When pediatric patients do not have experience with an eye care physician, either through previous ocular diagnosis or routine examination, detection and surgical repair of retinal detachment has a higher risk of being delayed, according to an analysis published in Ophthalmology Retina.
The cross-sectional study examined a claims database of more than 150 million individuals with employer-based health insurance. Patients were 18 years of age or younger, diagnosed with incident retinal detachment (RD) who also obtained repair between 2007 and 2016. Diagnoses were referenced by the International Classification of Disease, Ninth and Tenth Revision, Clinical Modification codes, and treatment using Current Procedural Terminology (CPT).
Of the 826 pediatric patients in the dataset, 77.0% experienced rhegmatogenous RD, 17.2% tractional detachment, and 5.8% serous RD. Of the total sample, 62.1% had no prior ocular diagnosis, although 37.9% presented a history of ocular risk factors such as trauma, lattice degeneration, or aphakia/pseudophakia.
Median time to RD repair was 2 days (IQR 0–9 days), but many patients with pre-existing ocular disorders received interventions in 1 day, compared with those without a prior condition who underwent repair at approximately 3 days (P =.003). The Stanford University investigators found individuals with previous eye disorders had a significantly shorter interval from date of last visit to time of RD diagnosis; 14.5 days compared with 44.5 days for those without pre-existing disease (P =.011). Further, the next to last appointment for patients already being followed was 70.5 days, as opposed to 159 days for children without prior conditions (P =.0005).
“History of trauma, aphakia/pseudophakia, and lattice degeneration composing most of the pre-existing ocular conditions in this study also highlights the need to consider more frequent screening in select populations as well as potentially earlier prophylactic treatment of high risk retinal lesions like lattice in young patients,” the investigators explain.
The median age of incident RD was 15 years of age, (62.0% boys, 38% girls, 59.8% were born at gestation of ≥37 weeks). Notably, children with prior eye conditions were younger at RD diagnosis, median age 14 years (P <.001), more often pre-term (P =.004), and attended at least 1 recent eye care visit (P =.079), or 2 visits (P =.002). Trends in RD treatment options included: scleral buckle for 31.5% and pars plana vitrectomy with or without scleral buckle 64.4%, as well as laser barricade in 11.7%, pneumatic retinopexy 3.1%, and cryotherapy 1.3%.
The researchers note there is not yet unanimity on the best age for general childhood ocular screening, or who should perform these assessments — from school nurses to ocular specialists. Also, neonatal and infant testing is often performed by pediatricians with a red reflex test, and primary care physicians may not be fully aware of signs less noticeable than leukocoria.
To date, papers regarding timing of repair for RD in children have been small case series.
A limitation of the current investigation was absence of clinical description for the detachment. Also, the database analyzed does not include uninsured or Medicaid plan-covered individuals. The report adds that dependents who have Medicaid insurance or no health insurance “may face greater barriers to care,” and by not taking this population into account, the resulting data may underestimate interval to treatment.
Archambault C, Azad AD, Al-Moujahed A, et al. Time to treatment of pediatric retinal detachments: a United States claims-based analysis. Ophthalmol Retina. Published online August 21, 2022. doi:10.1016/j.oret.2022.08.017