Why cataract specialists need a good knowledge of paediatric ophthalmology, even if they do not specialise in paediatrics and strabismus.
With the World Society of Paediatric Ophthalmology and Strabismus (WSPOS) Congress just around the corner, a very relevant question that needs to be asked is: “Do cataract specialists need a good knowledge of paediatric ophthalmology even if they do not specialise in paediatrics and strabismus?” Would it be a waste of time and resources to gain a working knowledge of this sub-speciality? The only way to know this effectively is to look at the possible advantages of having this knowledge.
According to a Google search, children form 27-35% of the world population, even rising up to 40% in areas like India, Africa etc. Since most cataract surgeons are also general ophthalmologists, we frequently see children, form the first point of contact, and therefore automatically become charged with the responsibility of keeping these young eyes healthy as well as treating them, or at least directing them towards appropriate treatment, if required. It is therefore important to be aware enough to clearly differentiate what needs and what does not need to be referred to a sub-specialist. This knowledge may be even more important in health systems where it is either difficult or expensive to meet a specialist, let alone a super/sub-specialist. With the strained health setups in most countries, smaller departments often have doctors multi-tasking, and it is not infrequent to have to examine, diagnose and treat children.
Plain non-availability of a paediatric ophthalmologist can put the onus of treating children on general ophthalmologists. According to an Indian study, only 28.7% of institutions provided paediatric eye care, and out of these it was only the advanced eye care hospitals that attended to larger numbers of paediatric patients and performed more paediatric surgeries, as compared to even secondary and tertiary eye care hospitals. Even in health setups with highly specialised separate paediatric ophthalmological departments, often the same set of adult sub-specialist doctors work together, but at a time or in a space meant exclusively for children. Thus, manpower shortage, high workload and shortage of dedicated facilities all contribute to the general ophthalmologist necessarily having to take up some of the responsibility.
It is therefore very important for every ophthalmologist to be knowledgeable about childhood diseases. There are many conditions where the non-specialist can easily start treatment, such as initiating massage for congenital nasolacrimal duct obstruction, prescribing glasses for refractive errors, convergence exercises, amblyopia therapy etc. Genetic conditions may be advised counselling and family screening by the cataract specialist. Diseases that children are prone to – both the rare, such as retinoblastoma, and the common, such as a simple refractive error – should be identifiable by every ophthalmologist, as consequences of delayed treatment of these can be grave. Every ophthalmologist also needs adequate training in the management of emergency conditions, accidents and injuries such as chemical burns, pencil stick injury, greenstick fracture of the orbit etc, which children may be prone to get.
Even specialists who limit themselves only to adult patients may come across patients who had childhood onset of a disease that has progressed into adulthood, eg refractive error, juvenile glaucoma, aniridia, keratoconus etc. Many of these conditions need treatment well into adulthood and can present at multiple points during the spectrum of progression. Knowledge of various stages in the disease gives the specialist a wider perspective regarding different possibilities and various diagnostic and treatment modalities.
Dr Kuheli Bhattacharya, Paediatric Ophthalmologist, Spectrum Clinic, Goa, says: “Squint – congenital or acquired – can point to dominance and is of importance in deciding which eye to operate on first. In addition, in patients with unilateral high uncorrected refractive error, part of visual loss may be secondary to amblyopia and the patient needs to be counselled accordingly to avoid postoperative disappointment.”
Dr Manjula Jayakumar, Paediatric Ophthalmologist, Dr Agarwal’s Eye Hospital, Chennai, goes on to add: “Patients with intermittent strabismus and good fusional control may decompensate with onset of cataract and present with frequent intermittent diplopia. They would benefit with a simultaneous surgical approach to both cataract and squint. Some patients with manifest strabismus undergoing combined cataract and squint surgery may complain postoperatively of diplopia for a few weeks following alignment if the patient had anomalous retinal correspondence. Preoperative diagnosis with a red filter after neutralisation of squint with prisms is important, as is counselling.”
Many times, ophthalmic sub-specialists are called to operate upon children with diseases in their fields of specialisations. It is therefore not infrequent for the cornea specialist to perform paediatric deep anterior lamellar keratoplasty, or the glaucoma specialist to implant a tube shunt. And for paediatric cataracts, who better than a cataract specialist to perform surgery, provided the nuances of paediatric cataract surgery and IOL power calculation are known!
For successful outcomes, surgical differences between paediatric and adult eyes must be understood, and therefore a knowledge of paediatric ophthalmology is important. Smaller size, lesser space, lower scleral rigidity, thicker Tenon’s tissue, greater elasticity of anterior capsule, greater chance of a peripheral capsular run-out, need for primary posterior capsulotomy and vitrectomy, greater proclivity to inflammation etc, are some differences that the ophthalmologist should be aware of to modify surgical steps accordingly. Even if the primary care/surgery has been carried out by a paediatric ophthalmologist, post-surgical care often comes back to the primary or secondary care ophthalmologist practising near the patient’s native place.
Postoperative care of children differs significantly from adults in terms of medication, dosage, difficulties involved in examining and investigating, special examination techniques required, greater need for examinations under anaesthesia, higher chances of emotionally labile attenders and so on, and the general ophthalmologist needs to be aware of these. Synergy between various levels of paediatric care as well as sound basic knowledge is therefore a must.
Taking all the above contexts into consideration, it is evident that all ophthalmologists do need a good knowledge of paediatric ophthalmology, and it is up to us to educate ourselves adequately!
Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation and Senior Consultant, Cataract and Glaucoma services at Dr Agarwal’s Eye Hospital, Chennai, India. She can be reached at firstname.lastname@example.org.