Commentary From the AAP Section on Ophthalmology: Century of Changes

Commentary From the AAP Section on Ophthalmology

The Section on Ophthalmology (SoOp), founded in 1987, is dedicated to improving the care of infants, children, and adolescents through clinical care and education of pediatricians. SoOp provides expertise in clinical care and evidence-based practice to the AAP in its work to develop policies and technical reports (eg, related to retinopathy of prematurity and diabetic retinopathy) and to establish guidelines for ophthalmologic examinations in all children and those with risk factors (eg, children with juvenile rheumatoid arthritis). The section fosters cooperation related to academics and advocacy on children’s ocular health issues with the American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus. The SOOp relied on the expert opinion of the most experienced members among the section and executive committee to achieve a daunting consensus selection of the most significant publications in each quarter century of Pediatrics’ first 75 years.

First Quarter Century (1948-1973)

Giving Credence to Credé’s Prophylaxis: Early Strategies for the Prevention of Blindness Due to Ophthalmia Neonatorum

Sylvia H. Yoo, MD, FAAP, FAAO¹

Affiliation: ¹Tufts University School of Medicine, Boston, MA

Highlighted Publications From Pediatrics

• Platou RV, Nelson WE, Alexander HE, Platou ES, Wegman ME, Greenbaum JV. Academy proceedings and reports: round table discussion on antibiotics. Pediatrics. 1948;1(2):270-287
• Mellin GW, Kent MP. Ophthalmia neonatorum: Is prophylaxis necessary? Pediatrics. 1958;22(5):1006-1015
• Snowe RJ, Wilfert CM. Epidemic reappearance of gonococcal ophthalmia neonatorum. Pediatrics. 1973;51(1):110-114

In 1958, the question “Ophthalmia Neonatorum: Is Prophylaxis Necessary?” was asked in Pediatrics.¹ The authors reported an observational study at a hospital in New York City following the 1956 repeal of a municipal requirement for prophylaxis treatment of ophthalmia neonatorum at the time of birth. They recommended reinstitution of prophylaxis based on their finding that the incidence of gonococcal ophthalmia neonatorum increased after cessation of silver nitrate treatment. This study likely played a role in the re-institution of prophylaxis at the hospital, as well as continued use of prophylaxis in many hospitals around the country. In 1973, Snowe and Wilfert reported an epidemic resurgence of gonococcal ophthalmia neonatorum, despite silver nitrate prophylaxis.² At the time, 47 states and the District of Columbia mandated prophylaxis. Still, the authors supported the continued use of silver nitrate prophylaxis due to prior reported increases in cases when prophylaxis was discontinued. A 1976 case series in Pediatrics³ that included the first report of a case of coexisting chlamydial and gonococcal ophthalmia neonatorum reinforced this practice and illustrated the need to consider that both infectious causes may be present when one etiology has been established.

Notably, the issue of ocular prophylaxis with silver nitrate versus penicillin was briefly discussed in the second issue of the first volume of Pediatrics in 1948 in a roundtable on antibiotics.⁴ It was not until the 1980s that silver nitrate was generally replaced by topical antibiotics due to a lower risk of chemical conjunctivitis and a presumption of greater efficacy in reducing the likelihood of chlamydial infection. In the 1990s, the use of 2.5% povidone iodine for prophylaxis of ophthalmia neonatorum was introduced⁵ and later found to be more effective than silver nitrate or erythromycin, with less toxicity and lower cost.⁶ However, erythromycin is the only drug approved by the US Food and Drug Administration for the prophylaxis of gonococcal ophthalmia neonatorum. Povidone iodine has not been readily accepted in the United States for prophylaxis, although low- and middle-income countries have adopted its use based on its lower cost and its established efficacy for prevention of both gonococcal and chlamydial ophthalmia neonatorum. Today as in 1976, chlamydia is the principal cause of ophthalmia neonatorum and can result in vision loss but through a slower process.

Since the early important reports on prophylaxis of ophthalmia neonatorum, the method of prophylaxis has evolved, and controlled studies have been conducted, but the question of whether prophylaxis is still necessary remains.⁷ Today, most US states mandate ocular prophylaxis for newborns, as recommended by the US Prevention Services Task Force.⁸ The AAP Red Book recommends prophylaxis in areas where gonorrhea is prevalent, if prenatal treatment cannot be ensured, or where required by law.

The early articles in Pediatrics helped ensure continued discussion and progress in the strategy for prophylaxis of ophthalmia neonatorum after Credé initially introduced silver nitrate prophylaxis in 1881, which dramatically decreased the incidence of blindness from gonococcal ophthalmia neonatorum.

References

1. Mellin GW, Kent MP. Ophthalmia neonatorum: Is prophylaxis necessary? Pediatrics. 1958;22(5):1006-1015
2. Snowe RJ, Wilfert CM. Epidemic reappearance of gonococcal ophthalmia neonatorum. Pediatrics. 1973;51(1):110-114
3. Armstrong JH, Zacarias F, Rein MF. Ophthalmia neonatorum: a chart review. 1976;57(6):884-892
4. Platou RV, Nelson WE, Alexander HE, Platou ES, Wegman ME, Greenbaum JV. Academy proceedings and reports: Round table discussion on antibiotics. Pediatrics. 1948;1(2):270-287
5. Isenberg SJ, Apt L, Wood M. A controlled trial of povidone-iodine as prophylaxis against ophthalmia neonatorum. N Engl J Med. 1995;332(9):562-566
6. Isenberg SJ, Apt L, Valenton M, et al. A controlled trial of povidone-iodine to treat infectious conjunctivitis in children. Am J Ophthalmol. 2002;134:681-688
7. Kapoor VS, Evans JR, Vedula SS. Interventions for preventing ophthalmia neonatorum. Cochrane Database Syst Rev. 2020;9(9):CD001862
8. US Preventive Services Task Force, Curry SJ, Krist AH, et al. Ocular prophylaxis for gonococcal ophthalmia neonatorum: US Preventive Services Task Force reaffirmation recommendation statement. 2019;321(4):394-398

Second Quarter Century (1973-1998)

Preventing Blindness Right Out of the Gate: The Race to Cure Retinopathy of Prematurity

Steven Rubin, MD, FAAP¹

Affiliation: ¹Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY

Highlighted Publications From Pediatrics

• Cryotherapy for Retinopathy of Prematurity Cooperative Group. Multicenter trial of cryotherapy for retinopathy of prematurity: preliminary results. Pediatrics. 1988;81(5):697-706 https://publications.aap.org/pediatrics/article/81/5/697/55219/Multicenter-Trial-of-Cryotherapy-for-Retinopathy
• Fierson WM, Palmer EA, Biglan AW, et al. Screening examination of premature infants for retinopathy of prematurity. A joint statement of the American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology. Pediatrics. 1997;100(2):273

When medical historians look back on the 20th century for the greatest achievement in pediatric ophthalmology, high on the list, if not at the very top, would have to be the advances in management of retinopathy of prematurity (ROP). As often is the case in medicine (and in life), solving one problem leads to others. ROP arose only after the advent and development of neonatal intensive care units (NICUs), which dramatically improved the survival of premature infants. The joy and relief of a surviving (and thriving) premature infant’s parents were often muted, and in some cases severely attenuated, by their baby’s prognosis for normal vision. Many of these survivors developed what is now named Stage 5 ROP, manifesting as a fibrous mass behind the crystalline lens first described by Terry in 1946,¹ giving rise to this condition’s original name, retrolental fibroplasia. Although oxygen was first “identified” as a major causative factor, other risk factors were sought (bright light, vitamin E deficiency, etc), but there remained no effective treatment for the first several decades of this epidemic. With extensive research around the world, we have a better understanding of the pathogenesis of ROP with its modifying factors, such as vascular endothelial growth factor (VEGF) and insulin-like growth factor 1.

Approximately 100 manuscripts on the topic of ROP were published by Pediatrics during the middle quarter century of its first 75 years, but chief among them is the landmark paper that heralded the first significant advance in conquering this potentially blinding disease: a multicenter randomized controlled trial (RCT) proved efficacy using an old treatment (at least in adult ophthalmology) in significantly reducing the visual morbidity of this “new” malady.² This paper was simultaneously published with the Archives of Ophthalmology, owing to the then unprecedented extensive cooperation between neonatologists, pediatric ophthalmologists, and retinal specialists across the 23 study centers. Cryotherapy was shown to reduce the risk of an “adverse outcome” by approximately half, a proportion that was essentially maintained throughout the several follow-up studies of the original cohort. The data from this study also played a pivotal role in developing the protocols for serial screening of infants at risk for ROP.³ These protocols are periodically revised as new data become available.

Although ROP still blinds some premature infants, this landmark RCT was the first step on the road to mitigating this condition. Laser photocoagulation and intravitreal injection of VEGF inhibitors has supplanted cryotherapy. These therapies, paired with a more judicious examination protocol, has allowed timely identification and effective treatment of this condition with minimal risk to the premature infant.

Many blinding diseases have existed for centuries with little or no progress made in treatment. ROP is a relatively new condition, arising only since the development of NICUs led to survival of premature infants. Yet clinician scientists have made significant strides in the half century or so since its emergence. Such a timeline certainly may not rival the development of a vaccine for the COVID pandemic, but still stands as a testament to the dedication, ingenuity, and cooperation of pediatricians and ophthalmologists.

References

1. Terry L. Retrolental fibroplasia. J Pediatr. 1946;29(6):770-773; doi: 10.1016/s0022-3476(46)80009-x
2. Cryotherapy for Retinopathy of Prematurity Cooperative Group. Multicenter trial of cryotherapy for retinopathy of prematurity: preliminary results. Pediatrics. 1988.81(5):697-706
3. Fierson WM, Palmer EA, Biglan AW, et al. Screening examination of premature infants for retinopathy of prematurity. A joint statement of the American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology. Pediatrics. 1997;100(2):273

Third Quarter Century (1998-2023)

Seeing into the Future: Pediatricians as Guardians of Vision

Douglas Fredrick MD FAAP¹

Affiliation: ¹Stanford University School of Medicine, South San Francisco, CA

Highlighted Publications From Pediatrics

• Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Association of Certified Orthoptists; American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology. Eye examination in infants, children, and young adults by pediatricians. Pediatrics. 2003;111(4):902-907
• US Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US Preventive Services Task Force recommendation statement. Pediatrics. 2011;127(2):340-346
• Donahue SP, Ruben JB, American Academy of Ophthalmology, et al. US Preventive Services Task Force vision screening recommendations. Pediatrics. 2011;127(3):569-570

From the time of Hippocrates and Galen, the role of the physician has been defined by a responsibility to detect and manage physical ailments. As the discipline of pediatrics has evolved, so has the role of the pediatrician, so that now we are charged with the responsibility to prevent, detect, and manage physical, behavioral, and developmental issues that arise in children. This dichotomy of roles was defined in the formative years of the journal Pediatrics when, in 1948, it was reported that pediatricians spent 54% of their time in “health supervision” (ie, parental education, preventive care, developmental assessment) and 46% of their time in “medical care of sick children.”¹ In the inaugural year of the publication of Pediatrics, pediatricians concerned themselves with Credé’s prophylaxis, but the ocular disease of retrolental fibroplasia and amblyopia were conditions diagnosed only late in their natural history with little hope of visual salvage. Flash forward to 1998, as Pediatrics entered its 50^th year of publication and the demands placed on pediatricians as “health supervisors“ had grown exponentially. Once hopeless ocular conditions, such as congenital cataracts, retinopathy of prematurity, and deprivation amblyopia, could be treated and visual losses averted, but only when detected in a timely fashion. That burden of detection falls to pediatricians. Pediatrics has become an integral partner with the AAP, the American Association for Pediatric Ophthalmology and Strabismus, the American Association of Certified Orthoptists, and the American Academy of Ophthalmology in the effort to educate pediatricians in their mission to detect these disorders. In the past 25 years, there have been 3 publications in Pediatrics that focus on the essential function of pediatricians as detectors of vision-threatening ocular disorders. Each report builds on its predecessor, evolving to address the value of our efforts to prevent vison loss and leveraging technology to assist in that goal.

In 2003, Pediatrics published a policy statement titled “Eye Examination in Infants, Children and Young Adults by Pediatricians,”² which clearly outlined at what age and how children should be examined and screened for ocular and visual disorders. The timing of assessment of vision is delineated in the AAP Bright Futures Periodicity Schedule, but the policy statement provided explicit instructions to help pediatricians perform these examinations at every age. When physicians who are not pediatricians view this Bright Futures pocket guide and see the myriad essential tasks that must be performed at every office visit, we appreciate and admire the daunting challenges encountered by pediatricians each day.

Delivering high-value care requires detection of disease and the initiation of care in a cost effective and efficient manner. The value of vision screening was addressed in a study by the US Preventive Services Task Force published in Pediatrics in 2011.³ The authors concluded that vision screening should take place between ages 3-5 years, but they stated there was insufficient evidence to recommend routine screening in children younger than 3 years. The publication elicited concerns from pediatric ophthalmologists, who feared that ignoring vision screening in the first 3 years of life would lead to omission of the ocular examination in these younger children, resulting in failure to diagnose vision- and life-threatening conditions, such as congenital cataracts, strabismus, and retinoblastoma. Fortunately, examination of the eyes is recommended as a part of every well-child visit in the Bright Futures guidelines.

As pediatricians are asked to do more and more for children with less and less payment for their efforts, technology has evolved to aid in the detection of amblyopia, a vision-threatening condition that occurs in up to 5% of the pediatric population that must be diagnosed and treated in the first decade of life. Incorporating technology while reaffirming the necessity for ocular examination and vision screening was the objective of our third most important publication in the third quarter century of Pediatrics, a collaborative document published in 2016 entitled “Procedures for the Evaluation of the Visual System by Pediatricians.⁴ The authors described how to use simple devices to assist pediatricians to detect amblyopia risk factors in preverbal preliterate children with high sensitivity and specificity and reaffirmed the importance of deliberate observation and examination outlined in the guidelines published 13 years earlier.

In the next 25 years, technology will continue to evolve, but the codependent relationship between pediatric ophthalmologists and pediatricians—their mutually shared roles as health supervisors of the well and physicians of the ill—will be unchanging. It is our hope that conducting research to ascribe and define value to these efforts to prevent and restore vison loss, succinctly stated as “valuing vision”⁵ by an editor of Pediatrics, will in turn be more highly valued by our patients, their families, and governmental agencies charged with protecting the health of our next generation.

References

1. Hubbard JP, Zibit S. Review of private practice; pediatricians and general practitioners. Pediatrics. 1948;1(3):379-386
2. Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Eye examination in infants, children, and young adults by pediatricians. Pediatrics. 2003;111(4):902-907
3. US Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US Preventive Services Task Force recommendation statement. Pediatrics. 2011;127(2):340-346; doi: 10.1542/peds.2010-3177
4. Donahue SP, Baker CN, Committee on Practice and Ambulatory Medicine, et al. Procedures for the evaluation of the visual system by pediatricians. Pediatrics. 2016;137; doi: 10.1542/peds.2015-3597
5. Kemper AR. Valuing vision. Pediatrics. 2004;113(2):404-405; doi: 10.1542/peds.113.2.404