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Round table: How to handle pediatric glaucoma suspect referrals
Part 1 in this series focuses on knowing when to treat, timing of follow-up, and measuring IOP and visual fields.
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Pediatric ophthalmologists often receive referrals, whether from optometrists or other ophthalmologists, for children with large cups, asymmetric cups and IOPs that may or may not be accurate.
At a round table event convened at the American Association for Pediatric Ophthalmology and Strabismus meeting in Nashville, Tennessee, what to do with glaucoma suspect referrals was the first topic tackled by members of the OSN Pediatrics/Strabismus editorial board in this initial installment of the round table series.
Robert S. Gold, MD: The first topic has to do with pediatric glaucoma suspects. We all get referrals. What is your evaluation, workup, follow-up, even the threshold for treatment in this situation?
Erin D. Stahl, MD: We have established a glaucoma suspect clinic within our practice, so both internal and external referrals go to that clinic. We take the patients through a standardized workup, including corneal thickness, OCT, visual field (if they are old enough), optic nerve photos, clinical exam, and Icare and Goldmann pressure testing. We then go through the data and put the patient into a risk profile: low, medium or high risk for developing glaucoma. Then we watch them at an interval that is determined by their risk.
Roundtable Participants
-
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
Rudolph S. Wagner, MD: Ideally, if you are in a practice where you have OCT available, that is great, but not all offices of pediatric ophthalmology have OCT available. Sometimes patients come in, their pressure is normal, the cup looks a little bit large but they look healthy, and then you have to differentiate who is a true glaucoma suspect, regardless of the referral, based on your own initial examination. That is the hard part. If I suspect glaucoma, then I try to get an OCT and a visual field if the child is old enough. If they are not old enough, then OCT is useful for looking at the retinal nerve fiber layer, whether there is damage or potential for damage. I guess I have a high threshold for determining who needs the full workup. Sometimes I will bring them back again and measure the pressure a few times before I initiate any more advanced workup.
R.V. Paul Chan, MD: How young are the children that you are talking about here? At what age do you feel that you can effectively get an OCT in the office? And for the very young patients, do you try to get an OCT under anesthesia in the operating room?
Wagner: I am not talking about congenital glaucoma or infantile types. I am talking about kids who are generally in the age group where we normally do not see glaucoma and are referred to us because they are glaucoma suspects and the incidence, of course, is low.
Kenneth P. Cheng, MD: I think we need to take a step backward. Is there an entity in the pediatric age range of either low-tension glaucoma or so much diurnal variation in pressure that a child would come in with normal pressure, with a normal slit lamp examination, with not a pigment-filled eye and not a pseudoexfoliation eye, without a significant family history, and with normal corneal diameters? Is there an entity in which a patient is going to have suspicious optic discs but otherwise be completely normal and end up having glaucoma? I cannot think of any condition that produces that scenario. So, if I see suspicious discs but everything else is normal, then I start to think about what other things make the discs suspicious. Most commonly it is just familial hereditary disc appearance. Then you look at the parents, and if one of them is at all representative, I say, “Good enough. We’re done.”
Prematurity is the other big one. A lot of these kids who were premature have increased cup-to-disc ratio as a manifestation of optic atrophy from their initial insult, and their rims otherwise look pretty good. So, I would back up and ask, is there an entity? Am I potentially missing something? Because I do not worry so much about these patients if they are otherwise completely normal.
Roberto Warman, MD: I agree. Almost all of these patients are between 10 and 16 years old when they come in, and the immediate thing that I ask is, is there a history of glaucoma in one of the parents that started around age 10 to 15 years? Because most real juvenile glaucoma is a dominant disease, and it is a rare condition. So you could eliminate that. However, most of these patients are referred after an abnormal reading on the air puff pressure test — which is absolutely useless in this setting — and then we confirm that pressure is normal. Another referral comes when a caregiver obtains an abnormal visual field on a 30-2 test, instead of their using something faster for the kids because they are young and do not pay attention. Basically, you just need to repeat the test to see that they do better. Many are just horizontal, physiologic cups, with no thinning, no hemorrhages, no anything. And you do the baseline. You take a fundus picture. If you can do the OCT, that is great, but it is only for documentation, then have them come back. The question is, how soon do we make them come back? I think a year is fine, and then after that year I think we are done. But maybe we will miss something if we do that.
Cheng: If the pressure is 21 mm Hg, then I will have them come back for another check at a different time during the day. If their first appointment was in the morning, I have them come back late in the afternoon or vice versa. And then I have them come back in a month or so, just to get another normal pressure reading; otherwise, I say a year, as long as everything else is completely normal and they are not oddly myopic or something like that.
Knowing when to treat
Chan: I think this age group is different from an adult glaucoma suspect. What is your threshold for saying, “I have findings consistent with glaucoma and therefore I need to treat this child?”
Scott E. Olitsky, MD: We are kind of in uncharted territory here. We now have these ancillary testing mechanisms and we are getting data, but we do not know what the data really mean. We do not have a lot of great normative data, and we do not know how the data may change over time. So, while collecting the data will be interesting and helpful, we still need to examine the data at some point. Right now, we do not really know how to use the new data because we have other ways of getting information. So, typically I would have said progression is my threshold, but I do not know what that means on an OCT now. What changes from year 4 to 5? That is where we are going to need a lot more information to help guide us.
Another thing to consider is the burden of treatment, in my opinion. It is hard to withdraw treatment once it has started.
Stahl: For me, the threshold is changes seen on OCT or visual field, as long as the patient does not present with classic juvenile open-angle glaucoma. When I first started the glaucoma suspect clinic about 5 years ago, I treated a lot more than I treat now.
Cheng: You actually saw progression on OCT in some of your patients with normal pressures?
Stahl: Yes, but it is rare. Of all the hundreds of kids that we follow, it is few. Usually it is like you talked about, when the pressure is 20 mm Hg and they come in with a 0.6 to 0.8 optic nerve and there are baseline changes on the OCT. The OCT is not normal to start with, and you say, “Hmm, I’m not sure.” Then over time, if I see a consistent drop in the nerve fiber layer numbers on the OCT, I will treat them. That is about the only time I would initiate treatment.
Gold: What about the pachymetry measurements in these children? Do you base some of your judgments for IOPs on pachymetry and whether the cornea is thicker or thinner?
Stahl: I see a pretty wide range, from 450 µm all the way up to as high as 700 µm in an otherwise normal eye. If pressure is 23 mm Hg and corneal thickness is 620 µm, I am going to take that into high consideration when I am deciding whether or not to treat. That is about the only time when it comes into play.
Timing of follow-up
Gold: You get a referral that has 0.6 or 0.7 or 0.8 cups, everything seems to be normal, and there are minimal risk factors. How soon will you see those patients back?
Stahl: If everything looks normal on the OCT and the visual field, and I am reassured by the optic nerves and pressure is normal, then I will see them back yearly. If there is any concern on any of those tests, then I see them back in 4 to 6 months, depending on my concerns.
Cheng: The overwhelming bulk of these are overreferrals from caregivers who are trying to measure pressures in children who are too young to have pressures measured accurately. Or they are using pneumotonometry, which is going to be inaccurate. Or the child is nervous and the pressure is falsely high from that. Or an Optos photo makes the optic disc and cup appear teeny-tiny and the child is sent on as a glaucoma suspect. Or the visual field is inaccurate because the child cannot cooperate, but the person looking at the field does not realize it is not valid. That is the overwhelming bulk of these referrals.
Wagner: I agree. The majority of the ones I see are referrals in this early teenage age group who are sent from optometrists who take photos of every patient they see and then they start looking for abnormalities.
Anthony P. Johnson, MD: I just have an observation: With the Icare, measuring pressures in the office, for me, has become exceedingly more reliable, easier and more trusted.
Chan: When taking the intraocular pressure during an examination in the office or under anesthesia, what do you think is the best way to do this?
Gold: In the office in an 8-, 9-, 10- or 11-year-old, I use the Icare tonometer. In general, I get accurate results. Occasionally I am obligated to use applanation, but mostly I use the Icare, which has been great also for my technicians, who are sometimes uncomfortable doing applanation.
Warman: I agree, but if I get an Icare reading of 20 mm Hg, 21 mm Hg or 22 mm Hg, I really do not worry because I do believe the data, and in my office, it does seem to measure 1 or 2 or sometimes 3 points higher. I do not check it out on the 7- and 8-year-olds often, but I do not get too excited with that number. But yes, it is extremely good, and if the pressure is more than 25 mm Hg, I am forced to find out what is going on.
Cheng: When do you start routinely measuring IOP on your patients as just a part of a routine exam?
Wagner: I do not do it until I am reasonably comfortable that I can do it easily — unless I saw something on exam, then I might work in reverse. If I saw something on my dilated retinal examination that bothered me, then I might make a bigger effort to do it, even in a smaller baby.
Johnson: Not routinely until probably a teenager, unless there is a reason to.
Olitsky: In this patient population, not unless there is an indication.
Gold: I normally do it right when they get to be about 12 or 13 years. If I have a 9- or 10-year-old who wants to wear contacts, I use the Icare tonometer as a test to see whether they will keep their eyes open, so that is about when I will start to do it.
Cheng: I do not start until they are 16 years unless there is an indication. Think about this. We are screening for a disease that may not even exist. So what is the cost of the false positives? That is the issue. I think that people out in the community are screening too early for a disease that may not exist.
Visual fields
Johnson: Also, I typically do not do visual fields if patients are younger than 7 or 8 years old. I know it is possible that you can, but I am curious what the threshold is for others to begin to feel comfortable interpreting those early visual fields?
Warman: I agree. Unless I have a real good suspicious reason to do a visual field on a child younger than 8 years, I do not do them unless it is to get them used to the machine or for the future for comparison, but they will not do good on that first test.
Stahl: I am even more conservative. I have a cutoff at 11 years — I do not do them younger than 11. I do not think you get good data, and it takes forever.
- For more information:
- R.V. Paul Chan, MD, can be reached at Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor St., Chicago, IL 60612; email: rvpchan@uic.edu.
- 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.
- 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.
- Roberto Warman, MD, can be reached at Miami Children’s Hospital, 3200 SW 60th Court, Suite 103, Miami, FL 33155; email: rwarman@eyes4kids.com.
Disclosures: The round table participants report no relevant financial disclosures.