March 2009

 

CATARACT/ IOL

 

Cutting down on pediatric patching


by Maxine Lipner Senior EyeWorld Contributing Editor

   

Study indicates that the 6-year rule can be bent

With time, children often become resistant to patching

Source: National Eye Institute

It may be possible to discontinue pediatric patching following cataract surgery earlier than the current protocol permits, according to new study results published in the August 2008 issue of Archives of Ophthalmology. While the norm in such cases is to continue patching until at least six years of age, study results show that those who halt patching sooner may do just as well, said Scott R. Lambert, M.D., professor of ophthalmology and pediatrics, Emory University, Atlanta.

“The most common reason to patch is because one eye has a different refractive error compared to the other eye,” Dr. Lambert said. Patching is also done in cases of strabismus where the eyes are misaligned. In both of these instances, however, patching tends to be for a limited period of time. “The thing that is different about the children who have had cataract surgery is generally this patching is recommended until the children are six to nine years of age,” Dr. Lambert said. “It’s a very long period of time for a child.”

Facing patching resistance

Because of the extended period of time that is needed here, many of these children become resistant to patching as they get older. “Often times we see children do quite well with the patching, but as time goes by they become less willing to do it,” Dr. Lambert said. “At some point they just refuse to have their eye patched any more.”

Dr. Lambert decided to launch the retrospective study after realizing that some of his patients had taken it upon themselves to cease patching despite his advice. “The main reason for doing the study is that I’ve had a number of cases come in where they stopped the patching before I had recommended and they still seemed to be doing well,” he said. “It seemed as if maybe we were doing more patching than we needed to do.”

To see whether these cases were an anomaly or the norm, Dr. Lambert, together with fellow investigators David Plager, M.D., and Edward Wilson, M.D., pooled their patients in a retrospective study. Altogether the study included nine children with unilateral cataracts. “All of the children had cataract surgery when they were less than six months of age,” Dr. Plager said. “They’d also all worn the optimum correction, which in most cases was a contact lens but in one was an intraocular lens.” Investigators included those cases that had done good patching until they were at least one year of age. “We wanted to see what happened between the time that they were one year in age until they were six years in age,” Dr. Plager said.

The patients had all been followed at regular intervals by the practitioners, who relied upon the parents to keep them updated on just how well the patching was going. “It was based upon what was in the chart, but parents told us how much they were patching,” Dr. Plager said. “Maybe it was an overestimate, maybe it was an underestimate.”

While at the 12-month mark, charts indicated that the children were patched for a mean of 6.7 hours per day; by six years of age this had declined to a mean of just 1.7 hours per day. In four cases even before the six-year examination could be conducted the children had abandoned patching altogether. Only one child lost any acuity. That child’s vision had dropped by two lines on the Snellen acuity chart. “At least in three to four patients there was no change in visual acuity after we stopped the patching,” Dr. Lambert said. “It suggests maybe we could get away with doing less patching and still achieve the same results for vision with these children.”

The results were not totally unexpected. “I suspected that probably we were patching more than we needed to,” Dr. Lambert said. “People are reluctant to do less because we want to be careful.”

Rethinking position

Armed with the study results, Dr. Lambert thinks that some may be willing to slightly rethink the six-year patching position. “I think that I’m more willing to cut back on the patching of these children,” he said. “I just had a mother come in the other day and we were talking about it. We discussed the findings of the paper and she was thinking that it would probably be reasonable to reduce the amount of patching.” This particular child had only been patched for about five years and the mother was very careful.

Going forward, however, Dr. Lambert would like to see a prospective study on this conducted. “I think that probably at some point this needs to be studied further,” he said. “We just had this retrospective data.” In addition to confirming the outcome here, investigators also need to determine just how much patching is actually needed in these cases, he believes.

Editors’ note: Dr. Lambert has no financial interests related to his comments.

Contact information

Lambert: 404-778-3709, slamber@emory.edu

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