Pediatric ophthalmology is now globally recognized as a specific subspecialty. Pediatric ophthalmology care in 2018 is no longer something general ophthalmologists do as an adjunct to their predominantly adult clinical practice. It is instead delivered in dedicated pediatric ophthalmology clinics by teams of experienced childcare professionals. Advances in diagnostic and imaging techniques originally developed for adult patients (eg optical tomography (OCT), widescreen digital imaging (Optos), and modern fluorescein angiography) have expanded the options for pediatric screening.
Easily available genetic testing has changed the way we approach the screening and management of children with rare and complex eye diseases. The application of new diagnostic techniques for deep phenotyping in combination with genetic testing enhances the accuracy of diagnosis and prognosis. This now enables the introduction of true ‘customized’ medicine for children with rare eye disorders.
Equally important, a growing awareness of social and protection issues has led to improved child protection strategies across pediatric healthcare to ensure that physicians and their teams better protect children from harm.
We believe that these advances in medical and surgical care will ensure that pediatric ophthalmology remains one of the most exciting subspecialties of the future. Additionally, recent regulatory changes mean that drug companies must consider the needs of children as well as adults when seeking a license for new treatments. In the future, doctors should be able to prescribe medicines to children who have a better evidence base for efficacy and safety. We anticipate that the need to grow and enhance the currently limited evidence base for much of pediatric eye care will lead to further research and, in particular, the creation of new clinical trials in this area.
Changes in the way children are cared for in pediatric ophthalmology
Children in 2018 are rarely seen in a “general” clinic that is predominantly adults, and are more likely to be evaluated in pediatric clinics, with dedicated facilities for children, and by experienced staff with appropriate protection training. This has greatly improved the experience of caring for children and their families. The majority of consultants who deal regularly with children now have an interest in subspecialties in pediatric ophthalmology, usually after fellowship training after CCT.
Pediatric ophthalmology clinics require multidisciplinary expertise. Orthoptists have traditionally played a key role, but other allied health professionals (AHPs) such as pediatric optometrists, visionologists, and eye clinic liaison officers (ECLOs) play an important role in the delivery of high-quality pediatric ophthalmology. AHPs often work independently, both within a hospital setting and in community clinics, and support traditional outpatients by working closely with pediatric ophthalmologists. Clinics are ideally supported by pediatric nurses with appropriate training and experience. An example of current modern practice is orthopedic-led clinics/in both the community and hospital. This can include specialized follow-up clinics, for example, pediatric cataract, or uveitis led by orthoptists or optometrists, which operate in parallel with a clinic led by a consultant.
All personnel working with children now receive mandatory protection training. This helps ensure that child protection issues or signs of abuse are detected and acted upon appropriately.
Advances in Imaging and Diagnostic Tools
Accurate assessment and monitoring of eye diseases in children has always been a challenge. It can be difficult to screen young children and children with neurodevelopmental problems. They may be anxious, upset, or upset and thus fail to cooperate fully. Physical limitations can also present limitations when using tools and techniques designed for use in adults. In the past, doctors often resorted to “examination under anesthesia” (EUA) for a child in whom it was impossible to obtain an IOP measurement or when a fundus examination was similarly difficult but very important. The availability of i-Care reflex tonometry, which can be used rapidly, without eye drops, on a child with minimal cooperation , has significantly reduced the number of EUAs performed. This has been particularly useful for children with conditions such as glaucoma, aniridia, or facial port wine stains, where regular IOP measurement is an important part of assessment and monitoring, but repeated anesthesia carries concerns about the effect on neurodevelopment.
Advances in treatment options for children with eye diseases
The last quarter of a century has seen many changes in the way we treat eye disorders in children, both medically and surgically. There have been simultaneous changes in care pathways and massive improvements in surgical equipment and techniques.
Advances in our understanding of the natural history of strabismus and the role of refractive error in the etiology of strabismus has led to more conservative management and less strabismus surgery being performed on the children in the UK. Thus there was less need for re-operations. Alternative treatment options such as “chemical blocking” of the extraocular muscles with botulinum toxin (Botox) have been introduced over the past 30 years for the management of strabismus in children with results similar to surgery for the management of esotropia in children . Botox is particularly useful in the treatment of severe medial strabismus (with or without sixth nerve palsy). This may also have contributed to less surgery and better results.
Advances in surgical instruments and techniques used in the pediatric intraocular surgery have reduced complications and improved surgical outcomes. In pediatric cataract surgery, performing posterior capsulotomy and anterior vitrectomy at the time of lensectomy reduced the rates of optic axis re-opacification. The use of smaller incisions (23 and 25 gauge), a non-traumatic surgical technique and strict anti-inflammatory regimens in the perioperative and postoperative period have reduced postoperative inflammation. It is possible, as in adults, that the use of intraocular antibiotics in surgery reduced the rate of postoperative endophthalmitis. Other major advances include a better understanding of the indications in the management of pediatric and childhood glaucoma for different surgical procedures – notably the increasing role of newer Seton devices (eg Baerveldt and Ahmed tubes) for congenital and unstable glaucoma.