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Pediatric ophthalmologists take on some of the toughest cases
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The surgical eye care of children was once a standard part of the comprehensive ophthalmologist’s practice. In my first 2 years out of training, I performed many strabismus surgeries as an associate in a busy private practice. I then joined the faculty at the University of Minnesota Department of Ophthalmology, and other than keratoplasty, my days of operating on children were over. Such is the case today for most comprehensive ophthalmologists residing in or near a large metropolitan area. So, I have few comments to make in this area, but like our readers, I enjoy being kept up to date in all fields.
The limbus-based vs. fornix-based conjunctival flap for surgery controversy has also been debated for decades among cataract and glaucoma surgeons. It is interesting to see the same debate being discussed among our pediatric colleagues. The majority of cataract and glaucoma surgeons today prefer fornix-based conjunctival flaps when not doing clear corneal surgery. It seems the modern pediatric ophthalmologist agrees.
For strabismus surgery, I was trained to use muscle resection and recession, and I still have the prism diopter per millimeter of resection and recession memorized. Plication is a centuries-old procedure, and it is interesting to see surgeons trying it again. Reoperated eyes confirm the amazing healing ability of young patients, with plicated muscles looking normal after a year or more.
In regards to retinopathy of prematurity, we all remember the challenge of examining and treating premature infants in the neonatal intensive care unit. This is a tough duty today usually delegated to the pediatric ophthalmologist or retinal specialist. The risk factors for ROP primarily include prematurity, low birth weight and oxygen therapy. Careful indirect ophthalmoscopic examination with scleral depression is recommended for diagnosis and staging. Some neonatal centers use devices such as the RetCam (Natus Medical) as an alternative with expert readers. Artificial intelligence might be applied here for diagnosis, staging and treatment selection.
It makes sense that an excess of vascular endothelial growth factor is present in the ROP eye, so treatment alternatives such as those used in diabetic retinopathy are logical. Much like in diabetes, destructive procedures such as cryotherapy and laser photocoagulation are being replaced with anti-VEGF injections into the vitreous. Some have also looked at propranolol, which has revolutionized our treatment of pediatric hemangioma. We need better studies, like those performed in the DRCR.net collaboration, to learn the best therapy for each stage of ROP. Until then, we will depend on physician experience in customizing a treatment plan for each patient.
These are tough cases that require low vision aids, special education teachers and lifelong support. I applaud my pediatric and retinal ophthalmologist colleagues for treating these difficult but important patients.