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 Table of Contents  
CURRENT OPINION
Year : 2019  |  Volume : 57  |  Issue : 1  |  Page : 60-64

Expert corner – Pediatric ophthalmology and strabismus


1 Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
2 Department of Paediatric Ophthalmology and Strabismus, Child Sight Institute, Jasti V Ramanamma Children's Eye Care Center, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, Telangana, India
3 Department of Paediatric Ophthalmology and Strabismus, Sankara Nethralaya, Chennai, Tamil Nadu, India
4 Department of Paediatric Ophthalmology and Strabismus, Baroda Children Eye Care and Squint Clinic, Vadodara, Gujarat, India
5 Department of Paediatric Ophthalmology and Strabismus, Sankara Nethralaya, Chennai, Tamil Nadu, India; Department of Paediatric Ophthalmology and Strabismus, Moorfields Eye Hospital, NHS Foundation Trust, UK
6 Department of Paediatric Ophthalmology and Strabismus, M. N. Eye Hospital, Chennai, Tamil Nadu, India

Date of Web Publication10-Jun-2019

Correspondence Address:
Dr. Shruti Nishanth
Department of Paediatric Ophthalmology and Strabismus, M. N. Eye Hospital, No. 781, T. H. Road, Tondiarpet, Chennai - 600 021, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_20_19

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How to cite this article:
Sharma P, Kekunnaya R, Agarkar S, Jethani J, Sobti SP, Nishanth S. Expert corner – Pediatric ophthalmology and strabismus. TNOA J Ophthalmic Sci Res 2019;57:60-4

How to cite this URL:
Sharma P, Kekunnaya R, Agarkar S, Jethani J, Sobti SP, Nishanth S. Expert corner – Pediatric ophthalmology and strabismus. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2019 Nov 11];57:60-4. Available from: http://www.tnoajosr.com/text.asp?2019/57/1/60/259880




  What Do You Consider as Progressive Myopia? and How Do You Prefer to Manage the Child? Top


Dr. Pradeep Sharma

An increase of at least −0.50 D spherical equivalent per year in at least one eye as per cycloplegic refraction is considered as progressive myopia according to the Atropine in the Treatment Of Myopia (ATOM) study. Adequate correction of the refractive error is given as spectacles or contact lenses. The child may be started on 0.01% atropine as described in the ATOM 2 study, with follow-up of every 6 months. Encouraging outdoor activities may also stop the progression of myopia.

Dr. Ramesh Kekunnaya

For children >5 years of age, I consider 0.5–1 D progression in 6 months to 1 year as progression. I always rule out syndromic myopia, lenticular myopia, and keratoconus and retinopathy of prematurity/cataract surgery-related myopia in children before considering treatment options for the prevention of progression. I prefer low-dose atropine, less screen time, and more outdoor activities as a strategy to halt/reduce myopia progression in children >5 years of age.

Dr. Sumita Agarkar

I define progressive myopia as an increase of −0.5 D or more over a period of 6 months. I usually document axial length and lag of accommodation if a child is above 6 years. I do consider atropine 0.01% once a day if there is a documented increase in myopia. I also stress on limiting the use of handheld gadgets and daylight outdoor activities for at least an hour.

Dr. Jitendra Jethani

I would normally consider an increase of −0.5 D spherical over 6 months or even −0.75 D at 1 year as progressive myopia. At present, I use atropine 0.01% eye drops once in the evening to prevent the progression of myopia.

Dr. Shalaka Sobti

I would consider an increase of 1 D or more per year as progressive myopia. I perform a dilated retina evaluation once a year for myopic children and rule out any syndromic associations of myopia. I always fully correct the myopic refractive error on cycloplegic refraction. As part of management, I would advise the restriction of use of handheld devices and adding outdoor activity/play every day. As medical management of myopia, low-dose atropine is not yet available as a treatment on the National Health Service, UK, so I do not end up prescribing this.


  What are Your Management Principles for Treating Severe Allergic Conjunctivitis? Do You Prefer Steroids or Immunosuppressants? Top


Dr. Pradeep Sharma

I start treatment with a topical dual-acting antihistamine–mast cell stabilizer agent such as olopatadine hydrochloride 0.1% or bepotastine besilate 1.5% and combined with antihistamine decongestant vasoconstrictor drops and a lubricating agent. Nonpharmacologic remedies (cold compresses) to provide temporary symptomatic relief are added. Topical steroids are typically avoided and sometimes in very resistant cases given for short durations (2–3 weeks) only until good control can be achieved with safer medications such as antihistamines, mast cell stabilizers, or dual-acting, single-molecule antihistamine–mast cell stabilizer agents.

Immunomodulators, such as cyclosporine A or tacrolimus, are used as replacement therapy for more resistant cases with severe papillary hypertrophy. Once the effect comes, I would switch to the initial treatment which I feel is safe and no risk for steroid-induced glaucoma.

Dr. Ramesh Kekunnaya

For mild cases, I advise olopatadine and artificial tear eye drops. For moderate-to-severe cases, I prefer steroids, artificial tear eye drops, cool compress, and olopatadine. To control allergy, I consider long-term olopatadine, and in resistant cases, I consider immunomodulators such as tacrolimus.

Dr. Sumita Agarkar

I prefer a short-tapering steroid to take care of acute symptoms and then switch to mast cell stabilizers and copious lubricants. Lifestyle changes such as avoidance of rubbing, wearing sunglasses, icepacks, and lid scrubs also help. Severe corneal involvement is best handled by corneal specialists.

Dr. Jitendra Jethani

Basic principles such as loteprednol eye drops with olopatadine eye drops in the beginning. The steroids are gradually tapered over a period of 4 weeks. The child is asked to continue olopatadine eye drops twice a day.

I prefer immunosuppressants, especially chloroquine eye drops, or if the child is not able to tolerate it, then tacrolimus eye ointment once in the evening, and if the child is not tolerating that, I would start cyclosporine in that order. I usually start a lubricating eye drops if I am starting an immunosuppressant. I start them after the steroid regimen is over which is around 3–4 weeks of the first visit.

I also start nonsteroidal anti-inflammatory drugs (NSAIDs) eye drops after 2 weeks of starting steroids; hence, usually, when the steroids eye drops are at twice a day tapering, I add the NSAID eye drops and ask the parents to continue till a month.

Dr. Shalaka Sobti

Allergic conjunctivitis is quite common in the UK during spring and summer due to the increased pollen count, and we see children having frequent and severe relapses during these months. Mild-to-moderate cases are treated with olopatadine and ocular lubricants, with topical steroids prescribed for severe cases. In case of frequent relapses, I prefer to start immunosuppressants instead of long-term steroid use after control of the allergy. Topical cyclosporine is my first choice of treatment. I also monitor the intraocular pressure of children while on topical steroid treatment.


  What are Your Principles on Prescribing Glasses for Hyperopia and Myopia? Top


Dr. Pradeep Sharma

While prescribing glasses, we should consider the patient's age, type, and magnitude of refractive error, amount of anisometropia, and presence of strabismus or amblyopia. Another important factor to be considered is emmetropization, which is an active and on-going process in children. Care must be taken to consider the normal amount of refractive error corresponding to the age group.

I follow the guidelines laid out by the modified American Academy of Ophthalmology and now published as the AIOS Guidelines after the PedOph and Strabismus group consensus meeting. Check that for details in Indian Journal of Ophthalmology 2018 Commentary. While correcting for hyperopia in children <6 years, I prefer to under-correct the refractive error, the residual refractive error being just above the mean for that age group. This is done to ensure the stimulus for emmetropization, except in conditions such as amblyopia and esotropia. In case of school-going children, myopia should be fully corrected; hyperopic errors >1.5 D should be corrected as well. However, in cases of asthenopia, esotropia, or amblyopia, the smaller hyperopic errors also deserve attention. In patients with esotropia, it is imperative to give full cycloplegic correction.

Dr. Ramesh Kekunnaya

With respect to myopia, I tend to fully correct in children except in infants and toddlers where I delay prescribing at least till they start walking. If the myopia is very high, I prescribe to children of any age.

In hyperopia in the presence of esotropia, I give full cycloplegic correction. In cases of orthotropia with hyperopia up to 3–4 D in infants – I do not prescribe. In toddlers, I undercorrect by 1–1.5 D. In older children, I perform Post mydriatic test PMT and prescribe glasses or arbitrarily undercorrect by 1.5–2 D.

Dr. Sumita Agarkar

Full correction should be prescribed for myopia. There is no role for under- or over-correction at all in myopia. Hyperopia is a bit tricky as children can compensate for hyperopia using accommodation. The most important factor in prescription of glasses for hyperopia is the presence of esotropia or phoria. In the presence of an esodeviation or even intermittent esodeviation, full cycloplegic prescription must be given. In orthophoric children, under-correction of 1.5–2.0 D can be done depending on the age and visual needs. Astigmatism also should be corrected fully.

Dr. Jitendra Jethani

Currently, I follow the AAPOS Guidelines for prescribing the glasses. Some changes have been made to them, but more or less I stick to the guidelines.

Dr. Shalaka Sobti

In case of hypermetropia without a convergent squint, I tend to monitor vision in younger children up to the age of 3 years. If the vision is acceptable for the age, I do not prescribe; if not and in children older than 3, I under-correct by 1.5–2 D. In children older than 10 years, I prefer to do a PMT or subjective refraction. In hypermetropia with esotropia, I give full hypermetropic correction. In myopia in children over the age of 2 years, I give full correction.


  Till What Age Do You Treat Amblyopia? Any Special Tips for Compliance and Good Outcomes? Top


Dr. Pradeep Sharma

I consider vision as a new language that we learn best in the first 5 years but can pick up, if motivated and compliant even later, but with advancing difficulty as we age. Good results can be obtained when amblyopia treatment is initiated at least by 6–8 years of age. For visual deprivation amblyopia, the upper limit is 6 years, and for anisometropic amblyopia, it may be even 20 years if motivated and compliant and the presenting vision is better than 6/36. Strabismic amblyopes do not usually respond after 12 years of age. Amblyopia treatment is more difficult in older age groups, but not impossible. Success of the amblyopia therapy depends upon presenting vision, age at treatment, and compliance and motivation of the patient for amblyopia therapy. Counseling the patient and parent and proper monitoring help in improving the prognosis. To obtain good compliance with occlusion therapy in children, several methods of “bribery” may be used, such as allowing the child to watch TV or use mobile phone only when patched. In cases of squint with amblyopia, occlusion therapy should precede surgical intervention as parents become less compliant with amblyopia therapy after surgery.

Dr. Ramesh Kekunnaya

I tend to give a trial of patching (if they have not done earlier) for any age group. I encourage parents to split the patching hours depending on the school hours, advice patch during homework, watching TV, playing video games, or drawing time. In addition, some reward system works well for pathing.

Dr. Sumita Agarkar

Following the IATS Recommendation, children up to 17 years can have a trial of occlusion if presenting for the first time. The same goes for children who have had inadequate therapy or poor compliance. Good outcomes are linked to compliance, type of amblyopia, and depth of amblyopia. It is a good strategy to have child and parents as your team members and reinforce the need for compliance to therapy in each visit. Gains, even the small ones such as increase in speed of reading or improvement in near vision, should be complimented and demonstrated to the parents to encourage them. Attractive patches do help.

Dr. Jitendra Jethani

I would give it at any age. A lot goes into talking to the parents and it is the most important aspect of patching. It works if the patient actually believes and does it. We have to tell them and give them evidence that this thing actually works. We give them pictures to trace or ask them to start a hobby of painting while patching. We ask them to us EI net, or even their own computer or tab while they are patching their better eye during the therapy.

Dr. Shalaka Sobti

If a child has never had patching, I would give a trial of patching to children even older than 7; however, most amblyopic children would get identified around the age of 4–5 years when they have their eye test as part of school screening. In these children, we continue patching until we get an improvement in vision. If the vision continues to remain stable for over a year in spite of good compliance and the child is over 7 years old, I tend to discontinue patching and accept the vision. Tips to improve compliance include using patches with the patterns/colors on them, also encouraging a makeshift patch over the eye of the child's favorite doll/soft toy while they have their own patch on. Other things that help are doing a reward/star chart for patching or associating a child's favored activity such as TV/drawing with patching.


  How Long Do You Wait Before Intervening for Congenital Nasolacrimal Duct Obstruction? Top


Dr. Pradeep Sharma

Since majority of the infants with Congenital nasolacrimal duct obstruction (CNLDO) spontaneously improve during the first several months of life, I prefer to treat these patients initially with conservative measures such as Crigler's massage. Demonstrating the proper technique to the parents is important. Topical antibiotics are also added in case of significant discharge. If the symptoms persist, we prefer to do therapeutic nasolacrimal probing, which has a high success rate, but defers till about a year unless the problem persists despite massage. If three successive probings at 4–6 weeks' intervals fail to yield results, dacryocystorhinostomy is done at 3–4 years of age.

Dr. Ramesh Kekunnaya

Conservative management of lacrimal massaging up till 1 year of age. In cases of dacryocele or repeated infection, immediate probing is required.

Dr. Sumita Agarkar

It really depends on the age of the child. Crigler's massage alone works well until 1 year of age. Spontaneous resolutions may happen below the age of 1 year. Hence, I suggest probing if the child is older than 1 year.

Dr. Jitendra Jethani

Usually, I wait until 10–12 months of age. I do not do office probing, and usually, we do it in the operation theater.

Dr. Shalaka Sobti

I tend to monitor and advise sac massage until around 15 months of age before listing the child for syringing and probing. Indications for probing before that would be a dacryocele or repeated dacryocystitis.


  What are Your Pearls for Managing Infantile Esotropia? Top


Dr. Pradeep Sharma

I would initially ensure the refractive correction as per atropine cycloplegia and free alternation and then operate as early as possible. The ideal timing in infantile esotropia is to detect around 5–6 months of age and operate within the 1st year. Although early surgery is not enough, it has to be early alignment; hence, following surgery, glasses have to be titrated to ensure alignment. Early surgery can ensure not only ocular alignment but also good binocularity.

The chances of under- and over-correction do bother us in early surgery, but that is not >10%. I operate the associated oblique muscles in the same sitting, and in very large esodeviations, I would do three horizontal muscle surgeries in the primary surgery itself because the goal is early alignment. The chances of consecutive exodeviations are more in higher hyperopes, those with cylindrical corrections or those with superior oblique overactions, and should be kept mind while planning surgery, as also the age and the limbus-insertion distance.

Dr. Kekunnaya

Measure at least 3 times before intervention, patch therapy if there is any fixation preference. Most of them will have dissociated vertical deviation (DVD) and V pattern. Detecting these in infants is very important. I perform surgery at around 1 year of age. Postoperative follow-up is extremely important in infants.

Dr. Sumita Agarkar

Look for amblyopia and treat it, it is more common than literature suggests!

Early surgery if esotropia is large and constant with no fixation preference. Conservative approach is preferred if child has small angle esotropia with other issues such as prematurity, seizures, and delayed development. I usually reduce the surgical dose by 1 mm while operating in children with neurodevelopmental delay. Continue follow-up after surgery even if alignment is satisfactory and keep watching out for amblyopia till they are older address additional issues such as patterns and DVD at appropriate time.

Talk to parents about follow–up; need for glasses and further procedures.

Dr. Jitendra Jethani

All the basic principles, history, refraction, occlusion if needed, glasses if needed, reassessment with glasses should be followed. Surgery is as soon as needed. We operate after 8 months if patient has presented fairly early and patient is ready. We present all the facts to the patient and help them decide about the surgery.

Dr. Shalaka Sobti

Babies with infantile esotropia need patching in case they develop a fixation preference. Ideally, try and get as many measurements as possible. I prefer to operate between the age of 1 and 2 years. In selected cases, bilateral medial rectus botulinum toxin may be used as a primary procedure in less than 1 year olds, very often, this leads to a smaller angle of esotropia when the child is older and less amount of surgery required with more reliable measurements.


  What is Your Experience on Use of Botulinum Toxin for Pediatric Squints? Top


Dr. Pradeep Sharma

Botulinum toxin, with or without prisms, has been used for the management of the sixth nerve palsy to expedite the recovery or tried in the waiting period for more eager patients; however, generally, I wait for three 2-monthly visits showing no improvement for surgery.

It has been used with success in infantile esotropia up to 7 months of age; however, since general anesthesia is required, and repeated injections are necessary, I do not recommend. Further, the results of botulinum injections are less predictable than surgery.

Dr. Ramesh Kekunnaya

I prefer the toxin in the isolated/traumatic sixth nerve palsy as temporizing measure, strabismus in children s/p cataract surgery or any other anti-segment or postsegment surgery, to augment transposition surgeries.

Dr. Sumita Agarkar

Works well for incomitant acquired strabismus mainly sixth nerve paresis. Of late, there has been a resurgent interest in Botox injections for small angle strabismus in children with neurodevelopmental issues where surgery carries a risk of consecutive exotropia. I have used Botox to augment bimedial recessions for large angle esotropia.

Dr. Jitendra Jethani

I am not a big fan of botulinum toxin in children. I do not use it much.

Dr. Shalaka Sobti

Botulinum toxin may be used as a primary treatment or as an adjunct to bimedial recession in certain cases of infantile esotropia. I have also used it successfully as an early treatment for acute onset esotropia with diplopia in older children who were known to be binocular in the past. Further, as a temporary means in children with the sixth nerve palsy to prevent medial rectus contracture and as an adjunct to transposition surgery.


  According to You, What are the Exciting Future Trends to Look Forward to in the Field of Pediatric Ophthalmology? Top


Dr. Pradeep Sharma

Targeted strabismus surgery for strabismus to achieve or restore stereopsis, binocular vision stimulation treatment for amblyopia in preschool children, atropine 0.01% eye drops for the prevention of myopia progression, gene therapy for Leber's congenital amaurosis, intravitreal or intra-arterial injections for retinoblastoma, and intralesional bleomycin injections for veno-lymphatic malformations are some of the many promising advances being made in the field of pediatric ophthalmology.

Dr. Ramesh Kekunnaya

Gene therapy, personalized medicine, application of deep learning and artificial intelligence, newer modalities for amblyopia, newer intraocular lens designs, better understanding of strabismus.

Dr. Sumita Agarkar

  • Role of low-dose atropine in myopia control
  • Gene therapy
  • Better dichoptic therapies for amblyopia.


Dr. Jitendra Jethani

Lots of exciting things may come in the future especially in pediatric ophthalmology. Since new is looking at a group where we have potential to change or build the future. Most important changes would be for the management of myopia.

  1. Need to know the concentration of atropine which is useful for prevention of progression. The optimum concentration is yet to be known. Mainly because there is no tear film biomarker apart from dopamine which may be known and changes with atropine instillation. Even the dopamine level measured in tears is variable. In our own study, we did find atropine 0.01% to be extremely useful and something which did affect the progression in most of the cases
  2. Role of 7 methyl xanthine has shown promising results in preventing the progression of myopia. The exact mechanism again is unknown, and it is an oral drug. The need to know more about this would also come
  3. The tear film biomarkers for progression of myopia need to be known. More work would suggest what exactly changes in the eye which would not only point toward to pathophysiology but also would point towards targeted approach
  4. Few software and primary work have been done to measure the saccades through cameras. We did make a basic arrangement for measuring the ocular excursion. More research and artificial intelligence would make sure that we would have the data more accurately.


Dr. Shalaka Sobti

More in-depth knowledge about the use of atropine for myopia progression and more treatment modalities for progressive myopia are required. Other things to look forward to are gene therapy for retinal dystrophies being available as a treatment to young patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.






 

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