The pediatric eye view

Dear Friends

Pediatric ophthalmology is a sub-specialty of ophthalmology associated with various congenital and acquired eye disorders, their impact on vision and their appropriate care. In a year, around 70 million cases of blindness have been reported to occur due to childhood ophthalmic disorders[1] and around 30% of the blind in India lose their eyesight before 20 years of age[2,3] with refractive errors, squint, vitamin A deficiency being the major contributors.[4] Considering the longer years of blindness from the loss of vision at a very early age, as a measure of priority World Health Organization (WHO) initiated the “Vision 2020: The right to sight program”.[5] Children being the vulnerable population for conducting clinical research; such trials are challenging.[6] Few of such challenging clinical studies are discussed in this issue of the Indian Journal of Ophthalmology.

The first one by Azad et al. evaluates various diagnostic modalities for children with congenital glaucoma. Congenital glaucoma is a rare entity manifesting at birth or within 3 years of age with two-thirds of the patients being diagnosed by the age of 6 months and 80% within the first year of life.[7] The triad of suspect includes watering eyes, photophobia, and cloudy cornea. The mainstay of evaluation is examination under anesthesia with a gonioscope or ophthalmoscope.[8] Despite being reliable, the hazard of administering anesthetic agents poses a threat.[9] Hence, there was a need for a technique that is safer without the need for administering anesthetic agents and RetCam is one such modality. This study was conducted on a total of 20 patients and was found to have better quality and higher magnification as compared with the indirect gonioscope. The promising results of this noninvasive modality should be considered within the scope of limitations as the sample size is small. A similar entity is primary juvenile-onset open angle glaucoma although this is primarily seen in individuals less than 40 years of age. The mainstay of treatment for this condition involves glaucoma filtering surgery. The use of mitomycin C for glaucoma filtering surgery is still contemplated upon. Pathania et al. has put forth his retrospective analysis on outcome of patients after performing trabeculectomy without mitomycin-C over a period of 12 years. The group had observed success rates to an extent of 92%, 89%, and 80% after 1, 3, and 5 years following the intervention, concurrent with the other reports in literature.[10,11]

Learning disabilities (LD) are a diverse group of disorders in which children, possessing at least average intelligence, have problems in processing information. Learning disorders in children range from mild intellectual to specific LD. The latter has been observed at a frequency of around 10–15% in school children.[12] A study from Pune estimated that nearly half of the children with LD have ocular disorders of which 30% have ocular disorders with uncorrected refractive errors.[13] Diagnosis of childhood emmetropia is similar to adults, with various charts for acuity testing that require a little understanding and coordination from the patients, which may not be possible in children with LD. Ambiguities persist with regard to the appropriate method of testing.[14] Bakar et al., in this issue, has discussed a study that had evaluated the testability potential of various charts for visual acuity, stereo acuity, and color vision perceptions among children studying in special schools. The group found that the nonverbal approach that needs lesser communication skills, works better. Similarly, such children require appropriate intervention to enhance their reading cum learning abilities. Kumar et al., in this issue, discusses about the efficiency of low vision care in children with multiple disabilities and visual impairment using a novel N of 1 study design.

This issue also features a randomized controlled clinical trial on children with ambylopia by Pawar et al. Ambylopia is the most frequent cause of monocular visual impairment in both children and adults.[15] A recent estimate from southern India shows that around 1% of school children are affected by ambylopia and nearly a third, having severe form of the disease.[16] After ruling out the organic causes for visual abnormalities, refractive errors have to be corrected. Following this, occlusion therapy of the amblyopic eye with patching is necessary. Although placed either as a part-time or throughout the day, the results of patching were not satisfactory especially over long term.[17] Citicholine is a novel compound with a neuroprotective effect, currently employed in the management of vascular dementia and Alzheimer's disease.[18,19] The results of the present study were promising with a significant improvement in the visual acuity. The study is limited by the fact that the patients were followed up only for a year and hence, the long-term effects of the intervention are unknown.

Hope this issue would be an eye opener for changing trends in pediatric ophthalmology and keeps your vision occupied till the end.

Happy reading!!!