Effect of gestational age and birth weight on the risk of strabismus among premature infants

Retinopathy of prematurity screening: prevalence and risk factors of ophthalmic complications in non-treated preterm infants

INTRODUCTION

Retinopathy of prematurity (ROP) is a vision-threatening disease of premature infants. Practice guidelines recommend that all infants screened for ROP receive follow-up eye examinations to screen for ophthalmic complications.1 The purpose of this study was to identify risk factors for the development of strabismus, amblyopia, high refractive error, and cataracts among ROP-screened, non-treated infants.

METHODS

Retrospective single-centre study of ROP-screened, non-treated premature infants with ophthalmic follow-up. Clinical variables were screened for association with ocular findings at follow-up. Multivariable logistic regression was used to determine the risk factors associated with ocular findings.

RESULTS

309 patients were seen for follow-up at 0.97 (0.69) [mean (SD)] years after neonatal intensive care unit (NICU) discharge. Strabismus was predicted by occipitofrontal circumference (OFC) z-score at NICU discharge (OR 0.61; 95% CI [0.42, 0.88]; p = 0.008), intraventricular haemorrhage (IVH) grade III or IV (OR 3.18; 95% CI [1.18, 8.54]; p = 0.02), and exclusive formula feeding at NICU discharge (OR 2.20; 95% CI [1.07, 4.53]; p = 0.03). Significant predictors of amblyopia were OFC z-score at discharge (OR 0.55; 95% CI [0.31, 0.96]; p = 0.03) and necrotising enterocolitis (NEC) (OR 6.94; 95% CI [1.38, 35.00]; p = 0.02). NEC was a significant risk factor for high refractive error (OR 7.27; 95% CI [1.39, 37.94]; p = 0.02).

CONCLUSIONS

Among premature infants screened but not treated for ROP, severe IVH, NEC, low OFC z-score, and exclusive formula feeding at NICU discharge were risk factors for ocular morbidity. These findings affirm the value of ophthalmic follow-up for all ROP-screened infants, particularly those with the identified risk factors.

Prevalence of strabismus and risk factors in adults born preterm with and without retinopathy of prematurity: results from the Gutenberg Prematurity Eye study

AIM

The purpose of this study was to assess the prevalence of strabismus and nystagmus and to analyse associated factors in preterm and full-term infants in adulthood.

METHODS

The Gutenberg Prematurity Eye Study is a retrospective cohort study with a prospective ophthalmological examination of participants born preterm and full-term (aged 18-52 years). Perinatal data were carefully assessed for risk factors and comprehensive ophthalmological examinations were conducted. The association between strabismus and nystagmus was assessed by analysing 16 different perinatal and actual risk factors in multivariable analysis. Participants were grouped into full-term controls (gestational age (GA) at birth ≥37 weeks), preterm participants without retinopathy of prematurity (ROP) and GA 33-36 weeks (group 2), GA 29-32 weeks (group 3), GA ≤28 weeks (group 4), non-treated ROP (group 5) and treated ROP (group 6).

RESULTS

In total, 892 eyes of 450 preterm and full-term individuals (mean age: 28.6 years, SD: ± 8.6 years, 251 females) were included. Strabismus was observed in 2.1% (3/140), 6.6% (9/137), 17.4% (16/92), 11.1% (2/18), 27.1% (13/48) and 60% (9/15) of participants and nystagmus in 0.7% (1/140), 1.5% (2/137), 4.3% (4/92), 5.6% (1/18), 10.4% (5/48) and 26.7% (4/15) of participants in the respective groups. In the multivariable regression model, strabismus was associated with GA (OR=0.90; p=0.046), anisometropia ≥1.5 diopter (OR=3.87; p=0.003), hypermetropia ≥2 diopter (OR=9.89; p<0.001) and astigmatism ≥1.5 diopter (OR=2.73; p=0.017). Esotropia was more frequent than exotropia and hypermetropia/hypometropia. Most strabismus cases occurred within the first 10 years of life. The strongest predictor associated with nystagmus was perinatal adverse events (OR=15.8; p=0.002).

CONCLUSION

Low GA and refraction of the eye are independent risk factors for strabismus, which typically occurs in the first 10 years of life. Perinatal adverse events are the most important factors for the presence of nystagmus in adulthood.

Early childhood eye diseases and perinatal risk factors: potential of record linkage between current information flows

BACKGROUND

The aim of this study was to analyze the occurrence of specific maternal, obstetric or neonatal factors, by performing a comparison between children with refractive error, strabismus and/or amblyopia (cases) and unaffected children (controls) in the province of Trento (North-East Italy).

METHODS

In 2012-2014, 14,346 children attending the second year of nursery school were assessed through the preschool orthoptic screening scheme (covering 91% of the preschool population). Record linkage was performed between the orthoptic screening database and birth records (birth confirmation certificate database) for the corresponding birth cohorts (2008-2010), to examine specific maternal factors (age, smoking, nationality/race), obstetric factors (type of delivery) and neonatal factors (gestational age, weight at birth, Apgar Score, congenital birth defects, hospitalization at birth). The correlations were investigated using univariate and multivariate analysis in accordance with the logistic regression method.

RESULTS

During orthoptic screening, 6.4% of children were found to have at least one refractive error, with astigmatism being the most common condition (5.1%). 1.9% of children were found to have strabismus and 1.8% amblyopia. Multivariate logistic regression analysis showed that the risk of developing a refractive error is associated with: maternal age ≥45 years, foreign nationality, vacuum-assisted delivery and neonatal weight <1500 grams. An excessive risk of strabismus was observed in children whose mother had smoked during pregnancy (adjusted OR=1.64).

CONCLUSIONS

Preschool orthoptic screening is a well-consolidated practice in the province of Trento, with adhesion values consistently over 90%. Studies of this type show the potential of record linkage between current information flows.

Comorbidities in autism spectrum disorder and their etiologies

Individuals with autism spectrum disorder (ASD), in addition to the core features of the disease, experience a higher burden of co-occurring medical conditions. This study sought to describe the frequency and distribution of comorbidit conditions in individuals with ASD, and systematically evaluate the possibility that pre- and postnatal exposures (e.g., preterm birth, hypoxia at birth, traumatic brain injury, and fetal alcohol syndrome) associated with ASD may also be linked with distinct comorbidities. We used the SPARK study database, launched by the Simons Foundation Autism Research Initiative (SFARI). Comorbidities considered in the study included neurological, cognitive, psychiatric, and physical conditions. The study sample consisted of 42,569 individuals with ASD and their 11,389 non-ASD siblings (full and half siblings). Majority (74%) of individuals with ASD had at least one comorbidity, and had a greater average number of comorbidities than their non-ASD siblings. Preterm birth and hypoxia at birth were the most common peri-natal exposures in the sample. In logistic regression models adjusted for covariates, these exposures were associated with several distinct comorbidities in ASD cases, including attention and behavior problems, psychiatric and neurological disorders, and growth conditions. A similar pattern of association was also observed in non-ASD siblings. Our findings underscore that individuals with ASD experience a greater burden of comorbidities, which could be partly attributable to the higher rates of perinatal exposures compared to their non-ASD siblings. Study findings, if replicated in other samples, can inform the etiology of comorbidity in ASD.

Level of prematurity as a predictor for the activity of retinopathy of prematurity and strabismus

Objective: To evaluate the prevalence of strabismus in premature children after the screening for retinopathy of prematurity (ROP) and to determine whether the level of prematurity (birth weight and gestation age) can be used as a predictor for both strabismus development and disease activity. Methods: This is a retrospective study, conducted in the Clinic for Eye Disease, section for Pediatric Ophthalmology of the Clinical Centre University of Sarajevo during the period from December 2013 until January 2017. 126 patients were involved. The inclusion criteria were gestational age ≤ 34 weeks, birthweight ≤ 2000 g and performed screening test for ROP. Patients were divided into three groups: patients without ROP, patients with spontaneous regression and patients with active ROP. Results: 52.4% patients were suffering from strabismus (30.2% esotropia, 22.2% exotropia). All the patients with active ROP had esotropia (60.0%). The average birth weight and gestational age were lower in patients with strabismus (1371.3 ± 58.0 g and 29.7 ± 0.4 weeks respectively). Conclusion: Lower gestational age and birth weight of premature children showed the increased probability of strabismus development especially esotropia. Prematurity level was significantly lower in patients with active ROP compared to the rest of the patients. Abbreviations: ROP = Retinopathy of prematurity, ICROP = International Classification of Retinopathy of prematurity, BCVA = best corrected visual acuity.

Local clinical informatics investments are required for in silico biomarker generation across the globe: lessons learned from a secondary analysis of the PROP trial

Background

Advances in statistical modelling and machine learning approaches, which can be deployed locally using open source programming languages, represent a unique opportunity to improve workflows and lower costs in health care across the globe through the creation of in silico biomarkers. The goal of this study was to extract meaningful data from the publicly available Prematurity and Respiratory Outcomes Program (PROP) trial data that could help generate useful clinical diagnostic aids with minimal cost for deployment in global healthcare settings.

Methods

A cluster analysis of the PROP dataset was conducted. We generated a simple model using an open-source software platform that generates a growth prediction of patients born less than 30 weeks. We then obtained validation data from a Uruguayan hospital to test the capacity for deployment of the models.

Results

Analysis revealed two main clusters of patients in the trial, with differentiation mainly based on the clinical and anthropomorphic measurements of birth gestational age, birth weight, and head circumference. The anthropometric measurements of daily weight, birth weight, head circumference, and birth gestational age were highly correlated with respiratory dysfunction and co-morbidities We note that deviation from this predicted growth curve in PROP patients was associated with culture-proven sepsis, and may represent a more sensitive anthropomorphic biomarker than the weight percentile systems routinely used globally such as Fenton curves. We found that early deviation from our projected growth model was highly associated with patient fatality. However, over long-term predictions, models trained on PROP clinical trial patients showed significantly more error in the Uruguayan patients.

Conclusions

Although these prediction models built upon PROP data were not generalizable to Uruguayan patients, our data suggest that prediction models using simple anthropomorphic measurements, if trained on local patients, may be able to provide value as a low-cost in silico biomarker. We concluded that local investment in clinical informatics infrastructure is needed to train models based on locally extracted clinical data.

Prematurity: A medical history of obligatory consideration when assessing the retinal ganglion cell complex

INTRODUCTION

Premature children birth and survival is becoming more frequent due to the improvement in obstetric and neonatal care. This makes it increasingly common to find patients with history of preterm birth in ophthalmology clinics, both in pediatric and adult ages. Premature birth can lead to ocular structural changes, being possible to affect the ganglion cell complex (GCC), among other structures, which can be studied using optical coherence tomography.

MATERIALS AND METHODS

To carry out a bibliographic review of the studies that analyze GCC in patients with a history of prematurity compared with patients born at term.

RESULTS

Several studies that analyze GCC in patients with a history of prematurity are referenced and their results are studied.

CONCLUSIONS

In our clinical practice, knowing the history of prematurity is fundamental in the assessment of GCC measured by optical coherence tomography, since this layer is different in the patients with a history of prematurity compared to patients born at term.

The role of screening and surveillance in the detection of childhood vision impairment and blindness in the UK

OBJECTIVE

Understanding pathways to detection for childhood visual impairment (VI) is critical for planning services. We aimed to describe patterns of detection for childhood VI.

DESIGN AND SETTING

Cross-sectional study using data from British Childhood Visual Impairment and Blindness Study 2.

PATIENTS

Children newly diagnosed with VI, severe vision impairment or blindness (SVI/BL)-that is, visual acuity worse than logMAR 0.5 in both eyes-were identified through active surveillance, with data collection at diagnosis and 1 year later.

OUTCOME MEASURE

Method of detection of vision/eyes problem.

RESULTS

784 children (45%, 356 girls) were identified, of whom 313 (40%) had VI, 471 (60%) had SVI/BL. Additional non-ophthalmic disorders or impairments (VI/SVI/BL 'plus'), were diagnosed in 72% (559/784). Of the 784, 173 children were detected through routine screening (22%), 248 through targeted examinations (32%) and 280 through family self-referral (36%). Parents and carers had only reported symptoms in 55% of children who manifested them, with evidence that families living in socioeconomically deprived areas were less likely to report concerns. Paediatricians were the professionals most likely to raise initial suspicion of visual disability.

CONCLUSIONS

Our findings show that targeted screening and surveillance is important for the detection of full spectrum childhood visual impairment (VI/SVI/BL), as a significant proportion of children will not have symptoms, or their parents or carers will not report symptoms. As paediatricians were the professionals most commonly involved in detection, it would be helpful if their core competencies included the skills needed to undertake simple assessments of vision.

Medical expenditure for strabismus: a hospital-based retrospective survey

Background and aims

The misconception of the purpose of strabismus treatment has, on the one hand, affected the motivation of strabismus patients to seek care and, on the other hand, has resulted in strabismus not being covered by health insurance, both of which interact to limit the motivation of strabismus patients and also impose a financial burden on strabismus patients. Previous studies on the cost of strabismus had only addressed the cost utility and functional and psychosocial benefits of strabismus surgery. The aim of this study was to estimate the direct medical expenditure incurred for strabismus surgery and analyze the trend for the period 2014–2019 using the data collected by local eye hospitals in northeast China.

Methods

This study was based on 6-year strabismus medical expenditure data collected from the eye hospital of the first affiliated hospital of Harbin medical university, covering 3596 strabismus patients who had strabismus surgery. All medical expenditure data were adjusted to 2014 using China’s annual consumer price index to remove the effects of inflation.

Results

The average direct medical expenditure for strabismus cares (in 2014) was 5309.6 CNY (US$870.4), and the annual growth rates from 2015 to 2019 (compared with the previous year) were 9.3, 7.7, 21.7, 14.5, and 4.3%, respectively. Surgical expenses accounted for the highest proportion (33.1%) of the total medical expenses followed by examinations expenses (19.7%) and medical consumables expenses (18.7%). The regression coefficient for general anaesthesia was 1804.5 and age was less than 0.

Conclusion

The average direct medical expenditure for strabismus increases year by year, and the growth rate is rapid. Anesthesia was the most important factor increasing medical cost, and age was negatively correlated with cost.

[Ocular abnormalities of children born prematurely at the Yaoundé Gynaeco-Obstetrics And Pediatric Hospital]

PURPOSE

To identify ocular abnormalities in premature children in order to treat reversible visual disorders and help prevent low vision and blindness in this population at risk.

METHODOLOGY

This was a cross-sectional, analytical study carried out from November 1, 2018 to July 31, 2019 at the Yaoundé Gyneco-Obstetric And Pediatric Hospital, including premature children, aged 3 to 15 years. The variables studied were age, sex, prenatal, birth and past ophthalmological history, visual acuity, oculomotor examination and fundus examination. For statistical analysis, we used the epi-info software 3.5.4, the Chi² test, odds ratio and a 95% confidence interval with a significance P<0.05.

RESULTS

Of the 50 patients examined, the mean age was 6.02 years±2.58. Of the 22 optically corrected patients, hyperopia and hyperopic astigmatism were predominant (70.5%) (n=31). Distance visual acuity, measured in 31 cooperative patients (62 eyes), was between 3/10 and 8/10 in 14 eyes (22.6%), and<3/10 in two eyes (3.2%). Strabismus was present in 21 patients (42%), of which 13 cases were esotropia (61.9%). Tropical endemic limbo-conjunctivitis was found in eight eyes (8%). There were no cases of retinopathy of prematurity. Very low birth weight (<1500g) and neonatal resuscitation were associated with strabismus.

CONCLUSION

Ocular abnormalities in preterm infants are dominated by strabismus, which is associated with very low birth weight and neonatal resuscitation.

Pattern of oculomotor and visual function in children with hydrocephalus

PURPOSE

To investigate the ocular motility disturbances, optic nerve changes, and refractive errors in children with or without surgically treated hydrocephalus.

METHODS

This retrospective study included 63 subjects diagnosed with hydrocephalus between 2007 and 2019 at the Baskent University Hospital. Full orthoptic and ophthalmic examination and brain magnetic resonance imaging were performed in all subjects.

RESULTS

The mean age of patients was 68.4±27.6 months, and the mean follow-up time was 21.3±5.2 months. Twenty-one (51.2%) patients had esotropia (ET), and 14 (34.1%) had exotropia (XT). Of the patients with ET, 9 (14.2%) had a sixth nerve palsy. Four patients (6.3%) had a fourth nerve palsy, and 1 had a superior rectus palsy. Eleven patients had manifest, and 2 latent, nystagmus. Thirteen (20.6%) patients had optic disc abnormalities. The mean BCVA was 0.4±0.2 (0.05-1.0) in the right eye and 0.5±0.2 (0.1-1.0) in the left eye. Of the 19 (30.1%) patients who had a significant refractive error, 9 (47.3%) had hyperopia. Thirty-six (57.1%) patients had ventriculoperitoneal shunt surgery, and 11 (30.5%) of them had shunt revision due to occlusion. Ocular motility disorders were found to be significantly more common in patients who underwent single shunt surgery and shunt revision than those who had no surgical procedure (P=0.041and P=0.032, respectively).

CONCLUSION

The evaluation of ocular motility disorders and visual dysfunction in hydrocephalic children can be a source of valuable information when diagnosing and following the disease.

Neuroophthalmological manifestations of congenital aqueductal stenosis

OBJECTIVE

Congenital aqueductal stenosis (CAS) is a common etiology of hydrocephalus that occurs in a subset of infants and may be linked to an increased incidence of ophthalmological abnormalities and delayed developmental milestones. Although hydrocephalus is common and widely studied, sparse literature exists on patients with isolated (no identifiable genetic link) CAS along with analysis of ophthalmological manifestations. In this study, the authors sought to describe the ophthalmological abnormalities and delayed developmental milestones of patients with isolated CAS.

METHODS

Data of patients with CAS were prospectively entered and monitored in a surgical database maintained by the Department of Neurological Surgery at Children's Hospital of Pittsburgh from January 2005 to October 2016. Patients with a family history of congenital hydrocephalus, positive testing for genetic forms of aqueductal stenosis, other congenital abnormalities suggesting an underlying genetic syndrome, and stenosis/obstruction due to secondary causes were excluded from this study. Prenatal and perinatal history, CSF diversion history, and a variety of outcomes, including ophthalmological deficits and developmental milestones, were collected and analyzed.

RESULTS

A total of 41 patients with isolated CAS were identified, with a mean follow-up duration of 6 years. Among that cohort, 26 patients (63.4%) developed neuroophthalmological complications, which were further stratified. Fourteen patients (34.1%) developed strabismus and 11 (26.8%) developed astigmatism, and 1 patient (2.4%) with papilledema was recorded. Among patients with ophthalmological abnormalities, 76.9% had delayed developmental milestones (p = 0.045).

CONCLUSIONS

Patients with CAS were found to have increased risk of ophthalmological abnormalities requiring correction, along with an increased risk of delayed developmental milestones. Importantly, there was a significant correlation between the development of ophthalmological abnormalities and delayed developmental milestones that was independent of CSF diversion history. Larger patient cohort studies are required to explore whether earlier development of hydrocephalus, as is the case in CAS, causes elevated rates of neurological and ophthalmological complications, and if earlier CSF diversion correlates with improved outcomes.

Subclinical markers of strabismus in children 5-18 years of age

PURPOSE

To report the prevalence of subclinical markers of strabismus from a community-based screening of children.

METHODS

A family history and ophthalmic examination (including six markers of strabismus: oblique muscle dysfunction, stereopsis <60 arcsec, monofixation, nasal-temporal pursuit asymmetry, dissociated strabismus, and anisometropia) were obtained from consecutive children, aged 5-18 years, in the local school system and the pediatric outpatient clinic of Mayo Clinic, Rochester, Minnesota.

RESULTS

A total of 1,000 children (498 males [49.8%]) were examined at a mean age of 10.6 years (range, 5-18.98). Of the 1,000, 57 (5.7%) had strabismus, and 130 (13%) had some form of phoria. Of the 943 children without strabismus, 103 (10.9%) had one or more of the six subclinical markers, including 43 (4.5%) with inferior oblique dysfunction, 37 (3.9%) with anisometropia, 34 (3.6%) with subnormal stereopsis, 6 (0.6%) with nasal-temporal pursuit asymmetry, 3 (0.3%) with monofixation, and none with dissociated strabismus. A subclinical marker of strabismus occurred in 20 (12.7%) of the 157 nontropic subjects who had a family history of either strabismus, amblyopia, or both and in 83 (10.6%) of the 786 nontropic children without a family history.

CONCLUSIONS

In this community-based screening of children, subclinical disorders of binocular vision occurred in 10%-13% of children without strabismus, of which inferior oblique muscle dysfunction, anisometropia, and subnormal stereopsis were most prevalent. Identifying these disorders among strabismic families may be useful in elucidating the genetic puzzle of childhood strabismus.

The impact of strabismus on psychosocial heath and quality of life: a systematic review

Strabismus can hinder an individual's ability to perform daily functions and negatively affect their well-being. I examine the impact strabismus has on psychosocial health and quality of life in children and adults and evaluate the challenges confronted by parents of children with strabismus. Numerous misconceptions exist regarding the impact strabismus has on overall health. Negative attitudes persist toward those affected, resulting in difficulties with self-image. Individuals with strabismus are at increased risk for both visual system and psychiatric disorders. Misinformation regarding available treatment options for children and adults with strabismus continues to exist, resulting in decreased access to care. Improved education of health care providers can increase appropriate referrals and initiation of treatment. Treatment of strabismus is not merely cosmetic and has the potential to improve psychosocial health and quality of life for children and adults with and without diplopia.

Prevalence, incidence and risk factors of strabismus in a Chinese population-based cohort of preschool children: the Nanjing Eye Study

AIMS

To evaluate the prevalence, incidence and their related risk factors of strabismus among preschool children in China.

METHODS

Children born between September 2011 and August 2012 in Yuhuatai District of Nanjing were invited to participate in the Nanjing Eye Study for a comprehensive eye examination annually since 2015. The data presented in this paper were obtained from 2015 to 2017, when these children grew from the age of 3 to 5 years. Eye examinations included visual acuity, anterior segment, posterior segment, refraction, and ocular alignment and motility. Risk factors were evaluated using univariable and multivariable logistic regression models for prevalent and incident strabismus.

RESULTS

In 2015, a total of 2018 children (87.7% response rate) of 2300 eligible preschoolers completed the baseline eye examination when they were 3 years old. Among the 2018 participants, 50 had strabismus (prevalence rate, 2.48%). In multivariable analysis, prevalent strabismus was independently associated with parental strabismus history (OR=11.60, p<0.001), hyperopia (OR=6.22, p<0.001), prematurity (OR=3.07, p=0.01) and astigmatism (OR=2.15, p=0.04). Among 1766 children followed up for 2 years, 63 developed strabismus (annual incidence rate, 1.78%), of whom 57 had exotropia and 6 had esotropia. In multivariable analysis, incident strabismus was significantly associated with parental strabismus history (OR=5.55, p=0.04) and prematurity (OR=3.77, p<0.001).

CONCLUSIONS

In this population-based cohort study, we found a higher incidence of strabismus and a higher exotropia:esotropia ratio than previous studies in preschool children. Parental strabismus history and prematurity were associated with a higher risk for both prevalent and incident strabismus.

Fifteen-minute consultation: Managing a child with a new-onset squint

OBJECTIVE

To provide a systematic approach to the child with a new squint.

METHOD

Review of the current available literature.

CONCLUSION

Squint is a common presentation in the paediatric population. Although the parents' primary concern may be cosmetic, a new squint in childhood may be the first sign of a serious or life-threatening ocular or neurological pathology. Thorough assessment and timely referral are essential.

Influence of prenatal environment and birth parameters on amblyopia, strabismus, and anisometropia

PURPOSE

To report the prevalence of amblyopia, strabismus, and anisometropia in a young adult population at a single center in Australia and to investigate the underlying prenatal and early-life risk factors.

METHODS

Participants in the Raine Study have been followed from mid-gestation (n = 2,868 newborns) to young adulthood. At age 20 years, 1,344 participants had a comprehensive eye examination, including visual acuity and a detailed orthoptic assessment. Risk factors were determined from medical records and questionnaires completed by the mothers at 18 weeks' gestation. The main outcome measures were the proportions of participants with amblyopia, esotropia, exotropia, or anisometropia (defined as >1 D difference).

RESULTS

Of the 1,125 white participants, 12 (1.1%) had amblyopia, 39 (3.5%) had strabismus, and 33 (2.9%) had anisometropia. In multivariable logistic regression, amblyopia was associated with a maternal history of pregnancy-induced hypertension (OR = 3.80; 95% CI, 1.19-12.13); esotropia, with lower gestational age (OR = 0.97; 95% CI, 0.95-0.97) and a heavier placenta (OR = 1.02; 95% CI, 1.00-1.04); exotropia, with a maternal history of previously treated hypertension (OR = 4.00; 95% CI, 1.06-15.03) and maternal use of recreational drugs during early pregnancy (OR = 3.61; 95% CI, 1.06-15.03); and anisometropia, with older maternal age (OR = 1.07; 95% CI, 1.01-1.14) and an abnormal umbilical cord (OR = 2.39; 95% CI, 1.04-5.47).

CONCLUSIONS

The prevalence of amblyopia, strabismus, and anisometropia in this cohort was similar to that in other studies. Preterm birth and maternal health may have adverse effects on eye development.

Maternal smoking during pregnancy and the risk of strabismus in offspring: a meta-analysis

The effect of maternal smoking during pregnancy on strabismus in offspring remains unclear. We conducted a meta-analysis to summarize epidemiological evidences on the association between maternal smoking during pregnancy and the risk of offspring strabismus. Eligible studies were searched from the PubMed, Ovid, Embase and CNKI databases up to May 2018. The qualities of included articles were assessed with the Newcastle-Ottawa Scale and the assessment scale recommended by the Agency for Healthcare Research and Quality. Odds ratios (ORs) corresponding with its 95% confidence intervals (CIs) were pooled to estimate the effects of maternal cigarette smoking on the risk of offspring strabismus. Subgroup analyses and meta-regression were performed to explore the potential sources of heterogeneity. The Begg's test and Egger's test were used to assess the publication bias. Eleven articles involving 4,833 patients with strabismus were included. The pooled OR showed that maternal smoking during pregnancy was significantly associated with strabismus in offspring (OR = 1.46, 95% CI = 1.32-1.60). Compared with less than 10 cigarettes per day (OR = 1.17, 95% CI = 1.06-1.29), maternal smoking 10 cigarettes or more per day during pregnancy significantly increased the risk of offspring strabismus (OR = 1.79, 95% CI = 1.39-2.31). The risk of developing esotropia and exotropia for smoking pregnant women, respectively, increased by 65% (OR = 1.65, 95% CI = 1.31-2.09 and OR = 1.65, 95% CI = 1.24-2.19) than those who did not smoke during pregnancy. Additionally, the increased risk of maternity smoking associated with offspring strabismus was stable across all subgroup analyses. Overall, maternal smoking during pregnancy was associated with a significantly increased risk of offspring strabismus and the result was persistent in subgroup analyses, suggesting the importance in changing smoking habit or smoking cessation for women who are pregnant or preparing to.

Prevalence and associated factors of strabismus in former preterm and full-term infants between 4 and 10 Years of age

Background

Limited data exist collating most of the associated factors for strabismus in one analysis. The aim of this study was to assess the prevalence of strabismus and to analyse associated factors in former preterm and full-term infants.

Methods

In this cross-sectional study, 239 former preterm infants with gestational age (GA) ≤ 32 weeks and 264 former full-term born infants with GA ≥ 37 weeks underwent detailed ophthalmologic examination in the age of 4–10 years and perinatal data assessment for risk factor analysis. Ophthalmologic examinations included cover testing, best corrected visual acuity, cycloplegic objective refraction, slit lamp as well as fundus examinations. For association analysis with strabismus, the following data was collected and included in multivariable analysis: sex, age at examination, anisometropia, myopic and hyperopic refractive error (≥ 3 dioptres), astigmatism, birth weight percentile, gestational age, retinopathy of prematurity occurrence, maternal age at childbirth, mother smoking, breastfeeding < 3 months, artificial ventilation, intraventricular bleeding, and other perinatal adverse events.

Results

Overall, 4/264 (2%) full-term infants, 15/125 (12%) preterm-infants with GA 29–32 weeks without ROP, 13/59 (22%) preterm infants with GA ≤ 28 weeks without ROP and 14/55 (26%) with GA ≤ 32 weeks with retinopathy of prematurity were affected by strabismus. In the multivariable regression model strabismus was associated with GA (OR = 0.84 per week; p = 0.001), hyperopic refractive error (OR = 4.22; p = 0.002) and astigmatism (OR = 1.68; p = 0.02).

Conclusion

This investigation highlights that low gestational age and refraction of the eye are independent risk factors for strabismus, while the other factors show less independent influence.

Intermittent Divergent Squint in Prematurity and Its Neurophysiological Aspects

Intermittent distance exotropia is a deviation characterized by an exophoria at near fixation and manifest exotropia at distance fixation. There is normal binocular fusional vergence and stereoacuity at near fixation, but the eyes tend to diverge in bright sunlight, tiredness, day dreaming and the patient may close one eye in such circumstances. Prematurity is associated with numerous eye pathology, besides retinopathy of prematurity, amblyopia, refractive errors, it is also associated with a higher risk esotropia and exotropia. We report a case of a 5-year-old girl (preterm and very low birth weight) with an intermittent deviation of both eyes since three years. On her detailed ocular examination diagnosis of divergence excess intermittent exotropia with normal accommodative convergence to accommodation ratio was made. Bilateral lateral rectus recession was done using hang back technique. Postoperatively, the eyes were aligned normally thereby achieving orthotropia. This article reviews various neurophysiological aspects of intermittent divergent squint delineating the etiopathogenesis, classification system, and management options in intermittent exotropia.

Sensorimotor outcomes in children with prenatal exposure to methadone

PURPOSE

To report the presentation and characteristics of strabismus in children with prenatal methadone exposure.

METHODS

The medical records of children with prenatal methadone exposure were retrospectively reviewed. Those who were evaluated by pediatric ophthalmology were included. Information on the timing and types of prenatal exposure by trimester of pregnancy was then collected from the patients' mothers' charts. The children's perinatal histories and ophthalmologic findings were collected from their pediatric clinic charts and ophthalmology clinic charts, respectively.

RESULTS

A total of 210 children with prenatal methadone exposure were identified, of whom 32 (15.2%) underwent eye examinations and 21 (10%) had strabismus. Five patients had esodeviations, with a mean age of onset of 11.6 months; 16 had exodeviations, with a mean age of onset of 6.8 months. Three patients with strabismus were born prematurely, and 2 had intracranial disease. Two patients underwent strabismus surgery.

CONCLUSIONS

The incidence of strabismus in patients with prenatal methadone exposure was higher than in the general population (10% vs 3%-4%). Intermittent exotropia was the most common type of strabismus and presented earlier than in the general population, with no association with other systemic disease. Prenatal exposure to methadone was likely confounded by exposure to other substances, environmental factors, and genetics. Poor compliance with follow-up reduced the power of the study.

Demographic, Systemic, and Ocular Factors Associated with Nonarteritic Anterior Ischemic Optic Neuropathy

OBJECTIVE

Nonarteritic anterior ischemic optic neuropathy (NAION) is a devastating ocular condition causing permanent vision loss. Little is known about risk factors for developing this disease. We assessed demographic, systemic, and ocular factors associated with NAION.

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

Beneficiaries between 40 and 75 years old without NAION at baseline enrolled in a large U.S. managed care network.

METHODS

Enrollees were monitored continuously for ≥2 years between 2001 and 2014 to identify those newly diagnosed with NAION (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 377.41). All persons were under ophthalmic surveillance and all cases had ≥1 confirmatory ICD-9-CM code for NAION during follow-up.

MAIN OUTCOME MEASURES

Multivariable Cox regression modeling was used to generate hazard ratios (HRs) with 95% confidence intervals (CIs) to describe the statistical relationship between selected demographic characteristics, systemic and ocular conditions, and the hazard of developing NAION.

RESULTS

Of 1 381 477 eligible enrollees, 977 (0.1%) developed NAION during a mean ± standard deviation (SD) follow-up of 7.8±3.1 years. The mean ± SD age for NAION cases at the index date was 64.0±9.2 years vs. 58.4±9.4 years for the remainder of the beneficiaries. After adjustment for confounding factors, each additional year older was associated with a 2% increased hazard of NAION (HR = 1.02; 95% CI: 1.01-1.03). Female subjects had a 36% decreased hazard of developing NAION (HR = 0.64; 95% CI: 0.55-0.74) compared with male subjects. Compared with whites, Latinos had a 46% decreased hazard of developing NAION (HR = 0.54; 95% CI: 0.36-0.82), whereas African ancestry was not significantly associated with NAION (HR = 0.91; 95% CI: 0.72-1.15). Systemic diseases associated with NAION included hypertension (HR = 1.62; 95% CI: 1.26-2.07) and hypercoagulable states (HR = 2.46; 95% CI: 1.51-4.00). Although diabetes mellitus (DM) was not significantly associated with NAION compared with those without DM (P = 0.45), patients with end-organ involvement from DM had a 27% increased hazard of NAION relative to those with uncomplicated DM (HR = 1.27; 95% CI: 1.01-1.59). Ocular diseases associated with NAION were age-related macular degeneration (HR = 1.29; 95% CI: 1.08-1.54) and retinal vein occlusion (HR = 3.94; 95% CI: 3.11-4.99).

CONCLUSIONS

Our study identified several modifiable risk factors that may be associated with NAION. Should future studies confirm these findings, they may offer opportunities to prevent or treat this debilitating condition.

Strabismus at Age 2 Years in Children Born Before 28 Weeks' Gestation: Antecedents and Correlates

Children born very preterm are at greater risk of ophthalmic morbidities, including strabismus, than children born at term. We evaluated perinatal factors associated with strabismus at age 2 years in a large population of infants delivered before 28 weeks' gestation. A total of 996 infants in the multicenter ELGAN (Extremely Low Gestational Age Newborn) study who had a retinal exam in infancy and a developmental assessment at 2 years corrected age are included. Their mothers were interviewed about the pregnancy, and both mother and newborn charts were reviewed. Certified examiners administered the Bayley Scales of Infant Development-II and performed an examination of ocular alignment. Time-oriented logistic regression risk models were created to evaluate the associations of characteristics and exposures with the development of strabismus. Overall, 14% (n = 141) of the children had strabismus at 2 years, and 80% of strabismic children had esotropia. Characteristics associated with strabismus were birth before 26 weeks' gestation, severe fetal growth restriction, and maternal history of aspirin ingestion. Associated postnatal factors included a SNAP-II (Score for Neonatal Acute Physiology) illness severity value ≥ 30, brain ventriculomegaly, type I retinopathy of prematurity, and ventilator-dependent severe bronchopulmonary dysplasia. Strabismus in very preterm populations is associated with a number of antenatal and postnatal antecedents as well as clinical and imaging correlates indicative of brain damage in these children. Routine ophthalmologic assessments in the early years can allow appropriate and timely interventions.

Reasons for Rehospitalization in Children Who Had Neonatal Abstinence Syndrome

BACKGROUND AND OBJECTIVES

Neonatal abstinence syndrome (NAS) occurs after in utero exposure to opioids, but outcomes after the postnatal period are unclear. Our objectives were to characterize childhood hospitalization after NAS.

METHODS

Population-based linkage study of births, hospitalization, and death records of all children registered in New South Wales (NSW), Australia, between 2000 and 2011 to a maximum of 13 years. Infants with an International Statistical Classification of Disease and Related Problems, 10th Edition, Australian Modification, coding of NAS (P96.1, n = 3842) were compared with 1,018,421 live born infants without an NAS diagnosis.

RESULTS

Infants with NAS were more likely to be admitted into a nursery (odds ratio 15.6, 95% confidence interval: 14.5-16.8) and be hospitalized longer (10.0 vs 3.0 days). In childhood, they were more likely to be rehospitalized (1.6, 1.5-1.7), die during hospitalization (3.3, 2.1-5.1), and be hospitalized for assaults (15.2, 11.3-20.6), maltreatment (21.0, 14.3-30.9), poisoning (3.6, 2.6-4.8), and mental/behavioral (2.6, 2.1-3.2) and visual (2.9, 2.5-3.5) disorders. Mothers of infants with NAS were more likely to be Indigenous (6.4, 6.0-7.0), have no antenatal care (6.6, 5.9-7.4), and be socioeconomically deprived (1.6, 1.5-1.7). Regression analyses demonstrated that NAS was the most important predictor of admissions for maltreatment (odds ratio 4.5, 95% confidence interval: 3.4-6.1) and mental and behavioral disorders (2.3, 1.9-2.9), even after accounting for prematurity, maternal age, and Indigenous status.

CONCLUSIONS

Children with NAS are more likely to be rehospitalized during childhood for maltreatment, trauma, and mental and behavioral disorders even after accounting for prematurity. This continues to adolescence and emphasizes the critical need for continued support of this vulnerable group after resolution of NAS.