Improving surgical outcomes for pediatric patients
Reviewed by Janet L. Alexander, MD
Several innovations are revolutionizing surgical care in pediatric ophthalmology, according to Janet L. Alexander, MD.
Speaking at the Women in Ophthalmology Summer Symposium 2021, Alexander presented a rapid-fire case series to discuss 4 innovations affecting several subspecialties of pediatric ophthalmology.
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Innovations included prenatal surgical planning to treat congenital hereditary diseases, endothelial keratoplasty, endocyclophotocoagulation (ECP) to treat refractory glaucoma, and ultrasound biomicroscopy (UBM) as a tool to guide complex cataract surgery.
Prenatal surgical planning
A case involving a child born with Norrie’s disease demonstrated the value of prenatal surgical planning to allow intervention before complications.
During her second trimester of pregnancy, a 30-year-old woman presented with carrier status for NPD mutation.
Confirmed fetal amniocentesis NPD mutation and ultrasound showed no fetal retinal detachment. Labor was induced at 34 weeks gestation for early retinal treatment.
The child was diagnosed with Norrie’s disease and bilateral vitreous hemorrhages at birth and underwent bilateral treatment with intravitreal anti-VEGF therapy and peripheral retinal laser.
Six months later, both eyes demonstrated robust light perceiving vision with an attached retina.
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Alexander, assistant professor of ophthalmology and pediatrics at the University of Maryland School of Medicine in Baltimore, noted that the case is a reminder that it’s never too early to begin prenatal surgical planning.
âPrenatal surgical planning requires proactive and timely genetic testing to identify surgical candidates, counseling for women with high-risk genetic traits, and the involvement of geneticists and genetic counselors,â she said.
Pediatric endothelial keratoplasty
The advantages and disadvantages of automated endothelial keratoplasty by descemet stripping (DSAEK) compared to penetrating keratoplasty (PK) were discussed through a case involving a 4 year old child who presented with a cloudy cornea 2 years later. have had cataract surgery.
The child was diagnosed with bullous keratopathy and underwent DSAEK.
âCompared to PK, DSAEK is associated with greater wound integrity, less astigmatism and faster visual recovery. It also avoids having to remove the host’s endothelium in children’s eyes, âsaid Alexander. “However, positioning the DSAEK graft can be very difficult in pediatric patients, and complications such as graft folds, detachment and dislocation, pupil block, endothelial immune rejection, and steroid response can occur.”
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PKU for glaucoma
Advantages can also be cited for choosing ECP over transscleral ciliary ablation to treat refractory glaucoma in pediatric patients.
Alexander presented a case involving a 7-year-old child who had suffered a traumatic cataract, then presented with 20/250 vision and elevated IOP despite maximal medical treatment, selective laser trabeculoplasty and goniotomy.
The most remarkable feature of CEP is that it is minimally invasive and has a more favorable safety profile compared to the transscleral technique.
“For example, phthisis in the absence of retinal detachment occurs in more than 30% of eyes treated transscleral but in less than 1% of eyes that undergo PCE,” said Alexander.
Other benefits of CEP include the avoidance of late infectious complications, such as wound leakage and endophthalmitis.
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However, PCE has a modest success rate and its benefits are somewhat short-lived.
The outcome data shows that it effectively reduces IOP in about 30% of the eyes, and about half of those eyes maintain IOP control for 1 to 2 years. In addition, CEP is not without serious complications: hypotonia, retinal detachment and vision loss can occur.
Pediatric cataract imaging
Preoperative ultrasound biomicroscopy assessment helps plan cataract surgery and avoid intraoperative surprises, according to Alexander.
Alexander demonstrated these points with several case examples. In one case, a 1 month old child presented with bilateral cataract, but cataract surgery was postponed for 3 months while the child underwent treatment for co-morbid heart failure.
Repeated imaging before scheduled cataract surgery showed that the lens thickness had significantly decreased over time.
Knowledge of the absorbed cataract guided proper surgical techniques, Alexander said.
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âPlanning for cataract surgery with UBM allows surgeons to assess the position of the IOL, the periphery of the lens and the ciliary body,â she said. “It is important to note that this allows us to avoid surprises, including absorbed cataracts, foreign bodies, lumps, cysts or membranes.”
Other cases involving uveitic cataracts have shown how imaging with UBM can document pathology that can complicate cataract surgery and inform the surgical approach.
Alexander presented a series of eyes in which the UBM revealed the presence of a cyclitic membrane, pupillary synechiae, and calcified plaque on the anterior capsule.
Alexander concluded that the quantitative UBM is an innovation that further improves the clinical utility of the UBM.
Quantitative UBM uses algorithms to analyze the images and generates information that helps clinicians interpret the images.
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The algorithms are also able to suggest clinical diagnoses and prognostic features, such as the risk of complications.
Janet L. Alexander, MD
E: [email protected]
Alexander has no relevant financial interests to disclose.