Race, Ethnicity, Insurance, and Population Density Associations with Pediatric Strabismus and Strabismic Amblyopia in the IRIS® Registry

Visual Outcomes after Strabismus Surgery in Pediatric Patients with Strabismic Amblyopia: An IRIS® Registry Study

PURPOSE

To evaluate the impact of strabismus surgery on visual outcomes in pediatric patients with strabismic amblyopia.

DESIGN

Retrospective analysis of the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight).

PARTICIPANTS

Pediatric patients aged 3 to 17 with strabismus and amblyopia.

METHODS

Visual acuity (VA) was assessed at 6, 12, and 24 months post amblyopia diagnosis. Patients were categorized based on age (3-7, 8-12, 13-17 years) and whether they had strabismus surgery before or within 6 months of amblyopia diagnosis. Propensity score matching (PSM) was used to pair the patients who performed strabismus surgery with patients who did not.

MAIN OUTCOME MEASURES

VA changes and treatment efficacy, assessed using the modified IRIS-50 outcome measure.

RESULTS

Of the 21,242 patients analyzed, 1,703 underwent surgery within 6 months of amblyopia diagnosis and 19,539 did not. In PSM cohort, among patients with baseline VA worse than 20/30, visual acuity significantly improved over time in both the strabismus surgery and no strabismus surgery groups. Overall, VA improved from 0.46 ± 0.21 logMAR at baseline to 0.29 ± 0.24 logMAR at 24 months (P < 0.001), with significant improvements observed in both groups at each follow-up (6, 12, and 24 months). Improvement was most pronounced in the youngest group (ages 3-7 years), while teenage patients (ages 13-17 years) showed no improvement. There were no significant differences in visual outcomes between patients who had strabismus surgery and those who did not at any time point. In multivariable logistic regression, there was no difference in the odds of treatment success, as measured by IRIS-50, at the final follow-up between patients who underwent strabismus surgery and those who did not. This was true in all age categories.

CONCLUSIONS

Strabismus surgery did not significantly impact visual outcomes in patients with strabismic amblyopia. Older patients, up to at least age 12, may still have visual benefits from both strabismus surgery and amblyopia treatment.

Socioeconomic associations of amblyopia in the All of Us research program

PURPOSE

To identify potential socioeconomic associations of amblyopia in a nationwide cohort.

METHODS

This is a retrospective, case-control study of participants in the All of Us Research Program. Cases were defined as adults 18-64 years of age with a diagnosis of amblyopia who answered the "Basics" survey questions of interest. Age-, sex-, and race-matched controls with no amblyopia diagnosis were sampled at a 4:1 control-to-case ratio. Univariate and multivariable testing was performed to determine socioeconomic associations of amblyopia, with P values of <0.05 considered statistically significant.

RESULTS

Of 1,714 patients with a diagnosis of amblyopia, 859 fell within the defined age range. Amblyopic participants were more likely to be of Black or African American (25.8% vs 21.8% [P = 0.004]) or Hispanic race/ethnicity (25.6% vs 22.6% [P = 0.04]) and were significantly older (50.0 vs 46.6 years [P < 0.0001]) than unmatched controls. After applying additional inclusion criteria limiting analysis to those with socioeconomic data available, a restricted set of 601 amblyopic participants were compared to 2,404 age-, sex-, and race/ethnicity-matched controls. Comparing cases and matched controls, participants with a diagnosis of amblyopia were significantly more likely to be unemployed (47.8% vs 39.3% [P = 0.0002]), non-home-owners (61.4% vs 55.8 % [P = 0.01]), have Medicaid insurance (33.8% vs 26.2% [P = 0.0002]), or have a household income under $35,000 annually (50.2% vs. 43.2% [P = 0.002]). Multivariable analysis revealed that amblyopic participants were significantly more likely to be unemployed (OR = 1.56; 95% CI, 1.25-1.94; P = 0.00006) and more likely to have Medicaid insurance (OR = 1.43; 95% CI, 1.13-1.82; P = 0.003).

CONCLUSIONS

There are potential long-term socioeconomic associations of amblyopia. Given reported differences in both screening rates and treatment outcomes based on race, ethnicity, and income level, it is vital that future studies adequately portray the diversity of the population through broad, representative recruitment.

Juvenile Idiopathic Arthritis Associated Anterior Uveitis Among Pediatric Patients in the IRIS Registry from 2013-2017

PURPOSE

To determine the prevalence, clinical characteristics, and visual outcomes in patients with juvenile idiopathic arthritis-associated uveitis (JIA-U).

METHODS

A retrospective analysis was conducted on the IRIS® Registry for patients < 18 years old diagnosed with JIA-U between 2013-2017. Visual acuity (VA) and intraocular pressure (IOP) were taken at baseline and months six and 12. Cox proportional hazard models were used to determine risk factors for poor visual outcomes. Event probability of outcomes was estimated using the Kaplan-Meier method.

RESULTS

One thousand ninety-nine patients with JIA-U were identified; the prevalence was 42.4 per 100,000 pediatric cases (95% CI: 40.0-45.0). Most participants were white (73%) and female (72%). Seventy-nine percent of participants had a VA of 20/25 or better at the time of cohort entry, as compared to 77% at six months and 78% at 12 months. Nineteen percent (95% CI: 15.9% - 22.8%) of patients with good baseline VA (20/25 or better) experienced a drop to 20/50 or worse in the first 12 months. Patients with poorer baseline VA were more likely to experience this event (HR: 2.72, 95% CI: 1.16-6.38, p = 0.018). Twenty percent of patients (95% CI: 16.5% - 22.7%) received their first immunomodulatory therapy in the first two years after cohort entry, and 60.6% added a second IMT within the subsequent year.

CONCLUSION

Our study reports a higher prevalence of JIA-U within the IRIS Registry than prior studies that drew from academic referral centers. Poorer baseline VA was significantly associated with poorer vision outcomes.

Disparities in Amblyopia Treatment Outcomes: The Impact of Sociodemographic Factors, Treatment Compliance, and Age of Diagnosis

PURPOSE

To identify clinical and sociodemographic factors associated with disparities in amblyopia treatment outcomes.

DESIGN

Retrospective chart review.

PARTICIPANTS

Children ≤ 8 years of age diagnosed and treated for unilateral refractive or strabismic amblyopia at our institution from 2012 to 2022.

METHODS

Children with amblyopia were categorized by outcome: resolved amblyopia (< 0.2 logarithm of the minimum angle of resolution [logMAR] interocular difference [IOD] in visual acuity [VA] or no fixation preference in nonverbal patients) or persistent amblyopia. Demographic and clinical data were recorded from the medical record. Zip codes were used to calculate Childhood Opportunity Index (COI) scores, estimated annual household income, and distance to hospital.

MAIN OUTCOME MEASURES

Sociodemographic and clinical factors were compared between children with resolved and persistent amblyopia. Factors significant at P < 0.10 on univariate analysis were included in a multivariable regression model.

RESULTS

A total of 168 patients met inclusion criteria, and 131 patients (78%) had resolved amblyopia. Demographic factors associated with resolution of amblyopia were younger age at diagnosis (3.3 ± 1.7 years vs. 4.5 ± 1.9 years; P = 0.0009), English as the primary language (79.4% vs. 62.2%; P = 0.04), higher estimated annual income ($83 315.93 ± $29 276.64 vs. $71 623.00 ± $26 842.56; P = 0.03), higher COI scores (50.9 ± 27.3 vs. 40.0 ± 26.4; P = 0.03), and living farther from our institution (28.6 ± 37.6 miles vs. 14.9 ± 12.7 miles; P = 0.003). Patients with resolved amblyopia also had higher rates of treatment compliance (83.2% ± 25.0% vs. 75.6% ± 24.4%; P = 0.009) and shorter delays in follow-up (40.1 ± 76.8 days vs. 61.1 ± 90.4 days; P = 0.02). Amblyopia persistence was borderline associated with governmental insurance and higher presenting IOD in VA (both P = 0.06). On multivariate analysis, only younger age at amblyopia diagnosis (P = 0.0010) remained significantly associated with amblyopia resolution.

CONCLUSIONS

Our findings suggest that disparities in amblyopia outcomes are related to differences in age at diagnosis. Interventions to lower the age at which amblyopia is diagnosed, such as programs to improve vision screening rates and access to pediatric eye care in at-risk groups, may directly address inequities in rates of amblyopia resolution.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Sociodemographic and Visual Outcomes of Juvenile Idiopathic Arthritis Uveitis: IRIS® Registry Study

Purpose

Understanding sociodemographic factors associated with poor visual outcomes in children with juvenile idiopathic arthritis-associated uveitis may help inform practice patterns.

Patients and Methods

Retrospective cohort study on patients <18 years old who were diagnosed with both juvenile idiopathic arthritis and uveitis based on International Classification of Diseases tenth edition codes in the Intelligent Research in Sight Registry through December 2020. Surgical history was extracted using current procedural terminology codes. The primary outcome was incidence of blindness (20/200 or worse) in at least one eye in association with sociodemographic factors. Secondary outcomes included cataract and glaucoma surgery following uveitis diagnosis. Hazard ratios were calculated using multivariable-adjusted Cox proportional hazards models.

Results

Median age of juvenile idiopathic arthritis-associated uveitis diagnosis was 11 (Interquartile Range: 8 to 15). In the Cox models adjusting for sociodemographic and insurance factors, the hazard ratios of best corrected visual acuity 20/200 or worse were higher in males compared to females (HR 2.15; 95% CI: 1.45-3.18), in Black or African American patients compared to White patients (2.54; 1.44-4.48), and in Medicaid-insured patients compared to commercially-insured patients (2.23; 1.48-3.37).

Conclusion

Sociodemographic factors and insurance coverage were associated with varying levels of risk for poor visual outcomes in children with juvenile idiopathic arthritis-associated uveitis.