Skeletal changes after midface surgery in patients with craniofacial deformities: a three-dimensional quantification method

To determine the skeletal changes after midface surgery in patients with syndromic craniosynostosis who underwent Le Fort III (LFIII), monobloc (MB), or facial bipartition (FB). This was a retrospective study including 75 patients: 33 treated by LFIII, 29 by MB, and 13 by FB. Twenty-five had a diagnosis of Apert, 39 Crouzon, and 11 craniofrontonasal syndrome. A three-dimensional mesh was created from the preoperative scan and registered to the postoperative scan to visualise the advancement. LFIII at age 7-12 years effectuated a higher mean advancement in the maxillary (15.5 mm) and zygomatic (7.6 mm) regions when compared to ≥13 years (10.2 mm and 5.5 mm). After MB, mean advancement of the fronto-orbital region was higher at <7 years (16.4 mm), and similarly lower at ages 7-12 (13.8 mm) and ≥13 (12.5 mm). The mean preoperative inter-dacryon distance (34.4 ± 4.4 mm) was reduced by 8.7 ± 4.2 mm after FB without distraction (n = 10). More advancement was seen when midface surgery was performed at a younger age, due to more severe cases and a desire for overcorrection. The highest mean advancement was observed in the fronto-orbital region. Antero-inferior rotational movement was seen after all three techniques.

Supervised dichoptic gaming versus monitored occlusion therapy for childhood amblyopia: Effectiveness and efficiency

PURPOSE

To compare the effectiveness and efficiency of supervised dichoptic action-videogame play to occlusion therapy in children with amblyopia.

METHODS

Newly diagnosed children with amblyopia aged 4-12 years were recruited, excluding strabismus >30PD. After 16 weeks of refractive adaptation children were randomized to gaming 1 h/week supervised by the researcher, or electronically monitored occlusion 2 h/day. The gaming group played a dichoptic action-videogame using virtual reality goggles, which included the task of catching a snowflake presented intermittently to the amblyopic eye. Contrast for the fellow eye was self-adjusted until 2 identical images were perceived. The primary outcome was visual acuity (VA) change from baseline to 24 weeks.

RESULTS

We recruited 96 children, 29 declined and 2 were excluded for language or legal issues. After refractive adaptation, 24 of the remaining 65 no longer met the inclusion criteria for amblyopia, and 8 dropped out. Of 16 children treated with gaming, 7 (6.7 years) completed treatment, whereas 9 younger children (5.3 years) did not. Of 17 treated with occlusion, 14 (5.1 years) completed treatment and 3 (4.5 years) did not. Of 5 children with small-angle strabismus, 3 treated with occlusion completed treatment and 2 treated with gaming did not. Median VA improved by 0.30 logMAR (IQR 0.20-0.40) after gaming, 0.20 logMAR (0.00-0.30) after occlusion (p = 0.823). Treatment efficiency was 1.25 logMAR/100 h (range 0.42-2.08) with gaming, 0.08 (-0.19-0.68) with occlusion (p < 0.001).

CONCLUSION

Dichoptic gaming seems a viable alternative for older children with refractive amblyopia after glasses adaptation. Treatment efficiency with gaming under continuous supervision was 15 times higher than with occlusion at home.

Quantitative detection and follow-up of intracranial hypertension in craniosynostosis: an optical coherence tomography study

BACKGROUND/PURPOSE

To evaluate in craniosynostosis: 1) the diagnostic accuracy of fundoscopy and optical coherence tomography (OCT) to detect intracranial hypertension (ICH); 2) the time course of retinal thickness after treatment of ICH; and 3) the relation between high hyperopia (HH) and fundoscopy/OCT scan findings.

METHODS

Syndromic, multisuture, unicoronal, unilambdoid and sagittal synostosis patients visiting our national center were included in this longitudinal cohort study and formed a consecutive series. Retinal layers on OCT, OCT fundus image and fundoscopy were evaluated. ICH was scored according to presence of abnormal intracranial pressures, hydrocephalus, progressive cerebellar tonsillar herniation or fingerprinting and growth arrest. Diagnostic accuracy of OCT, fundoscopy and fundus image, the time course of retinal thickness after ICH and interference of HH were analyzed using linear mixed models.

RESULTS

577 OCT scans in 307 patients were included. ICH was found in 7.2%. Combining total retinal thickness (TRT), OCT fundus image and fundoscopy resulted in a sensitivity of 76% and 81% specificity to detect signs of ICH. TRT was increased in patients who have had signs of ICH versus patients who never had signs of ICH (β+44.9 µm in patients who have had ICH, 95%CI 9.0-80.8,P=0.01). TRT decreased to normal in the years after surgery (β -3.6 µm/year, 95%CI -7.2 - -0.05, P=0.047). There were greater odds of having increased TRT in patients with HH (OR 2.9, 95%CI 1.1-7.6,P=0.03).

CONCLUSIONS

The correlation between TRT, OCT fundus image, fundoscopy and particularly for the combination of these parameters with ICP surrogate markers is fair. Increased TRT in the presence of a clinical suspicion of ICH warrants further screening.

Eye and Orbital Anatomy in Metopic Synostosis

Background

Metopic synostosis patients have a high prevalence of orthoptic anomalies, including hyperopia, astigmatism, and amblyopia. We hypothesized altered orbital anatomy contributes to suboptimal visual outcomes by adversely affecting eye anatomy and growth from early life onward. Therefore, we aimed to investigate eye and orbital anatomy in metopic synostosis.

Methods

We conducted a retrospective study in nonsyndromic metopic synostosis patients (n = 134, median age 0.43 years [IQR 0.45]) with nonsyndromic sagittal synostosis patients (n = 134, median age 0.27 years [IQR 0.23]) as controls. Primary analyses focused on eye dimensions (axial length, width, and globe height) and orbital dimensions, correcting for sex and age. Measurements were obtained from preoperative computed tomography scans.

Results

Axial length and width in metopic synostosis patients did not differ from sagittal synostosis patients, but globe height was significantly smaller (P = 0.0002). Lateral wall interorbital length, lateral orbital wall length, anterior medial interorbital length, and maximal medial interorbital length were significantly smaller, and anterior vertical orbital height and maximal vertical orbital height were significantly larger (P < 0.001). The central orbital axis and interorbital angle were significantly narrower, and medial-to-lateral orbital wall angle was wider (P < 0.001).

Conclusions

Metopic synostosis patients have more shallow, wider, and higher orbits. Eye dimensions are similar in sagittal synostosis patients, although globe height was smaller. Altered orbital and eye dimensions in metopic synostosis probably have a causal relation with an unknown order of development. How these dimensions relate to future orthoptic anomalies (eg, refractive error) needs further investigation.

Pre-Operative Ocular Findings and Long-Term Follow-Up in a Large Cohort of Non-Syndromic Unicoronal Craniosynostosis

(1) Background: Non-syndromic unicoronal craniosynostosis (UCS) is associated with a high prevalence of ocular anomalies. Currently, the etiology of this association remains obscure, however, it is presumed to be primarily attributed to their orbital malformations and/or secondary to craniofacial surgery. We assessed pre-operative ophthalmological examinations of non-syndromic UCS patients and compared them with their postoperative outcomes and long-term follow-up. (2) Methods: A retrospective case series was conducted on medical records of patients with non-syndromic UCS at Sophia Children's Hospital, Rotterdam. Ophthalmologic examinations were collected at different time periods: T1 (first visit), T2 (<1 year after cranioplasty), and T3 (long-term follow-up at last visit). The McNemar's test was used for statistical analysis. (3) Results: A total of 101 patients were included, for whom examinations were available at T1 and T3. Patients had a mean age of 2.8 years (±2.7) and 9.5 (±4.9) at T1 and T3, respectively. At T1, 52 patients (51.5%) were diagnosed with strabismus, and 61 patients (60.4%) at T3. Vertical strabismus increased significantly from 23 patients (22.8%) at T1 to 36 patients (35.6%) at T3 (p = 0.011). Followed by astigmatism, which increased significantly from 38 (37.6%) at T1 to 59 (58.4%) patients at T3 (p = 0.001). T1 was available in 20 patients prior to fronto-orbital advancement (FOA), therefore, a sub-analysis was conducted on these patients, which was followed shortly after FOA at T2. Prior to FOA, strabismus was present in 11 patients (55.0%) and in 12 patients (60.0%) at T2. After FOA, strabismus worsened in two patients. (4) Conclusions: This study showed the high prevalence of ocular anomalies in patients with non-syndromic UCS before and after cranioplasty and at long-term follow-up. The findings of this study show that ophthalmic and orthoptic examinations are an important part of the optimal treatment of patients with non-syndromic UCS.

Torticollis in Non-Syndromic Unicoronal Craniosynostosis Is Predominantly Ocular Related

(1) Background: Patients with unicoronal craniosynostosis (UCS) often show torticollis which can result from either an ocular cause or contraction of the sternocleidomastoid muscle. For clinicians, it is crucial to know the prevalence of ocular torticollis (OT) to ensure appropriate referral for treatment. Furthermore, associated ophthalmic features with OT in these patients are scarcely described. The aim of this study was to determine the prevalence of OT in non-syndromic UCS patients and investigate its associated ophthalmic features. (2) Methods: In this descriptive cross-sectional study medical records of non-syndromic UCS patients treated between 1994-2022 in one tertiary care hospital in The Netherlands were retrospectively reviewed. Collected data included: diagnosis and type of torticollis, binocular single vision (BSV), strabismus, ocular motility, alphabetical patterns, refractive error, and amblyopia. Patients were classified as OT, based on their ophthalmic and/or orthoptic diagnosis. Prevalence was determined with the 95% CI using the Clopper-Pearson exact test. Associations between OT and the ophthalmic features were determined using Chi-square or Fishers' exact test and its effect size was calculated using Cramer's V. (3) Results: In total, 146 patients were included, of whom 57 had torticollis. An ocular cause for the torticollis was found in 54 patients. The prevalence of OT was 37% (n = 146; 95% CI [0.292-0.454]). Significant associations were found between OT and strabismus (p < 0.001), ocular motility abnormalities (p < 0.001), alphabetical patterns (p < 0.001), and amblyopia (p = 0.002). BSV (p = 0.277) and refractive error (p = 1.0) were not significantly associated with OT. However, in OT the BSV was relatively poor (42.1%) and more frequently absent (26.3%) compared to the non-torticollis group (7% poor and 16.3% absent). In both groups, excyclotorsion was predominantly present (62.3%). (4) Conclusions: In 95% of cases, torticollis in UCS patients is ocular-related. Overall, one in three patients with UCS have OT. This study emphasizes the importance of a timely referral of all patients with UCS with torticollis to an orthoptist and/or ophthalmologist, specialized in diagnosing and treatment of OT, before considering physiotherapy.

Effect of Midface Surgery on Ocular Outcomes in Patients with Orbital and Midface Malformations

(1) Background: Orbital and midface malformations occur in multiple craniofacial disorders. Depending on the deformity, surgical corrections include orbital box osteotomy (OBO), Le Fort III (LFIII), monobloc (MB), and facial bipartition (FB). The aim of this study was to determine the effect of these procedures on ocular outcomes. (2) Methods: A retrospective analysis was performed. All patients with craniofacial disorders who had previously undergone midface surgery were included. The Wilcoxon signed ranks test was used for statistical analysis. (3) Results: In total, 63 patients were included: two patients were treated by OBO, 20 by LFIII, 26 by MB, and 15 by FB. Pre-operatively, strabismus was present in 39 patients (61.9%), in whom exotropia was most common (n = 27; 42.9%), followed by esotropia (n = 11; 17.5%). Postoperatively, strabismus significantly worsened (p = 0.035) in the overall population (n = 63). Pre-operative binocular vision (n = 33) was absent in nine patients (27.3%), poor in eight (24.2%), moderate in 15 (45.5%), and good in one (3.0%). Postoperatively, binocular vision significantly improved (p < 0.001). Before surgery, the mean visual acuity (VA) in the better eye was 0.16 LogMAR (Logarithm of the Minimum Angle of Resolution), and 0.31 LogMAR in the worse eye. Furthermore, pre-operative astigmatism was present in 46 patients (73.0%) and hypermetropia in 37 patients (58.7%). No statistical difference was found for VA (n = 51; p = 0.058) postoperatively. (4) Conclusions: Midface surgery has a direct and indirect substantial effect on several ocular outcomes. This study emphasizes the importance of appropriate ophthalmological evaluation in patients with craniofacial disorders undergoing midface surgery.

How do parents experience patching or dichoptic action video gaming as amblyopia treatment? A qualitative study exploring treatment preferences and information needs to facilitate decision-making

PURPOSE

To explore parents' experiences, preferences and information needs when either patching treatment or dichoptic action video gaming is used as an amblyopia treatment for their child.

METHODS

A qualitative study was carried out on parents whose newly diagnosed amblyopic children participated in a randomised controlled trial (RCT) comparing the effects of dichoptic action video gaming versus patching. A purposive heterogenic sample was selected for an additional interview after the study period. Semi-structured interviews were conducted with one or both parents and transcribed verbatim, and a thematic analysis was performed.

RESULTS

Ten families agreed to participate: seven in the patching group and three in the gaming group. Two themes emerged from the data exploring experiences with treatment: (1) factors influencing compliance and (2) burden with treatment. Parents reported creating a routine which improved compliance with patching, as opposed to gaming where parents felt less need to conduct the treatment themselves as it was performed in the outpatient clinic. In both groups, parents experienced an information hiatus regarding the role of refractive error. In deciding the type of treatment to be used, parents preferred to deliberate the choice with the healthcare professional and discuss considerations resulting in shared decisions. The emerging themes were (1) effect and efficiency of treatment, (2) organisational aspects of treatments and (3) their child's traits.

CONCLUSION

This study provides insight into the experiences of parents whose children underwent different types of amblyopia therapy. Both treatments have their own advantages and disadvantages. For parents, the effectiveness and efficiency of treatment were the most important aspects when deciding the method of management. Parents wish to come to a well-informed, shared decision regarding the type of amblyopia treatment.

Early and long-term skull growth after surgical correction for sagittal synostosis in relation to the occurrence of papilledema

OBJECTIVE

Stagnation of skull growth is correlated with papilledema in craniosynostosis. In this retrospective cohort study, we describe the postoperative skull growth after surgical correction for sagittal synostosis and its relation to the development of papilledema.

METHODS

Patients with isolated sagittal synostosis at our center between 2005 and 2012 were included. Occipitofrontal circumference (OFC) was analyzed, at 3 time points (preoperative, 2 years postoperative, and last OFC measurement) and 3 phases (initial postoperative growth, long-term growth, and overall growth), and related to papilledema on fundoscopy.

RESULTS

In total, 163 patients were included. The first time interval showed a decline in skull growth, with subsequent stabilization at long term. Papilledema occurred postoperatively in 10 patients. In these patients, the OFC at 2 years and at last follow-up (T3) were significantly smaller than in patients without papilledema. A larger OFC resulted in a decreased odds of developing papilledema at both postoperative time points (at T2 (OR = 0.40, p = 0.01) and at T3 (OR 0.29, p < 0.001)). Sensitivity and specificity analysis indicated that an OFC below 0.25 SD at T2 (sensitivity 90%, specificity 65%) and below 0.49 at T3 (sensitivity 100%, specificity 60%) are related to the occurrence of papilledema.

CONCLUSION

A small OFC is correlated with the occurrence of papilledema. A decline in OFC within 2 years postoperatively is common in sagittal synostosis and is acceptable up to a value of 0.25SD. Patients with an OFC at last follow-up of less than 0.5SD are at risk for developing papilledema.

Whole exome sequencing of known eye genes reveals genetic causes for high myopia

High myopia (refractive error ≤ -6 diopters (D)) is a heterogeneous condition, and without clear accompanying features it can be difficult to pinpoint a genetic cause. This observational study aimed to evaluate the utility of whole exome sequencing (WES) using an eye disorder gene panel in European patients with high myopia. Patients with high myopia were recruited by ophthalmologists and clinical geneticists. Clinical features were categorized into isolated high myopia, high myopia with other ocular involvement or with systemic involvement. WES was performed and an eye disorder gene panel of ~ 500 genes was evaluated. 113 patients with high myopia (mean (SD) refractive error - 11.8D (5.2) were included. Of these, 53% were children younger than 12 years of age (53%), 13.3% were 12-18 years, and 34% were adults (aged over 18 years). 23 out of 113 patients (20%) received a genetic diagnosis of which 11 patients displayed additional ocular or systemic involvement. Pathogenic variants were identified in retinal dystrophy genes (e.g.GUCY2D, CACNA1F), connective tissue disease genes (e.g. COL18A1, COL2A1), non-syndromic high myopia genes (ARR3), ocular development genes (e.g. PAX6) and other genes (ASPH, CNNM4). In 20% of our high myopic study population WES using an eye gene panel enabled us to diagnose the genetic cause for this disorder. Eye genes known to cause retinal dystrophy, developmental or syndromic disorders can cause high myopia without apparent clinical features of other pathology.

Prevalence of Ocular Anomalies in Craniosynostosis: A Systematic Review and Meta-Analysis

Background: The aim of this study was to describe the ophthalmic abnormalities and their prevalence in craniosynostosis prior to craniofacial surgery. Methods: A systematic search was conducted on Medline OVID, Embase, Cochrane, Google Scholar, Web of Science Core Collection. Inclusion criteria were English papers, children aged <18 years with non-syndromic and syndromic craniosynostosis, case reports, case series, and case-control studies. A system of domains was established consisting of an anatomic and functional ophthalmic domain. A meta-analysis of single proportions was carried out using random effects model and pooled mean proportions with 95% confidence intervals (CI) were calculated. Results: Thirty-two papers analyzing 2027 patients were included. Strabismus was the most common anomaly in non-syndromic craniosynostosis: Horizontal strabismus was highest prevalent in unicoronal craniosynostosis (UCS) 19% (95% CI 9–32), followed by vertical strabismus 17% (95% CI 5–33). In syndromic craniosynostosis, horizontal strabismus was most prevalent in Crouzon syndrome 52% (95 CI 26–76), followed by Apert syndrome 50% (95% CI 42–58). Vertical strabismus was most prevalent in Saethre-Chotzen 60% followed by Muenke’s syndrome 36%. Furthermore, astigmatism was the second most reported outcome in non-syndromic craniosynostosis and highest prevalent in UCS 35% (95% CI 21–51). In syndromic craniosynostosis, astigmatism was most frequently seen in Crouzon syndrome 43% (95% CI 22–65), followed by Apert syndrome 34% (95% CI 14–58). Moreover, in syndromic craniosynostosis, 5–40% had a decrease in visual acuity (VA) ≤ 0.3 LogMAR in the better eye and 11–65% had a VA ≤ 0.3 LogMAR in at least one eye. Discussion: This review demonstrates the high prevalence of ocular anomalies in non-syndromic and syndromic craniosynostosis. A multidisciplinary and systematic approach is needed for the screening and optimal treatment of these conditions in a timely manner.

Ocular and adnexal anomalies in Treacher Collins syndrome: a retrospective multicenter study

BACKGROUND

Treacher Collins syndrome (TCS) is a rare craniofacial disorder characterized by bilateral hypoplasia of facial structures and periorbital, ocular, and adnexal anomalies. The purpose of this multicenter study was to report the prevalence of ocular and adnexal anomalies in TCS and to identify patients at risk for visual impairment.

METHODS

The medical records of patients seen at four craniofacial centers were reviewed retrospectively. The following data were reported: primary and secondary ocular and adnexal anomalies, orthoptic and ophthalmological findings, and severity of TCS based on the facial deformity.

RESULTS

A total of 194 patients were included, of whom 49.5% were examined by an ophthalmologist or optometrist. The mean age at the first visual acuity measurement was 6.96 ± 6.83 years (range, 1.50-47.08); at final measurement, 11.55 ± 10.64 years (range, 1.75-62.58). Primary ocular anomalies were reported in 98.5% of cases, secondary anomalies in 34.5%, strabismus in 27.3%, refractive errors in 49.5%, and visual impairment in 4.6%. We found no association between ocular anomalies and visual impairment or between the severity of TCS and ocular anomalies or visual impairment, except for an increased prevalence of secondary ocular anomalies in patients with more severe manifestations of TCS.

CONCLUSIONS

Ocular anomalies were present in nearly all patients with TCS, even in mild cases.

Early onset X-linked female limited high myopia in three multigenerational families caused by novel mutations in the ARR3 gene

This study describes the clinical spectrum and genetic background of high myopia caused by mutations in the ARR3 gene. We performed an observational case series of three multigenerational families with high myopia (SER≤-6D), from the departments of Clinical Genetics and Ophthalmology of a tertiary Dutch hospital. Whole-exome sequencing (WES) with a vision-related gene panel was performed, followed by a full open exome sequencing. We identified three Caucasian families with high myopia caused by three different pathogenic variants in the ARR3 gene (c.214C>T, p.Arg72*; c.767+1G>A; p.?; c.848delG, p.(Gly283fs)). Myopia was characterized by a high severity (<-8D), an early onset (<6 years), progressive nature, and a moderate to bad atropine treatment response. Remarkably, a female limited inheritance pattern was present in all three families accordant with previous reports. The frequency of a pathogenic variant in the ARR3 gene in our diagnostic WES cohort was 5%. To conclude, we identified three families with early onset, therapy-resistant, high myopia with a female-limited inheritance pattern, caused by a mutation in the ARR3 gene. The singular mode of inheritance might be explained by metabolic interference due to X-inactivation. Identification of this type of high myopia will improve prompt myopia treatment, monitoring, and genetic counseling.

The use of OCT to detect signs of intracranial hypertension in patients with sagittal suture synostosis: Reference values and correlations

PURPOSE

To obtain pediatric normative reference values and determine whether optical coherence tomography (OCT) corresponds better with clinical signs of intracranial hypertension (ICH) compared to the traditional screening method fundoscopy in a large cohort of one type of single suture craniosynostosis.

METHODS

Control subjects without optic nerve diseases and isolated sagittal synostosis patients aged 3-10 years who underwent fundoscopy and OCT were included in this prospective cohort study. Normative reference values were obtained through bootstrap analysis. Main outcome was the association between peripapillary total retinal thickness (TRT) and total retinal volume (TRV) and appearance on fundoscopy. Signs and symptoms suggestive of ICH, including skull growth arrest, fingerprinting, and headache, were scored.

RESULTS

Sixty-four healthy controls and 93 isolated sagittal synostosis patients were included. Normative cut-off values for mean TRT are < 256 μm and > 504 μm and for mean TRV < 0.21 mm³ and > 0.39 mm³. TRT was increased in 16 (17%) and TRV in 15 (16%) of 93 patients, compared to only 4 patients with papilledema on fundoscopy (4%). Both parameters were associated with papilledema on fundoscopy (OR = 16.7, p = 0.02, and OR = 18.2, p = 0.01). Skull growth arrest was significantly associated with abnormal OCT parameters (OR = 13.65, p < 0.01).

CONCLUSIONS

The established cut-off points can be applied to screen for ICH in pediatrics. The present study detected abnormalities with OCT more frequent than with fundoscopy, which were associated with skull growth arrest. Therefore, a combination of OCT, fundoscopy, and skull growth arrest can improve clinical decision-making in craniosynostosis.

Long-term follow-up of an amblyopia treatment study: change in visual acuity 15 years after occlusion therapy

Purpose

To determine change in visual acuity (VA) in the population of a previous amblyopia treatment study (Loudon 2006) and assess risk factors for VA decrease.

Methods

Subjects treated between 2001 and 2003 were contacted between December 2015 and July 2017. Orthoptic examination was conducted under controlled circumstances and included subjective refraction, best corrected VA, reading acuity, binocular vision, retinal fixation, cover‐uncover and alternating cover test. As a measure for degree of amblyopia, InterOcular VA Difference (IOD) at the end of occlusion therapy was compared with IOD at the follow‐up examination using Wilcoxon’s signed‐rank test. Regression analysis was conducted to determine the influence of clinical and socio‐economic factors on changes in IOD.

Results

Out of 303 subjects from the original study, 208 were contacted successfully, 59 refused and 15 were excluded because of non‐amblyopic cause of visual impairment. Mean IOD at end of therapy (mean age 6.4 years) was 0.11 ± 0.16 logMAR, and IOD at follow‐up examination (mean age 18.3 years) was 0.09 ± 0.21 logMAR; this difference was not significant (p = 0.054). Degree of anisometropia (p = 0.008; univariable analysis), increasing anisometropia (p = 0.009; multivariable), eccentric fixation (p < 0.001; univariable and multivariable); large IOD (p < 0.001; univariable and multivariable) and non‐compliance during therapy (p = 0.028; univariable) were associated with IOD increase.

Conclusion

Long‐term results of occlusion therapy were good. High or increasing anisometropia, eccentric fixation and non‐compliance during occlusion therapy were associated with long‐term VA decrease. Subjects with poor initial VA had a larger increase despite little patching, but often showed long‐term VA decrease.

Saethre-Chotzen syndrome: long-term outcome of a syndrome-specific management protocol

AIM

To assess the long-term outcomes of our management protocol for Saethre-Chotzen syndrome, which includes one-stage fronto-orbital advancement.

METHOD

All patients born with Saethre-Chotzen syndrome between January 1992 and March 2017 were included. Evaluated parameters included occipital frontal head circumference (OFC), fundoscopy, neuroimaging (ventricular size, tonsillar position, and the presence of collaterals/an abnormal transverse sinus), polysomnography, and ophthalmological outcomes. The relationship between papilledema and its associated risk factors was evaluated with Fisher's exact test.

RESULTS

Thirty-two patients (21 females, 11 males) were included. Median (SD) age at first surgery was 9.6 months (3.1mo) for patients who were primarily referred to our center (range: 3.6-13.0mo), the median (SD) age at last follow-up was 13 years (5y 7mo; range: 3-25y). Seven patients had papilledema preoperatively, which recurred in two. Two patients had papilledema solely after first surgery. Second cranial vault expansion was indicated in 20%. Thirteen patients had an OFC deflection, indicating restricted skull growth, one patient had ventriculomegaly, and none developed hydrocephalus. Eleven patients had emissary veins, while the transverse sinus was aberrant unilaterally in 13 (hypoplastic n=10 and absent n=3). Four patients had mild tonsillar descent, one of which was a Chiari type I malformation. Four patients had obstructive sleep apnoea (two mild, one moderate, and one severe). An aberrant transverse sinus was associated with papilledema (p=0.01).

INTERPRETATION

Single one-stage fronto-orbital advancement was sufficient to prevent intracranial hypertension for 80% of our patients with Saethre-Chotzen syndrome. Follow-up should focus on OFC deflection and venous anomalies.

A 3-year follow-up study of atropine treatment for progressive myopia in Europeans

BACKGROUND

Atropine is the most powerful treatment for progressive myopia in childhood. This study explores the 3-year effectiveness of atropine in a clinical setting.

METHODS

In this prospective clinical effectiveness study, children with progressive myopia ≥ 1D/year or myopia ≤ -2.5D were prescribed atropine 0.5%. Examination, including cycloplegic refraction and axial length (AL), was performed at baseline, and follow-up. Outcome measures were spherical equivalent (SER) and AL; annual progression of SER on treatment was compared with that prior to treatment. Adjustments to the dose were made after 1 year in case of low (AL ≥ 0.3 mm/year) or high response (AL < 0.1 mm/year) of AL.

RESULTS

A total of 124 patients were enrolled in the study (median age: 9.5, range: 5-16 years). At baseline, median SER was -5.03D (interquartile range (IQR): 3.08); median AL was 25.14 mm (IQR: 1.30). N = 89 (71.8%) children were persistent to therapy throughout the 3-year follow-up. Median annual progression of SER for these children was -0.25D (IQR: 0.44); of AL 0.11 mm (IQR: 0.18). Of these, N = 32 (36.0%) had insufficient response and were assigned to atropine 1%; N = 26 (29.2%) showed good response and underwent tapering in dose. Rebound of AL progression was not observed. Of the children who ceased therapy, N = 9 were lost to follow-up; N = 9 developed an allergic reaction; and N = 17 (19.1%) stopped due to adverse events.

CONCLUSION

In children with or at risk of developing high myopia, a starting dose of atropine 0.5% was associated with decreased progression in European children during a 3-year treatment regimen. Our study supports high-dose atropine as a treatment option for children at risk of developing high myopia in adulthood.

Early intervention for children at risk of visual processing dysfunctions from 1 year of age: a randomized controlled trial protocol

Background

An increasing number of children are suffering from brain damage-related visual processing dysfunctions (VPD). There is currently a lack of evidence-based intervention methods that can be used early in development. We developed a visual intervention protocol suitable from 1 year of age. The protocol is structured, comprehensive and individually adaptive, and is paired with quantitative outcome assessments. Our aim is to investigate the effectiveness of this first visual intervention program for young children with (a risk of) VPD.

Methods

This is a single-blind, placebo-controlled trial that is embedded within standard clinical care. The study population consists of 100 children born very or extremely preterm (< 30 weeks) at 1 year of corrected age (CA), of whom 50% are expected to have VPD. First, children undergo a visual screening at 1 year CA. If they are classified as being at risk of VPD, they are referred to standard care, which involves an ophthalmic and visual function assessment and a (newly developed) visual intervention program. This program consists of a general protocol (standardized and similar for all children) and a supplement protocol (adapted to the specific needs of the child). Children are randomly allocated to an intervention group (starting upon inclusion at 1 year CA) or a control group (postponed: starting at 2 years CA). The control group will receive a placebo treatment. The effectiveness of early visual intervention will be examined with follow-up visual and neurocognitive assessments after 1 year (upon completion of the direct intervention) and after 2 years (upon completion of the postponed intervention).

Discussion

Through this randomized controlled trial we will establish the effectiveness of a new and early visual intervention program. Combining a general and supplement protocol enables both structured comparisons between participants and groups, and custom habilitation that is tailored to a child’s specific needs. The design ensures that all included children will benefit from participation by advancing the age at which they start receiving an intervention. We expect results to be applicable to the overall population of children with (a risk of) VPD early in life.

Trial registration

Netherlands Trial Register: NTR6952. Registered 19 January 2018.

Muenke syndrome: long-term outcome of a syndrome-specific treatment protocol

OBJECTIVE

The authors evaluated the long-term outcome of their treatment protocol for Muenke syndrome, which includes a single craniofacial procedure.

METHODS

This was a prospective observational cohort study of Muenke syndrome patients who underwent surgery for craniosynostosis within the first year of life. Symptoms and determinants of intracranial hypertension were evaluated by longitudinal monitoring of the presence of papilledema (fundoscopy), obstructive sleep apnea (OSA; with polysomnography), cerebellar tonsillar herniation (MRI studies), ventricular size (MRI and CT studies), and skull growth (occipital frontal head circumference [OFC]). Other evaluated factors included hearing, speech, and ophthalmological outcomes.

RESULTS

The study included 38 patients; 36 patients underwent fronto-supraorbital advancement. The median age at last follow-up was 13.2 years (range 1.3-24.4 years). Three patients had papilledema, which was related to ophthalmological disorders in 2 patients. Three patients had mild OSA. Three patients had a Chiari I malformation, and tonsillar descent < 5 mm was present in 6 patients. Tonsillar position was unrelated to papilledema, ventricular size, or restricted skull growth. Ten patients had ventriculomegaly, and the OFC growth curve deflected in 3 patients. Twenty-two patients had hearing loss. Refraction anomalies were diagnosed in 14/15 patients measured at ≥ 8 years of age.

CONCLUSIONS

Patients with Muenke syndrome treated with a single fronto-supraorbital advancement in their first year of life rarely develop signs of intracranial hypertension, in accordance with the very low prevalence of its causative factors (OSA, hydrocephalus, and restricted skull growth). This illustrates that there is no need for a routine second craniofacial procedure. Patient follow-up should focus on visual assessment and speech and hearing outcomes.

Papilledema in unicoronal synostosis: a rare finding

OBJECTIVE

Unicoronal synostosis results in frontal plagiocephaly and is preferably treated before the patient is 1 year of age to prevent intracranial hypertension (ICH). However, data on the prevalence of ICH in these patients is currently lacking. This study aimed to establish the prevalence of preoperative and postoperative signs of ICH in a large cohort of patients with unicoronal synostosis and to test whether there is a correlation between papilledema and occipitofrontal head circumference (OFC) curve stagnation in unicoronal synostosis.

METHODS

The authors included all patients with unicoronal synostosis treated before 2 years of age at a single center between 2003 and 2013. The presence of ICH was evaluated by routine fundoscopy. The OFC growth curve was analyzed for deflection and in relationship to signs of ICH.

RESULTS

In total, 104 patients were included in this study, 84 (81%) of whom were considered to have nonsyndromic unicoronal synostosis. Preoperatively, none of the patients had papilledema as determined by fundoscopy (mean age at surgery 11 months). Postoperatively, 5% of patients with syndromic synostosis and 3% of those with nonsyndromic synostosis had papilledema, and this was confirmed by optical coherence tomography. Raised intracranial pressure was confirmed in 1 patient with syndromic unicoronal synostosis. Six of 78 patients had OFC stagnation, which was not significantly correlated to papilledema (p = 0.22). One child with syndromic unicoronal synostosis required repeated surgery for ICH (0.96%).

CONCLUSIONS

Papilledema was not found in patients with unicoronal synostosis when they underwent surgery before the age of 1 year and was also very rare during follow-up. There was no relationship between papilledema and OFC stagnation.

Effect of omission of population-based eye screening at age 6-9 months in the Netherlands

PURPOSE

To investigate omission of population-based eye screening at age 6-9 months in the Netherlands.

METHODS

Prospective population-based consecutive birth cohort study was used. In two consecutive birth cohorts, children were eye screened at 1-2 and 3-4 months, but at general-health screening at 6-9 months, the second cohort was not eye screened, unless anything conspicuous was noted or in case of positive family history. Data were collected from screening records and anonymous questionnaires. Semi-structured daylong observations were made of physicians examining children aged 0-4 years, including children from the cohorts, by two orthoptic students.

RESULTS

58 of 6059 children (0.96%), in the screened, and 48 of 5482 children (0.88%) in the unscreened group were referred to orthoptist or ophthalmologist, mostly for observed strabismus. Amblyopia, all combined with strabismus, was diagnosed in ten screened (0.17%) versus six unscreened children (0.11%). Most physicians found preverbal examinations and decisions to refer difficult. The observations by orthoptic students revealed that cover test, pupillary reflexes, pursuit movements and eye motility were frequently performed inadequately, contrary to the Hirschberg test, at this age.

CONCLUSION

The screened and unscreened group differed little regarding the number of children referred and found to have amblyopia. Referral was mostly based on observed strabismus.

Rapid, high-accuracy detection of strabismus and amblyopia using the pediatric vision scanner

Purpose. The Pediatric Vision Scanner (PVS) detects strabismus by identifying ocular fixation in both eyes simultaneously. This study was undertaken to assess the ability of the PVS to identify patients with amblyopia or strabismus, particularly anisometropic amblyopia with no measurable strabismus. Methods. The PVS test, administered from 40 cm and requiring 2.5 seconds of attention, generated a binocularity score (BIN, 0%-100%). We tested 154 patients and 48 controls between the ages of 2 and 18 years. BIN scores of amblyopic children and controls were measured, and 21 children received sequential PVS measurements to detect any changes in BIN resulting from amblyopia treatment. Results. With the pass/refer threshold set at BIN 60%, sensitivity and specificity were 96% for the detection of amblyopia or strabismus. Assuming a 5% prevalence of amblyopia or strabismus, the inferred positive and negative predictive values of the PVS were 56% and 100%, respectively. Fixation accuracy was significantly reduced in amblyopic eyes. In anisometropic amblyopia patients treated successfully, the BIN improved to 100%. Conclusions. The PVS identified children with amblyopia or strabismus with high sensitivity and specificity, while successful treatment restored normal BIN scores in amblyopic patients without strabismus. The results support the hypothesis that the PVS detects strabismus and amblyopia directly. Future strategies for screening by nonspecialists may thus be based on diagnostic detection of amblyopia and strabismus rather than the estimation of risk factors, allowing for rapid, accurate identification of children with amblyopia early in life when it is most amenable to treatment.

Determinants and outcome of unsuccessful referral after positive screening in a large birth-cohort study of population-based vision screening

PURPOSE

The efficacy of population-based vision screening is hampered by unsuccessful referral after a positive screening test. We studied the nature and causes of unsuccessful referral in a 7-year birth cohort study of vision screening in Rotterdam, the Netherlands.

METHODS

All parents of children who had been unsuccessfully referred were asked whether they recalled the referral. Reasons for noncompliance, if any, were identified using semi-structured interviews. Screening records were checked for written evidence of the referral. The parents' fluency in Dutch and their socioeconomic status were also assessed.

RESULTS

Of the 561 screen-positive children, 129 (23%) had not been referred successfully. For the current study, 97 parents were successfully contacted. Of these, 14 parents had been willingly noncompliant and 83 said they were unaware of the referral, with 47% having poor to moderate fluency in Dutch. In 53 cases, the screening charts contained no written evidence of any referral. Amblyopia was identified in 3 of the unsuccessful referrals.

CONCLUSIONS

In this population-based screening program, 1 of 4 positively screened children was not successfully referred. Apart from parental noncompliance, the unsuccessful referrals can be explained by miscommunication, deficient documentation, and physician noncompliance with screening guidelines. An effective monitoring feedback system may improve the efficacy of child vision screening.

Short tag noose technique for optional and late suture adjustment in strabismus surgery

OBJECTIVE

To present and evaluate a new technique that allows the second-stage suture adjustment in strabismus surgery to be skipped or delayed if the immediate postoperative alignment is satisfactory.

METHODS

The "short tag noose" technique replaces long sutures with short tags that can be left under the conjunctiva after adjustment. Retrospectively, the medical records of all patients treated by a single surgeon with this approach between January 1, 2005, and December 31, 2008, were evaluated for success rate (< or =10 prism diopters [PD] horizontal and < or =6 PD vertical), reoperation rate, and complications.

RESULTS

Of 120 procedures reviewed, 27 (22.5%) were performed in children; 97 procedures (80.8%) were performed in patients with complex strabismus. Mean follow-up was 6 months. The success rate was 81.0% for horizontal strabismus and 70.7% for vertical strabismus at 2 months. The reoperation rate was 10.0% for horizontal strabismus and 19.0% for vertical strabismus. The noose slipped in 1 patient (0.8%) and was corrected by readjustment on day 4. Two patients (1.7%) required in-office excision of cysts or granulomas.

CONCLUSIONS

The short tag noose technique simplifies the logistics of suture adjustment and avoids the need for sedation in children who do not require adjustment. It provides the ability to defer adjustment for days after surgery.

Occlusion Treatment for Amblyopia: Assessing the Performance of the Electronic Occlusion Dose Monitor

Electronic Occlusion Dose Monitors (ODMs) are a fairly recent development. As part of the international Electronic Recording of Patching for Amblyopia Group (ERPAG), we are the first center in Germany to apply these devices. The aim of our independent study was a further assessment of their potential, including technical features and the practicability of long-term use under near-clinical conditions. The ODMs, taped to the occlusion patch, measure the temperature difference between the surface of the eye and the surroundings. Investigators and patients' families kept occlusion diaries while using ODMs. Measurements were performed on the eye (patch tight or detached), forehead, arm and in trouser pockets, and while varying the room temperature. Patients' occlusion was monitored for several months together with acuity development. ODM acceptance was assessed by questionnaire. Written and monitored occlusion times corresponded excellently. Proper measurements on the eye could be distinguished more readily from those with the patch detached or in the pocket than from measurements on the arm and forehead. Very high temperatures (33-37 degrees C) prevented reliable measurements. Using ODMs was convenient for parents but time-consuming for researchers. Despite occasional data loss (incomplete diaries, ODM failure), acuity development could be followed as a function of monitored occlusion dose. This study contributes to the specification of the ODM features and their refinement for clinical use.

Occlusion therapy for amblyopia

Electronic monitoring of compliance shows that prescribing longer periods of occlusion is not always better

Visusevaluierung in einer historischen Kohorte von 137 okkludierten Patienten, 30 - 35 Jahre nach Ende der Okklusionsbehandlung

BACKGROUND

Opinions differ on the course of the visual acuity in the amblyopic eye after cessation of occlusion therapy. This study evaluated visual acuity in a historical cohort treated for amblyopia with occlusion therapy 30-35 years ago.

MATERIALS AND METHODS

Between 1968 and 1975, 1250 patients had been treated by the orthoptist in the Waterland Hospital in Purmerend, The Netherlands. Of these, 471 received occlusion treatment for amblyopia (prevalence 5.0%, after comparison with the local birth rate). We were able to contact 203 of these patients, 137 were orthoptically re-examined in 2003. We correlated the current visual acuity with the cause of amblyopia, the age at start and end of treatment, the visual acuity at start and end of treatment, fixation, binocular vision and refractive errors.

RESULTS

Mean age at the start of treatment was 5.4 +/- 1.9 years, 7.4 +/- 1.7 years at the end and 37 +/- 2.7 years at follow-up. Current visual acuity in the amblyopic eye was correlated with a low visual acuity at the start (p < 0.0001) and end (p < 0.0001) of occlusion therapy, an eccentric fixation (p < 0.0001), and the cause of amblyopia (p = 0.005). At the end of the treatment, patients with a strabismic amblyopia (n = 98) had a visual acuity in the amblyopic eye of 0.29 logMAR +/- 0.3, and in 2003 0.27 +/- 0.3 logMAR. In patients with an anisometropic amblyopia (> 1 D, n = 16) visual acuity had decreased from 0.17 +/- 0.23 logMAR to 0.21 logMAR +/- 0.23. In patients with both strabismic and anisometropic amblyopia (n = 23), visual acuity had decreased from 0.52 logMAR +/- 0.54 to 0.65 logMAR +/- 0.54. Overall, acuity had decreased in 54 patients (39%) after cessation of treatment. Of these, 18 patients had an acuity decrease to less than 50% of their acuity at the end of treatment. In 15 of these 18 patients anisohypermetropia had increased.

CONCLUSIONS

A decrease in visual acuity after cessation of occlusion therapy occurred in patients with a combined cause of amblyopia or with an increase in anisohypermetropia.

Predictors and a remedy for noncompliance with amblyopia therapy in children measured with the occlusion dose monitor

PURPOSE

Noncompliance is one of the limiting factors in the success of occlusion therapy for amblyopia. Electronic monitoring was used to investigate predictors of noncompliance, and, in a prospective randomized clinical trial, determined the effectiveness of an educational program.

METHODS

Compliance was measured electronically during 1 week every 3 months in 310 newly diagnosed amblyopic children. The family's demographic parameters and the child's clinical parameters were assessed for their influence on the level of compliance. In addition to standard orthoptic care, children were randomized to receive an educational cartoon story, reward stickers, and an information sheet for the parents (intervention group), or a picture to color (reference group). These and the electronic device were distributed during home visits by researchers. The primary outcome measure was the percentage of compliance (actual/prescribed occlusion time) in the two groups. The secondary outcome measure was the influence of demographic and clinical factors on compliance.

RESULTS

Compliance was associated with parental fluency in the national language, country of origin, level of education, and initial visual acuity of the child. During the first 1-week measurement period children in the intervention group had better compliance than the reference group had (78% +/- 32% vs. 57% +/- 40%; P < 0.0001), and fewer children were not occluded at all (3 vs. 23 in the reference group; P < 0.0001). This difference remained throughout the study period.

CONCLUSIONS

Poor parental fluency in the national language, a low level of education, and poor acuity at the start of treatment were predictors of low compliance. An educational program primarily aimed at the child improved compliance and reduced the number of children who did not comply with occlusion at all.

Electronic recording of occlusion treatment for amblyopia: potential of the new technology

BACKGROUND

Approximately one third of all amblyopic eyes do not reach visual acuity of 20/40 in spite of occlusion therapy. One of the reasons is a lack of adherence to therapy, which, however, could not be quantified in the past. Experience with new devices (occlusion dose monitors, ODMs) for electronic recording of occlusion has recently been reported. The aim of the present study was to evaluate the potential of the ODMs developed in The Netherlands. Various features were tested, including the reliability of the ODM recordings compared to diaries, two ODMs used simultaneously on one patch, the influence of the ambient temperature, and the specificity of the recording pattern for measurements on the eye.

METHODS

The ODMs were taped to the outside of the standard occlusion patch and measured the temperature difference between their front and back surfaces. Members of the research group and the families of two patients kept occlusion diaries while using the ODMs. Recorded and written occlusion periods were compared. Measurements were carried out under various conditions: patch with one ODM tightly on the eye or detached (allowing peeping); ODMs taped to various parts of the body; two ODMs simultaneously on one patch; variation of room temperature.

RESULTS

There was good correspondence between the occlusion times recorded by the ODMs and those from the diaries, as well as between the recordings of two ODMs used simultaneously on one patch. High ambient temperatures (33 degrees C to 37 degrees C) prevented reliable ODM measurements. Measurements on other parts of the body were misclassified with probabilities between P=0.099 and P=0.325 as measurements with the patch tightly on the eye.

CONCLUSIONS

In spite of some technical limitations, the ODMs provide a chance for reliable assessment of compliance and therefore objective information on dose-response function for occlusion therapy. This will lead to a more evidence-based treatment for amblyopia.

Objective survey of the prescription of occlusion therapy for amblyopia

PURPOSE

To identify the variation within and consistency amongst orthoptists when prescribing occlusion therapy for amblyopia in an objective survey.

METHODS

A questionnaire was designed with five case examples of amblyopic children and distributed at annual meetings of orthoptists in The Netherlands and Germany. It was filled in simultaneously within 15 min in complete silence to avoid any exchange of opinions between orthoptists that would reduce variability. For each case the orthoptists were asked to give their prescription of hours or days of occlusion.

RESULTS

The questionnaire was filled in by 177 Dutch orthoptists and 227 German orthoptists. Their prescriptions of occlusion therapy were classified into five main regimens: part-time; part-time not every day; full-time; also occluding the amblyopic eye; alternating; and no occlusion therapy. The variation was large: the standard deviation was half the average prescribed hours of occlusion for each regimen in each of the five cases. All orthoptists were assigned a rank number for each of the five cases depending on whether their prescription was above or below average. These five rank numbers were not consistently above or consistently below average value per case.

CONCLUSIONS

The number of prescribed hours of occlusion varied widely per regimen per case. Orthoptists were not consistently strict or lenient in their prescription of occlusion therapy.

Electronically measured compliance with occlusion therapy for amblyopia is related to visual acuity increase

PURPOSE

We set out to determine whether the children who have low compliance (measured electronically) with occlusion therapy for amblyopia are those with insufficient increase of visual acuity.

METHODS

In 14 newly identified amblyopic children (mean age 4.3+/-1.9 years), compliance was measured electronically over a period of 1 week, 6 months after the start of occlusion therapy. Compliance was measured with an Occlusion Dose Monitor (ODM). The measurements took place during planned domiciliary visits. The children were diagnosed with anisometropia (n=5), strabismus (n=4) and anisometropia and strabismus (n=5). Compliance was expressed in percentages of the electronically registered time compared with the prescribed occlusion time. Satisfactory acuity increase following 6 months of occlusion therapy was defined on reaching any of the following criteria: acuity increase expressed as a ratio between acuity of the amblyopic eye and acuity of the good eye of more than 0.75, acuity of the amblyopic eye exceeding 0.5 as measured on the E-Chart or Landolt-C, or three LogMAR lines of increase in acuity.

RESULTS

Measured compliance averaged 80% in the eight children who had a satisfactory acuity increase and 34% in the six children who had an unsatisfactory visual acuity increase. Children with low acuity increase had statistically significantly lower compliance (P=0.038).

CONCLUSION

The general assumption among orthoptists, that compliance with occlusion therapy for amblyopia is low in children with insufficient acuity increase, has been validated by electronic, objective means.

A preliminary report about the relation between visual acuity increase and compliance in patching therapy for amblyopia

PURPOSE

The aim of this study was to establish a relation between visual acuity increase and compliance in children who have been prescribed patching therapy for their amblyopic eye.

METHODS AND MATERIALS

In 14 new amblyopic children (mean age 4.3 +/- 1.9 years) compliance was measured electronically during one week, six months after starting patching therapy, with an Occlusion Dose Monitor (ODM), distributed through house visits. The children were diagnosed with anisometropia (5), strabismus (4) and anisometropia and strabismus (5). The degree of amblyopia was expressed as the ratio between the acuity of the amblyopic eye and the acuity of the good eye. Satisfactory increase in acuity was assessed by means of the following three criteria: acuity amblyopic eye / acuity good eye >75%, acuity exceeding 0.5 E-chart, three lines LogMAR acuity increase.

RESULTS

Fourteen reliable recordings were obtained, which showed that children who did not patch, or were patched inconsistently, did not reach satisfactory acuity increase.

CONCLUSION

There is indeed a statistically significant relation between acuity increase and measured compliance.