Roundtable centers on vision screening, blepharitis in children
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In recent years, efforts have ramped up to expand and advance vision screening for pediatric patients.
Led by Section Editor Robert S. Gold, MD, OSN Pediatrics/Strabismus Board Members discussed vision screening, blepharitis and chalazions at the American Association for Pediatric Ophthalmology and Strabismus meeting in Scottsdale, Arizona.
Source: Robert S. Gold, MD
Robert S. Gold, MD: I think we should talk about vision screening. It is certainly a prominent topic at this meeting. David G. Hunter, MD, PhD, gave the Costenbader Lecture about his research and the technology that he has put together. Let’s discuss how you handle patients who are sent to you with failed vision screenings.
Rudolph S. Wagner, MD: The past year or so, I have seen more children coming from pediatricians with failed screenings and random printouts from the various devices that they use. It has become quite common, so I assume that a lot of the pediatricians have access to these spot vision screening devices and are using them more frequently.
Recently, I was speaking with someone from a local Lions Club, and she said that they used to have a pool of volunteers that would do vision screenings throughout the state, but it has really fallen off. She said the Lions Club has had difficulty recruiting younger people to join the clubs, participate and be part of this pool of screeners. That was of interest to me, as I have recognized that fewer screenings are being done in New Jersey in general. That is a loss because the Lions Club was always helpful with vision screening, but at least the pediatricians are picking up the slack.
Roundtable Participants
-
Moderator
- Robert S. Gold
- Douglas R. Fredrick
- Courtney L. Kraus
- Erin D. Stahl
- Rudolph S. Wagner
Gold: We do not have optometrists in our practice, so the pediatric ophthalmologists are seeing all of these patients. The pediatricians in our area are screening a ton of patients, so we are seeing a lot of them. We are having trouble with the false positives because you have to tell the parents that their child has a normal exam, and then there are reimbursement issues with insurance. So, we try to avoid that issue before they get to our office. We tell them that, if they feel like they do not want to see an ophthalmologist, they can seek alternative eye care. Most of them still want to see us, and that is great, but that has always been an issue in our situation. Although we know the technology is getting better, it is not perfect.
At this stage of the game, if pediatricians do not have screening devices in their office, then they are behind the times. That is why I try to encourage the pediatricians in my area to get a vision screening unit and to utilize it. Now they can be reimbursed, even if it is a small amount. Most of them will do that.
Douglas R. Fredrick, MD, FAAP: I have pretty strong opinions about the scientific vs. the pragmatic. Like everybody here, our office is overflowing with 1- and 2-year-olds who are failing reference-based, instrument-based vision screenings. They have astigmatism that falls outside of the preset factory-installed parameters, and they get sent in. I do not give them glasses, and they are usually fine. A recent study done by the Mayo group showed that moderate amounts of astigmatism do just fine with observation, so we are not doing anything with small amounts of astigmatism. Yes, pediatricians should check for red reflex because we want to pick up retinoblastoma and cataracts. I am fine with red reflex screening, but I think this is an issue that AAPOS needs to address because we have always been told to screen every child to make sure we are not going to miss amblyopia, but we all know amblyopia can be detected and successfully treated between the ages of 3 and 5 years.
With the workforce shortage that we have right now and the perils of overprescription and overtreatment, I think it is our responsibility to take a hard look at who should be screened. Screening devices come with information that says, “This is what you should set your devices on for referral,” but no pediatrician is going to change the reference on their devices. So, what comes out of the box is what they are going to use, and this is something that I think we should address honestly.
Gold: Let’s go back to something that everybody sees every single day: blepharitis and chalazions. In my practice in Florida, there is not a day that goes by that I do not see a dozen patients who have terrible lid disease and some sort of anterior segment disease. Prescribing steroids for these kids is scary. What is your regimen these days? I think it is important to share what we are doing because these are common issues, but people may handle it differently.
Erin D. Stahl, MD: For patients with blepharoconjunctivitis, we start out with just the lids — basic lid hygiene, omega-3s and warm compresses. If we see conjunctival but not corneal involvement, we consider erythromycin and more aggressive treatments that are steroid sparing. Then, once we have corneal involvement, we consider going to steroids. Once they have vision-threatening corneal involvement, then they come to me, and I may try a variety of treatments. I do meibomian gland probing and squeezing in the OR and sometimes start them on oral antibiotics. It is an inflammatory cycle, and I usually tell families, “This is a cycle, and we have to break it.” It does seem that if you are diligent and treat long enough, you can break that cycle and then just maintain with lid hygiene and not have it come back. I think one of the problems that I see with patients who are referred is that they are on steroids for too short of a period of time at too high doses, and if we can do longer-term lower-dose steroids and taper them, we will do better.
Gold: Topical steroids?
Stahl: Yes.
Gold: You are not worried about pressure elevation?
Stahl: I typically use three drops of prednisolone a day or less and then taper to twice a day for a month, once a day for a month, every other day for a month, every third day for a month, and then stop. By that time, usually we have broken the inflammatory cycle, and they do not have to go back to that regimen if they maintain their cleaning. I would like to add that when I say corneal involvement, I only put steroids on a vascular cornea. I need to see active vessels in the cornea before I will use steroids.
Courtney L. Kraus, MD: Do you ever take anyone to the OR to do meibomian gland expression?
Stahl: There is this small subset of kids who have occluded meibomian glands, and when you squeeze them in the OR, nothing comes out of a single gland, and they have this greasy cap. You cannot scrub them off. You cannot do anything, so I use a sterile safety pin, and I individually open every meibomian gland and then squeeze. I then treat them with a steroid ointment for a while, and I can keep them open fairly well. I perform this probing on only a few patients per year.
Wagner: I recently excised a chalazion in the operating room, and when I put the clamp on, there was a copious expression of sebaceous material from the glands within the eyelid margin. I decided to express the meibomian glands on the entire upper and lower lids. You have these linear, thick secretions coming out of almost all the meibomian glands in the entire lid, not just where the chalazion is located, so I think it makes sense.
Frederick: We have a difficult time getting in the OR now, so I do not take them to the OR much. I use a combination of treatments. I do not use drops. I always stay with ointment, or I use a combination antibiotic steroid, of which there are far fewer now. You cannot get generic tobramycin and dexamethasone ointment. Blephamide (sulfacetamide and prednisolone) and sulfa-steroids do not exist anymore, so it is pretty much a Maxitrol (neomycin, polymyxin B and dexamethasone) equivalent. I will write only one refill, and then, at the same time, I will write erythromycin. If I am seeing someone who is bad to start out with, I say, “You’re going to use this one and then switch to erythromycin.”
Every child outgrows this. I tell patients it is going to take years, and usually patients start to feel better after you show them the hygiene. When they come in and they do not look any better, I have the parent show me how they do the scrubs. Usually, it is because the kid is squeezing so tight that they are doing the brows and not the lashes. That is a good opportunity to demonstrate the correct technique, and I think that is a big reason for failure: They are not doing the scrubbing right.
- For more information:
- Douglas R. Fredrick, MD, can be reached at Kaiser Permanente Medical Group, 395 Hickey Blvd., Daly City, CA 94015; email: douglas.r.fredrick@kp.org.
- Robert S. Gold, MD, can be reached at 790 Concourse Parkway South, Suite 200, Maitland, FL 32751; email: rsgeye@gmail.com.
- Courtney L. Kraus, MD, can be reached at Wilmer Eye Institute, 615 N. Wolfe St., Wilmer 230, Baltimore, MD 21205 email: ckraus6@jhmi.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.
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