Pediatric Ophthalmology and Strabismus


Prof. Rohit Saxena
Professor, Dr. RP Centre For Ophthalmic
Sciences, AIIMS, New Delhi

The next ophthalmologist to get the nobel prize will be one who deciphers the myopia puzzle
Myopia is a leading cause of visual disability throughout the world with mounting evidence that it is on the rise. A recent study estimated that 30% of the world is currently myopic and by 2050, based on current trends, almost 50% will be myopic, that’s a staggering 5 billion people with 1 billon high myopes. While high risk factors include increased near work, lack of outdoor activity, parental myopia, intense school curriculum and possible increased genetic susceptibility the intervention that can prevent or halt this epidemic will be the breakthrough of the century in our field.

Amblyopia treatment using Dichoptics:
From eye pads to I-pads Dichoptic training possibly promotes a higher level of plasticity and is better than occlusion alone. Coming soon will be games and interactive videos that will mix the business of treating amblyopia with pleasure and enjoyment for the child.

Managing disease at the genetic level
The management of disease is rapidly shifting from the macroscopic to the microscopic level. The prevention of disease manifestation by enforcing changes in the genetic codeor on the expression of various genes is the future. Already a lot of work is underway in managing eye diseases in children by genetic intervention and the most successful example of ocular gene therapy was the gene replacement therapy for RPE65, Leber’s congenital amaurosis 2 (LCA2). We hope that genetic interventions can help to prevent and manage many sight threatening childhood disorders in the coming decade.

The coming decade should bring about huge advancements in the management of pediatric eye diseases which have long been ignored and neglected. It will mark the coming of age of a vital speciality that impacts the development of our future generations.

Open both eyes to the future
The future is not just 20/20 but 20/20/20 where the third 20 is for 20 seconds of arc 3D vision. The world of ophthalmology is belatedly waking up to the fact that God gave us 2 eyes for a purpose. While 3D technology is the future, it can be a challenge for the ophthalmologists. Quality of vision includes stereopsis and the growing demands from technology in the form of 3D movies, holographic images, phones and virtual reality will create dissatisfaction if we fail to restore it after a squint, cataract, refractive or any ophthalmic intervention.

It is time that outcomes of any procedure are measured not by par excellence uniocular visual acuity but by fine depth perception.

Customizing squint surgery for optimal outcomes
The field of strabismus surgery has evolved rapidly in recent years, with iconic innovators changing our understanding of eye muscles and movement. Newer insight has brought a paradigm shift in the management of complex strabismus and our understanding of the disease is continually being revised. The advent of high-resolution magnetic resonance imaging (MRI) has led to the discovery of extraocular muscle pulleys which are the condensation of the connective tissue of the posterior Tenon’s fascia. Instability of the rectus pulleys is believed to be associated with incomitant strabismus. Dynamic MRI can help in surgical planning by showing how the muscle contracts and corresponding globe movement. Harnessing newer technology to improve consistency and predictability in outcomes of squint surgery is the future. Exciting times are coming for the squint surgeon!

References:
1. Singh D, Saxena R, Sinha R, Titiyal JS. Stereoacuity changes after laser in situ keratomileusis. Optom Vis Sci. 2015 Feb;92(2):196-200.
2. Saxena R, Vashist P, Tandon R, Pandey RM, Bhardawaj A, Menon V, Mani K. Prevalence of myopia and its risk factors in urban school children in Delhi: the North India Myopia Study (NIM Study). PLoS One. 2015 Feb 26;10(2):e0117349.
3. Singh A, Sharma P, Saxena R. Evaluation of the Role of Monocular Video Game Play as an Adjuvant to Occlusion
Therapy in the Management of Anisometropic Amblyopia. J Pediatr Ophthalmol Strabismus. 2017 May 15:1-6
4. Saxena R, Vashist P, Menon V. Is myopia a public health problem in India? Indian J Community Med. 2013 Apr;38(2):83-5.
5. Saxena R, Vashist P, Tandon R, Pandey RM, Bhardawaj A, Gupta V, et al. Incidence and progression of myopia and associated factors in urban school children in Delhi:
The North India Myopia Study (NIM Study). PLoS ONE. 2017 12(12): e0189774.
6. Morgan IG, Ohno-Matsui K, Saw SM. Myopia. Lancet. 2012;379(9827):1739- 48
7. Holden, Brien A. et al. Global Prevalence of Myopia and High Myopia and Temporal Trends from 2000 through 2050. Ophthalmology , Volume 123, Issue 5 , 1036 – 1042.