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Dynamic landscape of pediatrics/strabismus niche demonstrated in changing practice habits
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At the annual American Association for Pediatric Ophthalmology and Strabismus meeting in New Orleans, OSN Pediatrics/Strabismus Section Editor Robert S. Gold, MD, led OSN board members in a discussion of what they are doing more of or differently now than in the past within their own practices. Whether more often offering surgical solutions for small angles of strabismus or stable diplopia in older adults, or enhancing the patient experience using EHR software, the round table participants are taking their practices in new directions.
New directions
Robert S. Gold, MD: What are you doing differently in your practice?
Scott E. Olitsky, MD: One thing I am doing more of, maybe not differently, but definitely more of, is to talk to patients about these small, partial tenotomies for small angles of strabismus.
These patients are adults who want to be spectacle-independent, where the spectacle is their prism. Maybe they are contact lens wearers. Maybe they have had LASIK in the past. Before I used to tell those patients, “There’s not much I can do for you,” but now I feel pretty comfortable offering them an option to get them out of those small amounts of prism if they want.
Roundtable Participants
-
Moderator
- Robert S. Gold
- Kenneth P. Cheng
- Anthony P. Johnson
- Scott E. Olitsky
- Roberto Warman
- M. Edward Wilson
Anthony P. Johnson, MD: I see a lot of preschool kids who fail the preschool screenings. In the past, as long as their refractive error was symmetrical, I tended to dismiss even some pretty high astigmatic errors. But in my practice, we are seeing a larger and larger Hispanic population that seems to have an incredibly consistent large amount of symmetrical cylinder, maybe 20/40 or 20/50. I am now quicker to put them in spectacle correction and not to just assume, “Well, this is probably good enough. They are early in their childhood.”
Kenneth P. Cheng, MD: I learned here last year from Roberto and Tony that progressive bifocals work for kids with high accommodative convergence/accommodation ratio, accommodative esotropia. I have tried it, and, sure enough, those patients tilt their chin up and they find the right spot on the bifocal. I certainly do not use it for all patients, but I throw it out there as an alternative to patients and those families who want to get rid of the [bifocal] line. I am quite anxious and hopeful to think that I am going to get some additional fusion out of those patients, although I do not know that for sure yet. But I am hopeful in that regard.
M. Edward Wilson, MD: One thing that comes to mind is that with elderly adults, and we are seeing more and more with stable diplopia, I am approaching them more with a surgical discussion first, and that is different for me. It used to be prisms. If prisms worked, I would suggest sticking with prisms and only operate when prisms did not work. But now, I think patients demand more, and I think we are getting a little more confident that even with small angle adult strabismus with diplopia or larger angle, we can move to surgery more quickly and maybe make it a primary discussion, reserving the prism only for those patients who are not good surgical candidates. That is the reverse of how I used to be.
Roberto Warman, MD: For a couple of years, I have been moving to doing more one-muscle surgeries than I used to, instead of splitting it in two, and I am becoming a little more cavalier, sometimes up to 20 D. For intermittent exotropia, I do one lateral [muscle] depending on the patient’s age. Before I did not, and it is working. I think we need to look at that more.
Gold: I will take this in a little different direction. What I have been doing over the last couple of years is trying to maximize part of my EHR system Many of us who have electronic medical records hate them, do not like to use them, curse them every day. But I try to use my electronic medical records as an adjunct to my treatment. I have the large computer screens in each room, and I try to visually show the families what we are talking about — whether it is the tear duct anatomy, whether it is the chalazions, whether it is strabismus surgery — to show them more graphically and visually what we are doing for their children, or for them.
Our EHR system has educational modules, and I pick and choose the ones that I like. For example, when you have a pseudostrabismus patient and the parents are absolutely convinced otherwise, you can show three or four pictures of exactly what it looks like, and they say, “Oh, yeah, that does look like my child.” So you show them in pictures rather than just describing it to them. Pictures say 1,000 words to most people. So that is what I have done a little bit more of and spending a little bit more time doing it.
Nasolacrimal duct probing
Warman: I just thought about one more thing I have done differently lately. I am a very strong proponent of nasolacrimal duct probing in the office. I have done it forever. But what I have found is, by necessity and for multiple reasons, I have pushed the envelope more and more to doing nasolacrimal duct probing in older kids, even if it is not my ideal. I have found myself probing in the office patients who are 18 months old and up to 20 and 22 months old more than before. And it is working very well. You have to be good at it, but I have been doing much more of that. Among other things, it is a big cost saving in the operating room and time saving for the physician.
Cheng: With families facing large deductibles and co-pays, the difference between $2,000 or $3,000 out of pocket vs. the office charge is huge to families. I think that opens up significant new considerations.
Warman: And the data are slowly creeping up. The less we have to do anesthesia in small kids, the better it is. So the combination of these two considerations, I think, is going to move us more and more to doing things like this.
Wilson: I do office probings, and I do them on the first visit so that we can get the problem solved, but only up to about 14 months. When they get really big, I usually suggest that we need to go to the operating room.
Gold: In a private office that does not have a life support system, you have to be very careful. But in a hospital situation like you have, I would say it might be acceptable. But you must be very careful and very prepared.
Wilson: You have to be really good at it. You have to be able to do a probing fast. If you cannot do a probing and irrigation in 30 seconds, then you need to go to the operating room.
- For more information:
- Kenneth P. Cheng, MD, can be reached at 100 Bradford Road, Suite 320, Wexford, PA 15090; email: kpchengmd@me.com.
- Robert S. Gold, MD, can be reached at 790 Concourse Parkway South, Suite 200, Maitland, FL 32751; email: rsgeye@gmail.com.
- Anthony P. Johnson, MD, can be reached at Jervey Eye Group, 601 Halton Road, Greenville, SC 29607; email: apj@jervey.com.
- Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108; email: seolitsky@cmh.edu.
- Roberto Warman, MD, can be reached at Miami Children’s Hospital, 3200 SW 60th Court, Suite 103, Miami, FL 33155; email: rwarman@eyes4kids.com.
- M. Edward Wilson, MD, can be reached at Albert Florens Storm Eye Institute, 167 Ashley Ave., Charleston, SC 29425; email: wilsonme@musc.edu.
Disclosures: The round table participants report no relevant financial disclosures.