Challenges abound with diagnosis, therapy of pediatric vision disorders
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The American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology and American Association of Certified Orthoptists develop pediatric vision screening recommendations.
The leading organization is the American Academy of Pediatrics, which disseminates the guidelines to pediatricians and family practitioners. At present, vision screening is recommended at birth, 6 months of age, 1 year and annually during regular examinations. The child’s health care professional is taught to perform an external examination with a light source to look for any obvious abnormalities or evidence of infection, to evaluate pupil size for symmetry and normal reaction to light, to screen for ocular alignment with a Hirschberg test, and to observe for a normal and symmetric red reflex using a direct ophthalmoscope. Once the child ages and can cooperate, their visual acuity is measured. If abnormalities are found, the child is referred to an eye care professional (ECP).
There are many challenges in the vision screening process. These can result in missed diagnoses, which may delay appropriate therapy, or many unnecessary referrals to ECPs if the child’s eyes are found to be normal.
My associates and I at Minnesota Eye Consultants participated for decades in annual free inner-city vision screenings at Phillips Eye Institute in Minneapolis. When we discovered ocular pathology, we found many parents did not follow through with the recommended eye evaluation by an ECP because they lacked the financial ability to pay for an eye examination. We therefore offered free eye examinations at our nearby inner-city office, but still many parents did not follow through and get their children’s eyes examined by our ECPs.
As a final challenge, when treatment was recommended by an ECP, including something as simple as spectacles, some children did not receive the recommended treatment as their parents could not afford the cost. We then created a foundation fund to cover the cost of eye examinations and any medical or surgical therapy required, but patient and parental compliance with our ECP recommendations were often ignored, even when the therapy, including glasses, was provided for free.
Vision screening will become even more important as we deal with the pandemic of progressive myopia and as effective treatments become available, including behavior modification, specialty optical correction and topical low-dose atropine eye drops.
We remain challenged and need a better approach to vision screening for children. Despite challenges with patient and parental compliance, vision screening for treatable eye disease remains critically important and leads to the preservation and/or restoration of vision for thousands every year. Perhaps our advancing ability to perform home-based digital testing of vision will improve our success rate in effectively screening every child’s eyes and motivating their parents to seek appropriate treatment.
Regarding the second topic in this issue’s roundtable discussion, ocular surface disease is a common primary diagnosis in children. As an easy mnemonic in the differential diagnosis of red eye, I teach ABCD: allergy, blepharitis, conjunctivitis and dry eye disease (DED). The more severe infectious keratitis, episcleritis/scleritis and uveitis do not present a differential diagnosis challenge.
Allergic conjunctivitis and bacterial conjunctivitis have always been seen frequently by the ECP whose practice includes children. In recent years, blepharitis and DED have increased in prevalence. Many think this is related to the American diet and increasing incidence of obesity. The same maladies of the eyelid margin that affect adults affect children, blepharitis and meibomian gland dysfunction (MGD).
A simple but useful way to classify blepharitis is into anterior blepharitis, primarily affecting the eye lashes and their follicles, and posterior blepharitis, primarily affecting the meibomian glands. Many patients elicit the signs and symptoms of both anterior and posterior blepharitis along with secondary evaporative DED. The most common forms of anterior blepharitis are seborrheic blepharitis, characterized by a greasy scaling lid margin with debris and scurf; staphylococcal blepharitis, often associated with significant lid margin hyperemia, corneal vascularization, phlyctenules or peripheral corneal infiltrates; and Demodex blepharitis with pathognomonic collarettes.
MGD is characterized by capping of the meibomian gland orifices, turbid to no meibum on manual expression, and gland tortuosity or dropout on meibography. Therapy is similar for adults and children and requires long-term compliance with the expectation of lifelong flares. Lid hygiene remains the base of the treatment pyramid. I find heat as applied by a Bruder mask or an alternative helpful in older cooperative children and hypochlorous acid spray easy to apply at any age. Antibiotic therapy with a macrolide antibiotic such as erythromycin ophthalmic ointment or azithromycin ophthalmic drops is safe and effective. The tetracycline family is usually avoided in children.
In staphylococcal blepharitis, an antibiotic with good efficacy against methicillin-resistant staph species, such as bacitracin ophthalmic ointment, Polytrim (polymyxin B/trimethoprim drops, AbbVie) or, in severe cases, compounded vancomycin, is effective. In patients with more severe inflammation and secondary corneal neovascularization, phlyctenules or corneal infiltrates, a short course of topical steroid may be necessary. I find the combination tobramycin/dexamethasone drops or loteprednol ointment at bedtime especially helpful.
Newer therapies for Demodex blepharitis are hopefully on the horizon, including lotilaner eye drops from Tarsus Pharmaceuticals. The off-label use of the dermatologic ivermectin cream Soolantra (Galderma) is a currently available alternative, as are tea tree oil preparations.
In severe cases, we have meibomian gland probing with manual expression, LipiFlow (Johnson & Johnson Vision), iLux (Alcon), BlephEx (BlephEx LLC), intense pulsed light and several other procedures available. In younger children, these procedures require sedation, as does treatment of any hordeolum or chalazion.
Timely diagnosis and proper therapy of vision disorders in children can be challenging as parental support, compliance and ability to pay can interfere with proper treatment. Ocular surface disease is common at all ages, with an increasing incidence of blepharitis, MGD and DED. The fact that early diagnosis and proper therapy can prevent a lifetime of visual disability motivates us all to do our best to preserve, restore and enhance the vision of our children.
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