BLOG: Refer or not to refer, that is the question
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by Christina Twardowski, OD, FAAO
Pediatric patients do not always make an eye exam an easy task. There are many times you find yourself on the ground with your retinoscope trying to get any view possible or sweating because the child is screaming just looking at you.
Regardless of the situation, a pediatric exam can be further compounded by trying to interpret the challenging data that were obtained. One of the exam findings that frequently gives practitioners difficulty is the refractive error; this can be an especially puzzling finding when verbal vision is unattainable or unreliable.
As a result, I want to share a few guidelines that help me streamline my thought process when evaluating pediatric patients for the concerning diagnosis of keratoconus and, ultimately, deciding when a referral for corneal cross-linking should be considered.
Large amounts of astigmatism
When astigmatism is present, and keratoconus is a potential diagnosis, many doctors are unsure as to what their next step should be. Although large amounts of astigmatism can be unnerving, remember that patients with early stage keratoconus often do not have large amounts of cylinder.
Also, be aware if the astigmatism is symmetric or asymmetric, as high amounts of symmetric bilateral cylinder tend to be just that, a large refractive error. Asymmetric astigmatism is very common in keratoconus patients, especially children, with one eye advancing more quickly than the other.
When performing retinoscopy try to focus on the process, not the end result, as the reflex can tell you a lot about the architecture of the cornea and is quite accurate in determining the presence of keratoconus.
Appropriate age for referral
There is a vast amount of evidence to indicate that keratoconus progresses at a much faster rate in pediatric patients compared with adults. In a study looking at the severity of keratoconus upon diagnosis and its scalability over a 2 year period, children were shown to be significantly more severe at diagnosis, with 27.8% being stage 4 vs. 7.8% of adults (Leoni-Mesplie et al). These facts are stated not to scare you, but to reassure you that the abnormal retinoscopy reflex in your chair is worth the referral for any age pediatric patient.
Too frequently the diagnosis of keratoconus comes in later adolescence, but the corneal ectasia process started at a much younger age. It is this early ectasia process that cross-linking can help halt and prevent a lifetime of visual consequences.
Keratometry values and keratoconus
When referring a patient for suspected keratoconus, please remember that keratometry measurements are not required. Whether your practice doesn’t have the necessary equipment, or your patient isn’t cooperating for testing, don’t allow these situations to place a hold on your referral.
In those difficult patients where it is hard to gather the full clinical picture, monitor the patient’s refractive error every 3 to 6 months for progression. As I previously stated, remember that one of your most useful tools in your pediatric exam is your retinoscope. An abnormal reflex associated with asymmetric astigmatism, family history of keratoconus or a history of atopic disease are all cases that warrant a referral.
No referral is a bad referral
When in doubt, refer! There is no harm in sending a patient for a second opinion that could truly save their vision. Remember, the overall goal is to prevent these children from requiring visual rehabilitation, as it is costly, time consuming and emotionally exhausting for families.
In summary, early detection and treatment are paramount to avoid serious visual impairment. Corneal cross-linking offers a true treatment for keratoconus, halting the corneal changes and avoiding the gamut of visual rehabilitation options. It is your early referral that will help ensure a positive visual prognosis for your patient, which, in return, offers immense benefits long-term for the patient and family.
References:
Al-Mahrouqi H, et al. Cornea. 2019;doi:10.1097/ICO.0000000000001843.
Leoni-Mesplie S, et al. Am J Ophthalmol. 2012;doi:10.1016/j.ajo.2012.01.025.
Zadnik K, et al. Cornea. 2002;doi:10.1097/00003226-200210000-00008.
For more information:
Christina Twardowski, OD, FAAO, practices in the ophthalmology department at Children’s Mercy Hospital and is the director of optometry services. She is also co-director of the pediatric optometric residency program and the director of the Illinois College of Optometry student externship program. Twardowski is on medical staff at the University of Missouri-Kansas City as an assistant professor.
Disclosure: Twardowski reports no relevant financial disclosures.
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Al-Mahrouqi H, et al. Cornea. 2019;doi:10.1097/ICO.0000000000001843.
Leoni-Mesplie S, et al. Am J Ophthalmol. 2012;doi:10.1016/j.ajo.2012.01.025.
Zadnik K, et al. Cornea. 2002;doi:10.1097/00003226-200210000-00008.