts
This issue of Ocular Surgery News features the varied opinions of OSN Pediatrics/Strabismus board members convened in a round table format at the American Association for Pediatric Ophthalmology and Strabismus annual meeting. Led by Section Editor Robert S. Gold, MD, the participants agreed — and did not — on patient selection, patching protocols and timing of surgical correction for intermittent exotropia. As well, the panel opined their institution protocols for preventing epidemic keratoconjunctivitis infection in the neonatal intensive care unit, particularly for physicians conducting retinopathy of prematurity screening.
Surgery vs. patching for intermittent exotropia is a timely topic that will elicit a variety of opinions, according to Robert S. Gold, MD, OSN Pediatrics/Strabismus Section Editor.
Image: SLACK Incorporated
Patching intermittent exotropia
Robert S. Gold, MD: This topic is timely: Patching for intermittent exotropia. This is a topic that comes up day after day, week after week, month after month, year after year. Do you think patching is beneficial?
Kenneth P. Cheng, MD: I am a patcher. I think it is worth trying in patients, especially in patients who are younger than 5 years of age, because avoiding surgery in those patients and not potentially turning them into monofixators is a big plus. Because the range of opinion on patching is so varied, we do need to answer the question of whether there is benefit to patching for intermittent exotropia.
Brian G. Mohney, MD, and colleagues on behalf of the Pediatric Eye Disease Investigator Group (PEDIG) presented a study at the AAPOS annual meeting in which only a small effect of part-time patching on intermittent exotropia was seen at 6 months in children aged 3 to 10 years old. I do not think that the study, as presented, fully answered the question, though, because there was a washout period after 5 months when patching was stopped. In my anecdotal experience in patients with patching, some of the patients get better while patching, and when they stop patching, the deviation returns and the parents start patching again. In the PEDIG study, in the month that was the washout period and before assessment of deviation control was made, the investigators potentially lost a lot of the patients who would have shown some improvement had they been patching up to the time of the visit.
M. Edward Wilson, MD: I do not recall very many patients whose patching allowed me to avoid surgery long term, but it is a recognized, nonsurgical treatment, and when you are worried that surgery is needed but the parents are not ready for it, then patching is something you can do to temporize. It often keeps the deviation from becoming more constant, although it does not improve the child enough to not have surgery, in my view. So, I use it to temporize until I can obtain more measurements and assess the surgical need. I look at it like this: Patching will not make you worse while we decide if this is a problem worthy of fixing surgically.
Roberto Warman, MD: I agree with that. I think the real question is, when is the time for surgery? When is the decompensation big enough? And, what happens in the very young kids whose deviation varies, getting better for months and then getting worse? The PEDIG study evaluated for only 6 months; how many were very young vs. 6-year-olds? There is a big difference after age 4 or so. We need to separate those groups. I agree that what we are doing with the patching helps the parents hold off because we do not want to do surgery so early when the exotropia is so variable, so intermittent, unless time of constant deviation is significant.
Roundtable Participants
-
Moderator
- Robert S. Gold
- Kenneth P. Cheng
- Anthony P. Johnson
- Erin D. Stahl
- Rudolph S. Wagner
- Roberto Warman
- M. Edward Wilson
Rudolph S. Wagner, MD: There are people who do alternate patching on all these kids, and some just patch the dominant eye.
Warman: I follow a lot of these patients by email, and we modify the regimen by email. We begin patching the dominant eye, but when the family reports to me a couple of months later by email, I may switch to alternate patching or back to dominant eye patching or to other eye patching — whatever it takes to keep them from having to make frequent visits to the office.
Erin D. Stahl, MD: I have only ever alternately patched one patient with intermittent exotropia. Either I watched them or operated on them.
Anthony P. Johnson, MD: I do a lot of alternate patching, and I find that this is one of the most motivated patient and parent populations. Once patching is stopped and the child does worse, then the family is reminded, on their own, to resume patching.
I also wonder if there is a provider bias because this is not an entity that is just going to go away. So one of the markers for success is never going to be that it just disappears. And so it is easy to say, “I’m going to save my energy and do something that is better accepted and more universal.”
Wilson: There is definitely provider bias. Some providers just do not feel comfortable talking about surgery on the first encounter. They want multiple visits. They want multiple measurements. They want to kind of ease the parents into it, and patching is one of the things that they recommend initially in almost all of them. I am a little more aggressive surgically. When I see a child with intermittent exotropia, especially those older than 4 or 5 years of age who can be measured well and whose short duration of overcorrection after surgery is less worrisome, I ask myself, “Is this something they can live with their entire life, or is it going to be operated on sooner or later?” If I think that the drifting occurs often enough that it is going to be operated on sooner or later, then I am an early surgery advocate. The ones who are most stable 10 or 20 years later are the ones who, when frequency of drift increased, we operated on them before they spent a substantial proportion of the day suppressing. So if you operate early, when they are still motivated to pull the eyes back in and they are not yet accepting out-turn for minutes or hours at a time, they are more stable over the long term. If you wait, there tends to be more recidivism. If you look at the patients 5 to 10 years later, many of them are coming back for more surgery.
So if they need surgery, I think they need it as soon as they begin to deteriorate. If they do not need surgery, then they probably do not need patching either. They just need watching because if they are not deteriorating, it is not really a problem, if the drift only occurs occasionally, when they get tired.
Wagner: The hard part is determining who is going to need surgery. Another difficulty is parental acceptance of the need for surgery. Acceptance is more difficult to obtain for intermittent exotropia than it is for, say, constant esotropia or something the parents see every day, because with intermittent exotropia, some days the child does look better. The parents are often hopeful that whatever the treatment is, it is going to somehow avoid surgery, even though we know that in many cases, surgery is inevitable.
Cheng: Some patients with well-controlled intermittent exotropia show improvement, and the deviation becomes less frequent as they get older. Whether patching helped those patients or whether they would have gotten better on their own is another question. Many of those patients probably would have gotten better on their own without anything. But I agree with what was said earlier: In patients with very poorly controlled intermittent exotropia, patching is not very likely to work and it probably is not worth trying. If a child has a deviation that is very frequent, 50% to 60% of the time when they first present, I do not think patching is going to do much for that patient, although I might try it for a little while just to avoid saying, “Your child needs surgery,” the first time I have met the parents. But in those patients who have reasonably well-controlled deviations, I think there is a role for it. It does not improve everybody, but I think there is a role for it.
One other comment: As long as the patient continues to control things well, I am not sure that it makes a difference whether we operate early or late. If there is a downside to delaying surgery on these well-controlled patients, it likely is not much and it is probably outweighed by the risk of overcorrection.
Neurologic impairment
Johnson: My difficulty is not so much with the neurologically normal child and the developmentally normal child. I struggle with the one that, for whatever reason, is reasonably well-functioning but has a number of other surgeries and a number of other issues that are at the forefront for the family. For those children, I probably err on the side of not doing surgery when, really, it only makes sense to do surgery. I definitely have a bias, and I do not know why I have that bias, but if the mom is not pushing for surgery, I tend to just postpone.
Warman: I tend to agree with you. I sometimes combine surgeries with other specialists and take advantage of the anesthesia, but otherwise, the possibility of recurrence is relatively high anyway.
Cheng: This is pure anecdote, but I have seen a number of patients with cortical visual impairment (CVI) with large-angle exotropia, and I have operated on some of those patients because the families have really wanted the surgery. Some of those patients show improvement in their CVI after the surgery. There is no way to know, but I wonder whether some of those patients with CVI issues do not have the automatic suppression that we assume most exotropes have and whether some of those patients have some visual confusion added on top of their CVI issue by their strabismus. In my experience, more than a handful of those patients have shown improvement in their CVI and visual behavior after strabismus surgery, and that was for both constant exotropes and constant esotropes.
Timing of surgery
Wilson: For the developmentally normal child who has good fusion, the Olmsted County natural history data seem to indicate that only about 4% of these kids are going to get better on their own, and we now have some data that perhaps part-time patching gives some temporary hold on it but probably does not prevent deterioration. The Olmsted County data showed that the majority deteriorated over time. For me, if the deviation is present at least once a day and the parent says that it is now happening more frequently, that alone is a trigger for me. If the child still sees double with the drift, even better. I can get them straight before they develop suppression. If you wait to operate until there is constant deviation — 50% or more of the day — I think you would find that those patients might be straight for 5 or 6 years but that exotropia would eventually return in the vast majority. So maybe the opportunity for a complete cure is at a time when most of us feel a little bit uncomfortable suggesting surgery.
Gold: This segues into the next question, which is timing of surgery.
Cheng: We are fairly divergent on this. I fully recognize that we are not good enough about measuring distance stereopsis when we look at these patients, so our gauge of how well the patient is really doing may not be very accurate. Traditionally, most of us feel that when the deviation is more than 30% or 40% of the day, we strongly think about surgery. For many of these patients whose deviation is intermittent like that, I try patching first to see if improvement is sustainable, but I am not at all uncomfortable with a patient whose eye deviates occasionally. Even if the parents see it four or five times a day, that four or five times a day is typically when the child is tired, sleepy, sick or ready to fall asleep after school. Just asking how many times a day the eye is seen to deviate may not be really representative of the bulk of their day, which is what may be more important.
Warman: I find that seeing how fast they re-fuse once you break them with the cover-uncover test is a very good determinant because I make a note of that for the following visit. As long as they re-fuse within the blink time, you know the brain is on your side and you can wait a little longer. If you see progressive worsening, then there is no point in waiting. I agree with that. If they are suppressing on exam by not re-fusing, that usually correlates with 30% to 40% of the day and worsening; that makes me move toward surgery.
Cheng: I would agree with that. I would add, though, that there are some children who are much better in the office than at home because in the office they are paying attention, but at home, they are just in their normal state of half looking at things and half daydreaming. Conversely, some children are worse in the office because they are scared to death and do not want any part of you.
Wilson: One more comment: Progression of how long they take to recover worries me more than progression in the number of times per day they drift, but I call both of those progression.
Preventing EKC
Gold: The Centers for Disease Control and Prevention reported recently on an outbreak of epidemic keratoconjunctivitis (EKC) in an Illinois neonatal intensive care unit where the affected infants were all screened for retinopathy of prematurity. For those of us who do ROP screening, I would like to talk about program goals in this setting with regard to preventing spread of infection.
Every infant who we see in our NICUs, and there are two very large NICUs in Orlando, we use foam disinfectant on our hands between each and every patient. We glove for every patient. And we have separate, sterilized instruments for every single patient we see. A new, different set is used — speculum and scleral depressor — on every patient. That is an expense, but it is an expense that is utilized every single time we see these children. If we see 25 infants in a week in one hospital, and sometimes that does happen, we have 25 sets ready to go. We have not seen an issue in our NICUs, basically because of that. When infants have contagious infections, such as with methicillin-resistant Staphylococcus aureus, or other respiratory issues, we are instructed to gown as well as glove. We take all those precautions.
Wagner: It is interesting that the outbreak was EKC — adenoviral conjunctivitis — because classically pediatric conjunctivitis, especially in infants, is more likely to be bacterial. In NICUs, frequently the infant is put on a topical antibiotic for conjunctivitis before culture results are available.
As far as precautions go, basically do what Dr. Gold said. Individually prepare and sterilize instruments for each child. Use individual bottles of drops for each child, disposing of them after they have been used for that one patient.
This is an interesting case because the virus spread throughout the NICU to the nurses and ophthalmologists. It is just another example of having to be careful and staying on top of the protocol.
Stahl: For our NICU ROP exams, we additionally sanitize the 28 D lens and all the handles. It is one more thing that you are touching from one infant to the next, so you have to go back to the lens and wipe the lens before moving on to the next patient.
Gold: Impressive. We also try to examine infants who are in isolation at the end of the exam time.
Warman: Is anybody using the disposable set in their NICU?
Gold: We have them available in case we run out of the already sterilized sets, but we have not had to use them. We do not sterilize the lenses between patients, except when we are seeing MRSA infants, and then we use CaviCide wipes (Metrex).
Wagner: We have the disposable sets available, too. We did look into the cost and the efficacy, and it seemed that it is less expensive to purchase the sets and sterilize them individually than it is to buy the disposable sets.
Gold: The key is to have enough sterilized sets on hand. If you average seeing 15 infants a week, you should have 18 or 20 available, just so you have enough, especially if you lose or drop one on the floor accidentally and cannot use it.
References:
For more information:
What steps do you take to prevent spread of infection during an ROP exam?
Hand hygiene is critical
R.V. Paul Chan
We have a very busy ROP service, and there are a number of important considerations in preventing the spread of infection during the ROP examination in the neonatal intensive care unit (NICU) and the outpatient setting. Hand hygiene is critical. In our NICU, we use Purell hand sanitizer (Gojo Industries) before and after every patient encounter. If an infant is on contact precautions (eg, they are identified as being MRSA positive), we will plan these exams at the end of our rounds, and we are required to use a gown and to glove prior to any patient contact for these patients. However, although other NICUs require gloves for each patient exam, our NICU does not specifically require the use of gloves for the examination if the patient is not on contact precautions. The hospital has purchased speculums and scleral depressors that are sterilized and individually packaged for each patient encounter. We think that this has made a significant impact in preventing the spread of infection during ROP exams. It is also very important to properly clean any instrument that will be used again on a different patient. For example, when using the RetCam (Clarity Medical Systems), we clean the lens thoroughly before and after each infant is imaged. Each NICU will have its own criteria and guidelines for preventing the spread of infection, and having a practical and systematic way of infection control is beneficial for the patient, NICU staff and physician.
R.V. Paul Chan, MD, FACS, is an OSN Pediatrics/Strabismus Board Member. Disclosure: Chan has no relevant financial disclosures.
EKC spares no age group
Rudolph S. Wagner
It is important to understand that EKC is easily spread in outpatient clinics and medical practices. The examination of an infected child in a pediatrician’s office or even in their presence in a waiting room can initiate an epidemic. The virus is spread by hand-to-eye contact and can be acquired from environmental surfaces on which it may survive for days if not properly disinfected. One needs only to picture a typical pediatric waiting area to understand how easily adenovirus can be spread. Children with conjunctivitis should be isolated from others and examined in a separate room that is disinfected after each patient visit. Staff hand hygiene is critical in preventing the spread of the infection. Instructing the child’s caregivers in home isolation, disinfection and frequent hand washing may prevent community spread.
As an ophthalmologist who screens for ROP, the report by the CDC last year of a NICU outbreak is disturbing. It illustrates that EKC infection spares no age group and that preventive measure must be strictly adhered to. Disposable, one-time-use lid speculums and sclera depressors or sterilized instruments used on one infant only and sent for sterilization and packaging for a future use are advisable. Drops used to dilate the infants eyes should be individualized for each child, never come in contact with the eye or eyelids, and be disposed of after use in that one infant. Of course, hand washing or disinfection before and after each examination and the use of gloves by the examining ophthalmologist and nurses assisting in the examination are critical.
Perhaps most important, but a difficult policy to institute, health care professionals with signs and symptoms of conjunctivitis must avoid contact with patients and staff. This is not easy to do for busy practitioners with many patients depending on them.
References:
Rudolph S. Wagner, MD, is an OSN Pediatrics/Strabismus Board Member. Disclosure: Wagner has no relevant financial disclosures.