Experts discuss infantile esotropia, airbag injuries and timing of surgery

Part 2 of a two-part round table. Topics included the pluses and minuses of dispensing eye wear.

  • Ocular Surgery News U.S. Edition, June 1, 2002

Ocular Surgery News convened a round table of experts to discuss controversial issues in pediatric ophthalmology at the 28th meeting of the American Association for Pediatric Ophthalmology and Strabismus in Seattle.

Surgeons conferred about treatment for infantile esotropia, the pros and cons of optical dispensing in pediatric ophthalmology practices and the increase in severe eye injuries caused by car airbags. Topics ranged from the use and effectiveness of atropine and occluding patches for amblyopia, early surgery for congenital esotropia and the viability of providing dispensing services to patients.

The moderator of the discussion was Robert S. Gold, MD, of Orlando, Fla. The participants were Naval Sondhi, MD, Anthony P. Johnson, MD, FACS, Kenneth P. Cheng, MD, and Scott E. Olitsky, MD.

This is the second part of a two-part discussion. The first segment appeared in the May 15, 2002 issue of Ocular Surgery News.

Congenital infantile esotropia

Robert S. Gold, MD: Let’s discuss management of esotropia in the first year of life. In January 2002, the American Journal of Ophthalmology published the article “Spontaneous Resolution of Early Onset Esotropia: Experience of the Congenital Esotropia Observation Study.” This group, the Pediatric Eye Disease Investigator Group, had 137 different investigators at 104 sites.

The results of this study showed that esotropia with onset early in infancy frequently resolves when found in patients first examined at less than 20 weeks of age, when the deviation is less than 40 and is intermittent and variable.

But with cases at constant deviation of 40 , those presenting after 10 weeks of age will have a low likelihood of spontaneous resolution. The group established a clinical profile to determine when persistent esotropia is expected, constant esotropia: at least 40 , refractive error less than 3 D of hyperopia and stable or increased angle at their second exam. Investigators felt that at that point, surgical correction at 3 to 4 months of ago could be reasonably considered.

Their rationale was getting the child straight early; that for possible development of binocular vision, the critical period is controversial but appears to be in the first 3 to 4 months of life for humans, and that stereopsis develops rapidly and is nearly completed in infancy. What are your thoughts and comments on the study, and what are your feelings as to early surgery for congenital infantile esotropia?

Scott E. Olitsky, MD: One of my first questions when reading through this study was what would our endpoint have to be to justify earlier surgery? I would be seeing more children at an earlier age who might resolve, and an increased number of returns for follow-up visits to make sure their angles are stable at an earlier age. To change my practice pattern I would have to see that the results of the surgery decrease risks of further surgery. Does binocular vision improve in that group, and are those patients less likely to ever require another strabismus surgery later in life?

I think another important question is what would be the effect of earlier surgery on the development of dissociated vertical displacement (DVD) and inferior oblique overaction (IOOA)? If early surgery helped prevent those occurrences I could buy into the idea of operating earlier, but until I see that, I don’t think I will.

Dr. Gold: Dr. Sondhi, your group was one of the clinical groups involved in this investigation?

Naval Sondhi, MD: Yes. First of all, this study group’s observation — that the strabismus that manifests very early on (less than 20 weeks of age) has a percentage of babies that do get better — corroborates some of the early infant motility studies that showed most babies have intermittent exotropia. A very small percentage have an intermittent esotropia, and for the most part these tend to improve in the first 2 to 3 months of life. That part backs up the earlier studies.

As far as getting an esotropia that is established by 3 to 4 months of age that is clinically and reliably diagnosable, I think it is a very doable thing. If you follow these children early on, you are able to establish that diagnosis. Unfortunately, in clinical practice, we still rarely get patients sent by that age.

We just had a paper presented here at the AAPOS meeting by Lawrence Tyson, MD, from St. Louis, which showed some abnormal connections in the visual cortex that if disrupted early resulted in patterns consistent with congenital esotropia findings. Yet if restored early they may — and I underline the word “may” — help prevent some of the problems we see with congenital esotropia (ie, absence of binocularity and the problems that stem from that). I would agree with Dr. Olitsky that we need a long-term study to do that, but nothing I have seen so far tells me that operating earlier has a negative effect on the long-term outcome. Whether it is significantly better … I think the jury is still out on that.

Kenneth P. Cheng, MD: To me, the patients who resolved are not true infantile esotropia patients. The study stated that these are the patients who were intermittent, and in whom the variation was smaller (less than 40 D). That’s not an infantile esotropia patient to me. I think this is a different subset of patients.

Regarding the early surgery, I think the jury is still out on whether these patients are going to do better or not. Just from a more practical standpoint, it is difficult to get those patients in and surgery performed at less than 3 months of age. It has to be recognized by the parent, then evaluated by the pediatrician, then the referral and appointment has to be obtained, then the patient has to be seen by the surgeon and the accommodative component eliminated with a brief trial of Phospholine Iodide (echothiophate iodide, Wyeth). Even if the patient is just assumed to have infantile esotropia and scheduled for surgery, to squeeze all that into less than 3 months is a difficult task.

It is not impossible, however, because we do treat congenital cataracts at this age range. I will need to be convinced, though. In doing the surgery, the practitioner needs to be careful that the numbers are smaller on these patients. When you are operating on a 3-month-old baby, that eye is in fact smaller than what we’re used to. A 5.5-mm-plus recession on an eye that’s got an axial length of only 19 mm is a different situation than what we are used to. I believe surgical measurements are going to be adapted, although as I have never operated on a 3-month-old for infantile esotropia I do not know for sure.

Anthony P. Johnson, MD, FACS: Dr. Cheng’s viewpoint is consistent with my personal experience. An example would be a 4 month old, +2.5 in both eyes, with a 35 D, 40 D or larger esotropia that seems to be stable. I will have followed him to make sure he is stable. I will do these cases before the patient is 6 months old.

Anecdotally, my overcorrection on those cases is greater than any other patient population set that I operate on (I have not actually gone back to analyze the data). Although I know that when high hyperopes, even if 6 to 8 months old, do not respond to glasses, they often overcorrect after surgical intervention. So I always want to make absolutely sure they do not correct with glasses before I recommend surgery. It makes me feel like there has got to be some kind of accommodative component there. Whether it is that the axial length is less and we are not adjusting for it or if this is just a population of patients that is more unstable is hard for me to reconcile.

Another point I find interesting is Dr. Olitsky’s comment about his recent article on critical time for visual maturation. Knowing he is not inclined to operate earlier until he sees further data makes me feel better about not operating any earlier until some of these questions are answered.

Dr. Gold: I’d like to go around the table and hear the earliest times you will operate. Dr. Olitsky?

Dr. Olitsky: I operate when they first come in; I generally do not see patients a second time when the diagnosis seems to be obvious. Usually it has been 4 months, and it is technically more challenging than a 6-month-old. That 6 weeks of age makes a big difference. I think what Dr. Cheng said about the mechanism to get them in earlier is going to be somewhat difficult, but not impossible. The rationale behind bringing in the congenital cataract patient as early as possible is a little different from what we are talking about here.

Dr. Sondhi: I have operated on a few occasions on 3- and 4-month-old patients. I do, however, see them on more than one occasion just for the reasons the study mentioned. I want a stable angle that I can see on more than one occasion. There is enough information out there discussing the fact that you do need to do smaller surgical numbers for these children, and adjust the surgery appropriately.

The research on trying to determine the long-term beneficial effects has been attempted, but with small study sizes. In two children — I think one was 2 months old and one was 3 months old — who underwent early surgery for esotropia, stereopsis was checked using complex stereovision testing mechanisms. Both children who had classical congenital esotropia showed restoration of stereopsis for a very short period only. Multidiscipline longitudinal studies will be required to study this complex problem.

When to perform surgery

Dr. Gold: Dr. Johnson had talked a little bit about glasses, which sort of segues into the question concerning the level of hyperopia you would correct in an infant prior to a surgical decision. It is a question that gets asked all the time and may not have one right answer.

Dr. Johnson: I usually will prescribe +2 and above on the cycloplegic refraction, even when it is in a clinical setting and it appears that it probably has nothing to do with an accommodative component, simply because I have seen a few in which even if it didn’t control the esotropia, it did decrease it some. This gives me a different target to operate for when we do the surgery.

Dr. Cheng: I use a lot of Phospholine Iodide, so I was quite distressed when it was removed from the market. I am happy that it is now temporarily back on the market. I am hoping there is not too much of a lag when it disappears again, before the company starts manufacturing it again. While it was unavailable, and if it disappears again, I will be putting babies in glasses at maybe around 2.75 of spherical equivalent. I like to see that to be reassured that there is not any accommodative component.

I have seen a number of patients improve some, but not enough to avoid surgery. I have seen patients go from the large angle of 60 or 70 to 35 . I still think that they are infantile esotropes; they have the characteristics that suggest it present from birth and not that much hyperopia, but they improve some. It’s not just that unusual kid who is +5 or +6 who will benefit.

Dr. Olitsky: I do not have a hard-and-fast rule. I look at age of onset, size of the angle and hyperopia. For the child who has classic infantile esotropia (crossing shortly after birth, a large deviation of around 60 or 70) who happens to have a higher level of hyperopia than his age-matched peer, I still think that child has infantile esotropia and needs surgery. I tend not to put them into glasses. I would for a very large amount of hyperopia, +5 or +6, but I think my numbers would probably be higher.

Dr. Sondhi: Probably +3D error would be the lowest I would prescribe glasses for. If you have a child that has a 40 D or 50 D esotropia and you try +2.50, and it goes to 35 D, which number do you operate for? I think the very small response to the hyperopic correction can be disregarded and the child treated with surgery for the full deviation.

Dr. Cheng: I cut back slightly on my numbers to avoid an overcorrection. Most of those patients will still end up doing fine without the glasses, so I don’t cut back much. I will end up doing a “long 5 mm.” I will warn the parent ahead of time that it would not surprise me at all if the patient will need glasses shortly after surgery, as I warn all these parents that at least 40% of the children will need glasses at some point in life for accommodative esotropia anyway. It probably does not change how I practice tremendously, but it is still a step that I feel more comfortable with because I do something a little different, depending on the response to the Phospholine Iodide. I cannot say that I have ever done it the other way and just gone ahead and operated, and it probably would come out the same. That’s just the way I do it.


Dr. Gold: I want to talk about optical dispensing in a pediatric ophthalmology practice. Around this table, three of us have optical dispensaries and two of us do not. It will allow us to have some discussions of pluses and minuses.

In an AAPOS workshop, I discussed the benefits of the one-stop shopping approach, convenience and patient confidence. I discussed some of the business models, and also fears about starting an optical dispensary: alienating referral sources, space consideration of the office, cost and other possible hassles. I would like to ask for comments on your experiences, why you do or do not do it, and whether those who are currently not offering this feature will be considering it for the future.

Dr. Johnson: I have had experience dating back to 1990. I was at the same place in 1990 that many of my colleagues are today, in terms of fear, concerns and treading in the area of the unknown. After having seen many children whose parents felt they did not have the options they needed to get quality eyewear, and seeing some of their frustration, it made me begin to explore the possibility that it could be a doable situation and one that could potentially benefit the patients.

All of my partners are adult ophthalmologists, so most of our optical care is for adults; however, we have a large pediatric portion of the practice. It has been a real blessing for these families to know that when they choose to use our optical shop, they will get top-quality care and that I am doing the very best that I can from a professional standpoint to examine their children and provide the proper prescription. They want the same care and concern that comes with the appropriate eyewear and have the confidence that, since their children are not old enough to tell them either way, it was done properly and in accordance with the prescription that was written. This is a very fair and cost-effective way to do that for them.

I think anyone who is considering it will not feel the way I feel about it until they have been through it and have the experience of dealing with happy moms who say, “Gosh, I really appreciate you doing this.” I would not go back and have any second thoughts about it. It has been a very positive thing for our patients.

Dr. Olitsky: The main reasons that we do not do it are really space and location. The main office practice is within the hospital, which unfortunately doesn’t have the space for it. It’s also not in the easiest place for patients to get to for that service. I think if we were not in that location, or there was another way of delivering that service, it is something we would look into.

Dr. Cheng: I think the decision needs to be very much individualized to your practice. I am a solo practitioner, and my patient base is relatively wide geographically. Clearly there are many patients who are going to be far better off getting their glasses fixed, adjusted and repaired locally. Also, being a solo practitioner, the volume of eyeglasses I am going to provide is going to make it much more difficult to meet the required volumes necessary to justify the added employees and complexities of space management.

Additionally, if you are in a multispecialty group or with adult ophthalmologists who will also be using the services, it clearly makes sense to provide pediatric eyeglasses as well because the space and the infrastructure are already there. I think anyone doing it just for children needs to consider that the types of markups involved with children’s glasses are much less than those for adult glasses. For an adult to spend several hundred dollars on a pair of glasses is not unreasonable because they are like a piece of jewelry. It is a very prominent piece of jewelry to an adult patient. However, for a 7-year-old who is going to break four pairs of glasses a year, to spend that kind of money on glasses is foolhardy.

For example, there are not the added markups such as the progressive bifocal, antireflective coating or a separate pair of sunglasses. On children’s glasses the markups are much lower, and the profit margins are much lower as well. What you have to absorb in terms of warranty work, repair work and the time that it takes your optician to fit, adjust and fix glasses, is all going to sap that margin. When I was in a practice that had pediatric eyeglass services, it was a lot of extra work with little extra profit. Plus, the patients could get adequate services closer to their homes. It is important, though, for you to identify shops where your patients can go to get quality work, and that is not always so easy. At some point, if I cannot continue to find places where my patients can receive good care, I may very well try to set something up.

Dr. Sondhi: Having been for a long time a naysayer, I had opted against a dispensary in the office. Just becoming a recent convert, I have had a great deal of headaches in going through some of the growing pains. I am optimistic, however, that it is a good idea for me to have this feature in my practice and I am looking forward to it.

Dr. Johnson: I think those are excellent points. One thing that has really surprised me is that my patients come from a fairly large geographic area, maybe a 60- to 70-mile radius, and there are clearly options that are closer to them. There have been times when I have actually encouraged them to use places closer to home and even identified a quality place for them; they realize we do a huge number of children’s glasses and recognize that quality. But they found other reasons to come back to Greenville, so it was not as big of a burden as I had thought it would be for them to return in a couple of days to pick up the glasses. Several times a month I see moms who choose to come anyway, even though I try to talk them out of it. I have been very surprised by that.

Another example, slightly unrelated, was a situation in which the child had accommodative esotropia with a high AC/A ratio, and also had a nonaccommodative component. She came from about 60 miles away. She had already been in single-vision glasses, and it was obvious to her referring doctor that the child was going to need surgery. After I did the surgery, her mother recognized there was a very high likelihood that the child was going to need glasses — even a multifocal prescription. I recommended that she go with the flat-top bifocal for all the obvious reasons, such as cost-effectiveness and being the gold standard. But the mother told me not to worry; she would be willing to spend the money for it. Unless I could actually tell her it was harmful for her child to have a progressive lens, or that she could not switch back to the gold standard, she wanted to try it.

These were two consumer experiences in which I was trying to hold their hands and direct them; be consumer-friendly to them. But it was obvious that they already had another idea, and they were going to do what they wanted to do.

Dr. Cheng: You make a good point. I do know that my patients are getting their glasses somewhere else, and I honestly have not identified many problems with the “Kmart glasses.” I haven’t encountered many situations with bad glasses that are clearly hurting the child. On the other hand, I am sympathetic with the parents who would take a lot of comfort in knowing that appetizers to dessert, so to speak, was being taken care of under my supervision. I think that is something to consider, and I am not oblivious to it. It may very well be that patients like the one-stop-shopping, but in my particular circumstances it is hard to weigh that balance.

Dr. Sondhi: There is also the issue that most of our families come with more than one child in tow. There is usually one patient and two or three other children, and to hand them a prescription and tell them to go out and look for some other place is just inconvenient. Most appreciate the one-stop shopping.

Also, from a medical standpoint, I am concerned that a lot of children are going to get glasses they don’t need. I think it already happens some right now, but there is potential for it to happen a lot more in the future. If you are able to satisfy their optical needs, they don’t have to go somewhere else, get examined and maybe get glasses that they don’t need.

Dr. Gold: One of the stimuli that caused me to start my optical dispensing 4 years ago was the desirability of taking care of my patients in a complete way, from beginning to end. I also wanted them to have confidence in me, not only as a physician examining their child but in me personally — in the prescription I am giving them and the eyeglasses I am now dispensing to them. My experience has been quite positive, but as Dr. Cheng said, it is an individual decision. I hope pediatric ophthalmologists continue to make those decisions as they grow with their practices.

Airbag injuries

Dr. Gold: We wanted to talk a little bit about a practical problem that is occurring infrequently: airbag eye injuries in children. I want to ask the members of the panel about their experiences.

Dr. Johnson: In the past 6 months I have seen two children with severe eye injuries due to airbags; each had one eye injured. I have wondered what other doctors’ experiences were with this, and I was a little surprised when I looked at the links on the American Academy of Pediatrics’ Web site and realized that it is not higher on the radar screen. Maybe I have just seen a couple of unfortunate children and it is not really that big of an issue.

The first child was a 6-year-old girl who was riding in the front seat. They had a head-on collision at around 30 or 40 miles per hour. She was hospitalized for the weekend but did not have a closed head injury or any long-bone fractures. But her face had been dermabraded from the airbag impact. She also had severe cornea edema. I couldn’t really view the anterior chamber, iris or lens for at least a week, and the cornea did not completely clear for about 3 weeks. She sustained a traumatic cataract for which she has now undergone surgery. She is patching now because she is just a little amblyopic, but she does have 20/25 vision in that eye.

The other child was a 12-year-old, also suffering passenger-side airbag injuries. The child had severe corneal edema and hyphema that was persistent for several days but did not require washout. Weeks of topical steroids were required because of anterior segment inflammation. Eventually a total post-traumatic cataract developed, and the patient is now about 1 month out of surgery. The surgery itself was uncomplicated, but she has had persistent submacular blood since the accident and is 20/200. She has improved from light perception, but I am sure she will never be any better than 20/200 because of the macular changes.

My concern is that despite the fact the 6 year old was in violation of basically all the recommendations, the 12 year old was basically adult size, so this could be affecting adults as well. My concern is whether we as an organization need to make this more visible to the governing bodies or appropriate organizations, or if this is uncommon enough that even though these children are injured by airbags, it is an OK tradeoff due to the fact that airbags decrease the incidence of traumatic brain injuries.

Dr. Gold: We are not questioning the efficacy of airbags because we know that they save lives. But as we get more experience with airbag deployment, we are also going to see more and more injuries. The injuries could include traumatic cataracts, hyphema, facial burns, glaucoma, corneal abrasions and corneal edema, among others. So this is why we bring it up, just to make people aware. There are eye injury databases supporting this.

Dr. Olitsky: I have seen a few of these, fortunately none as severe as what we just talked about. Mainly the problems were corneal abrasion, hyphema and corneal edema, which is probably now realized to be secondary to endothelial cell damage. Most of those children have done well. I think the reporting mechanism should be something to look into. Maybe if we consistently report these we can find a profile of a passenger size or age that is more likely to sustain these more severe injuries with long-lasting visual complications.

Dr. Sondhi: There is a mechanism in place for that. It is called the National Eye Injury Registry, and they do encourage everyone to report those cases.

There is one thing with airbags, in my mind, that involves [the automobile industry’s] science and evolution. The injuries reported so far are with the so-called “first generation” airbags that deploy at full velocity once triggered. The whole mechanism they are designed around is for the bag to be fully inflated before the body comes in contact with it.

The problem occurs with children who will be thrown forward more quickly than an adult will, and who will come into contact with a deploying airbag. I think the industry has recognized this — not necessarily based on children’s injuries but just in general — and is already in the process of employing second- and third-generation airbags. These will deploy at a slower rate in slower-speed impacts, and at a higher rate in higher-speed impacts. They will also only deploy to 70% or 80% of their full size in the lower-speed impact crashes. I am hoping some of these things will improve, thereby decreasing some of the common injuries we see.

One of the figures I found in the literature that is very concerning is that 34% or 35% of accidents involving children under 10 result in deaths due to airbag deployment. There is obviously a long way to go to minimize ocular trauma and still maintain lifesaving capabilities.

For Your Information:
  • Robert S. Gold, MD, can be reached at Eye Physicians, 225 W. State Road 434, Suite 111, Longwood, FL 32750; (407) 767-6411; fax: (407) 767-8160. Dr. Gold has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
  • Naval Sondhi, MD, can be reached at Midwest Eye Institute, 201 Pennsylvania Parkway, Indianapolis, IN 46280; (317) 817-1333; fax: (317) 817-1331. Dr. Sondhi has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
  • Anthony P. Johnson, MD, FACS, can be reached at 131 Commonwealth Drive, Suite 390, Greenville, SC 29615; (864) 458-7956; fax: (864) 458-8390. Dr. Johnson has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
  • Kenneth P. Cheng, MD, can be reached at 1000 Stonewood Drive, Suite 310, Wexford, PA 15090; (724) 934-3333; fax: (724) 934-3371. Dr. Cheng has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
  • Scott E. Olitsky, MD, can be reached at Children’s Hospital of Buffalo, 219 Bryant St., Buffalo, NY 14222; (716) 878-7204; fax: (716) 888-3807. Dr. Olitsky has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.


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