South Carolina Ophthalmologists on Performing a Pediatric Cataract Surgery

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Guest: Dr. Edward Wilson Jr.: - Ophthalmologist.

Host: Dr. Linda Austin – Psychiatry

Dr. Linda Austin: I am Dr. Linda Austin. I am talking with Dr. Edward Wilson, who is a Department in Chair of Ophthalmology at MUSC. Dr. Wilson, let us talk some more now about the process of what happens when a child is operated on by you for a cataract. Can you walk through the process that you go through first to evaluate that child?

Dr. Edward Wilson Jr.: Yes, when the child comes to visit us, most of the examination I need to do can be done after the child is asleep. So, I tell the parents that first thing I do is we have the child comfortably asleep in the operating room. I use ultrasound, I use the operating microscope to look carefully at the cataract and decide for myself if I think that it is visually significant and ready for surgery. So, at that point, I make sure that the nurses have not opened up any equipment; I can walk out to the waiting room and talk to the parents. So, I tell them whether I found anything I did not expect and whether at that last movement I agree with their other doctors that surgery is needed. Once that is understood and agreed upon then we have to remove the cataract. Now cataract is just a cloudiness of the lens in the eye, and the lens in the eye, like the lens of a camera focuses light on to the film, and in the eye the film is the retina. The lens has to be removed completely to get rid of the cataract, but we leave the sac or the lining of the lens, which is behind the pupil, we leave that in place and a new lens, which is made of acrylic plastic material, a foldable plastic is shrink-wrapped, if you will, in this empty sac. The lens of a child is soft and sort of gummy, and it is removed in a very different way than an adult cataract, which is hard and has to be broken up by ultrasonic energy. So, the machinery is different, but we remove the entire lens and we spray wash, if you will, we clean that sac as best we can. We either put the lens implant in that sac at the time of a cataract surgery or we leave that sac ready to receive an implant when the eye grows and the child gets bigger.

Dr. Linda Austin: So, is that only a question of size then?

Dr. Edward Wilson Jr.: It is not so much the size; with modern implants I can fit an implant into even a smallest eye. What it really is a matter of, it is a matter predicting growth; 90% of the growth of the eye is in the first two years, and when we put an implant in very young child’s eye, we are putting an implant that we hope will be good for the child’s life. So, in essence, we have to predict where that eye is growing to, and we leave some farsightedness on purpose, correct that farsightedness with glasses, let the eye grow into the power of the implant, the glasses get weaker and weaker until at some point they may be needed either seldom or not at all. The younger we put the implant in, the more we have to make a prediction about how much growth is going to occur. On the other hand, if a young child is left without an implant, we then use a contact lens, a silicon extended-wear contact lens, that the parents take out once a week and clean, wait for the majority of the growth to occur usually until the preschool years where most of the growth has occurred, we put the implant in then. It is much easier to predict the path when 90% of it is complete then it is at the very beginning. The advantages of having an implant even in a small baby are that most of the focusing power, 4/5th of the focusing power, is inside the eye and even when the glasses are removed, the eye sees pretty well. So, that is advantage. The disadvantage is that if we underestimated or overestimated growth then later on in the school years or the teenage years there may be more need for glasses than we had hoped for.

Dr. Linda Austin :Do you every replace the lens at that point?

Dr. Edward Wilson Jr.: We can replace the lens. We sometimes do that in young adults, but it is difficult because the implant we put in is, I use the term shrink-wrapped, it really is very firmly in place inside that sac. We have learned, we developed here at Storm Eye the methods, to reopen that sac carefully and remove the implant and place the new one in, but we don’t plan on doing that, we can do it but we don’t plan on it.

Dr. Linda Austin: It sounds you prefer not to if at all possible.

Dr. Edward Wilson Jr.: We would prefer not to.

Dr. Linda Austin: Now, I know that you yourself personally have done a lot of the research in work leading up to this, what were your contributions to developing these techniques?

Dr. Edward Wilson Jr.: Well, the technique most commonly used to remove pediatric cataracts and to open the sac, at least many of those techniques were developed Storm Eye.

Dr. Linda Austin: Here at MUSC.

Dr. Edward Wilson Jr.: Here at MUSC, and we have taken videos of those various techniques around to meeting for years and years, and every year we come up with new ways to more efficiently get the job done. So, I think the expectation often from the surgeons, who do this less often, is for us each year to give an update as to how to best do this procedure. So, I think the expectation of the ophthalmic community is that we will be leader and we will continue to innovate, and continue to advise other pediatric surgeons about what methods they should use.

Dr. Linda Austin: As well as train young residents and fellows, I am sure, in this procedure.

Dr. Edward Wilson Jr.: That’s true, now the pediatric cataract surgery is detailed enough and uncommon enough in the standard practice that our training tends to be only for those fellows or beyond residency folks who are going to set up a pediatric cataract practice in some other part of the country, the training aspect is not as active as it is with more common surgeries. The pediatric cataracts in a eye usually assure my partner referring pediatric ophthalmologist that surgeries have been done by me, and I think that is what the families expect, but we do have to have others around the country who are doing this and many time even if they are in practice, they will come and watch and observe and I will do the same, I will fly out there operating room and watch and observe. So, it is training but these cases are complicated enough that the individual child is not really subjected to, may be the same sort of training environment as you might expect at American University.

Dr. Linda Austin: Now back to the procedure itself, you, I gather, in most cases then will we place a lens, an artificial lens in the eyes?\

Dr. Edward Wilson Jr.: The intraocular lens today is standard after the first birthday so unless there are defects in that sac that is needed place the lens, after the first birthday when surgery is done after the first birthday the implant is standard. In the first year of life there is still a controversy, and when people asked me what would I do If it would be my child, I really don’t know. There are pulses and minuses for going in the two different directions. Now, because of that we started a study, a national study. I am on the Steering Committee for this study that is called the Infant Aphakia Treatment Study, and there is a website for the study. The administrative center is at Emory, but three of us including the doctor and we put the study together, and what we are doing is we are randomizing the babies to either an implant at the time of surgery or an implant later.

Dr. Linda Austin: So half get one and half get the other.

Dr. Edward Wilson Jr.: Right. Now, the benefit to the family is that the implants, glasses, and patches everything is free. There is a clinical trials coordinator that is available all the time by phone and the travel expenses are paid for. The FDA is watching this study with us because we got them involved, and it being funded by the National Institutes of Health. So, it is a very well controlled study. One of my jobs is to watch the video of every surgery done in this study in the 12 centers we have in the United States. So at MUSC, we have recruited more children for the study than anywhere else, but there are active centers around the country. We think that the baby will get excellent surgery because we have helped to define very precisely what steps a surgeon must take, and because of the oversight we also will learn a lot about how to take care of babies. Our study coordinators are dealing parent-stress questionnaires, and we are looking at how to best patch to prevent lazy eye, how to best teach parents how to deal with contact lenses or teach them how to keep glasses or child. So, even though the parent does not get to choose whether they get the implant or the contact lens, since most of us are absolutely convinced that the better outcome could come form either treatment, we think the study is justified and we think that it’s a way for the families to get excellent care and for us to find out what should be done in the future.

Dr. Linda Austin: It sounds like it is a wonderful opportunity for people to participate, get top level care for their child, and contribute to the future as well. Now, once a child leaves Storm Eye Institute here at MUSC, what happens then to that child?

Dr. Edward Wilson Jr.: After the surgery, I do the one day visit myself. We will have arranged for a partner doctor close to their home to do a quick examination at one week, and then at one month, and then every three months for the first year after the surgery. I like to see all the children I operate on once a year if possible. So upfront, we try to bring that up and say that, if I see the children once a year until they are old enough to have a complete eye exam awake, which is about age 7 or 8, until then if possible, if travel can be done, I like to do a brief asleep exam so that I am sure that the things that cannot checked in the office that we are looking after, we looking that the intraocular pressure, or examining the position of the implant, we are looking at the retina, parents who have read about cataracts know that it is a developmental problem with the eye and at sometimes there are also developmental problems with the drainage channel for fluid exiting the eye or for the retina in the back of the eye, and those problems can show up years later, so we feel that we should do a very careful exam and measure growth of the eye by ultrasound once a year whether its awake or sleep, in the younger children its asleep that takes some of the pressure off of the local doctor who can check for progress in the office as best as possible at that age and rely on the fact that we are going to do some very precise measurements to tract progress, and we can do those asleep.

Dr. Linda Austin: You mentioned that children will need a patch over the good eye, the non-operated upon for a while after the surgery, how long does that usually last?

Dr. Edward Wilson Jr.: Well it depends on how quickly the vision becomes equal in the two eyes. If a cataract has involved both eyes equally, patching is usually not necessary. If the cataract affects one eye only, then patching part of days required to try and get the vision to equalize in the two eyes. Now, for most children the brain is visually mature by about the 9th birthday, so we titrate patching all away up to the 9th birthday but we hope that if we catch the cataracts early and we do fairly intense patching early, which is often half the waking hours and the vision gets equal then we can reduce the patching either to zero of often we reduce the patching to a maintenance level, which is usually about an hour a day, 30 minutes to an hour a day, with intense activity meaning that, that eye plays video game or colors or does some new work. If we stop the patching completely and it is prior to the 9th birthday we have to monitor, and if the vision slips back we restart the patching. So, there is a titration of more patching if the vision is falling behind and less patching if vision is equal all the way up to the 9th birthday.

Dr. Linda Austin: I know, in adult when there are cataracts in both eyes, an Ophthalmologist will usually operate on one eye at a time, correct.

Dr. Edward Wilson Jr.: Yes.

Dr. Linda Austin: How about in children?

Dr. Edward Wilson Jr.: That is generally true too. We only operate both eyes at the same time if the child has other medical problems because the anesthesia is usually very safe, but if for some reason that the anesthesia should be done only once then we will do both eyes at the same time. Most children do so well with anesthesia that, that is not a consideration.

Dr. Linda Austin: What is your complication rate?

Dr. Edward Wilson Jr.: The most serious complication is an infection inside the eye so called endophthalmitis, that infection, about half the time it occurs, has a very devastating result on vision. Fortunately, the rate in pediatric cataract surgery in our hands and in others is less than 1/1000, probably 1/5000, still the risk is there, although it is small and that is one reason why we don’t like to put both eyes at risk at the same time.

Dr. Linda Austin: And one last question, what is the longest follow up you have on any of your patients with this surgery?

Dr. Edward Wilson Jr.: Well, I started putting implants in children after cataract surgery in 1987. Long before it was common place to do so, I moved back to Charleston, my home town, in 1990, so I have patients now who are in their 20s that we did when they were babies.

Dr. Linda Austin: How rewarding for you

Dr. Edward Wilson Jr.: Or at least when they were in their school age, and just this week I saw 21-year-old that I had done when she was four or five, doing very well. So, we have many, many patients with 10 years of follow up, some with 15, and even approaching 20 years.

Dr. Linda Austin: Dr. Wilson, thank you so much and congratulation on the incredible work you do.

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