It takes a village to beat visual system diseases in children

New standards have emerged for treating visual diseases in paediatric populations during the previous two decades, thanks to community involvement and external funding of research, according to Dr Richard W. Hertle, who described the progress achieved in various diseases as a result of these factors. Such progress is likely to continue in the future and spark continuing improvements in the treatment of a range of disorders.

Dr Hertle is chief of paediatric ophthalmology and director of the Vision Center at Akron Children’s Hospital in Akron, Ohio, United States. He is also director of the hospital’s paediatric ophthalmology fellowship programme, the Dr Robert “Boomer” and Jill Burstine Chair in paediatric Ophthalmology, and a professor of surgery at Northeast Ohio Medical University in Rootstown, Ohio.

Retinopathy of prematurity

Numerous studies of retinopathy of prematurity (ROP) have evaluated interventions such as cryotherapy, supplemental oxygen, light reduction and early laser treatment, which reduced blindness caused by abnormal development of blood vessels in thousands of infants annually to about 500.

Major findings included the following:

1. Cryotherapy decreased blindness by 50% in infancy and 17% by age 10 according to the study ‘Cryotherapy for Retinopathy of Prematurity’;
2. Supplemental oxygen therapy did not stop progression of ROP (as seen in ‘Supplemental Therapeutic Oxygen for Prethreshold Retinopathy of Prematurity Study’) and nor did reduction of ambient light (‘Light Reduction in Retinopathy of Prematurity Study’);
3. Early laser application reduced blindness by another 5% (‘Early Treatment for Retinopathy of Prematurity [ETROP] Study’); and
4. Artificial intelligence and use of telemedicine approaches for evaluating acute ROP decrease blindness worldwide.¹

A more recent treatment is injection of intraocular bevacizumab (Avastin, Genentech), which, when compared with laser therapy, has been found by physicians to be equally efficacious, with the same long-term benefits and fewer adverse effects, Dr Hertle said.²

Strabismus/amblyopia

The Pediatric Eye Disease Investigator Group in the US, a collaborative that conducts multicentre clinical research in strabismus, amblyopia and other diseases treated by paediatric ophthalmologists, functions internationally with hundreds of physicians. These trials, funded by more than $65 million raised since inception of the group in 1997, have developed new treatment protocols for strabismus, amblyopia, nasolacrimal duct obstruction, myopia, hyperopia and uveitis.³

Dr Hertle further recounted major findings of this group that were not the standard of care before the clinical trials, including the following:

1. Patching for 2 hours is as effective as patching for 6 or 8 hours in patients with moderate amblyopia;
2. Patching over 6 hours works as well as full-time patching in patients with dense amblyopia;
3. Atropine use can be as effective as patching; and
4. Spectacle use alone can treat amblyopia without patching or drops in strabismic amblyopia.⁴

“The changes in the current standards of practice in common eye diseases are the result of these large clinical trials,” Dr Hertle explained. “We are moving from anecdotes to the ability to practice rigorous ways to treat amblyopia and strabismus.”

Congenital cataract

The Infant Aphakia Treatment Study⁵ evaluated the use of an intraocular lens (IOL) compared with a contact lens during the first 6 months of life to treat unilateral congenital cataract. The results showed equal vision with both.

Convergence insufficiency

Children aged between 9 and younger than 18 years diagnosed with this disorder, which is present in 5–7% of children, were treated in a multicentre, randomised clinical trial⁶ to determine the effectiveness offour therapies: office-based vergence/accommodative therapy plus home reinforcement; home-based pencil push-ups; home-based computer vergence/accommodative therapy and pencil push-ups; and office-based placebo therapy.

“The results showed that doing therapy in the office with home reinforcement was better than any other type of therapy, including pencil push-ups,” Dr Hertle said. A separate convergence trial that included 221 patients showed that convergence therapy to treat attention and reading was ineffective for attention and reading and only helped convergence.⁶

Community support

When considering all the studies performed in thousands of patients with a variety of visual diseases, the community support was the most consequential factor.

“By allowing the family and their children to participate in these trials and the grants, gifts, endowments and time, we were able to progress in paediatric eye care,” Dr Hertle said.

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Richard W. Hertle, MD
e: rhertle@akronchildrens.org
Dr Hertle has no financial interest in this subject matter.

References

1. Suelves AM, Shulman JP. Current screening and treatments in retinopathy of prematurity in the US. Eye Brain. 2016;8:37-43.
2. Barry GP, Tauber KA, Greenberg S, et al. A comparison of respiratory outcomes after treating retinopathy of prematurity with laser photocoagulation or intravitreal bevacizumab. Ophthalmol Retina. Published online 5 June 2020. DOI:10.1016/j.oret.2020.06.002
3. Beck RW. Clinical research in pediatric ophthalmology: the Pediatric Eye Disease Investigator Group. Curr Opin Ophthalmol. 2002;13:337-340.
4. Gunton KB. Advances in amblyopia: what have we learned from PEDIG trials? Pediatrics. 2013;131:540-547
5. Lambert SR, Aakalu VK, Hutchinson AK, et al. Intraocular lens implantation during early childhood: a report by the American Academy of Ophthalmology. Ophthalmology. 2019;126:1454-1461.
6. CITT-ART Investigator Group. Treatment of symptomatic convergence insufficiency in children enrolled in the Convergence Insufficiency Treatment Trial–Attention & Reading Trial: a randomized clinical trial. Optom Vis Sci. 2019;96:825-835.