Page 22 - May 2024 SAM PDF
P. 22

EYE CARE AND
        EYE CARE AND                                                                                                                                                                                                    EYE CARE AND
       QUALITY OF LIFE
      QUALITY OF LIFE                                                                                                                                                                                                 QUALITY OF LIFE


                                                                                                                                    t’s a busy Tuesday in the Pediatric Ophthalmology clinic. Our first   others, particularly with regard to getting the dilating eye drops, but
                                                                                                                                    appointment involves a worried mother of a 6-month-old boy who   most all can be coaxed through their examinations through a mixture
                                                                                                                                Iis concerned that he may have crossed eyes. After the usual com-  of spinning light toys, movies on the television in the room, singing and
                                                                                                                                 plete eye examination and refraction (checking for a need for glasses),   various other distractions.
                                                                                                                                 the child is found to have only epicanthal folds but not true esotropia.   Around lunchtime, adult strabismus patients are scheduled. These
                                                                                                                                 The mother is reassured that he has normal eyes and no treatment is   patients can have quite complicated forms of strabismus, with etiolo-
                                                                                                                                 needed at this time. She is given a pamphlet with photos to demon-  gies ranging from broken-down childhood strabismus, restrictive or
                                                                                                                                 strate the difference between pseudostrabismus and true esotropia, and  mechanical problems such as scarring from previous trauma, retinal or
                                                                                                                                 the child is scheduled for a six-month follow-up with the Orthoptist to  glaucoma surgeries, or Graves’ disease. Others may have extraocular mus-
                                                                                                                                 double check the eye alignment before discharging the patient.  cle weakness due to cranial nerve palsies, damage due to neurological
                                                                                                                                   The next patient has a similar presentation. The 7-month-old girl’s   problems such as tumors, or neuromuscular issues such as myasthenia
                                                                                                                                 parents note that the family has been seeing the left eye crossing con-  gravis. Examination of these patients can be quite time-consuming, and
                                                                                                                                 stantly since the child began to make good eye contact. After a similar  often starts with an extended examination of their eye alignment with an
                                                                                                                                 examination, she is found to have a large angle of esotropia (crossing of   Orthoptist prior to meeting with the Pediatric Ophthalmologist. Addi-
                                                                                                                                 the eyes), along with amblyopia in the left eye, but an otherwise normal   tional workup is often needed, including imaging and laboratory studies.
                                                                                                                                 eye examination. The family is counseled that she has infantile esotropia  Each patient is counseled at length regarding treatment options. While
                                                                                                                                 and amblyopia. Because the right eye is becoming preferred, the parents   observation is almost always an option for adult strabismus patients,
                                                                                                                                 are given patching over that eye to correct the amblyopia. Older chil-  most have chosen to come to a pediatric office because this was no lon-
                                                                                                                                 dren with amblyopia may also be treated with atropine drops, but in  ger working well for them and they are seeking other treatment options.
                                                                                                                                 younger children, patching is more frequently used. The parents are also   These can include prism glasses, particularly for elderly patients with
                                                                                                                                 cautioned that it is very likely that she will require strabismus surgery  diplopia who normally wear glasses and have only small eye deviations.
                                                                                                                                 to correct the eye alignment once the vision is equal in the two eyes.   Many of the adult patients, however, ultimately opt for surgical cor-
                                                                                                                                 They are also informed that sometimes more than one surgery will be  rection to correct functional problems such as double vision, eye strain
                                                                                                                                 necessary. Follow-up is scheduled in two months to recheck vision with   or fatigue, or social issues such as being asked who they are talking to, or
                                                                                                                                 the Orthoptist.                                       why they aren’t making eye contact with someone. Interestingly, many
                                                                                                                                   Later in the morning, a 3-year-old boy is brought in for the new  of these patients are quite surprised to hear that surgical correction is an
                                                                                                                                 onset of crossed eyes. He has no other neurological issues and is doing   option, as they have been told for years that they are “too old” for stra-
                                                                                                                                 well developmentally. His examination shows intermittent crossing of   bismus surgery, though that is rarely the case. We have corrected patients
                                                                                                                                 the eyes but also, he is found to have a high degree of hyperopia (far-  as old as 90 years old, surgically, in order to improve their double vision,
                                                                                                                                 sightedness) at +5.00 diopters in each eye. Discussion with his fami-  which will hopefully improve their quality of life, restore the ability to
                                                                                                                                 ly includes the fact that normal farsightedness is no more than about   drive in some cases, and reduce the likelihood of falls due to stumbling.
                                                                                                                                 +3.00 diopters at this age, and his excessive farsightedness is causing the   When necessary, strabismus surgery is performed as an outpatient
                                                                                                                                 intermittent crossing. Fortunately, this is usually easily corrected with   procedure. Both general and local anesthesia are options in adults,
                                                                                                                                 glasses to eliminate the need for focusing, and the patient is unlikely to   though children are routinely done with general anesthesia. Surgeries
                                                                                                                                 require surgical correction. He will be seen for follow-up in a few months   are generally quick, lasting under 20 minutes of surgical time per muscle
                                                                                                                                 to ensure that the eyes are straight with glasses and the vision is equal,  corrected, plus anesthesia time. Patients generally only require topical
                                                                                                                                 but as long as both of these are the case, no additional treatment will be  treatment postoperatively, along with acetaminophen or ibuprofen for
                                                                                                                                 required.                                             pain. Patching is normally not necessary for children, though adults
                                                                                                                                   As the day progresses, another family presents with a concern that   may be patched overnight. The only statistically significant risk is that
                                                                                                                                 their 7-year-old girl’s eyes are drifting out intermittently, which has been  the patient may require additional surgery in the future, though for the
                                                                                                                                 occurring for a while but has worsened recently. Examination confirms   majority of patients, only a single surgery is necessary.
                                                                                                                                 that their suspicions are correct, with an otherwise normal examination.   After a long but interesting day in clinic, the staff and doctors go
                                                                                                                                 For this patient, the ability to control the drifting, or the lack thereof, will  home tired but satisfied with the problems solved today, and looking
                                                                                                                                 dictate the treatment plan. As long as the child has good control of their   forward to new patients that will present tomorrow. Sometimes allevi-
                                                                                                                                 eye alignment, then observation is prudent. If the control is poor, or is  ating the parents’ concerns is even more of a challenge than keeping the
                                                                                                                                 worsening over time, then various options for treatment are available. For   children calm and distracted, but this can normally be overcome with a
                                                                                                                                 younger children, a trial of alternate patching may help them to recognize   little extra time and a few more answered questions. At the end of each
        Pediatric Ophthalmology and Strabismus:                                                                                  the deviation when it is present, and therefore control it more effectively.  day, the challenges of treating the patients (and sometimes the parents,
                                                                                                                                 Overminus glasses (overcorrection of nearsightedness to induce focusing  too) provide a challenging and rewarding experience that keeps us com-
                                                                                                                                 and convergence of the eyes) can also sometimes be helpful but ultimately,  ing back day after day.
        Little Patients, Not So Little Problems                                                                                  surgical correction is an option if control remains poor.
                                                                                                                                   During the day, nearly 100 patients may pass through visits with the
                                                                                                                                 multiple providers in the clinic, with strabismus, amblyopia and other   Charles S. McCash, MD, specializes in Pediatric Ophthalmology
        By Charles S. McCash, MD                                                                                                 problems as varied as childhood cataracts, glaucoma, tear duct obstruc-  and Eye Alignment Disorders at the Children’s Eye Center of
                                                                                                                                 tions, chalazia, retinoblastomas, orbital cysts, ptosis and various other   South Texas. Dr. McCash is a member of the Bexar County
                                                                                                                                 eye problems. Some kids are more agreeable with the eye exam than   Medical Society.

         22     SAN ANTONIO MEDICINE  • May 2024                                                                                                                                                                     Visit us at www.bcms.org     23
   17   18   19   20   21   22   23   24   25   26   27