REVIEW URRENT C OPINION
Anesthesia considerations in pediatric glaucoma management Ta C. Chang and Kara M. Cavuoto
Purpose of review This article reviews the potentially adverse neurodevelopmental effects of early exposure to general anesthesia and examines a changing paradigm in the management of pediatric glaucoma. Recent findings Literature across multiple subspecialties has examined the potentially neurotoxic effects of general anesthesia on the developing child’s brain. Associations between general anesthesia exposure early in life and attention deficit hyperactivity disorder, language processing, and cognition have been suggested but not confirmed. Several population studies support the conclusion that early anesthetic exposure may increase the risk of neurodevelopmental deficits, although this is unsupported in sibling cohorts. Newer technology such as rebound tonometry may decrease the frequency of examination under anesthesia in the long-term management of patients with pediatric glaucoma and may decrease the risk of these potentially adverse neurodevelopmental outcomes. Summary As the potential long-term adverse neurodevelopmental effects of general anesthesia become better understood, pediatric glaucoma specialists should be cognizant of the relative lifelong risks and benefits of repeat examinations under anesthesia in young patients. Keywords anesthetic exposure in children, examination under anesthesia, neurodevelopmental dysfunction, pediatric glaucoma, rebound tonometry
INTRODUCTION The paradigm for evaluating and managing pediatric glaucoma has changed little since the advent of the surgical microscope in the 1950s. The clinical examination of children, particularly young children, is often limited by their cooperation, and subjective testing is often impossible. Pediatric glaucoma specialists typically rely on serial examinations under anesthesia (EUA) to achieve specific assessment goals: establishing a baseline examination, setting an intraocular pressure (IOP) goal, initiating therapy to lower pressure, monitoring treatment effect and glaucomatous progression, and modifying the IOP goal and treatment as indicated by the patient’s course. Analysis of the anterior chamber angle and the optic nerve as well as objective measures of disease status such as axial length and corneal diameter can be achieved during the EUA as well [1 ]. Although technologic advances such as the portable biomicroscope and integrated digital photography systems have improved both &&
www.co-ophthalmology.com
examination and documentation of children with pediatric glaucoma, these breakthroughs have not obviated serial EUA. The possible impact of multiple anesthetic exposures on neurodevelopment in children is a subject of significant clinical concern and active research. Basic laboratory findings suggest possible neurotoxic effects of early exposure to anesthetic agents, particularly in children prior to age of 3 years when cessation of active synaptogenesis occurs [2]. Most children with congenital or infantile-onset glaucoma are managed with regular EUA until they can cooperate with IOP measurements and fundus photos in the clinic, usually around age 4. It is Bascom Palmer Eye Institute, Miami, Florida, USA Correspondence to Ta C. Chang, MD, Bascom Palmer Eye Institute, 900 NW 17th Street, 450N, Miami, FL 33136, USA. Tel: +1 305 326 6000; e-mail: [email protected] Curr Opin Ophthalmol 2014, 25:118–121 DOI:10.1097/ICU.0000000000000032 Volume 25 Number 2 March 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Anesthesia in pediatric glaucoma management Chang and Cavuoto
KEY POINTS Epidemiologic evidence on anesthesia exposure with neurodevelopmental outcomes in children suggests but does not establish a modestly elevated risk of adverse outcomes in children with early exposure to anesthesia. Population studies suggest possible associations between early anesthetic exposure with language and cognitive dysfunctions and ADHD. The link between general anesthetic exposure and adverse behavioral outcome is not supported in a small sibling cohort study. Early anesthetic exposure may be unavoidable for most patients with infantile-onset glaucoma. Rebound tonometry is acceptably precise and seems to be better tolerated by children and, thus, may play a role in reducing the frequency of anesthesia in pediatric glaucoma management.
typical to perform three or four EUAs yearly, and some children undergo much more frequent examinations. This high frequency of early anesthetic exposure makes this population particularly vulnerable to any potential neurotoxic effect of anesthesia. In this review, we will examine recent evidence on the potential impact of general anesthesia on neurodevelopment as it applies to the pediatric population. We will also examine rebound tonometry as a possible means to decrease the frequency of anesthetic exposure.
EARLY ANESTHETIC EXPOSURE AND NEURODEVELOPMENTAL OUTCOMES A meta-analysis of epidemiologic evidence on anesthesia exposure with neurodevelopmental outcomes in children suggests a modestly elevated risk of possible adverse outcomes in children with early exposure to anesthesia [2]. In this study, the authors performed descriptive analyses of 12 studies that were evenly split between clinical and population-based samples. They found the unadjusted result for an association of an anesthetic event with a developmental outcome was 1.9 (95% credible interval 1.2–3.0), whereas the adjusted result for any exposure was slightly lower at 1.4 (95% credible interval 0.9–2.2). Population attributable risk was determined using the adjusted results and it was found that the risk for learning or behavioral disorders in the USA due to anesthesia is 2.6%. Additional studies have focused on specific behavioral and learning disorders. The cumulative incidence of attention deficit hyperactivity disorder
(ADHD) in a well defined pediatric cohort directly correlated with the number of exposures to anesthesia prior to age of 2 years [3]. In this retrospective, population-based, case–control cohort of 5357 children born between 1976 and 1982, ADHD cases were identified by an extensive review of school and medical records and assessed against established diagnostic criteria. In total, 93% of the cohort did not have anesthetic exposure prior to age of 2 years, whereas 5.7% of the patients had one exposure and 1.2% of the patients had two or more exposures. The cumulative incidence of ADHD in controls without anesthesia exposure was 7.3%, compared with 10.7% in those with one exposure and 17.9% in those with two or more exposures. Multiple, but not single, exposures to anesthesia prior to age of 2 years increased ADHD risk when adjusted for sex, birth weight, and gestational age [hazards ratio 2.49, 95% confidence interval (CI) 1.32–4.71]. The study was limited in its retrospective design and the inability to determine whether the anesthetic event was coupled with a nonsurgical or surgical procedure, either of which might introduce significant confounding factors such as systemic inflammation, postoperative analgesic usage, and overall poor childhood health. Studies have also examined the possible effects of anesthetic exposure on language, cognitive function, motor skills, and behavior. A birth cohort of 2608 children enrolled between 1989 and 1992 had prospective neuropsychological tests performed at age 10 [4]. Those with self-reported anesthetic exposure prior to age of 3 scored significantly worse in tests of language (receptive, expressive and total) and cognition, but there were no differences in behavior and motor function outcomes. The adjusted risk ratio for disability in receptive, expressive, and total language were 1.87 (95% CI 1.20–2.93), 1.72 (95% CI 1.12–2.64), and 2.11 (95% CI 1.32–3.14), respectively. The adjusted risk ratio for disability in abstract reasoning was 1.69 (95% CI 1.13–2.53). It is not clear from the study methods whether the neuropsychological tests were administered by examiners masked to the participants’ prior anesthetic exposure history, nor were the details of anesthetic events known since selfreported history and patient questionnaires were used. Furthermore, the most prevalent anesthetic agent at the time of study was halothane, which is seldom used today. Associations between exposure to general anesthesia at a young age and neurodevelopmental dysfunctions such as ADHD, language processing, and cognition have been suggested in population studies. However, no association was found in a more tightly controlled sibling pair study, which
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Glaucoma
was designed to minimize environmental and socioeconomic confounders [5 ]. In a large, multisite pilot study, neuropsychological assessments were prospectively performed on 28 retrospectively identified sibling pairs, one of whom had anesthesia exposure prior to age of 3 years for inguinal hernia repair, whereas the other remained unexposed [5 ]. After review of detailed medical and anesthesia records, no differences were found between the siblings in intelligence quotient (verbal, performance, and total). However, nearly half of the sibling pairs contacted declined to discuss the study, and of those willing (105 sibling pairs), more than half either refused to participate or were ineligible (79 sibling pairs), resulting in a low enrollment rate that could have introduced participation bias. The discordant findings among various studies on the effect of early-age anesthesia exposure on neurological development demonstrate the complexity of the issue in question and make formal clinical recommendations difficult. When an infant presents with a sight-threatening condition that requires examination and/or surgery, the benefit of anesthesia exposure outweighs any theoretical, future harm. Most patients with early childhood glaucoma will, therefore, have at least some anesthetic exposure. However, if future research clearly demonstrates an association between frequency of anesthetic and neurodevelopmental deficits, efforts to decrease or minimize EUA frequency are warranted. &&
&&
REBOUND TONOMETRY AND THE PEDIATRIC EYE EXAMINATION The use of rebound tonometry as an adjunct to applanation tonometry in the management of pediatric glaucoma has recently gained interest in the ophthalmologic community. Compared with applanation tonometry, rebound tonometry is acceptably precise and seems to be better tolerated by children. It has also been suggested as a potential means of reducing the frequency of anesthesia in children to measure IOP. A current ophthalmic technology assessment report by Lambert et al. [6 ] summarized four recent studies comparing rebound tonometry with Goldmann applanation tonometry and addressed its tolerability in children. No study met the strict criteria for level I evidence, including a generalizable study population, widely accepted reference method, randomized order of testing, masked examiners, presentation of data in a Bland–Altman plot, and addressing varying differences between two methods as function of &&
120
www.co-ophthalmology.com
underlying measurements. The authors concluded that rebound tonometry is better tolerated than applanation tonometry in children, and in general measures the IOP to be 2–3 mmHg higher with a greater difference at higher IOP. Other studies specifically compared rebound tonometry with Goldmann applanation in children with manifest or suspected glaucoma. In a prospective study of 60 pediatric patients between the ages of 5 and 17 years, Gandhi et al. [7] compared tonometry measurements, evaluated the trend of IOP after repeated measurements, and assessed the feasibility of instructing parents to perform rebound tonometry. Rebound tonometry measurements were performed by clinical examiners and parents in alternating sequence prior to Goldmann applanation, which in turn was performed by a designated examiner who was masked to the rebound tonometry readings. The study demonstrated a significant difference between rebound tonometry measurements and Goldmann applanation tonometry with a mean absolute difference of 3.3 4.0 mmHg, and between rebound tonometry measurements by clinical examiner versus parents resulting in a mean absolute difference of 1.9 1.9 mmHg. The differences were not related to the baseline IOP levels. In a retrospective review of clinical practice patterns during the introduction of rebound tonometry in a tertiary, hospital-based pediatric ophthalmology practice, Grigorian et al. [8] compared the number of glaucoma clinic visits with the number of EUAs performed for pediatric glaucoma patients over three time periods: 10 months prior to the introduction of rebound tonometry, a 5-month transition period during which rebound tonometry was introduced but not yet mastered, and 10 months after the introduction and mastery of rebound tonometry in the clinic. Prior to rebound tonometry, 71% of IOP measurements were obtained during EUA. During both the transition period and the 10-month period after mastery of rebound tonometry, only 33 and 12% of IOPs were obtained during EUA, respectively. Furthermore, the number of EUA decreased from 55 (in 37 patients) prior to rebound tonometry to 18 (in 15 patients) after the introduction and mastery of rebound tonometry. This suggests that rebound tonometry may decrease the frequency of EUA by allowing clinic-based IOP measurements in young children. The authors did not address other examination elements, such as serial disc photography and biometric measurements that may be integral to pediatric glaucoma management. The study also did not discuss referral patterns during the three time periods or compare the number of new versus established pediatric Volume 25 Number 2 March 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Anesthesia in pediatric glaucoma management Chang and Cavuoto
glaucoma patients within each period. This is particularly relevant as new patients often require more frequent examinations compared with established patients, while a biased referral pattern may introduce potential confounders.
CONCLUSION In summary, the current evidence for an increased risk of adverse neurodevelopmental outcomes in children with early anesthetic exposure is controversial. High-quality, prospective studies on the effects of early anesthetic exposure on neurodevelopment are needed. For infants with congenital glaucoma, anesthetic exposure may be unavoidable, although the clinical use of rebound tonometry may decrease the frequency of EUA required in long-term management. Future efforts on rapid image capture and autofocus technology may allow high-quality disc photography to be obtained even in uncooperative children, thus allowing monitoring of disease progression in the clinic. In the future, practitioners will need to perform risk–benefit analysis in the management of pediatric glaucoma patients in order to maximize visual outcome while minimizing long-term risks. Acknowledgements The authors wish to acknowledge Dr Elizabeth Hodapp for her assistance in preparing this article.
Conflicts of interest The authors have no relevant sources of funding in regard to this study. There are no conflicts of interest for any authors.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest In: Weinreb RN, Grajewski AL, Papadopoulos MP, Freedman S, Grigg J, editors. Glaucoma of childhood. Amsterdam: Kugler Publications; 2013. This paper is a current, comprehensive review on the evaluation and management of pediatric glaucoma. 2. DiMaggio C, Sun LS, Ing C, Li G. Pediatric anesthesia and neurodevelopmental impairments: a Bayesian meta-analysis. J Neurosurg Anesthesiol 2012; 24:376–381. 3. Sprung J, Flick RP, Katusic SK, et al. Attention-deficit/hyperactivity disorder after early exposure to procedures requiring general anesthesia. Mayo Clin Proc 2012; 87:120–129. 4. Ing C, DiMaggio C, Whitehouse A, et al. Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics 2012; 130:476–485. 5. Sun LS, Li G, DiMaggio CJ, et al. Feasibility and pilot study of the Pediatric && Anesthesia NeuroDevelopment Assessment (PANDA) project. J Neurosurg Anesthesiol 2012; 24:382–388. This high-quality prospective pilot study will likely expand into a key trial based on which many future clinical decisions on pediatric anesthesia are made. 6. Lambert SR, Melia M, Buffenn AN, et al. Rebound tonometry in children: && a report by the American Academy of Ophthalmology. Ophthalmology 2013; 120:e21–e27. This paper is a succinct yet informative report on the use of rebound tonometry technology in children. 7. Gandhi NG, Prakalapakorn SG, El-Dairi MA, et al. Icare ONE rebound versus Goldmann applanation tonometry in children with known or suspected glaucoma. Am J Ophthalmol 2012; 154:843–849. 8. Grigorian F, Grigorian AP, Olitsky SE. The use of the iCare tonometer reduced the need for anesthesia to measure intraocular pressure in children. J AAPOS 2012; 16:508–510. 1.
&&
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
121
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Anesthesia considerations in pediatric glaucoma management Ta C. Chang and Kara M. Cavuoto
Purpose of review This article reviews the potentially adverse neurodevelopmental effects of early exposure to general anesthesia and examines a changing paradigm in the management of pediatric glaucoma. Recent findings Literature across multiple subspecialties has examined the potentially neurotoxic effects of general anesthesia on the developing child’s brain. Associations between general anesthesia exposure early in life and attention deficit hyperactivity disorder, language processing, and cognition have been suggested but not confirmed. Several population studies support the conclusion that early anesthetic exposure may increase the risk of neurodevelopmental deficits, although this is unsupported in sibling cohorts. Newer technology such as rebound tonometry may decrease the frequency of examination under anesthesia in the long-term management of patients with pediatric glaucoma and may decrease the risk of these potentially adverse neurodevelopmental outcomes. Summary As the potential long-term adverse neurodevelopmental effects of general anesthesia become better understood, pediatric glaucoma specialists should be cognizant of the relative lifelong risks and benefits of repeat examinations under anesthesia in young patients. Keywords anesthetic exposure in children, examination under anesthesia, neurodevelopmental dysfunction, pediatric glaucoma, rebound tonometry
INTRODUCTION The paradigm for evaluating and managing pediatric glaucoma has changed little since the advent of the surgical microscope in the 1950s. The clinical examination of children, particularly young children, is often limited by their cooperation, and subjective testing is often impossible. Pediatric glaucoma specialists typically rely on serial examinations under anesthesia (EUA) to achieve specific assessment goals: establishing a baseline examination, setting an intraocular pressure (IOP) goal, initiating therapy to lower pressure, monitoring treatment effect and glaucomatous progression, and modifying the IOP goal and treatment as indicated by the patient’s course. Analysis of the anterior chamber angle and the optic nerve as well as objective measures of disease status such as axial length and corneal diameter can be achieved during the EUA as well [1 ]. Although technologic advances such as the portable biomicroscope and integrated digital photography systems have improved both &&
www.co-ophthalmology.com
examination and documentation of children with pediatric glaucoma, these breakthroughs have not obviated serial EUA. The possible impact of multiple anesthetic exposures on neurodevelopment in children is a subject of significant clinical concern and active research. Basic laboratory findings suggest possible neurotoxic effects of early exposure to anesthetic agents, particularly in children prior to age of 3 years when cessation of active synaptogenesis occurs [2]. Most children with congenital or infantile-onset glaucoma are managed with regular EUA until they can cooperate with IOP measurements and fundus photos in the clinic, usually around age 4. It is Bascom Palmer Eye Institute, Miami, Florida, USA Correspondence to Ta C. Chang, MD, Bascom Palmer Eye Institute, 900 NW 17th Street, 450N, Miami, FL 33136, USA. Tel: +1 305 326 6000; e-mail: [email protected] Curr Opin Ophthalmol 2014, 25:118–121 DOI:10.1097/ICU.0000000000000032 Volume 25 Number 2 March 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Anesthesia in pediatric glaucoma management Chang and Cavuoto
KEY POINTS Epidemiologic evidence on anesthesia exposure with neurodevelopmental outcomes in children suggests but does not establish a modestly elevated risk of adverse outcomes in children with early exposure to anesthesia. Population studies suggest possible associations between early anesthetic exposure with language and cognitive dysfunctions and ADHD. The link between general anesthetic exposure and adverse behavioral outcome is not supported in a small sibling cohort study. Early anesthetic exposure may be unavoidable for most patients with infantile-onset glaucoma. Rebound tonometry is acceptably precise and seems to be better tolerated by children and, thus, may play a role in reducing the frequency of anesthesia in pediatric glaucoma management.
typical to perform three or four EUAs yearly, and some children undergo much more frequent examinations. This high frequency of early anesthetic exposure makes this population particularly vulnerable to any potential neurotoxic effect of anesthesia. In this review, we will examine recent evidence on the potential impact of general anesthesia on neurodevelopment as it applies to the pediatric population. We will also examine rebound tonometry as a possible means to decrease the frequency of anesthetic exposure.
EARLY ANESTHETIC EXPOSURE AND NEURODEVELOPMENTAL OUTCOMES A meta-analysis of epidemiologic evidence on anesthesia exposure with neurodevelopmental outcomes in children suggests a modestly elevated risk of possible adverse outcomes in children with early exposure to anesthesia [2]. In this study, the authors performed descriptive analyses of 12 studies that were evenly split between clinical and population-based samples. They found the unadjusted result for an association of an anesthetic event with a developmental outcome was 1.9 (95% credible interval 1.2–3.0), whereas the adjusted result for any exposure was slightly lower at 1.4 (95% credible interval 0.9–2.2). Population attributable risk was determined using the adjusted results and it was found that the risk for learning or behavioral disorders in the USA due to anesthesia is 2.6%. Additional studies have focused on specific behavioral and learning disorders. The cumulative incidence of attention deficit hyperactivity disorder
(ADHD) in a well defined pediatric cohort directly correlated with the number of exposures to anesthesia prior to age of 2 years [3]. In this retrospective, population-based, case–control cohort of 5357 children born between 1976 and 1982, ADHD cases were identified by an extensive review of school and medical records and assessed against established diagnostic criteria. In total, 93% of the cohort did not have anesthetic exposure prior to age of 2 years, whereas 5.7% of the patients had one exposure and 1.2% of the patients had two or more exposures. The cumulative incidence of ADHD in controls without anesthesia exposure was 7.3%, compared with 10.7% in those with one exposure and 17.9% in those with two or more exposures. Multiple, but not single, exposures to anesthesia prior to age of 2 years increased ADHD risk when adjusted for sex, birth weight, and gestational age [hazards ratio 2.49, 95% confidence interval (CI) 1.32–4.71]. The study was limited in its retrospective design and the inability to determine whether the anesthetic event was coupled with a nonsurgical or surgical procedure, either of which might introduce significant confounding factors such as systemic inflammation, postoperative analgesic usage, and overall poor childhood health. Studies have also examined the possible effects of anesthetic exposure on language, cognitive function, motor skills, and behavior. A birth cohort of 2608 children enrolled between 1989 and 1992 had prospective neuropsychological tests performed at age 10 [4]. Those with self-reported anesthetic exposure prior to age of 3 scored significantly worse in tests of language (receptive, expressive and total) and cognition, but there were no differences in behavior and motor function outcomes. The adjusted risk ratio for disability in receptive, expressive, and total language were 1.87 (95% CI 1.20–2.93), 1.72 (95% CI 1.12–2.64), and 2.11 (95% CI 1.32–3.14), respectively. The adjusted risk ratio for disability in abstract reasoning was 1.69 (95% CI 1.13–2.53). It is not clear from the study methods whether the neuropsychological tests were administered by examiners masked to the participants’ prior anesthetic exposure history, nor were the details of anesthetic events known since selfreported history and patient questionnaires were used. Furthermore, the most prevalent anesthetic agent at the time of study was halothane, which is seldom used today. Associations between exposure to general anesthesia at a young age and neurodevelopmental dysfunctions such as ADHD, language processing, and cognition have been suggested in population studies. However, no association was found in a more tightly controlled sibling pair study, which
1040-8738 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
www.co-ophthalmology.com
119
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Glaucoma
was designed to minimize environmental and socioeconomic confounders [5 ]. In a large, multisite pilot study, neuropsychological assessments were prospectively performed on 28 retrospectively identified sibling pairs, one of whom had anesthesia exposure prior to age of 3 years for inguinal hernia repair, whereas the other remained unexposed [5 ]. After review of detailed medical and anesthesia records, no differences were found between the siblings in intelligence quotient (verbal, performance, and total). However, nearly half of the sibling pairs contacted declined to discuss the study, and of those willing (105 sibling pairs), more than half either refused to participate or were ineligible (79 sibling pairs), resulting in a low enrollment rate that could have introduced participation bias. The discordant findings among various studies on the effect of early-age anesthesia exposure on neurological development demonstrate the complexity of the issue in question and make formal clinical recommendations difficult. When an infant presents with a sight-threatening condition that requires examination and/or surgery, the benefit of anesthesia exposure outweighs any theoretical, future harm. Most patients with early childhood glaucoma will, therefore, have at least some anesthetic exposure. However, if future research clearly demonstrates an association between frequency of anesthetic and neurodevelopmental deficits, efforts to decrease or minimize EUA frequency are warranted. &&
&&
REBOUND TONOMETRY AND THE PEDIATRIC EYE EXAMINATION The use of rebound tonometry as an adjunct to applanation tonometry in the management of pediatric glaucoma has recently gained interest in the ophthalmologic community. Compared with applanation tonometry, rebound tonometry is acceptably precise and seems to be better tolerated by children. It has also been suggested as a potential means of reducing the frequency of anesthesia in children to measure IOP. A current ophthalmic technology assessment report by Lambert et al. [6 ] summarized four recent studies comparing rebound tonometry with Goldmann applanation tonometry and addressed its tolerability in children. No study met the strict criteria for level I evidence, including a generalizable study population, widely accepted reference method, randomized order of testing, masked examiners, presentation of data in a Bland–Altman plot, and addressing varying differences between two methods as function of &&
120
www.co-ophthalmology.com
underlying measurements. The authors concluded that rebound tonometry is better tolerated than applanation tonometry in children, and in general measures the IOP to be 2–3 mmHg higher with a greater difference at higher IOP. Other studies specifically compared rebound tonometry with Goldmann applanation in children with manifest or suspected glaucoma. In a prospective study of 60 pediatric patients between the ages of 5 and 17 years, Gandhi et al. [7] compared tonometry measurements, evaluated the trend of IOP after repeated measurements, and assessed the feasibility of instructing parents to perform rebound tonometry. Rebound tonometry measurements were performed by clinical examiners and parents in alternating sequence prior to Goldmann applanation, which in turn was performed by a designated examiner who was masked to the rebound tonometry readings. The study demonstrated a significant difference between rebound tonometry measurements and Goldmann applanation tonometry with a mean absolute difference of 3.3 4.0 mmHg, and between rebound tonometry measurements by clinical examiner versus parents resulting in a mean absolute difference of 1.9 1.9 mmHg. The differences were not related to the baseline IOP levels. In a retrospective review of clinical practice patterns during the introduction of rebound tonometry in a tertiary, hospital-based pediatric ophthalmology practice, Grigorian et al. [8] compared the number of glaucoma clinic visits with the number of EUAs performed for pediatric glaucoma patients over three time periods: 10 months prior to the introduction of rebound tonometry, a 5-month transition period during which rebound tonometry was introduced but not yet mastered, and 10 months after the introduction and mastery of rebound tonometry in the clinic. Prior to rebound tonometry, 71% of IOP measurements were obtained during EUA. During both the transition period and the 10-month period after mastery of rebound tonometry, only 33 and 12% of IOPs were obtained during EUA, respectively. Furthermore, the number of EUA decreased from 55 (in 37 patients) prior to rebound tonometry to 18 (in 15 patients) after the introduction and mastery of rebound tonometry. This suggests that rebound tonometry may decrease the frequency of EUA by allowing clinic-based IOP measurements in young children. The authors did not address other examination elements, such as serial disc photography and biometric measurements that may be integral to pediatric glaucoma management. The study also did not discuss referral patterns during the three time periods or compare the number of new versus established pediatric Volume 25 Number 2 March 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Anesthesia in pediatric glaucoma management Chang and Cavuoto
glaucoma patients within each period. This is particularly relevant as new patients often require more frequent examinations compared with established patients, while a biased referral pattern may introduce potential confounders.
CONCLUSION In summary, the current evidence for an increased risk of adverse neurodevelopmental outcomes in children with early anesthetic exposure is controversial. High-quality, prospective studies on the effects of early anesthetic exposure on neurodevelopment are needed. For infants with congenital glaucoma, anesthetic exposure may be unavoidable, although the clinical use of rebound tonometry may decrease the frequency of EUA required in long-term management. Future efforts on rapid image capture and autofocus technology may allow high-quality disc photography to be obtained even in uncooperative children, thus allowing monitoring of disease progression in the clinic. In the future, practitioners will need to perform risk–benefit analysis in the management of pediatric glaucoma patients in order to maximize visual outcome while minimizing long-term risks. Acknowledgements The authors wish to acknowledge Dr Elizabeth Hodapp for her assistance in preparing this article.
Conflicts of interest The authors have no relevant sources of funding in regard to this study. There are no conflicts of interest for any authors.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest In: Weinreb RN, Grajewski AL, Papadopoulos MP, Freedman S, Grigg J, editors. Glaucoma of childhood. Amsterdam: Kugler Publications; 2013. This paper is a current, comprehensive review on the evaluation and management of pediatric glaucoma. 2. DiMaggio C, Sun LS, Ing C, Li G. Pediatric anesthesia and neurodevelopmental impairments: a Bayesian meta-analysis. J Neurosurg Anesthesiol 2012; 24:376–381. 3. Sprung J, Flick RP, Katusic SK, et al. Attention-deficit/hyperactivity disorder after early exposure to procedures requiring general anesthesia. Mayo Clin Proc 2012; 87:120–129. 4. Ing C, DiMaggio C, Whitehouse A, et al. Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics 2012; 130:476–485. 5. Sun LS, Li G, DiMaggio CJ, et al. Feasibility and pilot study of the Pediatric && Anesthesia NeuroDevelopment Assessment (PANDA) project. J Neurosurg Anesthesiol 2012; 24:382–388. This high-quality prospective pilot study will likely expand into a key trial based on which many future clinical decisions on pediatric anesthesia are made. 6. Lambert SR, Melia M, Buffenn AN, et al. Rebound tonometry in children: && a report by the American Academy of Ophthalmology. Ophthalmology 2013; 120:e21–e27. This paper is a succinct yet informative report on the use of rebound tonometry technology in children. 7. Gandhi NG, Prakalapakorn SG, El-Dairi MA, et al. Icare ONE rebound versus Goldmann applanation tonometry in children with known or suspected glaucoma. Am J Ophthalmol 2012; 154:843–849. 8. Grigorian F, Grigorian AP, Olitsky SE. The use of the iCare tonometer reduced the need for anesthesia to measure intraocular pressure in children. J AAPOS 2012; 16:508–510. 1.
&&
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