There’s A Hack For That
Optimizing existing technology to treat glaucoma and cataracts in kids

“My goal is to decrease childhood blindness by treating pediatric eye disease in an innovative way,” says Bibiana Jin Reiser, MD, MS, director of the Cornea and Glaucoma Institute at The Vision Center at Children’s Hospital Los Angeles. Using technology developed for adults, she is modifying or “hacking” it to treat children. Ophthalmologists who treat adults have access to high-tech, ultraprecise equipment. Yet the transfer of that technology to pediatric ophthalmology has been slow. Reiser explains that one of the reasons for this lag is that many ophthalmologists are very conservative in how they treat children. Although “conservative” might sound like the best and safest approach where children’s vision is concerned, that supposition isn’t always true.

“The disease process is totally different in adults and kids, and so is their anatomy,” says Reiser, who is one of the few doctors in the United States who treats pediatric patients with cataracts. She explains that unlike adults, a baby or young child with an untreated cataract may be slowly going blind. The cloudy lens that distinguishes a cataract blocks light from reaching the retina, affecting the ability of the retina to relay visual information to the brain. The eyes and brain must work together for a baby to learn to see. If surgery is done too late, even if the cataract is removed, the child may never be able to see well.

Bibiana Jin Reiser, MD, MS

Reiser was instrumental in The Vision Center’s acquisition of a Trabectome, a minimally invasive device marketed for the treatment of adult-onset glaucoma. CHLA is the first children’s hospital to have a dedicated device for its pediatric patients. “I would not have been able to get this device and use it on kids anywhere but at CHLA,” she says.

Instead of leaving raw edges typical of an incision that can scar and result in a failed surgery, the Trabectome is equipped with an electrocautery device that can minimize scar tissue and ultimately increase success rates. Surgery done with this device can also eliminate the need for an invasive implant. Reiser is currently using the Trabectome on children 8 years of age and older while beginning a clinical trial to study its use in babies and young children.

She’s also employing a laser, marketed for refractive laser surgery (LASIK), and an imaging device used in a procedure called anterior segment optical coherence tomography (AS-OCT), developed for adults, to achieve high-resolution corneal imaging at a microscopic level to make surgeries safer and more precise. Because of The Vision Center’s worldwide reputation, which draws a large number of patients requiring complex corneal surgery, CHLA has a dedicated AS-OCT in its operating room—a prototype developed specifically for CHLA. This setup allows Reiser to image the eye while the child is under general anesthesia, then immediately use that information to perform the most precise surgery possible.

“Kids are not the same as adults. That’s why at CHLA, everything we do and every instrument we use is specifically chosen for children.” – Bibiana Jin Reiser, MD, MS

At CHLA, a significant number of pediatric corneal transplants are performed. This complex surgery can restore vision to a child following a trauma to the eye or a serious infection. Reiser explains that corneal transplants in children are quite complex, and successful outcomes lag behind those in adults.

Luckily, Reiser has a hack for that, too. Taking an unconventional approach to imaging technology she’s optimized for pediatric use, Reiser can precisely image a scar, excise it, and puzzle-piece a section of donor cornea ordered from an eye bank. By placing the piece that fits precisely where the corneal scar used to be, she can ultimately restore the child’s vision.

Reiser and her colleagues at The Vision Center know that kids deserve the best that medicine has to offer, but since the anatomy and the disease processes of children and adults are so different, high-tech devices need to be optimized in order to deliver precision ophthalmic surgery for children.

“Kids are not the same as adults,” Reiser says. “That’s why at CHLA, everything we do and every instrument we use is specifically chosen for children.”

Laser's Edge

Reiser and Nick Moreno

Soon after birth, Nick Moreno was diagnosed with persistent hyperplastic primary vitreous, a rare condition that results in cataracts. His family was immediately referred to Children’s Hospital Los Angeles, where Nick had his first of many eye surgeries—this one to remove the cataract—when he was just 12 weeks old.

At age 7, he developed glaucoma—a condition that occurs secondary to cataract surgery in 5 to 30 percent of cases. With glaucoma, intraocular pressure increases, resulting in damage to the optic nerve and loss of vision. Treatment involves draining fluid from the eye to decrease the pressure. Nick had a shunt, a type of drainage device, placed in his eye when he was 12. He also required three types of eye drops each day.

“The recovery time was significant,” says Vivien Moreno, Nick’s mom. “Following the surgery, he had to spend two weeks flat on his back. Then, he needed to stay home for another month. When he was finally able to return to school, I had to go to the school every day to give him eye drops—three sets, each separated by five minutes.”

Vivien explains that she and Nick gladly complied, but she felt it was a lot to ask of a child.

Eventually, the shunt stopped working. When Nick was 15, his intraocular pressure was significantly above the normal range. His family was also concerned about the quantity of eye drops—they were damaging Nick’s cornea. In fact, he was being considered for a corneal transplant.

Bibiana Jin Reiser, MD, MS, was now Nick’s doctor. She confirmed what Nick and his mom already knew—something had to be done. She could replace the shunt in Nick’s eye or his family could consider an experimental option.

“Dr. Reiser was doing a study on the Trabectome—a device licensed for eye surgery in adults—only she was testing its use in kids,” says Nick. The Trabectome uses a laser to cut and cauterize an opening in the eye to allow drainage and reduce pressure.

Vivien was concerned about her son’s quality of life—she wanted something that worked better than the shunt and wouldn’t require him to miss so much school. “Dr. Reiser told me the post-op recovery would be much easier, probably just one week.”

In fact, Nick returned to school in three days.

“Before, my pressure just kept going up,” says Nick. “After the Trabectome surgery, it dropped.” As a self-proclaimed nerd, Nick created a scatterplot to monitor his daily pressure. Now it’s consistently within the normal range. Nick also needs fewer eye drops, so his cornea has healed and he no longer needs a transplant.

“All because of a single procedure,” says Vivien. “It’s pretty amazing.”