Discover the ‘smooth’ ways of treating children with corneal surface diseases

Cornea and Ocular Surface in Children

The Rough with the Smooth by Sam McCommon

One of the subspecialty symposia on day two of the 37th World Ophthalmology Congress (WOC2020 Virtual®) focused on the cornea and ocular surface in children. Treating children comes with a unique set of circumstances that must be considered in addition to the normal treatment of a condition. Below are two highlights from the discussion.

Allergic conjunctivitis

The first topic tackled was allergic conjunctivitis (AC), covered in a presentation by Prof. Yair Morad of the Sackler Faculty of Medicine at Tel Aviv University in Israel. Prof. Morad discussed a range of treatment options, from managing common to extreme conditions. The condition leads to itchy, red eyes that many are unfortunately familiar with.

AC is quite common, affecting 15% to 40% of the population affected. It’s seasonally exacerbated by things like pollen, though some 25% of sufferers are affected year round. It’s more common in children with an atopic background and is also more common in males.

Primary treatments can be simple: avoiding allergens like pets, carpets, or pollinating trees, for example. Cold compresses and water-based lubricants can also help reduce symptoms. But, as Prof. Morad noted, these ‘solutions’ often fail.

He humorously compared treatments like topical antihistamines, mast cell stabilizing agents like cromolyn sodium, and non-steroidal anti-inflammatory drugs (NSAIDs) like ketorolac to lousy cars, with doctors offering them to patients before offering the comparative shiny Mercedes: multiple action drugs. Why not simply offer the higher quality product to begin with?

Prof. Morad instead recommended multiple action drugs like nedocromil (Tilavist), azelastine (Optilast) or olopatadine (Patanol).

In acute cases, he suggested using as mild a topical steroid as possible, like metholone — not prednisolone or dexamethasone. Another safe option is loteprednol, which is relatively safe for prolonged use. However, he stressed that steroids should only be used in the case of exacerbations.

Steroids cannot be used forever and even they sometimes fail — so, Dr. Morad turned to what he dubbed “wonder drugs”. He therefore recommended 1% topical cyclosporine or tacrolimus — which he said has greater immunosuppression than cyclosporine, less stinging sensation, and no side effects. In the event these drugs aren’t tolerated, systemic steroids like prednisone at 1mg/kg can be used for

alternate day treatment.

Another option is a supra-tarsal injection of equal parts triamcinolone and tacrolimus, while continuing cyclosporine or tacrolimus treatment. He noted that patients experienced dramatic relief of symptoms within 1-5 days, with little need for repeated treatments.

And if the case is truly difficult? Prof. Morad advised to turn to systemic cyclosporine.

Managing keratoplasty in children

Prof. Nikolas Ziakas of the Aristotle University of Thessaloniki in Greece. discussed keratoplasty surgery in children — and all the special considerations one must take into account.

These considerations include pre-, intra-, and postoperative complications as well as physiological differences between children and adults. Unsurprisingly, children are less cooperative and communicative than adults, which can lead to inaccurate visual acuity measurements and imprecise examinations.

Physiologically, children have low scleral rigidity, thinner and more pliable corneas, smaller anterior segment dimensions, and a higher posterior vitreous pressure.

Because of the lower scleral and corneal rigidity, Prof. Ziakas recommended oversizing the graft by 0.5-1 mm, particularly in the aphakic eye. This is in conjunction with choosing a corneal diameter of 5.5-7.0 mm. He noted that it’s especially important to oversize the graft when working with thin tissue, since compression of the tissue can compromise the wound. He also highlighted using the Price graftover-host technique to maintain positive pressure during penetrating keratoplasty.

Postoperatively, children and infants require more control than adults. For example, the infant cornea heals much faster than the adult one, and sutures should be removed as soon as possible. Any microabscesses or neovascularization can indicate inflammation, which can lead to graft rejection.

10 out of 10 patients agree they wish they had not had traumatic ocular injury.

The ‘Traumatic’ in Ocular Injuries

by Brooke Herron

Worldwide, ocular trauma is an important (but perhaps lesser recognized) cause of blindness. Naturally, the initial injury itself (be it physical, postoperative or other) can be difficult to manage — however, it can also lead to other sight debilitating conditions such as traumatic cataract and glaucoma.

Updated information on these injuries was presented during the Management of Anterior Segment Trauma: The Good, the Bad and the New session on the second day of the 37th World Ophthalmology Congress (WOC2020 Virtual®).

What’s the prognosis, doc?

According to Dr. Ahmed Bardan from the University of Alexandria, Egypt, the initial visual acuity (VA) in patients with ocular injury significantly affects the final visual outcome.

“There are other factors, like neglected injuries causing endophthalmitis; the presence of relative afferent pupillary defects (RAPD), which cause severe posterior segment and optic nerve damage; retinal detachment; and the size and location of the wound,” he said, adding that although those are the main factors, there are others including: lens injury, hyphema/vitreous hemorrhage and older age. Further, Dr. Bardan detailed the prognostic tool used to classify ocular trauma and estimate visual outcomes: the Ocular Trauma Score (OTS). “The higher the score, the better the prognosis,” he explained, after going through the score’s different elements in detail.

The zone of injury is another important aspect, said Dr. Bardan. “The more posterior the injury, the worse the outcome.”

Not your average glaucoma

Traumatic glaucoma can look very different with a subtle or dramatic appearance, began Dr. Robert Chang from Stanford University, California in the United States.

“It’s helpful to classify ocular trauma into two main categories: blunt and penetrating trauma,” he continued. “According to one study, blunt trauma causes glaucoma more frequently (19%) versus penetrating trauma at about 3%.”

In addition, Dr. Chang said that it’s of significant importance to differentiate between angle recession and a cyclodialysis cleft: “A cleft may have low [intraocular] pressure initially, but the pressure can then spike to high after the hole closes.” There are other reasons for high pressure, he continued. “For example, right after the injury you may see trabecular meshwork direct injury, leading to traumatic iritis or inflammation, lens dislocation, hyphema, and choroidal hemorrhage in the back of the eye.

“Later, you may see the angle recession that develops or rare conditions like ghost cell glaucoma, hemolytic/ hemosideritic glaucoma, or even patients who already had cataract surgery and had their lens dislocated, or lens induced glaucoma from violating the lens capsule, leading to subsequent inflammation,” explained Dr. Chang.

Traumatic cataract is different, too

The incidence of traumatic cataract is very common, said Dr. Alex Ng from Hong Kong Ophthalmic Associates. “Over half of serious injuries involve lens damage.”

Dr. Ng noted that there are several controversies when it comes to treating traumatic cataract: “Mainly, it’s the timing of surgery. When we are approaching a cataract, sometimes we do it as early as possible, or sometimes we do it with other surgeries. The other controversy is whether we put in the IOL primarily or secondarily.

“For the primary cataract removal, the advantage is that it prevents some cataract induced inflammation and glaucoma, especially when there’s lens material in the AC [anterior chamber],” explained Dr. Ng. He said early removal can also offer better visualization of the posterior segment. Secondary cataract removal also has benefits: being a hot versus quiet eye, better biometry, less inflammation, better surgical planning, among others.

“The timing of surgery really depends on the presence of any other ocular injury,” he pointed out. The surgeon’s experience in dealing with traumatic cases is also critical.

“Remember that traumatic cataract is not your daily day-in, day-out age-related cataract,” Dr. Ng emphasized.