Indian Journal of Ophthalmology

GUEST EDITORIAL
Year
: 2019  |  Volume : 67  |  Issue : 6  |  Page : 720--721

Children - Not just small adults!


Lingam Gopal 
 Department of Ophthalmology, National University Hospital, Singapore

Correspondence Address:
Lingam Gopal
Department of Ophthalmology, National University Hospital
Singapore




How to cite this article:
Gopal L. Children - Not just small adults!.Indian J Ophthalmol 2019;67:720-721


How to cite this URL:
Gopal L. Children - Not just small adults!. Indian J Ophthalmol [serial online] 2019 [cited 2019 Sep 16 ];67:720-721
Available from: http://www.ijo.in/text.asp?2019/67/6/720/259073


Full Text



Most general discussions on pediatric medicine start with the metaphor “child is not a young adult.”[1] This is useful in terms of calculating drug dosage and so on. However, in terms of the impact on the adults that surround the child (parents and medical personnel), the metaphor is better phrased as “the child is much more than an adult.”

Retinal disorders in children pose a special challenge to the retinologist due to many reasons as mentioned below:

The patience needed in handling a child

An experienced and patient examiner is able to avoid unnecessary anesthetic examinations. Very often important clinical decisions are possible from the quick examination that is possible in the clinic.

The patience and tact needed in handling the parents and their expectations

It is not easy to break news to the anxious parents about diseases such as bilateral stage 5 retinopathy of prematurity (ROP) and bilateral retinoblastomas. The retinologist should be sensitive to the situation, should express genuine concern, and share with the parents the poignancy of the situation. At the same time, repeated explanations are needed to bring their expectations down to the reality of the situation.

The apparent crudity of “pinning a child down, placing a speculum, and examining while the child is bringing the roof down”

It is best to ask the parents to stay outside the room – both to spare them the mental trauma and to prevent difficult situations (mothers fainting). Routine use of sedation is not encouraged due to the risks associated with sedation.

The impact of inadequate examination on the diagnosis and management.

If a premature child is screened and declared normal and subsequently develops stage 5 ROP, it can only be termed a “disaster.”

The periodic need for general anesthesia (as in retinoblastoma) and its implications.

Keeping the child fasting, frequent cancellations due to upper respiratory tract infections and other general health issues, the need for specialized anesthesia team, and so on.

The socioeconomic impact.

It is impossible to imagine the impact on the family – of a precious pregnancy resulting in a child who becomes blind with bilateral ROP and also has delayed milestones or cerebral palsy.

The need to interact with other specialists in almost every case such as oncologists, interventional radiologists, radiotherapists, and geneticists

This issue of Indian Journal of Ophthalmology is dedicated to the subject of pediatric retinal disorders with special emphasis on ROP. There are articles on almost all facets of the disease including epidemiology, screening techniques, lasers, antivascular endothelial growth factor (VEGF) drugs, surgery, and rehabilitation.

ROP poses unique problems to the subcontinent in the detection and appropriate management of all the infants at risk. These include the mismatch between the number of infants at risk and the available retinologists, the socioeconomic factors that limit access to medical care and the number of follow-up visits that are possible, and the need to provide a stable end point in the shortest period of time.

Some solutions have evolved with time. These include the following:

Screening by technicians using RetCam or similar cameras as primary contact with the infants at risk [2],[3]Laser as primary modality of treatment. Despite the relative ease of administration of anti-VEGF drug versus performing a painstaking laser, most retinologists have thankfully continued to use laser as first treatment option except in specific situations such as aggressive posterior ROP.[4] With laser photocoagulation, the exit from critical follow-up is reached early in a majority of the casesRetinologists in India can perform lasers comfortably without resorting to general anesthesia (a luxury we can ill afford due to the paucity of trained pediatric anesthetists). This acquired skill has perhaps helped in large measure to combat the problem of preventable blindness due to ROP.[5]

The community of retinologists looks forward to a day wherein there is more uniform quality of neonatal practice that reduces the iatrogenic contribution to ROP, a better predictive model that can be used to channel the workforce better, and of course an elixir that can normalize the retinal vascularization in a premature infant.

References

1Gillius J, Loughlan P. Not just small adults: The metaphors of paediatrics. Arch Dis Child 2007;92:946-7.
2Athikarisamy SE, Patole S, Lam GC, Dunstan C, Rao S. Screening for retinopathy of prematurity (ROP) using wide-angle digital retinal photography by non-ophthalmologists: A systematic review. Br J Ophthalmol 2015;99:281-8.
3Vinekar A, Jayadev C, Mangalesh S, Shetty B, Vidyasagar D. Role of tele-medicine in retinopathy of prematurity in rural outreach centres in India – A report of 20214 imaging sessions in the KIDROP program. Semin Fetal Neonatal Med 2015;20:335-45.
4Darlow BA, Ells AL, Gilbert CE, Gole GA, Quinn GE. Are we there yet? Bevacizumab therapy for retinopathy of prematurity. Arch Dis Child Fetal Neonatal Ed 2013;98:F170-4.
5Jalali S, Azad R, Trehan HS, Dogra MR, Gopal L, Narendran V. Technical aspects of laser treatment of acute retinopathy of prematurity under topical anesthesia. Ind J Ophthalmol 2010;58:509-15.