Future Reflections July 1982, Vol. 1 No. 4
By J. Kemper Campbell, M.D.
Ophthalmolgical surgery has undergone tremendous changes in the past decade and many conditions which were previously thought to cause irreversible blindness may now be ameliorated by early surgical intervention. The possibility of at least partial conservation or retention of eyesight should always be fully explored. Psychologically it is easier for both child and parents to accept and adjust to blindness if they feel everything possible has initially been done to preserve vision. Therefore several special points should be made to parents of children with potentially blinding conditions.
First, since many of the serious eye disorders of infants are rare, in most instances, consultation at a large ophthalmological center for a "second opinion" should be obtained. Disorders such as retinoblastomas (eye tumors), retrolental fibroplasia (RLF), congenital glaucoma, and congenital cataracts are now treated and managed in a much different manner than ten years ago. The initial evaluation and recommendations of ophthalmic subspecialists at these centers who may see larger numbers of patients with similar problems are often useful in later management by the local ophthalmologist.
Also, sophisticated equipment is available which allows assessment of the brain's electrical responses to visual stimuli. This test, called a visually evoked reponse (VER); and a test of the electrical response of the eye to light stimuli (electroretinogram or ERG) may often be helpful in predicting an infant's visual prognosis. Both tests can be done in larger medical centers.
Finally, if the child is found to have an inherited blinding disease, genetic counselling will also be available which can be of aid to parents in future family planning.
After the child's initial workup and diagnosis have been completed, then the child's parents and primary ophthalmologist must decide upon the goals of future treatment. Parents should never be afraid to ask any question of the physician however basic it might seem.
"Will my child be able to perceive light or color?" Will the eyes become ugly or painful?" Will they swell up and burst?" "How many operations may be necessary and how much will they cost?" These are all questions which the ophthalmologist will be prepared to answer.
Multiple examinations under anesthesia may be required for proper management and followup of younger children. However, if the financial burden for the child's care becomes too great for the family, "crippled childrens'" funds for this purpose are available in most states. The physician should be able to help the family make an application for these services as well as helping them contact state organizations for the visually impaired. Pediatric ophthalmic surgery and anesthesia are no longer the unpleasant and traumatic experiences which many blind adults remember from their own childhoods. Ether, with its unpleasant odor and after effects, is no longer used. In the hands of the modern anesthesiologist, pediatric anesthesia is safe, painless, and usually no more uncomfortable than drifting off to sleep.
Surgery and anesthesia for crossed eyes and blocked tear ducts is very common and usually performed before the child's first birthday. Many surgeons utilize an outpatient surgical setting so that the child does not have to spend a night in unfamiliar hospital surroundings. Preparing a poorly sighted child for surgery should be no different than preparation of a child with normal eyesight. Prior to age two or three, the experience is only minimally disturbing to the child since hospitals encourage parents to remain with the child in his room as much as possible. For older children a preoperative visit to the pediatric ward can be arranged to help alleviate any unnecessary anxieties about the hospital. It is also important for the ophthalmologist to directly discuss the childs' fears as well as those of his parents. Many children will be satisfied by simply being told that "the doctor is going to fix his eyes." Some will have more specific questions and worries such as whether the eyes will be patched, or whether the eye is removed from the socket during surgery.
In summary, surgery for blind children is approached in the same way as surgery for a normally sighted child. Patient, parents and ophthalmologist must communicate well and discuss the goals, visual expectations and possible complications of the surgical procedure. It is important for the doctor to take enough time to fully explain the present and future plans for the child in terms that the parents understand so that the disappointment of falsely high expectations may be avoided. If this communication is lacking, the ophthalmologist has failed to fulfill his most basic responsibility to the patient.
Dr. Campbell is an opthomologist, well-known and respected by Federationists and professionals in Lincoln, Nebraska where he practices. His willingness to be frank with his patients is refreshing and appreciated.