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Round table: Aggressive lid management needed to prevent vision-threatening anterior segment disease in children
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In this issue of Ocular Surgery News, members of the OSN Pediatrics/Strabismus board offer their personal protocols and their anecdotes, addressing medical management, surgical management and family dynamics they see in practice every day. Convened at the American Association for Pediatric Ophthalmology and Strabismus meeting in Vancouver and led by Section Editor Robert S. Gold, MD, the round table participants discuss how to manage blepharitis, chalazia and meibomianitis in children to prevent more sinister anterior segment disease processes, and they discuss their surgical approach to esotropia. For cases of sudden functional vision loss in children, the participants give their frank insights into how to deal with delicate family matters.
Rigorous lid hygiene
Robert S. Gold, MD: In our offices in Florida, we see a tremendous number of patients with anterior disease processes — blepharitis, chalazia, meibomianitis. I want to talk about what treatment you use and when you do surgery.
Erin D. Stahl, MD: This is a big part of my practice. I only see patients who have significant corneal involvement with their blepharitis so I am very aggressive about treatment. I talk to my pediatric optometrists about how I want them to deal with lids so that those patients do not end up having to see me. The biggest thing it comes down to is keeping the eyelids clean. No parent wants to do it. No child wants to do it. It is a big challenge, but you can avoid long-term use of antibiotics and steroids in most cases by religiously and vigorously cleaning the eyelids.
Image: Stahl ED
I am also a big advocate of supplementing with omega-3s — good-quality omega-3s that contain EPA.
M. Edward Wilson, MD: Do you use doxycycline frequently in older children?
Stahl: I will use erythromycin or azithromycin in younger patients and I use doxycycline in older children, but my underlying goal in all these patients is to avoid as much antibiotic and steroid as possible. I try the non-pharmacologic treatments first and keep those going long term to avoid antibiotics and steroids.
Gold: The dosage of omega-3s is much higher than even adult doses of omega-3s. How well is that tolerated in children, and how compliant are people in giving those “gummy bears,” or whatever it might be, in that situation?
Image: SLACK Incorporated
Stahl: I do not like the gummy bears. One of the most common versions has 32 mg of omega-3 per gummy, so you have to eat a lot of those. There are some liquid supplements that are fairly palatable to children and have good-quality omega-3s. The problem is, it is not a big deal to buy one bottle at $20, but to continue to do that for years on end, it gets really expensive.
Rudolph S. Wagner, MD: Maybe that will encourage patients to manage their children’s eyelids and eyelashes with warm compresses, which is what you really want them to do. The problem cases are the ones that Erin described. Children come in with corneal involvement, and they are very difficult to manage. You have to put them on steroids at some point, and it is a problem. I do see some children who are a little bit older and who I think probably have a combination of rosacea, chronic chalazia and peripheral corneal disease.
I agree that lid management is the most important thing, but it is very difficult to get people to do. It is difficult, but it works.
Gold: I agree with aggressive treatment. In our typical patient, a pediatrician has been treating the child for weeks and weeks and weeks for conjunctivitis, and the patient comes to us with Staphylococcus hypersensitivity and corneal phlyctenular disease, and it is truly a mess to treat.
Scott E. Olitsky, MD: The other thing we struggle with is that some parents see a chalazion as being the end result that is pretty simple to treat. They say, “If I don’t do this, then this bump forms and we can take care of that.” But I really do not like taking those children to an operating room. There is some miscommunication or misunderstanding, perhaps, about what we can do to prevent that chalazion from happening and why we do not want to do that surgical procedure if we do not need to.
Heat and healthy diet
Kenneth P. Cheng, MD: When the child has a chalazion, especially when the lids are thickened and you can see the meibomitis, the biggest thing to tell parents is to instruct them to vigorously apply heat and warm compresses as soon as they see anything. Just as Erin said, they should also keep up with that constant regimen of lid hygiene and cleaning, but the heat is really important for those children.
And to touch on one other thing that Erin talked about with the supplements: It is a really complicated subject because the control of supplements and how they are made is very loose. You do not know how they are made or what is in them, especially with omega-3s and fish oil. It depends on whether the fish are wild caught, if it is a big fish vs. a little fish, exposure to mercury and everything else, so it gets really complicated. I tell parents to use supplements as a last resort and to try to go with a normal, healthy, varied diet containing a lot of green, leafy vegetables. Going along those routes seems best.
Anecdotally, I did have a parent of a Down syndrome patient, who as a group are susceptible to blepharitis and this problem, and she related to me that whenever she saw her child having a problem she would increase vitamin A-containing foods. She would give him pumpkin pie, and that seemed to quiet things down. This probably happened 15 years ago. I started telling some parents of Down syndrome patients that story, and it seems to make a difference for a lot of those patients. That is purely anecdotal, but it has worked for me on more than a few occasions.
Chronic blinking
Wilson: Related to this topic, I see children who come in with these nonspecific complaints of blinking all the time that perhaps has been diagnosed as an anxiety reaction or a tic. In these cases, especially in children who are reluctant to get into the slit lamp, I think that lid margin disease is underdiagnosed, especially the meibomian gland dysfunction. Oil mounds on the lid margin, tear breakup time is fast, and they are blinking because they do not have a good oil coat over the tears. I find that many times in a child who is a little bit harder to examine, we are just missing it. I look for that now, especially in children with chronic blinking; it is not necessarily just a behavioral problem, often it is a treatable lid margin disease.
Stahl: A little bit of artificial tears and lid hygiene does not hurt anyone.
Gold: That is very common in our office — the blinking. When I am doing my exam, I try to find a) if they cannot see, b) if their eyes are crossing and drifting because that is sometimes a cause, c) if they have some type of allergy, lid disease or anterior segment problem, or d) I don’t know what it is. And then you have to look further. If I cannot find anything, I will often put patients on a regimen of cold compresses and warm compresses and artificial tears over a couple of weeks, and I ask them to call me if these symptoms continue because then I might like the pediatrician to look into it, if it is a tic, if it is something neurologic or anxiety-prone. I rarely get a call after those 2 to 3 weeks, so something is working. Or maybe they just do not call me.
Wilson: It seems to me that with the oil that is thick and mounds up, these young patients go through stages as they age, which may be hormonally driven, where this is a big problem that needs attention and then it goes away. I have not seen a study on that, but it has certainly been true in my practice.
Cheng: I do think that transient tic is a for-real phenomenon that does affect a large percentage of these patients, but for those children with blinking and rapid tear breakup time, if the lids do not look horrible, I do talk to parents about flaxseed oil and fish oil caps.
Wagner: About surgery for chalazia, as much as we try to avoid it, sometimes it is necessary. I avoid using local anesthesia for surgery on all children and some teenagers. Besides not getting the cooperation, when you infiltrate with the anesthesia, it distorts the anatomy of the eyelid surrounding the chalazion. With general anesthesia, I think it is easier to localize the chalazion and to get the entire contents out of the capsule if you want to dissect it out. Then you can also see what the lids look like, and you might even find that there are other smaller chalazia that could be opened at that time. That is not so easy to do with local anesthesia.
Stahl: When I take these patients to the operating room, I always squeeze all four lids. I warn them that they are going to come out looking puffy on both sides because I take two Q-tips and I squeeze every one of their meibomian glands. I tell them, “This is a reset. Now you have to keep them clean. You have to do warm compresses, lid hygiene, omega-3s, all that stuff. But I have started you out clean.” They would never tolerate that procedure in the clinic.
Surgery for infantile esotropia
Gold: What is your approach for infantile esotropia? In particular, depending on the angle, would you do two-, three- or four-muscle surgery?
Cheng: I like to do two-muscle surgery much more than three-muscle surgery. When you start doing the third muscle, you start getting a little less predictable. I will go up to 40 ∆D with two muscles, and if the angle is really more than 40 ∆D, then you think about doing more muscles.
Now, the infantile esotropia patients are different, and they can have huge angles, and they do fine in my hands with bimedial rectus recession.
Wilson: In the infantile esotropia group in our practice (we studied this years ago and published it), we did not have a higher reoperation rate with two-muscle surgery in the above 50 ∆D group compared to the below 50 ∆D group. So, I still like to do two-muscle surgery, and then if necessary add to it. We know that consecutive exotropia a decade later is very common, so I do not want to overoperate those children when they are very young.
Wagner: I agree. I try to use two-muscle surgery in all of these cases, since the longer you follow the three-muscle cases, there is a significant incidence of overcorrection. What you get initially might be OK, but as you watch these children down the line, you will often see consecutive exotropia develop. Because of that I am not so disappointed if I have a little undercorrection initially in a lot of these cases. I would rather have that than any overcorrection, so I prefer to use the two muscles.
Olitsky: I feel exactly the same way. For the patients I see, two-muscle surgery works well. In some parts of the world there are reports of enormous angles, but we do not see those very often. And people who talk about that longer-term exotropia might say, “Well, maybe it’s because you did too much on the medials,” but I just do not think we have any data to support that. I have been very happy with two-muscle surgery and have not changed my practice.
Gold: What about acquired or decompensated esotropia? How do you change your regimen?
Wilson: In infantile esotropia, the most significant factor in the dose-response relationship between the number of millimeters of surgery in strabismus is the angle that you start with, so strabismus surgery dosing is a little bit self-adjusting. You get more when you have more, so for the larger angles you get more correction per millimeter of surgery, and that works in our favor.
In the decompensated accommodative esotropia group, the dose-response curve is different from the infantile esotropia group. Most of our nomograms that are published in textbooks are based more on the infantile esotropia type of patient. A truly decompensated accommodative esotropia patient, meaning one that was straight in glasses initially and then subsequently developed a non-accommodative component, is the patient you need to do higher-dose surgery on. I think most of us would fudge up on the numbers, or we would do a prism adaptation test to reduce the incidence of undercorrection.
Cheng: The patients who I can think of who would do better with three-muscle surgery are the adult patients who come in with large-angle esotropia present for a long time. For those patients who are 40 ∆D or more, if I do two-muscle surgery on them, an adduction deficit may result. Those patients do better, I believe, with three-muscle surgery.
Functional vision loss
Gold: Let’s talk about functional vision loss in children. In my practice, there are days when a child comes in and says he cannot see, but lo and behold, when you put him in front of the phoropter with the plano in the phoropter, his vision is miraculously 20/20. How do you handle that discussion with the parents?
Olitsky: I think it would be interesting to know how a group of other medically trained professionals such as a psychologist or psychiatrist would handle this because I do not know if I do it the right way. I tend to talk to the parent alone, and we are very nonjudgmental. I explain what my findings are. I tell the parent that we are going to have a plan. Usually the “treatment” involves removing the child’s cell phone for a while until his vision is better. I tell the parents to call me if that is not the case in a couple of days. I have never gotten a phone call, so I suspect that it helps.
Wagner: I think the same, although I have a little different approach. You do need to talk to the parents. There is almost always some issue, some secondary thing that is going on that is not a deep-seated psychological problem — maybe simply the child wanting their parents to be with them. But generally, I tell the caretakers that once that issue is improved and they are satisfied that there is not a real problem, the child should see well. After talking to the caretakers, I say to the child, “You have these drops in your eyes. You see how blurry you are now? You are really blurry.” And I will normally show them something up close and they will say, “Certainly, I am.” And I say, “When these drops wear off you are going to see better than you’ve seen in a long time, and I’m hoping that you don’t need glasses for this, and we’ll see.” And then I will tell the parents, many times, if they want to bring the child back within a short period of time, a few weeks or so, they can. Very rarely do they come back. Most of the time the problem is solved.
Wilson: We can spend time trying to figure out whether the child is doing it on purpose or not, whether it is a volitional thing or a hysterical thing, but I do not think it matters. Treatment is the same. I tell the child and the parent, “This appears to be a response to stress and worry. Some children respond to stress and worry by getting an upset stomach, and some get vision loss. We need to sort this out; we need to look at the causes of stress and worry.” And that gives them a task. Their assignment is to figure out what stress and worry may have contributed to this.
Cheng: I would add that it is really important to let the parent know that they should be talking to the child to make sure that there isn’t something else going on at home or at school, maybe being bullied. That is an important thing from a safety standpoint.
And the only thing I would add to Rudy’s discussion is that I do exactly the same thing. I explain that, “When these drops wear off your vision should be a lot better. But if it gets worse again we can start using these drops at home for a little while,” and that pretty much stops it.
Gold: I also speak to the parents alone. I have my technician take the child to the autorefractor, which is outside of the room, and re-do the autorefraction during the period of discussion. I ask whether the child’s best friend just got glasses, or if there is something going on with a teacher at school, or if there is something going on in the home. I am very frank asking those questions, because when I put my finger through the phoropter and show them there is nothing, no power, no lens in there, I want them to realize that something else is going on.
Olitsky: I also find a large number of parents who behave exactly the opposite. You are the third or fourth person they have seen. They just need somebody to tell them, “It’s OK to stop here.” It is important to say, “There may be something else going on. If this continues, maybe speak to your pediatrician.” But they really need to hear somebody say, “We’re done.”
- 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.
- 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.
- Erin D. Stahl, MD, can be reached at Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108; email: edstahl@cmh.edu.
- Rudolph S. Wagner, MD, can be reached at Doctors Office Center, Suite 6100, P.O. Box 1709, Newark, NJ 07101; email: wagdoc@comcast.net.
- M. Edward Wilson, MD, can be reached at Albert Florens Storm Eye Institute, 167 Ashley Ave., Charleston, SC 29425; email: wilsonme@musc.edu.
Disclosures: Stahl reports a financial interest in Treehouse Health. The other round table participants report no relevant financial disclosures.
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