Eyeworld

EW FEATURE 102 by Faith A. Hayden EyeWorld Staff Writer An overview of what children need from bedside manner to medication O phthalmologists by trade are excellent multitaskers, but the pediatric ophthal- mologist in particular is a master juggler. Doctors in this subspecialty treat children as young as infants for a vast array of eye problems, ranging from the very benign such as myopia to compli- cated and potentially blinding eye diseases such as retinopathy of pre- maturity. Pediatric ophthalmologists don't just treat the child, they treat the parents and must act as a psy- chologist, surgeon, cheerleader, and friend all rolled into one. What goes into running a suc- cessful pediatric eyecare center? Much more than one might guess. In addition to being highly compe- tent surgeons, these doctors need to be compassionate, gentle, and infi- nitely patient. Parents of children with eye diseases are often dis- traught, stressed, scared, and looking to their doctor for reassurance. A successful pediatric ophthalmologist must tiptoe across the fine line be- tween empathy and coddling, be- tween encouragement and reality. And that just covers beside manner. Different needs "Children are a totally different ball- game than a traditional adult oph- thalmology practice," said Thomas Lee, M.D., director, Retina Institute, The Vision Center, Children's Hospi- tal Los Angeles. "There's a lot of sen- sitivity a pediatric ophthalmologist has to bring to the practice. With an adult practice, you don't have the same level of anxiety." Pediatric practices are set up dif- ferently than adult practices. While an adult waiting room may have magazines to help grown-ups pass the time, pediatric waiting rooms may have toys and videos to keep children relaxed and entertained. Also, the exam room is longer than one found in a traditional practice because children need to look at a fixation target up to 20 feet away for accurate eye measurements. "In my exam room there are electrically operated animals and videos for children to fixate on," said Robert Gold, M.D., pediatric ophthalmologist, Eye Physicians of Central Florida. "I turn on the mo- torized animals to try to get the child's attention, or sometimes I sing. When the child and the parent see you're having a good time, they usually will as well." Exams and consultations with children take more time, especially if the parent has questions, which means pediatric doctors can't see as many patients in a day as adult-fo- cused practices can. Furthermore, young children have short attention spans and problems sitting still, so the doctor may have the child sit on a parent's lap during the exam to get the child accustomed to the new en- vironment. "You have to be very careful to do the parts of the exam that are most important to the particular complaint or evaluation first," said M. Edward Wilson, M.D., chair, department of ophthalmology, Med- ical University of South Carolina. "Kids have limited attention spans. It's not the doctor who decides when the exam is over, it's the child." Doctors have to be prepared for unpredictable mood swings when examining children. Youngsters may throw temper tantrums or cry hys- terically for no apparent reason. Dealing with these situations re- quires patience, understanding, and flexibility with appointments. If an accurate assessment can't be made at the time of the exam, doctors may ask the family to come back and try again. "Children can be quite ornery," said Dr. Gold. "Examining them takes time, patience, energy, effort, and encouragement. Some behav- ioral issues you can't overcome, but you do the best you can to get an ac- curate examination." Compliance challenges Compliance with treatments is one of the biggest hurdles for pediatric doctors and the parents of the chil- dren they treat. Doctors can sit down and explain to adult patients why they need surgery or medica- tion, but doctors can't reason with an infant. Instead, pediatric ophthal- mologists must do their best to ex- plain to the parent why compliance is important. "Kids don't always follow direc- tions," said Dr. Wilson. "When we are planning treatment, we have to understand that the child and their parents mean to comply with every- thing we say but aren't always able to." For example, it's often ex- tremely difficult for parents to use topical steroids on children after an- terior segment surgery, especially if the drug needs to be administered multiple times a day. Also, all children traumatize their eyes by rubbing and digging. It's nearly im- possible for infants and toddlers to be completely hands off. In order to get the results needed, pediatric doc- tors must meticulously plan a child's treatment from what goes inside the eye during surgery to how the eye is covered after surgery. "We suture wounds even if they appear to be water tight at the end of surgery," said Dr. Wilson. "We look at a wound and determine whether it will hold up to the ex- pected level of trauma. We're con- stantly thinking about what we can put in the eye at the end of surgery to reduce the dependence on exact compliance." Parents can have a tough time enforcing treatments, especially when it appears to be uncomfortable for the child. For example, if an 18- month-old is given glasses and keeps crying and pulling them off, parents may grow weary of forcing the child to wear them. The same goes for patching therapy for amblyopia. Not only does the child dislike wearing a patch, but parents may not like how their child looks with it on. "There's tremendous variability with compliance," said Dr. Wilson. "Sometimes the parents can do it and sometimes they can't. The par- Before and after shots of the effects of Avastin on ROP Source: Maria Martinez-Castellanos, M.D. February 2011 PHARMACEUTICAL CORNER March 2011

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