If you’re looking to up your pediatric surgical retina skills, look no further than this Day 3 Surgical Pediatric Retina session at the 5th World Congress of Paediatric & Surgical Retina (WCPOS V 2024) in Kuala Lumpur, Malaysia.
Experts in pediatric retina from around the region came strapped with some seriously practical pearls across five notoriously difficult-to-manage diseases and conditions. Over the course of the session, Drs. Manoharan Shunmugam (Malaysia), Andrew Tsai (Singapore), Wai-Ching Lam (Hong Kong), Gavin Tan (Singapore) and Pei-Chang Wu (Taiwan) led attendees through case studies and the ins and outs of the detection, treatment and management of these maladies.
We were on hand live to gather the most impactful tips from each of these luminaries, so without further ado and condensed for your viewing pleasure:
Pediatric IOL fixation without bag support (Dr. Manoharan Shunmugam)

1. Clear the vitreous before either scleral or iris fixation of an IOL in pediatric retina.
“Make sure all the vitreous is clear and that there isn’t any at all”, said Dr. Shunmugam. He also provided the following handy table for users in pars plana and pars plicata vitrectomies for limbus-to-sclerotomy distance.

2. In scleral fixation for children, remove the capsular bag.
Dr. Shunmugam explained that although he prefers to leave a part of the capsular bag in adults, it’s a different story for children. “In children, [leaving behind a piece of the capsular bag] is a disaster, because the lens’ epithelial cells are so much more aggressive. They form scarring and can even cause detachment in very rare cases.”
Pediatric Coats disease (Dr. Andrew Tsai)

1. Consider anti-VEGF and intravitreal steroids as adjuvant therapy in Coats disease.
“I would still say that the definitive therapy for Coats is some form of ablation,” said Dr. Tsai. “But when I gave this child multiple anti-VEGF therapy and laser, his vision improved from 6/120 to 6/9”. He also noted the use of intravitreal steroids as adjunct therapy. Dr. Tsai was firm, however, in noting that research on use of anti-VEGF and intravitreal steroid therapy is needed to clarify usage and regimens.
2. Use a variety of imaging throughout the diagnosis, treatment and management.
Dr. Tsai noted ultra wide-field imaging (UWF; for peripheral telangiectasia and spotting areas of capillary non perfusion) optical coherence tomography (OCT; for retinal exudation in stage 2B and for other signs like hyperreflective dots, outer retinal intubations, subfoveal nodules, EZ disruption and break in the ELM) and OCT angiography (OCT-A, for helping understand the underlying disease more) as playing a variety of roles. He also pointed towards the promise of intraoperative fluorescein angiography. “This might be the future,” Dr. Tsai said.
Juvenile retinoschisis (Dr. Wai-Ching Lam)
1. Spectral domain OCT (SD-OCT) is the go-to in juvenile retinoschisis.
The widespread use of OCT in retinal diseases has been a major boon to confidently sighting juvenile retinoschisis, and Dr. Lam was adamant. “The key to making the diagnosis is OCT,” said Dr. Lam. “Seeing the significant changes to the foveal and peripheral retina allows you to make that definitive diagnosis.”
2. Start with medical intervention, but surgery becomes necessary after failure and retinal detachment.
Dr. Lam’s preferred medical intervention is a carbonic anhydrase inhibitor, but he noted that these have their limitations. “If that fails, and there is associated retinal detachment, then you can do scleral buckle surgery, depending on the locations of the breaks.” He also noted the utility of pars plana vitrectomy with or without inner-schisis retinectomy as a possible surgical intervention.
Familial exudative vitreoretinopathy (Dr. Gavin Tan)
1. Treating the underlying retinal ischemia is critical
According to Dr. Tan, the nature of familial exudative vitreoretinopathy (FEVR) makes the treatment of underlying restriction in blood flow to the retina as critical over both the short and long term. “Intervention is determined by the severity and stage of the disease, and the disease can progress accordingly at any point in the patient’s lifetime,” Dr. Tan explained. “So it’s extremely important to treat the underlying ischemia.”
A major tool in treating this ischemia is fundus fluorescein angiography. Dr. Tan noted that this is not only important for identifying peripheral vascular changes and confirming diagnosis, but guiding the treatment of an avascular or ischemic retina.
2. Tractional or rhegmatogenous detachment is the tipping point
Surgical intervention is always a careful consideration, and for Dr. Tan, there is a line for this in FEVR. “In cases where there is a tractional or rhegmatogenous detachment, surgery may be indicated,” he explained. “It’s mainly traction and peripheral traction that you’re trying to address with surgery,” he said. “Quite often scleral buckling alone can be useful.”
“Overall surgery has a very good success rate, even at later stages, though at stage five this failure rate is much higher,” he continued, pointing to rates as high as 71.4%.
3. Screen family members
When a diagnosis is confirmed, the difficult-to-detect nature of the disease makes scanning family members critical, according to Dr. Tan, as this is a genetic disease.
Retinal detachment in cavitary optic disc anomaly (Dr. Pei-Chang Wu)

1. Use triamcinolone acetonide to ensure posterior vitreous detachment
According to Dr. Wu, a pars plana vitrectomy is his preferred method for obtaining a posterior vitreous detachment and reducing traction, with triamcinolone acetonide as his assistant of choice.
Editor’s Note: Reporting for this article occurred at the 5th World Congress of Paediatric Ophthalmology & Strabismus (WCPOS V 2024) from 11-13 July in Kuala Lumpur, Malaysia.