Newsletter Volume 2


Gerald W Zaidman MD
Westchester County
Medical Center
Valhalla, NY 10595
The goals of the Pediatric Keratoplasty Association and Pediatric Keratoplasty Foundation are to improve our understanding and treatment of children (under the age of 17) and infants with corneal disease. We will especially concentrate on those issues related to corneal transplant surgery.
bulletThe Pediatric Keratoplasty Association Meeting
bulletHow I do It - Post Operative Course

The Pediatric Keratoplasty Association Meeting

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.

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How I do It - Post Operative Course

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.

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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)

Penlight exam __________
Slit lamp exam __________
Tonometry __________
Funduscopy __________
Ultrasound __________

Do you do an EUA?  __________

If yes, how soon after first visit  __________

How do you measure VA

Snellen, picture chart or E game  __________
Penlight Fixation  __________
Other  __________

How soon do you perform surgery, when indicated, for a child with

Unilateral opacity  __________
Bilateral opacity  __________
If early, why  __________
If you wait, why  __________

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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:   ________________________________________________

Diagnosis Operated eye ______________
Fellow eye ______________

Was the diagnosis suspected pre-operatively   Y  ___    N  ___

Associated Conditions:
Operated eye Y  ___ N  ___
Fellow eye Y  ___ N  ___
Operated eye Y  ___ N  ___
Fellow eye Y  ___ N  ___
Retinal pathology:
Operated eye Y  ___ N  ___
Fellow eye Y  ___ N  ___
Previous corneal transplants:
Operated eye Y  ___ N  ___
Fellow eye Y  ___ N  ___
Surgical Technique:
Full thickness _____ Size of host _____
Partial thickness _____ Size of donor _____
Cataract extraction Y  ___ N  ___
Surgery on Iris (iridoplasty, synechialysis) Y  ___ N  ___
Vitrectomy Y  ___ N  ___
Anterior Y  ___ N  ___
Posterior Y  ___ N  ___
Retinal Surgery Y  ___ N  ___
Suture style running interrupted combined
Suture type
Intraoperative complications: Lens prolapse Vitreous loss
Vitreous Hemorrhage
Expulsive hemorrhage Other
Reason for surgery (check all that apply)
Visual rehabilitation ______________
Anatomic restoration of globe ______________
Cosmesis ______________
Surgeon's Estimate of Anatomic Success (Graft clarity)
0-25% ______________
26-50% ______________
51-75% ______________
>75% ______________
Any other comments:

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Frequency of follow-up visits
Daily __________ Starting when __________
3 times/week __________ Starting when __________
Weekly __________ Starting when __________
Every 2-3 weeks __________ Starting when __________
Other __________ Starting when __________
When are all sutures removed?
Within 1 month __________
1-3 months __________
3-4 months __________
4-6 months __________
> 6 months __________
Are EUA's routinely performed Y  ___ N  ___
If yes, how often __________
Preferred Method of Checking IOP
Pneurnotonometer __________
Goldman tonometer __________
Perkins tonometer __________
Schiotz tonometer __________
Finger Tension __________
Is sedation used in the office? Y  ___ N  ___
What type? __________
Routine post-operative therapy (check all that apply). Duration of therapy
Steroids - topical ____________________
- periocular ____________________
- oral ____________________
Antiglaucoma agents ____________________
- topical ____________________
- oral ____________________

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