Lensectomy as treatment for refractory or progressive retinopathy of prematurity narrow-angle glaucoma

We present the case of a patient with a history of laser-treated retinopathy of prematurity (ROP) who developed narrow angles and intermittent angle closure. Despite laser peripheral iridotomy/iridoplasty, 1 year later, the patient had recurrent narrowing that resolved following clear lens extraction with intraocular lens placement. This case highlights the importance of continued monitoring for narrow angles in patients with ROP history.

Levodopa/Carbidopa to Augment the Treatment of Amblyopia: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature on the use of levodopa/carbidopa to augment the treatment of amblyopia.

METHODS

Literature searches for English language studies were last conducted in October 2022 in the PubMed database with no date restrictions. The combined searches yielded 55 articles, of which 23 were reviewed in full text. Twelve of these were considered appropriate for inclusion in this assessment and were assigned a level of evidence rating by the panel methodologist. Nine studies were rated level I, and 3 studies were rated level II; there were no level III studies.

RESULTS

The duration of treatment was limited to 3 to 16 weeks because of concern about long-term adverse effects such as tardive dyskinesia. This complication was not reported in any of the study participants. The dose of levodopa ranged from 1.5 to 8.3 mg/kg/day, generally divided into 3 daily doses. The carbidopa dose was approximately 25% of the levodopa dose in all treatments. Evidence from these studies indicates that augmenting traditional patch occlusion therapy with the oral administration of levodopa/carbidopa can improve the vision of amblyopic children, but the effect was small (0.17-0.3 logarithm of the minimum angle of resolution [logMAR] units) and only statistically significant when compared with patching alone in 2 of the 12 studies cited. Regression of vision was reported in the majority of studies (9 of 12 reported; range, 0-0.17 logMAR unit regression) after discontinuation of therapy. Short-term side effects of the medications were not consistently reported but were most frequently mild and included headache and nausea.

CONCLUSIONS

The best available evidence is currently insufficient to show that augmenting amblyopia therapy using up to 16 weeks of levodopa/carbidopa will result in meaningful improvement in visual acuity. Given the potential for significant side effects such as tardive dyskinesia with long-term therapy, levodopa/carbidopa does not appear to be a viable option for amblyopia therapy FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Genetic testing for infantile nystagmus syndrome with or without associated findings

PURPOSE

To review the published literature assessing the clinical utility of genetic testing in individuals with infantile nystagmus syndrome (INS), defined as binocular conjugate nystagmus and onset prior to 6 months of age, with or without associated findings.

METHODS

A literature search was last conducted in October 2022. The results were limited to articles published in English. The search yielded 517 abstracts, of which 72 papers were reviewed in full text. Of these papers, 4 met the criteria for inclusion and were graded by a study methodologist.

RESULTS

The 4 studies that met inclusion criteria used next-generation sequencing with gene panels ranging from 31 to 336 genes. The overall molecular diagnostic rate ranged from 35% to 60% in the included studies, although the yield was higher when genetic testing was guided by clinical phenotyping (approximately 80%) and in the subsets of patients with a family history (up to 88%). As many as 30% of patients tested had a reclassification of the diagnosis based on the genetic testing results.

CONCLUSIONS

Genetic testing has the potential to provide a definitive diagnosis and identify treatable conditions in patients presenting with INS, especially when considered in conjunction with clinical phenotyping and family history.

A Pilot Randomized Clinical Trial of Base-in Relieving Prism Spectacle Treatment of Intermittent Exotropia

SIGNIFICANCE

This pilot randomized trial, the first to evaluate a specific base-in relieving prism treatment strategy for childhood intermittent exotropia, did not support proceeding to a full-scale clinical trial. Defining and measuring prism adaptation in children with intermittent exotropia are challenging and need further study.

PURPOSE

This study aimed to determine whether to proceed to a full-scale trial of relieving base-in prism spectacles versus refractive correction alone for children with intermittent exotropia.

METHODS

Children 3 years old to those younger than 13 years with distance intermittent exotropia control score of ≥2 points on the Intermittent Exotropia Office Control Scale (Strabismus 2006;14:147-150; 0 [phoria] to 5 [constant]), ≥1 episode of spontaneous exotropia, and 16 to 35∆ by prism-and-alternate-cover test, who did not fully prism adapt on a 30-minute in-office prism-adaptation test were randomized to base-in relieving prism (40% of the larger of distance and near exodeviations) or nonprism spectacles for 8 weeks. A priori criteria to conduct a full-scale trial were defined for the adjusted treatment group difference in mean distance control: "proceed" (≥0.75 points favoring prism), "uncertain" (>0 to <0.75 points favoring prism), or "do not proceed" (≥0 points favoring nonprism).

RESULTS

Fifty-seven children (mean age, 6.6 ± 2.2 years; mean baseline distance control, 3.5 points) received prism (n = 28) or nonprism (n = 29) spectacles. At 8 weeks, mean control values were 3.6 and 3.3 points in prism (n = 25) and nonprism (n = 25) groups, respectively, with an adjusted difference of 0.3 points (95% confidence interval, -0.5 to 1.1 points) favoring nonprism (meeting our a priori "do not proceed" criterion).

CONCLUSIONS

Base-in prism spectacles, equal to 40% of the larger of the exodeviations at distance or near, worn for 8 weeks by 3- to 12-year-old children with intermittent exotropia did not yield better distance control than refractive correction alone, with the confidence interval indicating that a favorable effect of 0.75 points or larger is unlikely. There was insufficient evidence to warrant a full-scale randomized trial.

Surgical Treatments to Improve Visual Acuity in Infantile Nystagmus Syndrome: A Report by the American Academy of Ophthalmology

PURPOSE

To review the literature on the efficacy of surgical procedures to improve visual acuity (VA) in patients with infantile nystagmus syndrome (INS).

METHODS

Literature searches were last conducted in January 2022 in the PubMed database for English-language studies with no date restrictions. The combined searches yielded 354 abstracts, of which 46 were reviewed in full text. Twenty-three of these were considered appropriate for inclusion in this assessment and were assigned a level of evidence rating by the panel methodologist.

RESULTS

One included study was a randomized trial; the remaining 22 were case series. The 23 studies included children and adults with INS and a variable proportion with anomalous head position (AHP), strabismus, and sensory diagnoses. The surgical interventions evaluated included large recessions, tenotomy and reattachment (TAR), myectomy with or without pulley fixation, and anterior extirpation of the 4 horizontal rectus muscles, as well as various procedures to correct an AHP in which VA was reported as a secondary outcome. The data were mixed, with improvements in binocular best-corrected visual acuity (BCVA) ranging from no improvement to 0.3 logarithm of the minimum angle of resolution (logMAR), or 3 lines. (Most studies were in the range of 0.05-0.2 logMAR.) Statistically significant improvement in VA was noted in 12 of 16 studies (75%) that performed statistical analyses, with no clear advantage of any single procedure. Complications and reoperations were lowest in patients who underwent TAR and highest in those who underwent myectomy or anterior extirpation.

CONCLUSIONS

The best available evidence suggests that eye muscle surgery in patients with INS results in a modest improvement in VA.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Effectiveness of Laser Refractive Surgery to Address Anisometropic Amblyogenic Refractive Error in Children: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature assessing the safety and effectiveness of laser refractive surgery to treat anisometropic amblyogenic refractive error in children aged ≤ 18 years.

METHODS

A literature search of the PubMed database was conducted in October 2021 with no date limitations and restricted to publications in English. The search yielded 137 articles, 69 of which were reviewed in full text. Eleven articles met the criteria for inclusion and were assigned a level of evidence rating.

RESULTS

The 11 included articles were all level III evidence and consisted of 1 case-control study and 10 case series. Six studies used laser-assisted in situ keratomileusis (LASIK), 1 used photorefractive keratectomy (PRK), 1 used refractive lenticule extraction/small incision lenticule extraction, and the rest used a combination of LASIK, PRK, laser epithelial keratomileusis (LASEK), or refractive lenticule extraction/small incision lenticule extraction. Five studies enrolled patients with anisometropic myopia, 2 studies enrolled patients with anisometropic hyperopia, and the remainder were mixed. Although all studies demonstrated an improvement in best-corrected visual acuity (BCVA), the magnitude of improvement varied widely. As study parameters varied, a successful outcome was defined as residual refractive error of 1 diopter (D) or less of the target refraction because this was the most commonly used metric. Successful outcomes ranged between 38% and 87%, with a mean follow-up ranging from 4 months to 7 years. Despite this wide range, all studies demonstrated an improvement in the magnitude of anisometropia. Regression in refractive error occurred more frequently and to a greater degree in myopic eyes and eyes with longer follow-up, and in younger patients. Although one study reported 2 free flaps, most studies reported no serious adverse events. The most common complications were corneal haze and striae.

CONCLUSIONS

Findings from included studies suggest that laser refractive surgery may address amblyogenic refractive error in children and that it appears to decrease anisometropia. However, the evidence for improvement in amblyopia is unclear and long-term safety data are lacking. Long-term data and well-designed clinical studies that use newer refractive technologies in standardized patient populations would help address the role of refractive surgery in children and its potential impact on amblyopia.

Testing depth of suppression in childhood intermittent exotropia

A test of suppression was developed to provide a standardized approach to detecting and grading density of suppression in children with intermittent exotropia when manifestly exotropic. This new Office Suppression Test is a three-step procedure to grade suppression on a 4-point scale (from 0 for "negligible suppression" to 3 for "dense suppression"). The test was performed in 57 children 3-13 years of age with intermittent exotropia (distance angle of 16^Δ-35^Δ, with spontaneous tropia) during enrollment in a randomized trial. Of the 57 children, 51 could complete testing: 28 (55%) had dense suppression, 12 (24%) had moderate suppression, 5 (10%) had mild suppression, and 6 (12%) had negligible suppression. In a subgroup of 20 untreated children, suppression was evaluated again at 8 weeks. There was moderate agreement between suppression scores at baseline and at 8 weeks (weighted κ = 0.65 [95% CI, 0.45-0.84]).

Increasing Readiness for Early Integrated Palliative Oncology Care: Development and Initial Evaluation of the EMPOWER 2 Intervention

CONTEXT

Early integrated palliative care improves quality of life, but palliative care programs are underutilized. Psychoeducational interventions explaining palliative care may increase patients' readiness for palliative care.

OBJECTIVES

To 1) collaborate with stakeholders to develop the EMPOWER 2 intervention explaining palliative care, 2) examine acceptability, 3) evaluate feasibility and preliminary efficacy.

METHODS

The research was conducted at a North American cancer center and involved 21 stakeholders and 10 patient-participants. Investigators and stakeholders iteratively developed the intervention. Stakeholders rated acceptability of the final intervention. Investigators implemented a pre-post trial to examine the feasibility of recruiting 10 patients with metastatic cancer within one month and with a ≥50% consent rate. Preliminary efficacy outcomes were changes in palliative care knowledge and attitudes.

RESULTS

Using feedback from four stakeholder meetings, we developed a multimedia intervention tailored to three levels of health-literacy. The intervention provides knowledge and reassurance about the purpose and nature of palliative care, addressing cognitive and emotional barriers to utilization. Stakeholders rated the intervention and design process highly acceptable (3.78/4.00). The pilot met a priori feasibility criteria (10 patients enrolled in 14 days; 83.3% consent rate). The intervention increased palliative care knowledge by 83.1% and improved attitudes by 18.9 points on a 0 to 51 scale (Ps < 0.00001).

CONCLUSIONS

This formative research outlines the development of a psychoeducational intervention about palliative care. The intervention is acceptable, feasible, and demonstrated promising pilot test results. This study will guide clinical teams in improving patients' readiness for palliative care and inform the forthcoming EMPOWER 3 randomized clinical trial.

Adjustable Sutures in the Treatment of Strabismus: A Report by the American Academy of Ophthalmology

PURPOSE

To review the scientific literature that evaluates the effectiveness of adjustable sutures in the management of strabismus for adult and pediatric patients.

METHODS

Literature searches were performed in the PubMed database through April 2021 with no date limitations and were restricted to publications in English. The searches identified 551 relevant citations, of which 55 were reviewed in full text. Of these, 17 articles met the inclusion criteria and were assigned a level of evidence rating by the panel methodologist. The search included all randomized controlled studies regardless of study size and cohort studies of 100 or more patients comparing the adjustable versus nonadjustable suture technique, with a focus on motor alignment outcomes or reoperation rates.

RESULTS

The literature search yielded no level I studies. Of the 17 articles that met the inclusion criteria, 11 were rated level II and 6 were rated level III. Among the 12 studies that focused on motor alignment outcomes, 4 small randomized clinical trials (RCTs) did not find a statistically significant difference between groups, although they were powered to detect only very large differences. Seven of 8 nonrandomized studies found a statistically significant difference in motor alignment success in favor of the adjustable suture technique, both overall and in certain subgroups of patients. Successful motor alignment was seen in both exotropia (in 3 studies that were not limited to children) and esotropia (in 1 study of adults and 2 of children). The majority of included studies that reported on reoperation rates found the rates to be lower in patients who underwent strabismus surgery with adjustable sutures, but this finding was not uniformly demonstrated.

CONCLUSIONS

Although there are no level I studies evaluating the effectiveness of adjustable sutures for strabismus surgery, the majority of nonrandomized studies that met the inclusion criteria for this assessment reported an advantage of the adjustable suture technique over the nonadjustable technique with respect to motor alignment outcomes. This finding was not uniformly demonstrated among all studies reviewed and warrants further investigation in the development and analysis of adjustable suture techniques.

Botulinum Toxin Injection for the Treatment of Strabismus: A Report by the American Academy of Ophthalmology

PURPOSE

To review the available evidence comparing the effectiveness of extraocular muscle botulinum toxin type A (BTXA) injection with eye muscle surgery for restoring ocular alignment in children and adults with nonparalytic, nonrestrictive horizontal strabismus.

METHODS

Literature searches in the PubMed Cochrane Library, and clinical trial databases with no date restrictions, but limited to articles published in English, were conducted last on January 10, 2021. The searches yielded 515 citations, 40 of which were reviewed in full text by the first author. Fourteen articles met the criteria for inclusion (randomized or nonrandomized comparative studies, or case series with a minimum 50 patients; evaluating extraocular muscle BTXA injection for initial or repeat treatment of horizontal, nonparalytic, nonrestrictive strabismus; with at least 6 months of follow-up) and were graded by a methodologist.

RESULTS

The 14 included studies consisted of 2 randomized clinical trials, 3 nonrandomized comparative studies, and 9 case series. All 5 comparative studies were graded level II evidence, and the 9 case series were graded level III evidence. Successful motor outcomes after BTXA injection were relatively consistent across 4 of the 5 comparative studies at 60%, when adjustment was made for differential selection bias in 1 of the studies. In the 4 studies, successful motor outcomes after surgery ranged from 66% to 77% with a mean follow-up of 23 to 75 months, and the outcomes were not significantly different from those after BTXA injection. In the fifth level II study, success was significantly higher with BTXA injection than with surgery (94% vs. 72%). The level III BTXA case series demonstrated higher motor success rates of 87% to 89% when children were treated in 2 muscles at a time; rates were lower in adults treated with single-muscle BTXA injection.

CONCLUSIONS

Extraocular muscle injection of BTXA achieves a high rate of successful motor alignment, comparable with that achieved after eye muscle surgery for nonparalytic, nonrestrictive horizontal strabismus. Good alignment may require multiple BTXA injections, and it is not yet clear whether sensory outcomes are equivalent for BTXA injections versus eye muscle surgery in young children.

Home- and Office-Based Vergence and Accommodative Therapies for Treatment of Convergence Insufficiency in Children and Young Adults: A Report by the American Academy of Ophthalmology

PURPOSE

To review home- and office-based vergence and accommodative therapies for treatment of convergence insufficiency (CI) in children and young adults up to 35 years of age.

METHODS

Literature searches were conducted through October 2020 in the PubMed database for English-language studies. The combined searches yielded 359 abstracts, of which 37 were reviewed in full text. Twelve of these were considered appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist.

RESULTS

Of the 12 studies included in this assessment, 8 were graded as level I evidence, 2 were graded as level II evidence, and 2 were graded as level III evidence. Two of the level I studies included older teenagers and young adults; the remainder of the studies exclusively evaluated children. Two randomized controlled trials found that office-based vergence and accommodative therapies were effective in improving motor outcomes in children with symptomatic CI. However, the studies reported conflicting results on the efficacy of office-based therapy for treating symptoms of CI. Data were inconclusive regarding the effectiveness of home-based therapies (including pencil push-ups and home computer therapy) compared with home placebo. In young adults, office-based vergence and accommodative therapies were not superior to placebo in relieving symptoms of CI.

CONCLUSIONS

Level I evidence suggests that office-based vergence and accommodative therapies improve motor outcomes in children with symptomatic CI, although data are inconsistent regarding symptomatic relief. Evidence is insufficient to determine whether home-based therapies are effective.

Visual Outcomes and Complications After Lensectomy for Traumatic Cataract in Children

Importance

The Pediatric Eye Disease Investigator Group Cataract Registry provides a multicenter assessment of visual outcomes and complications after lensectomy for traumatic pediatric cataract.

Objective

To report visual acuity (VA) and the cumulative proportion with strabismus, glaucoma, and other ocular complications by 15 months after lensectomy for traumatic cataract among children younger than 13 years at the time of surgery.

Design, Setting, and Participants

From June 18, 2012, to July 8, 2015, 1266 eyes of 994 children from 33 pediatric eye care practices seen within 45 days after lensectomy were enrolled in a multicenter, prospective observational registry. Of these, 74 eyes of 72 participants undergoing lensectomy for traumatic cataract were included in a cohort study. Follow-up was completed by November 2, 2015, and data were analyzed from March 20, 2018, to July 7, 2020.

Exposures

Lensectomy after ocular trauma.

Main Outcomes and Measures

Best-corrected VA from 9 to 15 months after lensectomy for traumatic cataract (for those 3 years or older) and the cumulative proportion with strabismus, glaucoma, and other ocular complications by 15 months.

Results

Of 994 participants in the registry, 84 (8%) had traumatic cataract. The median age at lensectomy for 72 participants examined within 15 months after surgery was 7.3 (range, 0.1-12.6) years; 46 (64%) were boys. An intraocular lens was placed in 57 of 74 eyes (77%). In children 3 years or older at outcome, the median best-corrected VA was 20/250 (range, 20/20 to worse than 20/800) in 6 eyes with aphakia and 20/63 (range, 20/20 to 20/200) in 26 eyes with pseudophakia. Postoperative visual axis opacification was reported in 18 of 27 eyes with pseudophakia without primary posterior capsulotomy (15-month cumulative proportion, 77%; 95% CI, 58%-92%). The cumulative proportion with strabismus was 43% (95% CI, 31%-58%) in 64 participants with ocular alignment data; exotropia was present in 14 of 23 participants (61%). The cumulative proportion with glaucoma was 6% (95% CI, 2%-16%).

Conclusions and Relevance

Trauma was not a common cause of pediatric cataract requiring surgery. For children with traumatic cataract, substantial ocular morbidity including permanent vision loss was found, and long-term eye and vision monitoring are needed for glaucoma, strabismus, and capsular opacification.

Glaucoma-Related Adverse Events at 10 Years in the Infant Aphakia Treatment Study: A Secondary Analysis of a Randomized Clinical Trial

Importance

Glaucoma-related adverse events constitute serious complications of cataract removal in infancy, yet long-term data on incidence and visual outcome remain lacking.

Objective

To identify and characterize incident cases of glaucoma and glaucoma-related adverse events (glaucoma + glaucoma suspect) among children in the Infant Aphakia Treatment Study (IATS) by the age of 10.5 years and to determine whether these diagnoses are associated with optic nerve head (ONH) and peripapillary retinal nerve fiber layer (RNFL) assessment.

Design, Setting, and Participants

Analysis of a multicenter randomized clinical trial of 114 infants with unilateral congenital cataract who were aged 1 to 6 months at surgery. Data on long-term glaucoma-related status and outcomes were collected when children were 10.5 years old (July 14, 2015, to July 12, 2019) and analyzed from March 30, 2019, to August 6, 2019.

Interventions

Participants were randomized at cataract surgery to either primary intraocular lens (IOL), or aphakia (contact lens [CL]). Standardized definitions of glaucoma and glaucoma suspect were created for IATS and applied for surveillance and diagnosis.

Main Outcomes and Measures

Development of glaucoma and glaucoma + glaucoma suspect in operated-on eyes up to age 10.5 years, plus intraocular pressure, axial length, RNFL (by optical coherence tomography), and ONH photographs.

Results

In Kaplan-Meier analysis, for all study eyes combined (n = 114), risk of glaucoma after cataract removal rose from 9% (95% CI, 5%-16%) at 1 year, to 17% (95% CI, 11%-25%) at 5 years, to 22% (95% CI, 16%-31%) at 10 years. The risk of glaucoma plus  glaucoma suspect diagnosis after cataract removal rose from 12% (95% CI, 7%-20%) at 1 year, to 31% (95% CI, 24%-41%) at 5 years, to 40% (95% CI, 32%-50%) at 10 years. Risk of glaucoma and glaucoma plus glaucoma suspect diagnosis at 10 years was not significantly different between treatment groups. Eyes with glaucoma (compared with eyes with glaucoma suspect or neither) had longer axial length but relatively preserved RNFL and similar ONH appearance and visual acuity at age 10 years.

Conclusions and Relevance

Risk of glaucoma-related adverse events continues to increase with longer follow-up of children following unilateral cataract removal in infancy and is not associated with primary IOL implantation. Development of glaucoma (or glaucoma suspect) after removal of unilateral congenital cataract was not associated with worse visual acuity outcomes at 10 years.

Trial Registration

ClinicalTrials.gov Identifier: NCT00212134.

Office- or Facility-Based Probing for Congenital Nasolacrimal Duct Obstruction: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature assessing the efficacy and safety of in-office probing compared with facility-based probing to treat congenital nasolacrimal duct obstruction (NLDO).

METHODS

Literature searches were conducted in March 2020 in the PubMed database with no date restrictions and limited to studies published in English and in the Cochrane Library database with no restrictions. The combined searches yielded 281 citations. Of these, 21 articles were deemed appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist. Four articles were rated level I, 2 articles were rated level II, and 15 articles were rated level III.

RESULTS

Treatments consisted of observation, in-office nasolacrimal probing, or facility-based nasolacrimal probing. Success rates and complications or recurrences were recorded from 1 week to 6 months after surgery. Complete resolution of symptoms after surgery ranged from 66% to 95.6% for office-based procedures versus 50% to 97.7% for facility-based procedures. Level I evidence indicated that 66% of cases spontaneously resolved after 6 months of observation in infants between 6 and 10 months of age. Success rates for in-office probing were lower for bilateral than for unilateral NLDO (67% vs. 82%), whereas success rates were high in both unilateral (83%) and bilateral (82%) patients who underwent facility-based probing after 6 months of observation. Cost data did not indicate a definitive cost savings of either treatment method ($562 for in-office vs. $701 for facility-based, depending on cost models predicting spontaneous resolution rates at different ages). No serious adverse events with treatment or anesthesia were reported for either treatment method.

CONCLUSIONS

Evidence supports the efficacy and safety of both in-office and facility-based surgery for congenital NLDO. However, treating bilateral NLDO in a facility setting may be better. Because a significant percentage of children achieved resolution spontaneously before 12 months of age, deferring treatment until 12 to 18 months of age is a reasonable option. Additional research may address symptom burden on families and the impact of anesthesia and emotional trauma of nonsedated office probings on patients and may explore further the cost of treatment for each treatment method.

Imaging Methods for Differentiating Pediatric Papilledema from Pseudopapilledema: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature on the accuracy of ophthalmic imaging methods to differentiate between papilledema and pseudopapilledema in children.

METHODS

Literature searches were conducted in January 2020 in the PubMed database for English-language studies with no date restrictions and in the Cochrane Library database without any restrictions. The combined searches yielded 354 abstracts, of which 17 were reviewed in full text. Six of these were considered appropriate for inclusion in this assessment and were assigned a level of evidence rating by the panel methodologist. All 6 included studies were rated as level III evidence.

RESULTS

Fluorescein angiography, a combination of 2 OCT protocols, and multicolor confocal scanning laser ophthalmoscopy (Spectralis SD-OCT; Heidelberg Engineering, Heidelberg, Germany) demonstrated the highest positive percent agreement (92%-100%; 95% confidence interval [CI], 69%-100%) and negative percent agreement (92%-100%; 95% CI, 70%-100%) with a clinical diagnosis of papilledema in children. However, results must be interpreted with caution owing to methodologic limitations, including a small sample size leading to wide CIs and an overall lack of data (there was only 1 study each for the above methods and protocols). Ultrasonographic measures showed either a high positive percent agreement (up to 95%) with low negative percent agreement (as low as 58%) or vice versa. Autofluorescence and fundus photography showed a lower positive (40%-60%) and negative (57%) percent agreement.

CONCLUSIONS

Although several imaging methods demonstrated high positive and negative percent agreement with clinical diagnosis, no ophthalmic imaging method conclusively differentiated papilledema from pseudopapilledema in children because of the lack of high-quality evidence. Clinicians must continue to conduct thorough history-taking and examination and make judicious use of ancillary testing to determine which children warrant further workup for papilledema.

Visual Acuity and Ophthalmic Outcomes in the Year After Cataract Surgery Among Children Younger Than 13 Years

Importance

Cataract is an important cause of visual impairment in children. Outcomes reported from a large clinical disease-specific registry can provide real-world estimates of visual outcomes and rates of adverse events in clinical practice.

Objective

To describe visual acuity and refractive error outcomes, as well as rates of amblyopia, glaucoma, and additional eye surgery, during the first year after lensectomy in children.

Design, Setting, and Participants

A prospective observational study was conducted from June 18, 2012, to July 8, 2015, at 61 pediatric eye care practices among 880 children younger than 13 years at the time of lensectomy in at least 1 eye with follow-up within 15 months after surgery. Statistical analysis was performed from December 12, 2016, to December 14, 2018.

Exposures

Lensectomy with or without implantation of an intraocular lens.

Main Outcomes and Measures

Visual acuity as well as rates of amblyopia, glaucoma, suspected glaucoma, and other intraocular surgery.

Results

Among the 880 children (432 girls and 448 boys; mean [SD] age at annual follow-up, 4.9 [3.8] years) in the study, lens surgery was bilateral in 362 (41.1%; 95% CI, 37.9%-44.4%) children and unilateral in 518 (58.9%; 95% CI, 55.6%-62.1%). An intraocular lens was implanted in 654 of 1132 eyes (60.2%; 95% CI, 57.0%-63.4% [proportions reported for eye-level outcomes account for the potential correlation induced by enrolling both eyes of some individuals; for participants who received bilateral surgery, these numbers will differ from the quotient of the number of cases divided by the total sample size]). Amblyopia was identified in 449 children (51.0%; 95% CI, 47.7%-54.3%). In children age 3 years or older, mean visual acuity was 0.30 logMAR (about 20/40) in 153 bilateral pseudophakic eyes, 0.49 logMAR (about 20/63) in 141 unilateral pseudophakic eyes, 0.47 logMAR (about 20/63) in 21 bilateral aphakic eyes, and 0.61 logMAR (about 20/80) in 17 unilateral aphakic eyes. Mean visual acuity improved with older age at surgery in eyes with bilateral pseudophakia by 0.2 logMAR line (99% CI, 0.02-0.4; P = .005) and by 0.3 logMAR line (99% CI, 0.04-0.60; P = .004) in eyes with unilateral pseudophakia. A new diagnosis of glaucoma or suspected glaucoma was made in 67 of 1064 eyes that did not have glaucoma prior to lensectomy (5.9%; 95% CI, 4.6%-7.7%); 36 of 273 eyes with bilateral aphakia (13.2%; 95% CI, 9.0%-19.0%), 5 of 308 eyes with bilateral pseudophakia (1.5%; 95% CI, 0.6%-4.2%), 14 of 178 eyes with unilateral aphakia (7.9%; 95% CI, 4.7%-12.8%), and 12 of 305 eyes with unilateral pseudophakia (3.9%; 95% CI, 2.2%-6.8%). Additional intraocular surgery, most commonly vitrectomy or membranectomy to clear the visual axis, was performed in 189 of 1132 eyes (17.0%; 95% CI, 14.8%-19.6%).

Conclusions and Relevance

Amblyopia was frequently observed during the first year after lensectomy in this cohort of children younger than 13 years. For children age 2 years or older at surgery visual acuity was typically less than normal for age and was worse with unilateral cataract. Management of visual axis obscuration was the most common complication requiring surgical intervention during the first year after surgery.

Long-term Outcomes Following Surgery for Infantile Nystagmus Syndrome With Abnormal Head Positioning

PURPOSE

To evaluate long-term outcomes of surgical treatment for abnormal head positioning (AHP) associated with infantile nystagmus syndrome (INS).

DESIGN

Retrospective observational case series.

METHODS

Review of 150 patients who underwent surgery for AHP associated with nystagmus. Outcomes included head positioning, duction limitations, and strabismus, and were evaluated several times postoperatively. Successful collapse of AHP was defined as being ≤10°.

RESULTS

Thirty-one patients had surgery for AHP in the pitch (chin up/down) position, whereas 119 had surgery for a horizontal AHP. In addition, 54 underwent 50%-60% augmentation, 19 underwent 40% augmentation, 5 underwent less than 40% augmentation. Thirty-eight had surgical dose modified to correct strabismus, and 3 underwent surgery different from standard Kestenbaum procedures. Collapse of AHP: At the 1-3-week follow-up (n = 131), 125 patients (95%) had collapse of AHP. The percentage trended down at the 2-5-month (91%, n = 106) and 2-year follow-ups (83%, n = 57). However, at 5 and 10 years, it was 93% (n = 42) and 93% (n = 14), respectively, due to reoperation in a small minority. Over- and undercorrection: At 1-3 weeks, 5% of patients were overcorrected whereas 0% were undercorrected. Over- and undercorrection rates peaked at 2 years postoperatively. Ten years out, there were no overcorrections and 7% undercorrections. Four percent of patients required reoperation for overcorrection (mean 2.7 years) and 5% did for undercorrection (mean 3.9 years).

CONCLUSION

Surgery for the head positioning associated with INS produces excellent outcomes throughout 10 years postoperatively. Overcorrection presents early and resolves either over time or with additional surgery. Undercorrection develops later and can persist despite reoperation.

Management of Strabismus Associated With Infantile Nystagmus Syndrome: A Novel Classification to Assist in Surgical Planning

PURPOSE

There is no consensus on the surgical management of head position associated with infantile nystagmus syndrome (INS) when strabismus coexists, and few outcome data have been published. We propose classifying strabismus into concordant or discordant based on the relationship between head positioning and strabismus and then modifying surgery accordingly. Our objective is to describe this system and to review surgical outcomes.

DESIGN

Retrospective observational case series.

METHODS

Twenty-eight patients with INS and coexisting horizontal strabismus underwent surgery for horizontal head positioning and had ≥2 months of follow-up from 1995-2018 at the Vanderbilt Eye Institute. Outcome variables included head positioning (minimal, ≤10°; mild, 11-30°; moderate 31-44°; and severe ≥45°), strabismus (range 0-70 prism diopters [PDs]; minimal ≤10 PD), and reoperation rates. Nonparametric Wilcoxon signed rank, Fisher exact, and Mann-Whitney U tests were used for statistical analysis.

RESULTS

Twenty-one cases were concordant and 7 were discordant; the mean follow-up was 4.1 years. Ninety-six percent of patients had moderate to severe head positioning at baseline. Correction rates (to minimal) were 100% at 2-5 months postoperatively and 86% at last follow-up (P < .0001 at both time points compared with preoperatively). The magnitude of strabismus decreased compared with preoperative strabismus (30.8 ± 10.8 PDs; n = 28), strabismus at 2-5 months (9.1 ± 11.9 PDs; P = .0001; n = 26), and last follow-up (12.0 ± 14.1 PDs; P = .0003; n = 28). The overall reoperation rate was 32%.

CONCLUSIONS

Our classification system in patients with INS allows a systematic way to surgically improve head positioning and strabismus in cases of moderate to severe baseline head positioning.

Colorado retinopathy of prematurity model: a multi-institutional validation study

PURPOSE

The Colorado retinopathy of prematurity (ROP) prediction model (CO-ROP), developed using a cohort of infants from Colorado, calls for ROP examination of infants meeting all of the following criteria: gestational age of ≤30 weeks, birth weight of ≤1500 g, and a net weight gain of ≤650 g between birth and 4 weeks of age. The purpose of this study was to perform an external validation to assess the sensitivity and specificity of the CO-ROP model in a larger cohort of babies screened for ROP from four academic institutions in the United States.

METHODS

The medical records of neonates screened for ROP according current national guidelines was conducted at 4 US academic centers were retrospectively reviewed. Sensitivity, specificity, and respective 95% confidence intervals in detecting ROP using CO-ROP were calculated for type 1, type 2, and any grade of ROP.

RESULTS

A total of 858 cases were included. The CO-ROP algorithm had a sensitivity of 98.1% (95% CI, 93.3%-99.8%) for type 1 ROP, 95.6% (95% CI 78.0-99.9%) for type 2 ROP, and 95.0% (95% CI, 93.1-97.4%) for all grades of ROP. The CO-ROP model would have reduced the total number of infants screened by 23.9% compared to current 2013 screening guidelines.

CONCLUSIONS

CO-ROP demonstrated high sensitivity in predicting ROP and would have greatly reduced the number of infants needing examination.

Three and Four Horizontal Muscle Surgery for Large Angle Exotropia

PURPOSE

Surgery on two horizontal recti typically is most effective for angles less than 40 prism diopters (PD). The authors evaluate their experience operating on three or four rectus muscles for angles exceeding 40 PD.

METHODS

Retrospective chart review of 47 patients who underwent a first surgical procedure for a large angle comitant exodeviation. Patients were observed for a minimum of 2 months. Success was defined as deviation ±10 PD.

RESULTS

Median age was 48 years (range: 1 to 79 years). Thirty-four patients underwent three muscle surgery and 13 underwent four muscle surgery. Mean preoperative angles were 55 ± 9.8 and 72 ± 8.8 PD, respectively. Following three muscle surgery, rates of success, undercorrection, and overcorrection were 67%, 27%, and 7% at 2 months and 42%, 58%, and 0% at final follow-up (12 ± 8.7 months), respectively. Rates for four muscle surgery were 44%, 33%, and 22% at 2 months and 50%, 38%, and 13% at final follow-up (11 ± 12.2 months), respectively. Patients who were successfully aligned at 2 months had a mean preoperative angle of 55 PD, whereas those who were undercorrected had a mean preoperative angle of 67 PD (P = .009). Between 1 week and 2 months, 77% of patients experienced exotropic drift averaging 10 ± 9.1 PD. By final follow-up, 90% experienced exotropic drift averaging 15 ± 14.1 PD. Success rates for traditional and adjustable suture surgeries did not differ significantly.

CONCLUSIONS

Three and four horizontal muscle surgeries are effective for correcting large angle exotropia. Higher preoperative deviations predisposed to undercorrection. Postoperative exotropic drift should be anticipated.

Corneal Changes in Children after Unilateral Cataract Surgery in the Infant Aphakia Treatment Study

PURPOSE

We report endothelial cell (EC) characteristics and central corneal thickness (CCT) from the Infant Aphakia Treatment Study (IATS) patients at the 5-year examination.

DESIGN

Randomized, controlled trial of the treatment of unilateral cataract with aphakic contact lens (CL) versus primary intraocular lens (IOL) implant.

PARTICIPANTS

A total of 114 infants with unilateral cataract.

METHODS

The EC density, coefficient of variation (CV), and percent hexagonal cells were measured by noncontact specular microscopy. The CCT was measured using contact pachymetry. Fellow eyes served as controls.

MAIN OUTCOME MEASURES

Mean differences between treated and fellow eyes of CL and IOL groups were compared with a paired t test. A 1-way analysis of variance model and the Tukey-Kramer multiple comparison procedure were used to assess the effect of a diagnosis of glaucoma or glaucoma suspect.

RESULTS

A total of 105 subjects (52 with CLs, 53 with IOLs) had specular microscopy or corneal thickness data recorded. Mean EC densities were higher in aphakic eyes compared with fellow eyes (3921 vs. 3495 cells/mm2, P<0.0001). Mean CV was higher (27 vs. 24, P=0.0002) and mean percent hexagonal cells was lower (72% vs. 76%, P=0.002) in aphakic eyes compared with fellow eyes. Mean CCT of aphakic eyes was higher than in controls (637 vs. 563 μm, P<0.0001). There was no difference in EC density in eyes treated with IOLs compared with fellow eyes (3445 and 3487 cells/mm2, P=0.68). Means for CV (25 vs. 24, P=0.07) and percent hexagonal cells (74 vs. 76%, P=0.27) were also not significantly different. Mean CCT was higher in eyes with IOLs (605 vs. 571 μm, P<0.0001) compared with fellow eyes. Compared with treated eyes without glaucoma or glaucoma suspect, treated eyes with glaucoma had lower EC density (3289 vs. 3783 cells/mm2, P=0.03) and treated eyes with glaucoma suspect had greater mean corneal thickness (660 vs. 612 μm, P=0.0036).

CONCLUSIONS

Cataract extraction during infancy with IOL implantation was not associated with a reduced EC count in treated compared with fellow eyes, although CCT was increased. Extended-wear aphakic CLs may cause corneal polymegathism with increased EC density and CCT. Glaucoma diagnosis was associated with reduced EC counts and increased CCT.

Ophthalmic manifestations of relapsing acute childhood leukemia

Acute lymphoblastic leukemia is the most common malignancy in children. We report 3 patients who presented to their general pediatricians and pediatric oncologists with ocular complaints as the only evidence of their leukemic relapses. All patients presented with persistent conjunctival injection and were referred to an ophthalmologist for further management. Two patients were diagnosed with recurrent anterior uveitis, which after extensive workup and treatment with topical glucocorticoids was found to be a result of leukemic ocular disease. One patient had a conjunctival tumor, which was biopsied and confirmed to be leukemic infiltration. All children eventually succumbed to their recurrent disease. These cases demonstrate the need for a high index of suspicion when evaluating ocular symptoms in patients with a prior history of acute lymphoblastic leukemia. Anterior chamber paracentesis and biopsy of suspicious lesions should be considered as possible diagnostic procedures in addition to standard hematologic studies. Collaboration between a primary care physician, pediatric oncologist, and ophthalmologist is essential for optimal diagnosis and treatment.

DVD--a conceptual, clinical, and surgical overview

Dissociated vertical deviation (DVD) is a slow, disconjugate hypertropic deviation of a nonfixating eye. It is usually bilateral, asymmetrical, and often associated with congenital esotropia. The deviating eye elevates, abducts, and excyclotorts. This type of strabismus is often variable, making measurement and clinical quantification difficult. Specific knowledge of the mechanisms and characteristics of the dissociated deviation are required for proper assessment and effective treatment. There is currently no consensus on the mechanisms and pathophysiology of DVD. In this workshop, participants discuss the characteristics and most current methods for assessing and quantifying the deviation and explore the potential etiologies, clinical characteristics, and indications for surgical intervention and nonsurgical management of DVD.

Hypoxia-induced expression of VEGF splice variants and protein in four retinal cell types

The purpose of this study was to investigate the hypoxia-induced Vegf120, Vegf164 and Vegf188 mRNA expression profiles in rat Müller cells (MC), astrocytes, retinal pigmented epithelial cells (RPE) and retinal microvascular endothelial cells (RMEC) and correlate these findings to VEGF secreted protein. Cultured cells were exposed to normoxia or hypoxia. Total RNA was isolated from cell lysates and Vegf splice variant mRNA copy numbers were assayed by a validated qRT-PCR external calibration curve method. mRNA copy numbers were normalized to input total RNA. Conditioned medium was collected from cells and assayed for total VEGF protein by ELISA. Hypoxia increased total Vegf mRNA and secreted protein in all the retinal cell types, with the highest levels observed in MC and astrocytes ranking second. Total Vegf mRNA levels in hypoxic RPE and RMEC were comparable; however, the greatest hypoxic induction of each Vegf splice variant mRNA was observed in RMEC. RPE and RMEC ranked 3rd and 4th respectively, in terms of secreted total VEGF protein in hypoxia. The Vegf120, Vegf164 and Vegf188 mRNA splice variants were all increased in hypoxic cells compared to normoxic controls. In normoxia, the relative Vegf splice variant mRNA levels ranked from highest to lowest for each cell type were Vegf164 > Vegf120 > Vegf188. Hypoxic induction did not alter this ranking, although it did favor an increased stoichiometry of Vegf164 mRNA over the other two splice variants. MC and astrocytes are likely to be the major sources of total Vegf, Vegf164 splice variant mRNAs, and VEGF protein in retinal hypoxia.

Patching compliance with full-time vs. part-time occlusion therapy

BACKGROUND AND PURPOSE

Amblyopia is commonly treated with part-time occlusion (PTO) therapy. We have made two anecdotal observations regarding this therapy. First, children undergoing full-time occlusion seem to have better success and compliance rates. Secondly, a subset of children exists that fail PTO but can improve with more aggressive therapy.

METHODS

A retrospective review where treatment, visual outcome, and compliance scores were recorded. Compliance was graded on percent adherence reported by family. Patients scored “1” (for no compliance), “2” (for 1–25% of prescribed treatment performed), “3” (for 26–50%), “4” (for 51–75%), or “5” (for 76–100%).

RESULTS

Seventy-six children were enrolled in the study: forty-five were treated with part-time occlusion, twenty-two were treated with full time occlusion (FTO), and nine had a history of failed PTO and were subsequently treated with FTO. Visual outcomes for FTO versus PTO were not statistically significant (P = 0.82). However, compliance rates in FTO were significantly better (P = 0.02). Of the nine patients that failed PTO, four improved an average of three lines with full-time occlusion, and five had no change with more aggressive patching.

CONCLUSIONS

This study confirms previous reports of similar visual outcomes between PTO and FTO. However, compliance rates for FTO seem to be higher and some children who have failed PTO may improve with FTO.

The use of dimenhydrinate in conjunction with dexamethasone for induction of parturition in beef cattle

Forty-eight crossbred Chianina cows (3 to 5 years of age), with an expected gestation length of 288 days, were randomly divided into four treatment groups to evaluate the use of dimenhydrinate (an antihistamine agent) in conjunction with dexamethasone (DEX) for inducing parturition in beef cattle. Group (A) received a 20 mg dose of DEX (im) on day 282 of gestation and a carrier vehicle (iv) 24 hours later (day 283); Group (B) was given a carrier vehicle (im) on day 282 and 500 mg of dimenhy-drinate (DMH) diluted in 200 ml of 2.5% dextrose-0.9% saline solution given (iv) on day 283 and Group (C) received 20 mg of DEX (im) on day 282 and 500 mg of DMH in solution (iv) on day 283 of gestation. The remaining 12 cows assigned to Group (D) were not handled and were allowed to calve under natural conditions. The number of cows calving and percent calving within 60 hours after the first injection were: 10(91%), none(0%) and 12(100%) for the DEX, DMH and DEX plus DMH groups, respectively. The mean gestation length of the control cows in Group (D) was 288.6 days. Frequency of dystocia was: 18.2, 8.3, 0 and 0% and retained placentae (>/=24 hours) was: 72.8, 16.6, 33.3 and 0% for DEX, DMH, DEX plus DMH and control groups, respectively. In this study, a 20 mg dose of DEX (im) followed 24 hours later with 500 mg of DMH (iv) was more successful for calving induction than when DEX or DMH was used alone. The combination DEX and DMH treatment induced calving in a shorter interval from treatment (P<.05) and decreased the incidence of retained placentae (P<.01) when compared with those induced following DEX treatment.

The efficacy of superior oblique Z-tenotomy in the treatment of overdepression in adduction (superior oblique overaction)

INTRODUCTION

To evaluate the efficacy of superior oblique Z-tenotomy in the treatment of overdepression in adduction (superior oblique overaction) with respect to collapse of A-pattern strabismus and normalization of versions.

METHODS

The medical records of patients who underwent bilateral superior oblique Z-tenotomy for mild to moderate overdepression in adduction and A-pattern strabismus between June 2004 and August 2010 were retrospectively reviewed. Surgical indications included mild to moderate overdepression in adduction (+2 to 3) and an A pattern of 10(Δ) to 40(Δ) between upgaze and downgaze. A monopolar electrode microdissection needle was used to make two tenotomies, 60% to 80% in width and 8 mm apart, perpendicular to the axes of the tendon in opposite directions. Surgical success included a postoperative A pattern of ≤10(Δ) and overdepression in adduction of ≤1.

RESULTS

A total of 20 patients (mean age, 9.8 years; age range, 3-34) underwent bilateral superior oblique Z-tenotomy during the study period: 2 patients (10%) with esotropia and 18 with exotropia (90%). Average decrease in pattern was 16(Δ) (range, 0(Δ)-32.5(Δ)). Success rate for pattern collapse was 78%, with resolution of overdepression in adduction of 90%.

CONCLUSIONS

Z-tenotomy of the superior oblique tendon collapsed A-pattern strabismus and normalized versions.

Posterior capsular plaque in bilateral congenital cataracts

BACKGROUND

Many cases of unilateral congenital cataract have an associated posterior capsular plaque. Observations such as this have led to the hypothesis that posterior capsular plaque is caused by persistent fetal vasculature, generally a unilateral condition, even if no obvious hyaloid remnant is visible. We investigated the incidence of posterior capsular plaque associated with bilateral congenital cataracts.

METHODS

Children with bilateral congenital cataracts were identified from three surgical practices. Children were included if lensectomies were performed prior to age 7 months. Surgical videos were evaluated for cataract morphology.

RESULTS

Fourteen children with bilateral cataracts were identified. Surgical videos were available for 24 eyes. Five eyes (21%) had evidence of persistent hyaloid remnants. Of the remaining 19 eyes, cataracts were categorized as nuclear in 10 cases, nuclear with cortical extension in 6 cases, and posterior cortical in 3 cases. Evidence of posterior capsular plaque was seen in seven cases (37%) on video review.

CONCLUSIONS

Video review revealed a much lower incidence of posterior capsular plaque in eyes with bilateral congenital cataracts compared to unilateral congenital cataracts, lending presumptive evidence to the hypothesis that most unilateral lens opacities arise from persistent fetal vasculature.

The Infant Aphakia Treatment Study: evaluation of cataract morphology in eyes with monocular cataracts

PURPOSE

To describe a video-documented assessment of cataract type in the eyes of patients with monocular infantile cataract who were enrolled in the Infant Aphakia Treatment Study.

METHODS

The Infant Aphakia Treatment Study is a randomized clinical trial in which the investigators compared intraocular lens (IOL) versus contact lens correction in 114 infants, aged 28 days to <7 months. A total of 83 videos were available for morphological analysis of cataract. Three examiners reviewed all surgical recordings and agreed on the cataract characteristics by using a score sheet to record the lens layer or configuration of the opacity.

RESULTS

Nuclear cataract was present in 45 of 83 eyes (54%). Posterior capsule plaque was observed in 73 eyes (88%). All eyes with fetal nuclear cataract had associated posterior capsule plaque. Cortical cataract without nuclear involvement was seen in 21 eyes (25%). Posterior bowing of the posterior capsule was noted in 4 eyes (5%). Evidence of persistent fetal vasculature (PFV) was present in 18 eyes (22%). PFV was the only finding in 5 eyes but was also seen in combination with nuclear (7 eyes) and cortical cataracts (6 eyes). The entire lens was white in 3 eyes (4%), whereas the lens was partially resorbed in 7 (8%) eyes. Anterior capsule fibrosis was noted in 5 eyes with advanced cataract (1 with total cataract, 4 with partially resorbed lens).

CONCLUSIONS

Nuclear opacities were common, but many different cataract types presented in infancy. PFV occurred in isolation or in association with cataract. Posterior capsule plaque was frequently noted, especially when a nuclear cataract was present.

Infant Aphakia Treatment Study: effects of persistent fetal vasculature on outcome at 1 year of age

BACKGROUND

The Infant Aphakia Treatment Study is a randomized trial that compares the treatment of unilateral congenital cataract with primary intraocular lens (IOL) implantation versus aphakic contact lens (CLs). The purpose of this study was to compare the outcomes for infants with lens opacity associated with persistent fetal vasculature (PFV) to those without.

METHODS

Retrospective subgroup analysis of grating visual acuity at 1 year of age and adverse events up to 1 year after surgery in eyes identified intraoperatively as having evidence of mild PFV from the IATS.

RESULTS

Of 83 infants, 18 (22%: 11 CL, 7 IOL) had PFV. Median logMAR visual acuity was 0.88 for patients with PFV and 0.80 for patients without PFV (P = 0.46). One or more adverse events up to 1 year after surgery occurred in 12 infants (67%) with PFV and 30 infants (46%) without PFV (P = 0.18). The incidence of adverse events was significantly greater in patients with PFV compared with patients without PFV in the CL group (55% vs 20%, P = 0.049) but not in the IOL group (86% vs 71%, P = 0.65), possibly because all children receiving IOLs had greater rates of adverse events when compared with aphakic children (73% vs 29%, P < 0.001).

CONCLUSIONS

Aphakic infants with mild PFV treated with CL had a greater incidence of adverse events after lensectomy compared with children with other forms of unilateral congenital cataract; nevertheless, similar visual outcomes at 1 year after surgery were obtained.

Further examination of the prevalence of MIH in the Wellington region

OBJECTIVES

The aim of this study was to further investigate the prevalence of Molar Incisor Hypomineralisation (MIH) in the Wellington region, in order to expand on the findings of a recent study.

DESIGN

A survey of MIH in a sample of 7-to-10-year-old children attending primary school in Central Wellington, together with data from a similar survey conducted earlier in Wainuiomata.

METHOD

Using the modified Developmental Defects of Enamel index, a single paediatric dentist examined students in the classroom. Any visible occurrences of demarcated opacities, post-eruptive breakdown of enamel and hypoplasia were recorded, along with dental caries experience in primary and permanent teeth. The data were combined with those from the previous study, and statistical analysis was undertaken using the combined data-set.

RESULTS

In the Central Wellington study, examinations were conducted on 235 children (participation rate 58.8%, mean age 8.2 years). MIH prevalence was 18.8%. Demarcated opacities and post-eruptive breakdown affected 23.9% and 8.1% (respectively) of the sample. Pooling the data from Central Wellington and Wainuiomata gave a total sample of 756 (mean age 8.2), among which MIH prevalence was 15.7%. Demarcated opacities and post-eruptive breakdown (of any tooth) affected 18.0% and 4.6%, respectively. Hypoplasia of any tooth was observed in 0.7% of the pooled sample. There was no statistically significant association between MIH and either ethnicity or school decile. Although MIH prevalence was 3.9 percentage points higher in the Central Wellington schools than in Wainuiomata, socioeconomic status (measured through school decile) was not significantly associated with MIH. The presence of developmental defects of enamel was associated with greater caries experience in the permanent dentition.

CONCLUSIONS

In the Wellington schools involved in the study, approximately one in six 7-10-year-old children had MIH. Neither school decile nor ethnicity were modifying factors in the occurrence of MIH.

Surgical management of residual or recurrent esotropia following maximal bilateral medial rectus recession

OBJECTIVE

To describe the effect of graded unilateral vs bilateral lateral rectus resection in the treatment of residual or recurrent esotropia after maximal medial rectus muscle recession.

METHODS

Retrospective case series of children with residual or recurrent esotropia. All children underwent initial eye muscle surgery for angles of 40 to 60 prism diopters (medial rectus recession of 5.5-6.5 mm; 11.0-11.5 mm from surgical limbus). If significant esotropia persisted or recurred, surgical results from graded lateral rectus resection were recorded.

RESULTS

Thirty-eight children were identified for the study. Unilateral lateral rectus resection ranging from 4 to 7 mm resulted in mean esotropic corrections of 10.5 to 14.9 prism diopters. Differences in surgical response per millimeter of unilateral lateral rectus resection were not significant. Bilateral lateral rectus resection of 5, 6, and 7 mm resulted in a mean correction of 19.75, 28.75, and 33.5 prism diopters, respectively.

CONCLUSIONS

Graded lateral rectus resection can produce highly variable results on a case-to-case basis, but mean values trend in the expected direction. Residual deviations larger than 15 prism diopters need to be addressed with bilateral surgery.

Longitudinal follow-up of hypermetropic children identified during preschool vision screening

PURPOSE

Early childhood hypermetropia is an important risk factor for the development of amblyopia and esotropia. Understanding the natural history of these complications aids in management decisions.

METHODS

A retrospective observational review was undertaken of 149 patients referred from a preschool photoscreening program who were determined to have hypermetropia of >or=+3.75 D spherical equivalent on criterion standard examination and were treated/followed by one group of academic pediatric ophthalmologists. The prevalence and incidence of accommodative esotropia and amblyopia were determined.

RESULTS

At presentation 19% of hypermetropic children had amblyopia, 32% had esotropia, and 13% had both. Follow-up data of 108 patients during a mean of 40 months showed that 20 (24%) of 83 initially nonamblyopic patients developed amblyopia and that 22 (33%) of 67 initially nonstrabismic patients developed accommodative esotropia. Of patients initially managed with observation, 38% (6 of 16) developed amblyopia, and 31% (5 of 16) developed accommodative esotropia as compared with 21% (14 of 67) and 33% (17 of 51), respectively, for those given full or partial refractive correction. For patients without amblyopia or strabismus at presentation, only 20% developed amblyopia and 35% esotropia. Strabismic patients responded well to treatment, with no cases developing partially accommodative strabismus requiring surgery during follow-up.

CONCLUSIONS

In this case series we found a high prevalence of amblyopia and strabismus. The results support the importance of early preschool vision screening and spectacle correction of moderate to high hypermetropia (>+3.50 D) to reduce the risk of amblyopia, although more research is needed.

Risk of refractive pathology after spontaneously regressed ROP in emmetropic patients

PURPOSE

To evaluate the development of refractive error abnormalities after a normal first examination in children with spontaneously regressed retinopathy of prematurity (ROP).

METHODS

Two hundred twenty-six children with a history of spontaneously regressed ROP who had a cycloplegic refraction prior to 18 months of age were examined by a pediatric ophthalmologist. Children with a history of threshold ROP, strabismus, or a structural abnormality of the eye were excluded. A normal cycloplegic retinoscopy was defined as plano to less than +3.5 diopters of hypermetropia, less than +1.50 of symmetric astigmatism, and no anisometropia greater than 1.5 diopters in any meridian.

RESULTS

Of the 226 children, 87 had a second examination and cycloplegic refraction at a mean of 2 years after the initial visit. In 63 of the children, the second examination and refraction remained normal. Three (3.4%) children had significant refractive error and were treated with spectacles: two had anisometropia and one had myopic astigmatism. Twenty-one had symmetric low magnitude myopia that did not warrant treatment.

CONCLUSION

Children with spontaneously regressed ROP and no significant refractive error on cycloplegic retinoscopy at first follow-up examination have a risk of developing ametropia that is similar to that of the general population. Such children can likely be observed with a verbal vision screening in the pediatrician's office at 3 to 4 years of age.

Intravitreal bevacizumab as adjunctive treatment for retinopathy of prematurity

BACKGROUND

While laser photocoagulation remains the standard of care in the treatment of advanced retinopathy of prematurity (ROP), regression is not seen in all cases (especially in aggressive posterior disease) following laser alone. We report the results of the use of the anti-vascular endothelial growth factor monoclonal antibody bevacizumab in eyes with ROP at high risk for progression.

METHODS

Records of all infants with ROP treated with bevacizumab were reviewed. Bevacizumab was given when conventional laser therapy was not possible in patients with poor pupillary dilation from iris rubeosis, dense vitreous hemorrhage, or increasing vascular activity and vitreoretinal traction despite completed laser therapy. We recorded birth weight, gestational age at birth, severity of ROP, anatomic result, any additional ophthalmic interventions, and early or late adverse systemic effects.

RESULTS

Thirteen eyes of 7 infants (median gestational age, 25 weeks; median birth weight, 700 g; follow-up, 9 months [range, 2-17]) were treated with an intravitreal injection of 0.75 mg bevacizumab under sterile conditions by 1 surgeon following detailed discussion with family and attending neonatologists. Injection was not used as monotherapy in any case. Definitive treatment (laser or vitrectomy) was completed successfully within 72 hours of injection. No systemic complication attributable to bevacizumab treatment has been recorded within 2 to 17 months of follow-up.

CONCLUSIONS

Treatment with bevacizumab may be used to improve visualization for more definitive laser or surgical treatment and may facilitate disease regression without obvious systemic toxicity. Optimization of dosing, timing, and indications will require additional study.

The prevalence of Molar-Incisor Hypomineralisation (MIH) in Wainuiomata children

OBJECTIVES

The aim of this study was to determine the prevalence of Molar-Incisor Hypomineralisation (MIH) in Wainuiomata children and describe differences in prevalence among Māori, Pacific Island and New Zealand European ethnic groups.

DESIGN

Cross-sectional survey of developmental defects of enamel in a random sample of children attending primary school in Wainuiomata, Wellington.

METHOD

Study information and consent forms were sent to 850 7-to-10-year-old schoolchildren. Using the modified Developmental Defects of Enamel index, a single paediatric dentist examined students in the classroom. Dental caries experience was recorded as decayed, missing or filled primary and permanent teeth.

RESULTS

Examinations were conducted on 522 children (participation rate 61.4%). The mean age of the children was 8.2 years (range 7 to 10 years). MIH prevalence was 14.9%. The prevalence ofhypomineralisation ofany tooth was 15.3%, and that for hypoplasia was 4.0%. There was no statistically significant ethnic difference in MIH prevalence. The mean DMFT was 0.16 (SD, 0.54) in those without a developmental defect, 0.54 (SD, 1.12) in those with hypomineralisation and 1.85 (SD, 1.85) in those with hypoplasia (p < 0.01).

CONCLUSIONS

Approximately one in seven Wainuiomata children have MIH. Ethnicity is not a modifying factor in the occurrence of developmental defects of enamel. The presence of hypomineralisation and/or hypoplasia was associated with significantly greater caries experience in the permanent dentition.

Patching vs atropine to treat amblyopia in children aged 7 to 12 years: a randomized trial

OBJECTIVE

To compare patching with atropine eyedrops in the treatment of moderate amblyopia (visual acuity, 20/40-20/100) in children aged 7 to 12 years.

METHODS

In a randomized, multicenter clinical trial, 193 children with amblyopia were assigned to receive weekend atropine or patching of the sound eye 2 hours per day. Main Outcome Measure Masked assessment of visual acuity in the amblyopic eye using the electronic Early Treatment Diabetic Retinopathy Study testing protocol at 17 weeks.

RESULTS

At 17 weeks, visual acuity had improved from baseline by an average of 7.6 letters in the atropine group and 8.6 letters in the patching group. The mean difference between groups (patching - atropine) adjusted for baseline acuity was 1.2 letters (ends of complementary 1-sided 95% confidence intervals for noninferiority, -0.7, 3.1 letters). This difference met the prespecified definition for equivalence (confidence interval <5 letters). Visual acuity in the amblyopic eye was 20/25 or better in 15 participants in the atropine group (17%) and 20 in the patching group (24%; difference, 7%; 95% confidence interval, -3% to 17%).

CONCLUSIONS

Treatment with atropine or patching led to similar degrees of improvement among 7- to 12-year-olds with moderate amblyopia. About 1 in 5 achieved visual acuity of 20/25 or better in the amblyopic eye.

CLINICAL RELEVANCE

Atropine and patching achieve similar results among older children with unilateral amblyopia.

TRIAL REGISTRATION

(clinicaltrials.gov) Identifier: NCT00315328.

Congenital oculomotor nerve synkinesis associated with fetal retinoid syndrome

INTRODUCTION

Isotretinoin (RA), used for the treatment of cystic acne, is a powerful teratogen, causing craniofacial dysmorphisms and neural tube defects. We present two patients with RA embryopathy and oculomotor nerve synkinesis.

METHODS

Retrospective review of patient records.

RESULTS

Two patients presented with third nerve synkinesis and fetal RA exposure. Both had marked elevation of the upper eyelids on adduction such that the lid fissures alternately opened and closed on gaze from side to side. Both patients showed typical dysmorphisms of RA embryopathy. The first patient had complete agenesis of the cerebellar vermix and died at 2 years. The second patient had restricted extraocular muscles in one eye and was exotropic and hypotropic.

DISCUSSION

Both patients demonstrated simultaneous innervation of the medial rectus and levator palpebrae muscles causing coincident lid elevation in adduction. This evidence of oculomotor nerve synkinesis is consistent with animal studies showing abnormalities in the formation of cranial nerve ganglia following fetal RA exposure.

CONCLUSION

RA is a powerful teratogen. These patients provide additional clinical evidence of its influence on neural migration during early development.

Severe amblyopia of the sound eye resulting from atropine therapy combined with optical penalization

The potential amblyogenic effect to the sound eye of atropine combined with optical penalization is powerful, and frequent patient monitoring is necessary when using this therapy. We report two cases of amblyopia developing in the previously sound eye as a result of noncompliance during atropine therapy combined with optical penalization. Both cases required active treatment to correct the reverse amblyopia. Vision returned to normal in one patient, while the second patient was lost to follow-up with poor acuity.

Acute myeloid leukemia presenting as bilateral proptosis from diffuse extraocular muscle infiltration

PURPOSE

To report a case of acute myeloid leukemia with bilateral proptosis as the sole presenting sign.

DESIGN

Observational case report.

METHODS

A patient with bilateral proptosis was seen in consultation by pediatric ophthalmology.

RESULTS

Complete blood count, computerized tomography, and bone marrow biopsy confirmed the diagnosis of acute myeloid leukemia, with the proptosis due to diffuse infiltration of all extraocular muscles.

CONCLUSION

In a child with the sudden onset of proptosis without any other systemic findings, the diagnosis of acute leukemia must be considered.

Ophthalmologic involvement in the syndrome of headache, neurologic deficits, and cerebrospinal fluid lymphocytosis

PURPOSE

To emphasize that papilledema and other ophthalmic manifestations may occur in the syndrome of headache, neurologic deficits, and cerebrospinal fluid lymphocytosis (HaNDL).

DESIGN

Two interventional case reports.

METHODS

Two patients were seen with ophthalmologic findings, including decreased vision, papilledema, sixth nerve palsy, and a variety of neurologic deficits. Each underwent cerebrospinal fluid analysis and intracranial pressure measurement by spinal tap and neuroimaging studies to confirm the diagnosis of HaNDL.

RESULTS

Both patients received acetazolamide to lower intracranial pressure. The first patient had complete resolution of signs and symptoms. The second, who was also given systemic corticosteroids, was left with diminished visual acuity in the right eye with nasal visual field loss and optic atrophy.

CONCLUSIONS

The diagnosis of HaNDL is one of exclusion, which must be made in conjunction with a neurologist. HaNDL may be accompanied by elevated intracranial pressure and papilledema. As in other disorders causing papilledema, these patients may have permanent visual sequelae. Recognition by the ophthalmologist of this rarely reported syndrome will facilitate prompt patient diagnosis and treatment.

Influence of prepartum body condition score change on reproduction in multiparous beef cows calving in moderate body condition

Multiparous, spring-calving beef cows (n = 250) were used to determine whether large changes in body energy reserves during mid- to late gestation influenced subsequent reproductive performance of cows calving in moderate body condition. In three states, cows were blocked by BW and body condition score (BCS; 1 = emaciated to 9 = obese) then allotted to receive either a high or low plane of nutrition from late summer to early winter over a 3-yr period. This generated an array of BCS by the beginning of the last trimester of pregnancy when cows were grouped by BCS as follows: Group 1, BCS < or = 4; Group 2, BCS of 5 or 6; and Group 3, BCS > or = 7. Each group was managed so that individual cows would calve with a BCS of 5 to 6. At the time of group assignment, mean BW and BCS differed (P < .01) among groups and were 480 kg and 3.6, 541 kg and 5.5, and 594 kg and 7.1 for Groups 1 to 3, respectively. Within 28 d before calving, BW and BCS were similar (P > .20) among groups averaging 555 kg and 5.1. Prepartum BCS changes averaged 1.4, -.4, and -2.0 units for Groups 1 to 3, respectively (P < .01). Cows were managed as a single group after calving in each state. Location effect was significant for the prepartum and postpartum BW and BCS changes but not for postpartum reproductive performance. Significant location x BCS group interactions were found for the 90-d prepartum BW, BCS at calving, and prepartum changes in BW, but were caused by differences in magnitude among locations. The percentage of cows with luteal activity at the start of a subsequent breeding season was not affected (P > .20) by either location or BCS group, and averaged 66%. Mean pregnancy rates at 20, 40, and 60 d of a subsequent breeding season were 55, 76, and 89% for Group 1; 51, 67, and 82% for Group 2; and 64, 79, and 89% for Group 3 (P > .30). Mean days to conception were 89, 87, and 85 for Groups 1 to 3, respectively (P = .70). Neither calf birth weight (x = 38.6 kg) nor adjusted 205-d weight (x = 223.6 kg) were affected by prepartum BW and BCS changes. We conclude that reproductive performance of cows calving in moderate body condition is not influenced by large changes in body energy reserves during the last trimester of pregnancy.