The first meeting of the Pediatric Keratoplasty Association was held on Tuesday, November 16 at the recent AAO meeting. We would like to thank Storz Ophthalmics for their sponsorship of this meeting. Attending the meeting were ophthalmologists (identified through the PKA survey) who frequently perform pediatric corneal transplants and who expressed an interest in assisting in the development of the PKA.
In attendance at the meeting were Dr. Gerald W. Zaidman, Dr. John W. Cowden, Dr. Daniel Goodman, Dr. Peter Laibson, Dr. Norman Medow, Dr. Robert Phillips, Dr. Alan Sugar, and Dr. Hugh Sauer.
A number of organizational and administrative issues were discussed. We decided that the organization will concentrate and focus on the treatment and management of corneal diseases and corneal transplant surgery in children 17 years of age and younger. The first goal will be to develop a data base of all pediatric keratoplasties performed in the United States and internationally by members of the PKA. To accomplish this I have enclosed a data survey form. This form asks you to describe your current techniques for managing the child with a corneal opacity. I have also included another form to use prospectively on your children who have undergone penetrating keratoplasties. The latter form is similar to an eye bank form and is to be used whenever you do a corneal transplant on a child. The reverse of this for m is also to be used at various "post operative intervals. This form can be duplicated as is necessary. All completed forms should be returned to this office where data will be collected and analyzed.
Several other issues were also discussed. The first is to rename the Pediatric Keratoplasty Association, the Pediatric Keratoplasty Foundation. The foundation will then consist of two sections. One section will continue to be the pediatric keratoplasty association and this will be primarily for physicians and medical personnel. The other section will be a laymen's division which will be for parents of children who have had corneal transplants. To enlist in this latter endeavor we ask you (or your eye bank) to identify any parents of children who have had corneal transplants who might be willing to volunteer their name (or phone time) as a contact person for other parents.
Also beginning with 1994 dues will be collected from members of the organization. Annual dues will be $50. This will be used to computerize our mailing list and data base, pay for the newsletter, the survey and mailings, and arrange for future meetings. It is felt that this minimal amount is a small price to pay to support this worthwhile endeavor. Please mail dues to Pediatric Keratoplasty Association, c/o Dr. G. Zaidman, Dept. of Ophthalmology, Westchester County Medical Center, Valhalla, NY 10595.
In the next issue of the newsletter I would like to begin a discussion of the surgical management of some of these difficult cases. If you have an interesting case that you want to discuss, please submit it to this office.
This brief report will summarize my post-operative regimen in children with corneal transplants. This approach is influenced by two parameters - the age of the patient and the diagnostic reason for the corneal transplant.
In general most children over 8 years old (and many over 5-6 years of age) can be examined at the slit lamp. In many aspects of their care they can be treated and examined like young adults. Usually one can check the intraocular pressure (especially with the pneumotonometer), remove sutures for astigmatism (though this may occasionally require sedation) and check for rejection or * other complications. They and their parents can be trained and educated as to how to recognize the early signs of graft rejection and many children, even at this young age, are good reporters of sudden changes in visual acuity.
Like Many adults, graft prognosis depends on the underlying diagnosis. In my experience the most common causes of corneal transplantation between the ages of 8-17 are scarring secondary to trauma or infections (especially HSV), and keratoconus. Since the corneas in the first two diagnoses are often vascularized and irregular their prognosis is not as good as keratoconus patients. In general however I manage these patients with a therapeutic regimen very similar to adults.
It is in the group Of children less than 6-8 years of age or those children with emotional or psychological problems (in whom cooperation is poor) that the post operative course is most difficult.
Prior to surgery on any child in this age group I tell the parents that I expect their total and absolute cooperation. They must understand that surgery on children in this age group is like running a marathon. Because of the child's age and general lack of cooperation very frequent office exams and exams under anesthesia are necessary (sometimes at very short notice). The parents must be willing to deal with the psychological ups and downs and stresses associated with this post operative course.
Other than the child's age the post operative regimen is strongly influenced by the underlying diagnosis. Essentially these patients can be divided into two groups - children with congenital disease (anterior segment dysgenesis, Peter's anomaly, congenital glaucoma, metabolic or chromosomal disorders, etc.) or children with acquired diseases (primarily trauma and infections). The first group more likely to have had severe ocular pathology requiring more extensive anterior segment surgery (glaucoma, cataract surgery, vitreous surgery, etc.) than the latter. Therefore the post operative course is more complicated, requiring more attention to intraocular pressure control, complications of retinal or vitreous surgery, etc.
Despite their differences certain similar principles are followed for both groups. Both groups are similar in terms of very rapid wound healing and high rejection rates. Therefore daily eye exams are performed for the first 3 weeks. Patients at high risk for glaucoma, retinal or vitreous pathology have weekly exams under anesthesia. This is also done to evaluate the status of the corneal sutures. If there is any sign of suture loosening the sutures are removed.
After 3 weeks and after the third EUA the sutures are usually out in the younger children. They are then examined twice a week, weekly and then every 2- weeks as the months pass. Chloral hydrate is frequently used in the office to sedate the patient in order to check the intraocular pressure.
In the older children (or those with a less complicated course) after the first few weeks, office exams are done slightly less often (initially weekly and then no less often than every 2-3 weeks). This continues until all sutures are removed - : (usually within 3-4 months). Again exams under anesthesia in the O.R. or chloral hydrate in the office are used as necessary to follow the clinical course in these patients.
Finally during the post-operative period I have the parents obtain a penlight and I train them to examine the eye. Motivated parents can be taught to recognize changes in corneal clarity, collection of mucus around potentially loose sutures and increased conjunctival discharge or redness. I tell the parents that other signs of ocular pathology include changes in the child's normal attitude or temperament, rubbing of the eyes or decreased ability to follow a bright, silent, object. I expect the parents to immediately call my office if there is a problem.
Prospective Study on Pediatric Keratoplasty
All questions refer to your initial management of the child (< 17 yrs) with a corneal opacity
Initial office visit includes (check all that apply)
Do you do an EUA? __________
If yes, how soon after first visit __________
How do you measure VA
How soon do you perform surgery, when indicated, for a child with
To be used on all Children under Age 17 at time of Surgery
Surgeon's name _________________________________________________________
Surgeon's address _______________________________________________________
Patient's initials _________________________________________________________
Patient's Age (in years and months) at surgery: ________________________________
Patient's Age at diagnosis: ________________________________________________
Was the diagnosis suspected pre-operatively Y ___ N ___
Pediatric Keratoplasty Association Copyright © 1996-2013 All Rights Reserved. Please send us comments and questions.