Eyeworld

EW FEATURE 104 it can in kids," Dr. Wilson said. Because of the aforementioned compliance issues, pediatric oph- thalmologists strive to use once- daily medications instead of drugs that require multiples doses; it's one less battle the parent has to have with the child. Doctors also favor medications with limited stinging or burning so it's easier on the child. Up for debate Major developments in pediatric ophthalmology have been limited over the last few years, but there are ongoing studies addressing two major issues in this subspecialty. One is the use of IOLs in pediatric cataract patients under 1 year old, and the other is Avastin (beva- cizumab, Genetech, South San Fran- cisco, Calif.) for treating retinopathy of prematurity (ROP). The Infant Aphakia Treatment Study (IATS) is a randomized clinical trial funded by the National Eye In- stitute that is being conducted in 12 U.S. cities. The goal of the study is to determine which route is better for infants with cataracts: an IOL im- plant or contacts until roughly age 2. The study is currently following two groups of children. One group had an IOL implanted before 6 months of age, and the other group used contact lenses. "Is it better to do it now or later?" asked Dr. Wilson. "Pretty much everyone is going to get an implant sooner or later, we just need to decide if it's better to have it done during the cataract surgery." Beyond the first birthday, im- planting an IOL during the initial cataract is standard and not contro- versial. Enough development has oc- curred by then that surgeons can predict where the eye is going to be when it finishes growing. "There are more returns to the operating room if you use an im- plant before the first birthday com- pared to a contact lens," Dr. Wilson explained. "The decision about how or what implant to put in is much more difficult. We still do it, but in infancy it's more common to leave the eye aphakic and use a contact lens." Contacts are currently preferred because they can be easily adjusted to fit the child's needs as the eyes change. An implant, however, is a commitment. When you put an IOL into a fast-growing eye, you have to put glasses on top of it and change the prescription every time the eye grows. "Parents often think it's a choice between an implant and a contact lens," said Dr. Wilson. "When they find out it's really a choice between a contact and an implant plus glasses, then some parents believe that the contact will be easier to handle than glasses and a lot less noticeable." The earlier children start using contacts the better because the process becomes part of their rou- tine and they won't fight their par- ents as much. Most children are fit with a silicon type of contact that is relativity well-tolerated and can be left in for up to a month. That being said, some parents and children don't do well with contacts. Chil- dren can easily lose the lens by rub- bing it out of their eye, and they aren't always comfortable. Which method is better? Ac- cording to 1-year results of IATS, vi- sion was equal in the two groups, but there were more returns to the operating room for secondary mem- branes in the IOL group. "IOLs didn't make the vision worse at the 1-year point, but they didn't show an advantage either," said Dr. Wilson, who is an investiga- tor on the study. "We're going to fol- low that same cohort of children until age 5, and we don't know which group will have better vision at that point. But at least for the 1- year results, we advise caution when implanting IOLs in the first year of life." Maria Martinez-Castellanos, M.D., the Association to Prevent Blindness in Mexico, has been work- ing with Avastin for ROP treatment for the last 5 years with promising results. ROP is a serious and potentially devastating disease in premature children with widely varying stages. Some degree of ROP occurs in 60% of all premature births, and 10% of these infants will get to an advanced stage, according to Dr. Lee. About 90% of infants with stage 1 and 2 ROP improve without treatment, ac- cording to Stanford University Med- ical School statistics, but half of the children with stage 3 and most of those with stage 4 ROP will develop significant eye damage. Stage 5, which leads to complete retina de- tachment, can be blinding. "If the child is screened properly and receives treatment in a timely fashion, the risk of blindness drops to 10%," said Dr. Lee. "Even with that success rate of 90%, if you sub- divide that category and look at the high-risk children, the fail rate is still close to 50%." Doctors would love to get that statistic down, and Avastin, which is frequently used in adults with age- related macular degeneration, may be one way to. "ROP is basically 30 years of dia- betic retinopathy in 2 weeks," said Dr. Lee. "We've stayed away from using Avastin because it's very po- tent. Unlike in a 70-year-old adult, we're not really sure what the effects of Avastin will be in a neonate." Hopefully Dr. Martinez- Castellanos' research will help change that. She has injected Avastin in more than 200 children with an average age of 30 weeks and so far, these patients are showing no signs of systemic problems. "We've had really good out- comes," she said. "We did the injec- tions in the first group in 2005. We measured everything from develop- mental outcomes to visual acuity and the eyes look normal. Many of the babies have heart and lung dis- ease because of the prematurity and it hasn't gotten worse because of the injection." Dr. Martinez-Castellanos pre- sented her research in some public forums and is currently working on publishing the 5-year results in Oph- thalmology. "We believe there are no sys- temic problems, but it's only been 5 years," she said. "We need to have a longer follow-up." Despite the challenges working with children and their nervous par- ents, pediatric ophthalmologists find their job incredibly rewarding. "I get more satisfaction from treating kids and watching them grow, develop, and change," said Dr. Wilson. "It's really gratifying to see these children become adults, get married, have kids, and then bring those kids into the office." EW Editors' note: None of the doctors inter- viewed revealed financial interests related to this article. Contact information Gold: rsgeye@aol.com Lee: Thlee@chla.usc.edu Martinez-Castellanos: marianamartinez- castellanos@hotmail.com Wilson: wilsonme@musc.edu An overview continued from page 103 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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