Pediatric ocular surface reconstruction: Managing lesion excision challenges

(Image Credit: AdobeStock/sp3n)

Although I mainly treat adult patients in my practice, I often work with pediatric ophthalmologists on cases involving complications of the ocular surface, such as injuries or diseases that can lead to the formation of scar tissue. Pediatric patients present specific challenges, requiring the consideration of factors including differences in anatomy and a greater need for attention to postoperative care.¹

Pediatric patients also have different levels of maturity and ability to adhere to postoperative care instructions. Thus, special attention is warranted with this population at every step, from the initial diagnosis through the postoperative course.

Factors affecting lesion excision

The factors to consider when deciding whether a lesion in a pediatric patient requires excision differ from those typically considered for an adult patient. Childhood ocular surface cancers are rare,² but a benign lesion with an unusual appearance can still have a substantial impact on a child’s social well-being, as they may face stigma, teasing from peers, and psychological stress.³

The potential impact of a lesion on a child’s visual development is another key concern, particularly in younger children. Lesions on the cornea or limbus can cause irregular astigmatism that may be poorly corrected with spectacles and could lead to the development of amblyopia.^4,5

Prior to surgery, topography may be indicated to understand the effect of the lesion on the corneal shape and on refraction. If there is concern that the lesion may be a squamous neoplasia, high-resolution optical coherence tomography may be helpful in delineating the lesion type and formulating a suitable surgical approach.⁶

Ocular surface reconstruction

When working with a pediatric population, it is vital to prioritize patient comfort and make recovery from surgery as painless as possible. In my experience, if a child has a painful or traumatic surgical experience, they become much more frightened and anxious about receiving further medical care, and it becomes more difficult to take care of them.

To help address this issue during ocular surface reconstruction, I place an amniotic membrane graft over the area from where the lesion was removed immediately post excision. The amniotic membrane provides several benefits. Most importantly, it facilitates healing and helps re-epithelialize the ocular surface while reducing the possibility of developing scar tissue.⁷ The quicker the affected areas re-epithelialize, the quicker the pain will subside, making it less likely for the patient to be traumatized by the surgery. Additionally, the amniotic membrane can be fastened without sutures using fibrin glue, making postoperative care easier and eliminating the need for another trip to the operating room to remove stitches under anesthesia.

The use of amniotic membranes has been found to be safe and effective for ocular surface reconstruction after lesion excision in pediatric patients.⁸ I prefer to use amniotic membrane preparations that have been cryopreserved rather than dehydrated because this better retains the matrix component responsible for much of the membrane’s therapeutic effects.⁹

Whenever possible, if I am removing scar tissue from a pediatric patient’s eye, I opt for a graft of conjunctiva from the same or fellow eye to provide some viable epithelium to the area and minimize the chance of redeveloping scar tissue. I then cover the graft harvest site with amniotic membrane to facilitate healing (Figure 1 and Figure 2). Amniotic membrane can also be used adjunctively over the conjunctival graft to further decrease inflammation and act as a bandage. I have found that in young children it may be challenging to apply drops consistently, so anything that can provide a prolonged anti-inflammatory effect without requiring frequent reapplication is valuable.

Postoperative considerations

Following ocular surface reconstruction, I most often protect the eye with a patch or eye shield to decrease the chance of rubbing, which may be detrimental to healing. This is especially relevant for very young patients, who may not understand what they are going through and so may be particularly prone to these behaviors.

Postsurgical inflammation can prevent proper re-epithelization and may lead to significant tissue damage, which could manifest as corneal thinning, perforation, and/or scarring.¹⁰ To control inflammation, I use corticosteroid drops or ointments in conjunction with amniotic membranes for a few weeks up to a few months following surgery, depending on the patient and the procedure.

Topical steroids have shown efficacy in resolving inflammation and pain following surgery, but it should be noted that they may lead to increased IOP.¹¹ In my experience, topical steroids in ointment form are often more comfortable and easier to apply for pediatric patients than are drops, but they may also cause the patient to experience more blurred vision, which presents a bit of a trade-off. I prefer starting a patient on a stronger topical corticosteroid, like dexamethasone, but switching to a different steroid with a lower risk of IOP elevation, such as fluorometholone at a low concentration, after a few weeks.¹²

Counseling considerations

When counseling pediatric patients, it is important to remember that no 2 children are the same. Regardless of age and maturity level, building rapport is essential when counseling pediatric patients. Understand that examining them will take more time than with an older patient. Be patient with them. Letting a child feel a little like they are in charge of the examination can help give them a sense of agency and control over their experience.

Similarly, it is critical to ensure that you are acknowledging the parents’ concerns and making yourself available to them. Many times, these situations are even more stressful for parents, so letting them know their child is in caring and attentive hands can go a long way toward mitigating their anxiety.

Conclusion

Although pediatric patients require slightly different considerations than adults, treating children’s eyes is among the most rewarding aspects of my work. By thinking through the nuances of working with pediatric patients and their eyes, you can set yourself up for success and help ensure a smooth and positive experience for both you and your patients.

Darren Gregory, MD

E: darren.gregory@cuanschutz.edu

Gregory is an ophthalmologist practicing at the University of Colorado Sue Anschutz-Rodgers Eye Center in Aurora, Colorado, where he specializes in cataract surgery and treatment of diseases of the cornea and ocular surface. He has no relevant financial conflicts to declare.

References

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8. Bulut O, Palamar M, Yaman B, Egrilmez S, Yagci A, Barut Selver O. Amniotic membrane transplantation for reconstruction of ocular surface lesion excisions in pediatric population. Eye Contact Lens. 2023;49(9):370-373. doi:10.1097/ICL.0000000000001010

9. Tighe S, Mead OG, Lee A, Tseng SCG. Basic science review of birth tissue uses in ophthalmology. Taiwan J Ophthalmol. 2020;10(1):3-12. doi:10.4103/tjo.tjo_4_20

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