Pediatrics roundtable addresses cataract surgery in children
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Pediatric cataract surgery can be challenging to learn and perform, sparking discussion on who should perform the procedure.
Led by Section Editor Robert S. Gold, MD, Healio | OSN Pediatrics/Strabismus Board Members discussed performing pediatric cataract surgery and prescribing bifocals for high accommodative convergence/accommodation (AC/A) ratios in strabismus.
Source: Margaret Wood Atwood
Robert S. Gold, MD: Dr. Wilson, you brought up the topic of who should perform pediatric cataract surgery. It is an argument that we hear all the time. Because of your expertise, I would like to hear what you think.
M. Edward Wilson, MD: It is a question that is still being debated. I don’t think it is that much different than the debate about who treats retinopathy of prematurity. We teach our fellows to screen and treat, both with injection and laser, and I think that should be taught in as many places as possible so that you do not necessarily have to bring in the retina doctors. Cataract surgery is the same. The answer is different depending on where you practice and who is the most interested in the problem. In the international community, I meet a lot of cataract surgeons, and it seems that it is much more common for the adult cataract doctors to do all the pediatric cataracts internationally than it is in the United States. I would like to think that pediatric cataract surgery is different enough from adult cataract surgery in that it should be within the purview of the pediatric ophthalmologist, but that is not necessarily true in all communities. It depends on who is willing to put in the time and effort to get good outcomes.
Roundtable Participants
-
Moderator
- Robert S. Gold
- Douglas R. Fredrick
- Jordana M. Smith
- Erin D. Stahl
- Rudolph S. Wagner
- Roberto Warman
- M. Edward Wilson
I would not say absolutely it should be one or the other. I do think that if it is an adult cataract surgeon, they have to appreciate the differences between children and adults and not enter into it cavalierly. But I also think that one of the beauties of pediatric ophthalmology is that we are more comprehensive than the comprehensive ophthalmologist. Most of us do ptosis surgery, ROP treatment, strabismus, intraocular surgery and glaucoma surgery. I want to maintain that comprehensive nature as much as we can.
Rudolph S. Wagner, MD: You need experienced surgeons like Dr. Wilson to be sure these pediatric cataract surgery cases are done at the right time with the right technique. I don’t believe most pediatric ophthalmologists come out of fellowship with tremendous experience in performing pediatric cataract surgery. I think it is one of those procedures that many pediatric ophthalmologists defer to surgeons they consider “experts” in cataracts. You have to have people who are trained. We have a few well-trained pediatric ophthalmologists in our area who decided to emphasize pediatric cataract surgery in their practice These surgeons do very good work, and most of the pediatric ophthalmologists are happy to refer their patients to these very competent surgeons.
Erin D. Stahl, MD: Recently, somebody put on the adult cornea listserv a question regarding what to do in a 14-year-old who needed cataract surgery. I sent back my standard cataract approach in a 14-year-old. But I then was interested to see the responses that came in from the adult cataract surgeons, and it gave me a different perspective. They talked about all the things that they have dealt with in people who had pediatric cataract surgery 30 or 40 years prior and from their perspective what they would have done differently in the initial surgery. The adult cataract surgeons talked much more about polishing, cleaning and meticulous cortical removal, posterior optic capture, and considering a capsular tension ring. I thought it was interesting to read their comments because we do not see our patients 30 years later. I wonder about the benefit of combining our expertise with that of the adult doctors who see our patients down the road. In addition to the things that we find challenging, sometimes ophthalmologists who work with adult patients do not always have in their mind visual development age groups and what goes into dealing with children in general.
Jordana M. Smith, MD: That is a great point. I would love to hear some feedback from adult cataract surgeons on problems or complications in their patients that we have previously cared for. For example, do adult surgeons feel like they have to go back in and replace sulcus lenses? What refractive issues are they seeing?
Having surgeons who are comfortable with pediatric cataract surgery in general is critical, and not just the surgical care but the postoperative management. While an adult surgeon may feel capable of performing the surgery, many surgeons in my area are not comfortable with handling the perioperative management, including lens choice and more frequent postoperative care that may involve examinations under anesthesia. If a surgeon is not planning to perform all of that care themselves, they need to make sure they have identified someone familiar with pediatrics who will provide that level of care to the patient and family prior to scheduling surgery.
Roberto Warman, MD: I think we should teach our residents and fellows that if they want to, they should go into as many things as they want, but they should know when to stop doing them. I did incredibly good cataract surgery on children my first 15 years in practice. A pediatric ophthalmologist will manage the amblyopia much better, and I am happy to see my previous patients as adults with incredible vision and monocular cases in significant amounts. But after about 15 years, I realized I was not performing enough cataract surgery. Some people, like Dr. Wilson, perform many cataract surgeries. They can perform cataract surgery until any age they want. But most pediatric ophthalmologists will end up encountering 10 or 15 cases a year if they are lucky, and sometimes less. There comes a time as the years go by that you should transfer the torch to younger surgeons, and you should concentrate on other things. You need to know when it is time to let go of certain procedures.
Wilson: There was an article published recently on the scope of pediatric ophthalmology. About 50% of pediatric ophthalmologists surveyed said that they performed pediatric cataract surgery in their practice. Now, that may be limited to certain ages and things like that, but a fair number do offer it. I would say that if you have an active niche, and you are a pediatric ophthalmologist — whether that is pediatric cornea, pediatric glaucoma or pediatric cataracts — you have an obligation to stay up to date on what is current. When I go to the American Society of Cataract and Refractive Surgery meeting, I am learning from the adult cataract surgeons. There are new things that might be applicable to pediatrics, but I also need to share what is different about pediatrics with adult surgeons who are starting to jump into this area of surgery. We have an obligation in pediatrics not to be isolated in any of those niches — cornea, glaucoma and cataract come to mind, maybe oculoplastics as well — but to communicate across the adult-pediatric spectrum and stay up to date.
Prescribing bifocals for high AC/A ratios
Gold: A topic that comes up a lot is whether we are still prescribing bifocals for high AC/A ratios in accommodative esotropia.
Warman: I do use bifocals, but only if there is a big discrepancy of deviation or no deviation at distance than there is at near. There are not many patients like that. The great majority you can start with a single lens if their hyperopia is enough, and there are a few who need the bifocal. You can wean most of them off of the bifocals at a relatively young age. I do not like them to go to teenager years with bifocals. I agree with the argument that they can be binocular at certain distances and that it is not indispensable to prescribe bifocals in these patients. But the patients look crossed, and the families do not want to see them crossed. Why not give them the bifocal?
Wagner: I agree with Dr. Warman. I think we do not see it as frequently as we used to. I don’t know why that would be. I am of the same mind as Dr. Warman, in that I am going to use bifocals for children who have no deviation at distance and only deviation at near with low hyperopia. In most cases, I use progressive lenses. When I monitor the patients, I like to check their stereoacuity when they are old enough. This is helpful in determining if your treatment is effective. I use a progressive lens because it seems to be better tolerated, but the traditional method of bisecting the pupil with the upper segment is still used in many cases. But I am happy with my results using progressive lenses.
Gold: I agree. I am seeing much less of this as I have practiced over the years. I have been using progressive lenses for those patients for many years, and the way that I prescribe them is you elevate the optical center of the progressives 2 mm. Whether it is right or wrong, it has worked well for me.
Wilson: There is no doubt that bifocals help the children who need it. It helps them fuse at near. There has always been doubt as to whether prescribing the bifocal will alter the natural history of the disease itself. If you are fusing at distance, whether you prescribe the bifocal or not probably does not change whether that child is going to eventually need surgery or not need surgery in the future. But I put the bifocal in.
I think some young pediatric ophthalmologists were taught to prescribe a bifocal in the first pair of glasses if the near deviation measured greater than the distance. That is wrong because many times they are more interested in the target up close. It looks like a high AC/A, but you put them in regular glasses, and that false near deviation being larger just goes away. If children are straight into glasses and they come back and are crossing at near, I can establish in the office that they fuse when I hold up a simulated bifocal, and those kids need a bifocal. Then you try to wean them out when you can. I start with a line bifocal, and then once they know how to use it, I will give them a progressive. I rarely will give the progressive at first. Maybe it works, but I think they need to get used to a line first before moving onto progressive.
Gold: Astute, but progressives work fine as the initial treatment for me. Everybody does it differently, which is fine.
Douglas R. Fredrick, MD, FAAP: I agree with everyone. I still use bifocals. I like telling parents when a child does need surgery that I have done everything short of doing surgery on the kids who truly have a high AC/A, would benefit and are fusers. But to say, “No, we’re going to avoid bifocals and go right to surgery,” I do not want them coming back to me later and saying, “How come you didn’t try bifocals?” I think that has kept me out of trouble.
Wilson: When I use a line bifocal, I prescribe a large flat-top D at the bottom of the pupil. I do not like to split the pupil. I think that is a little too high. I do not like to use the executive. They are heavier and more expensive. In a small child’s frame, a large flat-top D goes almost all the way across, and putting it at the bottom of the pupil is fine.
- Reference:
- Lueder G, et al. J Binocul Vis Ocul Motil. 2023;73(2):53-54.
- For more information:
- Douglas R. Fredrick, MD, of Kaiser Permanente South San Francisco, can be reached at douglas.r.fredrick@kp.org.
- Robert S. Gold, MD, of Eye Physicians of Central Florida, can be reached at rsgeye@gmail.com.
- Jordana M. Smith, MD, of University of Arizona College of Medicine, can be reached at jsmith@eyes.arizona.edu.
- Erin D. Stahl, MD, of Children’s Mercy Hospitals and Clinics, Kansas City, Missouri, can be reached at edstahl@cmh.edu.
- Rudolph S. Wagner, MD, of Hudson Eye Physicians & Surgeons, New Jersey, can be reached at wagdoc@comcast.net.
- Roberto Warman, MD, of Miami Children’s Hospital, can be reached at rwarman@eyes4kids.com.
- M. Edward Wilson, MD, of Storm Eye Institute, Medical University of South Carolina, can be reached at wilsonme@musc.edu.
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