1	Pediatric Ophthalmology for the 21^st Century Monte D. Mills, MD Director of Ophthalmology The Children’s Hospital of Philadelphia August 30, 2006
2	Relevant pediatric eye and vision issues relevant in 2006 Causes of severe visual impairment in children of Ukraine, 2006* Refractive, degenerative myopia – 32.7% Cataract, aphakia – 13.2% Retinopathy of prematurity – 13.2% Congenital eye anomaly, microphthalmia, microcornea, coloboma, nystagmus – 11.8% Optic nerve atrophy – 8.8% Glaucoma – 2.9% * Serhiy Rykov, Chief Ophthalmologist, Ukraine
3	Pathology identified during first year of life causing severe visual impairment as a result of: Hereditary factors – 35% Pathological factors – 15% Prematurity – 10% Infections or chronic diseases during pregnancy – 9%
4	Number of blind children/million, by cause and level of development
5	Why relevant in 2006? Advances in scientific understanding of pathology New technology, treatments, innovation Iatrogenic problems introduced by new medical technology (prematurity)
6	Pediatric cataracts Congenital cataract Hereditary, genetic factors Sporadic Associated with other ocular abnormalities Acquired, childhood Metabolic diseases Iatrogenic, drug-induced Trauma
7	Requirements for effective cataract blindness prevention, detection and treatment Early detection – red reflex eye screening in all newborns and at each health assessment Simple screening with direct ophthalmoscope for quality, symmetry of pupillary reflex Referral of all failures to qualified ophthalmologist for full exam Early surgery Qualified, experienced pediatric eye surgeon Anesthesia Intraocular lens implantation or contact lens
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12	Principles of treatment Early surgical treatment cataract aspiration with automated vitrectomy/capsulectomy With contact lens visual rehabilitation, < 2 years With intraocular lens implantation, > 2 years Re-operation for capsular opacification, glaucoma, strabismus Close followup with aggressive amblyopia treatment
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15	Frontiers/future developments in the detection and treatment of pediatric cataracts Improved detection and treatment of complications, glaucoma, capsule opacification, inflammation Improved surgery technique – automated aspiration/vitrectomy Intraocular lenses in younger patients, improved lenses, small incision foldable lenses
16	Pediatric glaucoma Congenital glaucoma Hereditary, genetic Associated with other ocular abnormalities Acquired glaucoma in childhood Associated with cataract surgery (iatrogenic) Associated with medication (iatrogenic) Trauma
17	Requirements for effective glaucoma blindness prevention, detection and treatment Early detection – Cloudy cornea Corneal enlargement (buphthalmos) Early treatment Topical medications Early surgery Anesthesia Close observation on treatment
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19	Congenital glaucoma treatment Medications useful temporarily Surgery usually definitive Angle surgery (goniotomy, trabeculotomy) Seton surgery (glaucoma tube shunt)
20	Goniotomy
21	Frontiers/future developments in the detection and treatment of pediatric glaucoma Improved screening and early detection and treatment Improved topical medications Improved surgery technique – microscopic angle surgery, tube shunt surgery
22	Retinopathy of Prematurity
23	Retinopathy of prematurity Neovascular retinopathy leading to retinal detachment and vision loss Occurs exclusively in infants born prematurely, during the first few months of life Ablative treatment is effective, but must be used at specific point in disease course
24	"Epidemic of ROP in areas..." Epidemic of ROP in areas with developing medical infrastructure/ middle income countries Improvement in survival of premature infants Iatrogenic problem, possibly worsened by overuse of supplimental oxygen Need for access, training, treatment
25	ROP as a cause of childhood blindness in high income countries
26	ROP as a cause of childhood blindness in middle income countries (2)
27	ROP blindness risk
28	Characteristics of babies with “severe” ROP in UK, USA and Canada
29	Characteristics of babies with “severe” ROP in low / middle income countries
30	"Characteristics of infants with severe..." Characteristics of infants with severe retinopathy of prematurity in countries with low, moderate, and high levels of development: implications for screening programs. Gilbert C, Fielder A, Gordillo L, Quinn G, Semiglia R, Visintin P, Zin A; International NO-ROP Group. Pediatrics 2005 115: e518-525
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33	Requirements for effective ROP prevention, detection and treatment Prevention Detection Treatment
34	Requirements for effective ROP prevention, detection and treatment Prevention Experienced neonatology Monitored use of oxygen in neonates Best possible medical care – obstetrics and prenatal care, surfactant, antibiotics, ventilation Detection Effective screening program to examine children in neonatal units (indirect ophthalmoscopy) beginning at 31-32 weeks postconceptual age Experienced examiners with time to screen in hospitals on regular basis
35	ROP Natural History
36	Current screening criteria (USA) <1500 gm at birth < 32 week postconceptual age at birth *American Academy of Pediatrics, February 2006, http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;117/2/572 Screening criteria should be adjusted depending on epidemiology of ROP in each country, Ukraine may need different guidelines
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38	Potential approaches to access/screening issues Training programs for training pediatric and general ophthalmologists for neonatal screening Potential non-ophthalmologist (non-physician?) screening Photoscreening with remote reading (telemedecine)
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40	Fundus photo before and after laser photocoagulation
41	Requirements for effective ROP prevention, detection and treatment Treatment Laser photocoagulation of peripheral avascular retina in advanced stages, prior to retinal detachment Potential future medical treatment with anti-neovascular drugs (Avastin, etc)
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43	Future developments in detection and treatment of retinopathy of prematurity Future improvements in neonatology Improving access to screening and treatment Training, potential alternative screeners, photos with remote screening Improving access to laser photocoagulation Potential medical treatments
44	Conclusions Pediatric cataracts, glaucoma and retinopathy of prematurity are responsible for a large proportion of preventable childhood blindness Early detection and access to current technology can improve outcomes in children with cataracts, glaucoma and retinopathy of prematurity Recent and potential future developments in our management of these problems will continue to improve outcomes Continued focus on access, training and clinical innovation are important to reduce childhood blindness
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