Amblyopia treatment outcomes in patients with neurodevelopmental disorders

PURPOSE

To compare amblyopia treatment outcomes between patients with neurodevelopmental disorders and their typically developing peers.

METHODS

Of 2,311 patients diagnosed with amblyopia between 2010 and 2014 at Boston Children's Hospital, 460 met inclusion criteria (age 2-12 with anisometropic, strabismic, or mixed amblyopia [interocular difference (IOD) ≥2 lines]). Treatment and visual outcomes were analyzed according to neurodevelopmental status: neurodevelopmental delay (DD) versus typical development (TD).

RESULTS

The DD group (n = 54) and TD group (n = 406) were similar in demographics, amblyogenic risk factors, baseline visual measures, prescribed therapy, and adherence (P ≥ 0.10). Between-visit follow-up time was longer for the DD group (0.65 [0.42- 0.97] years) than for the TD group (0.5 [0.36-0.82] years; P = 0.023). IOD improved similarly in each group by the last visit (DD, -0.15 logMAR [-0.31 to -0.02]; TD, -0.2 logMAR [-0.38 to -0.1]; P = 0.09). Each group reached amblyopia resolution by the last visit at similar frequencies (DD, 23/54 [43%]; TD, 211/406 [52%]; P > 0.2). DD diagnosis did not independently influence amblyopia resolution (HR, 0.77; 95% CI, 0.53-1.12; P = 0.17), but each additional month of interval time between follow-up visits reduced the likelihood of resolution by 2.7% (HR, 0.67; 95% CI, 0.51-0.87; P = 0.003).

CONCLUSIONS

Patients with DD and those with TD responded similarly to amblyopia therapy; however, follow-up intervals were longer in patients with DD and correlated with the likelihood of persistent amblyopia, suggesting that greater efforts at assuring follow-up may benefit patients with DD.

Detection of visuomotor dysfunction in mild traumatic brain injury using binocular retinal polarization scanning

OBJECTIVE

The head and intraocular trauma tool (HITT) is a portable, binocular retinal polarization scanner (RPS) that detects ocular fixation with high precision to assess visuomotor function. We conducted a pilot evaluation of a prototype binocular RPS device to evaluate alterations in fixation stability, binocularity (convergence), and saccadic latency after mild traumatic brain injury (mTBI).

METHODS

Two groups were studied prospectively: (1) single observation study of mTBI patients in a hospital ER (n = 7) and age-matched controls (n = 43); (2) high-school athletes preseason (n = 28), after sports-related mTBI (n = 3), and at season end (n = 5). Subjects were asked to fixate on an internal target and track randomly presented peripheral and central targets as fixation was assessed using binocular RPS.

RESULTS

There were clinically and statistically significant alterations in the hospital ER group after mTBI, including a decrease in fixation stability (54.6% in patents vs 90.2% in controls, p = 0.014) and binocularity (28.7% in patients vs 86.6% in controls; p = 0.004). Similar trends, not statistically significant, were observed in saccadic latency in the hospital ER group as well as in the injured high school athletes.

CONCLUSION

The HITT device shows promise as an objective, noninvasive method for assessment of the impact of mTBI on visuomotor function. Additional studies with larger patient populations are required to evaluate efficacy for clinical use.

Association of Neighborhood Child Opportunity Index with presenting visual acuity in amblyopic children

PURPOSE

To demonstrate the use of a novel measure of neighborhood quality, the Child Opportunity Index (COI), for investigating health disparities in pediatric ophthalmology.

METHODS

This study included children 2-12 years of age from a registry of patients diagnosed with amblyopia at an urban pediatric hospital between 2010 and 2014. Children previously treated for amblyopia were excluded. Patient demographics, residential addresses, and logMAR visual acuities were collected. The association between visual acuity at presentation and COI was examined using linear mixed-effects models adjusting for individual-level factors, including age, sex, race, ethnicity, and insurance type.

RESULTS

This study included 1,050 amblyopic children, of whom 317 (37%) were non-White and 149 (19%) were Hispanic; 461 (44%) had public insurance. Regarding residence, 129 (12%) lived in areas of very low opportunity (COI <20); 489 (47%) in areas of very high opportunity (COI ≥80). Children residing in the lowest opportunity neighborhoods correctly identified approximately two fewer letters at presentation with their better-seeing eye compared with children from the highest opportunity neighborhoods after adjusting for individual-level factors (-0.0090 logMAR per 20 unit increase in COI; 95% CI, -0.0172 to -0.0008; P = 0.031). No difference was appreciated in the worse-seeing eye.

CONCLUSIONS

Amblyopic children residing in communities with low neighborhood opportunity had slightly worse visual acuity in the better-seeing eye at presentation. Although statistically significant in the better-seeing eye, the two-letter difference attributable to neighborhood environment may not be clinically significant, and the impact of this disparity on treatment outcomes deserves further investigation.

Subthreshold Amblyopia: Characterization of a new cohort

PURPOSE

Published studies of amblyopia include only patients with visual acuity (VA) worse than 20/40 in one or both eyes. The purpose of this study is to evaluate patients diagnosed and treated as amblyopic despite not meeting traditional VA criteria for amblyopia.

DESIGN

Retrospective clinical cohort study.

METHODS

Setting: Institutional practice.

PATIENT POPULATION

All patients diagnosed with amblyopia at Boston Children's Hospital between 2010 and 2014.

INCLUSION CRITERIA

VA better than 20/40 but not correctable to 20/20 in one or both eyes; age 2 to 12 years.

OBSERVATIONS

Demographics, VA, baseline characteristics.

OUTCOME MEASURES

Resolution, defined as VA 20/20 in both eyes; stereopsis at the last follow-up.

RESULTS

Of 2311 patients reviewed, 464 (20.1%) had subthreshold amblyopia. A majority (61.7%) had an amblyogenic factor, most commonly anisometropia (32.8%). Patients were followed for a median of 3.1 years; nearly all (97.5%) were treated. Of 318 patients who returned for follow-up, 47.8% achieved resolution, including 55.7% of treatment-naïve patients, and 62.5% (5 of 8 patients) offered observation alone. Median stereopsis improved by 0.4 log units in those who achieved resolution, with no change in those with persistent amblyopia. In the multivariate analysis, a longer length of follow-up was significantly associated with resolution of subthreshold amblyopia (odds ratio: 1.38; 95% confidence interval: 1.22-1.57, P < .001).

CONCLUSIONS

Patients with subthreshold amblyopia represent a sizeable cohort in real-world amblyopia practice. When offered treatment, half achieved 20/20 vision in both eyes with improved stereopsis as well. Further studies are needed to assess whether observation alone would result in similar outcomes.

Identifying Characteristics Predictive of Lost-to-Follow-Up Status in Amblyopia

PURPOSE

To identify demographic and disease-related characteristics predictive of Lost-to-Follow-Up (LTFU) status in amblyopia treatment and create a risk model for predicting LTFU status.

DESIGN

Retrospective cohort study METHODS: Setting: Single-center, ophthalmology department at Boston Children's Hospital (BCH).

PATIENTS

2037 patients treated for amblyopia at BCH between 2010 and 2014.

OBSERVATION PROCEDURE

LTFU was defined as patients who did not return after initial visit, excluding those who came for second opinion. Multiple variables were tested for association with LTFU status.

OUTCOME MEASURE

Odds ratio of LTFU risk associated with each variable. Multivariate logistic regression was used to create a risk score for predicting LTFU status.

RESULTS

A large proportion of patients (23%) were LTFU after first visit. Older age, nonwhite race, lack of insurance, previous glasses or atropine treatment, and longer requested follow-up intervals were independent predictors of LTFU status. A multivariable risk score was created to predict probability of LTFU (area under the curve 0.68).

CONCLUSIONS

Our comprehensive amblyopia database allows us to predict which patients are more likely to be LTFU after baseline visit and develop strategies to mitigate these effects. These findings may help with practice efficiency and improve patient outcomes in the future by transitioning these analyses to an electronic medical record that could be programmed to provide continually updated decision support for individual patients based on large data sets.

The User Experience on a 3-Dimensional Heads-Up Display for Vitreoretinal Surgery Across All Members of the Health Care Team: A Survey of Medical Students, Residents, Fellows, Attending Surgeons, Nurses, and Anesthesiologists

Purpose:

This work assesses the educational use of a 3-dimensional (3D) heads-up visualization system for vitreoretinal surgery.

Methods:

A cross-sectional survey was performed among 18 medical students, 18 residents, 7 VR fellows, 6 nurses, 4 anesthesiologists, and 3 surgeons on their experience with the Ngenuity 3D Visualization System (TrueVision and Alcon) compared with the standard microscope.

Results:

Most medical students (88%) reported better identification of surgical landmarks; 63% ranked the Ngenuity as their preferred method of learning (vs microscope or 2-dimensional display). Residents reported a superior understanding of anatomy (69%), an increased ability to ask questions (63%), and improved ergonomics (94%). Epiretinal membrane peel, internal limiting membrane peel, and core vitrectomy were most enhanced (69% to 77%) for residents. Fellows’ experience with trocar placement, vitrectomy, and oil/gas insertion was the same as before (67% to 100%), whereas endolaser and closing were worse (67% to 100%). Regarding autonomy, 83% of fellows reported no change, whereas 17% reported increased levels. Nurses were better able to track case progress (67%) and anticipate which tools were needed (50%). All anesthesiologists reported the same or worse engagement in cases, noting it was difficult to switch between the 3D screen and the anesthesia equipment. All surgeons reported a better awareness of trainees in the room and an improved ability to point out landmarks; 67% reported being more comfortable with resident and fellow autonomy.

Conclusions:

The Ngenuity is most helpful to students and residents. Integrating 3D displays into the surgical curriculum is beneficial, with care to ensure nurse and anesthesiologist satisfaction.

Effect of Primary Occlusion Therapy in Asymmetric, Bilateral Amblyopia

PURPOSE

Many bilateral amblyopia patients have asymmetric visual acuity (VA). There is no standard treatment for these patients, and outcomes have not been well described. Our goal is to compare VA outcomes in this group based on timing of occlusion therapy.

DESIGN

Retrospective interventional comparative case series.

METHODS

Setting: Institutional practice. PatientPopulation: Patients diagnosed with amblyopia at Boston Children's Hospital between 2010 and 2014. InclusionCriteria: VA ≥ 0.3 logMAR bilaterally by objective optotype-based measures, interocular difference (IOD) ≥ 0.18 logMAR, age 2-12 years. ExclusionCriteria: Loss to follow-up, managed surgically, deprivation amblyopia. Patients had either primary or secondary occlusion (primary = initiated when VA ≥ 0.3 logMAR bilaterally; secondary = initiated to correct residual IOD once VA improved to ≤0.18 logMAR in the stronger eye). ObservationProcedure: Patient demographics, VA, IOD, and stereopsis were compared between groups. OutcomeMeasures: VA improvement at 12-18 months and at last visits.

RESULTS

Of 2,200 patients reviewed, 167 (7.6%) had asymmetric, bilateral amblyopia; 98 met inclusion and exclusion criteria. Patients were equally divided between primary (n = 50) and secondary (n = 48) occlusion groups. There were no differences in demographics, baseline VA, or IOD between groups (P ≥ .22), although the primary occlusion group had a higher proportion of strabismic amblyopia (P = .007). VA in both eyes, IOD, and stereopsis improved similarly between groups, even after stratifying by amblyopia subtype (P ≥ .48). The secondary occlusion group was more likely to achieve 20/30 bilaterally and IOD ≤ 1 line at 12-18 months (P ≤ .4), although this equalized by the last visit.

CONCLUSION

In patients with asymmetric, bilateral amblyopia, VA improved by 4 lines in the weaker eye and 2 lines in the stronger eye, while IOD improved by 2 lines, irrespective of occlusion status. Primary occlusion thus provided no further benefit over spectacle correction alone.

Anomalous superior oblique muscles and tendons in congenital fibrosis of the extraocular muscles

PURPOSE

To evaluate the finding of anomalous superior oblique muscles in congenital fibrosis of the extraocular muscles (CFEOM), a feature not previously emphasized in this condition.

METHODS

The medical records of all patients clinically or genetically diagnosed with CFEOM at Boston Children's Hospital between 2010 and 2018 were reviewed retrospectively. Those who underwent strabismus surgery during the study period were included in the analysis. Baseline patient characteristics, type of CFEOM, results of genetic testing, and intraoperative features of the superior oblique muscle or tendon were recorded.

RESULTS

Of 24 patients identified (age range, 1 month to 62 years), 10 (42%) had genetically confirmed CFEOM, and 22 underwent strabismus surgery, 14 (64%) involving the superior oblique muscle. Of these, 7 (50%) had anomalously inserted tendons (most commonly attached nasal to the superior rectus muscle), whereas 7 (50%) had increased superior oblique muscle tension.

CONCLUSIONS

Half of CFEOM patients who underwent superior oblique surgery had abnormally inserted superior oblique tendons, and 50% had tight muscles or abnormally thin tendons, findings that have not been well-characterized in this condition. The findings suggest that abnormal insertion of the superior oblique muscles and tendons are additional features of the disease process in CFEOM that have not been described previously. These features may contribute to the severe upgaze limitation in CFEOM and highlight the importance of superior oblique tenotomy in surgical management.

Peripheral Vestibular Disorders in Children and Adolescents with Concussion

Objective To review peripheral vestibular disorders in pediatric patients with dizziness following concussion. Study Design Case series with chart review. Setting Pediatric vestibular clinic and pediatric multidisciplinary concussion clinic at a tertiary level pediatric hospital. Subjects and Methods We retrospectively reviewed 109 patients seen for dizziness following a concussion between September 2012 and July 2015. Patients were ≤20 years of age at the time of concussion. Incidences of specific peripheral vestibular disorders were assessed along with timing of diagnosis relative to the date of injury, diagnostic test findings, and treatment interventions associated with those diagnoses. Results Twenty-eight patients (25.7%) were diagnosed with peripheral vestibular disorders. None of these disorders were diagnosed prior to evaluation in our pediatric vestibular clinic or our multidisciplinary concussion clinic, which occurred a mean of 133 days (95% confidence interval, 89.2-177.3) after injury. Benign paroxysmal positioning vertigo was diagnosed in 19 patients, all of whom underwent successful canalith repositioning maneuvers. Other diagnoses included temporal bone fracture (n = 3), labyrinthine concussion (n = 2), perilymphatic fistula (n = 2), and superior semicircular canal dehiscence (n = 2). Both patients with perilymphatic fistula and 1 patient with superior semicircular canal dehiscence underwent successful surgical management, while 1 patient with superior semicircular canal dehiscence was managed nonsurgically. Conclusion Peripheral vestibular disorders may occur in pediatric patients with dizziness following concussion, but these disorders may not be recognized until symptoms have persisted for several weeks. An algorithm is proposed to guide the diagnosis and management of peripheral vestibular disorders in pediatric patients with concussion.