Steroid-sparing effect of ciclosporin A 1 mg/mL: 5-year case series of 107 children and young people with vernal keratoconjunctivitis

Background/aims

To explore the steroid-sparing and other therapeutic effects of ciclosporin A (CsA) 1 mg/mL in the management of vernal keratoconjunctivitis (VKC).

Methods

Open retrospective single-group interventional consecutive cohort study (case series) of 107 children and young people (CYP) age 4.4–18 years with severe and/or recurrent VKC who were prescribed CsA 1 mg/mL between November 2015 and May 2021 at one institution. Review of electronic patient records, noting clinical indication for prescribing CsA 1 mg/mL, dosage prescribed at initiation and follow-up, impact on steroid usage before and after commencing CsA as well as adverse events and indications for discontinuation of treatment.

Results

The median number of inflammatory episodes requiring treatment with topical corticosteroids fell from 3 (IQR 2–4) during the 12 months prior to CsA 1 mg/mL to 1 (IQR 0–3) during the 12 months after, excluding steroid prescriptions with the first CsA 1 mg/mL prescription (Wilcoxon signed ranks test, two tailed, p<0.01). In the 12-month period following initiation of CsA 1 mg/mL with concomitant prescription of topical corticosteroids (n=82), daily dosage of steroids was reduced in 79 (96.3%) and discontinued in 67 (81.7%). The median number of hospital clinic visits fell from 4 (IQR 3–5) to 3 (IQR 2–5) (Wilcoxon p<0.01). Adverse events leading to discontinuation of CsA 1 mg/mL within 12 months of starting included stinging (instillation site pain) (6/107, 5.6%) and skinrash (1/107, 0.9%).

Conclusion

Commercial preparations of CsA 1 mg/mL, licensed for severe VKC in CYP, significantly reduce the need for concomitant topical corticosteroids and hospital clinic visits. Adverse events which may lead to discontinuation are stinging and skin rash.

Phase 2a randomised controlled feasibility trial of a new 'balanced binocular viewing' treatment for unilateral amblyopia in children age 3-8 years: trial protocol

INTRODUCTION

Treatments for amblyopia, the most common vision deficit in children, often have suboptimal results. Occlusion/atropine blurring are fraught with poor adherence, regression and recurrence. These interventions target only the amblyopic eye, failing to address imbalances of cortical input from the two eyes ('suppression'). Dichoptic treatments manipulate binocular visual experience to rebalance input. Poor adherence in early trials of dichoptic therapies inspired our development of balanced binocular viewing (BBV), using movies as child-friendly viewable content. Small observational studies indicate good adherence and efficacy. A feasibility trial is needed to further test safety and gather information to design a full trial.

METHODS/ANALYSIS

We will carry out an observer-masked parallel-group phase 2a feasibility randomised controlled trial at two sites, randomising 44 children aged 3-8 years with unilateral amblyopia to either BBV or standard occlusion/atropine blurring, with 1:1 allocation ratio. We will assess visual function at baseline, 8 and 16 weeks. The primary outcome is intervention safety at 16 weeks, measured as change in interocular suppression, considered to precede the onset of potential diplopia. Secondary outcomes include safety at other time points, eligibility, recruitment/retention rates, adherence, clinical outcomes. We will summarise baseline characteristics for each group and assess the treatment effect using analysis of covariance. We will compare continuous clinical secondary endpoints between arms using linear mixed effect models, and report feasibility endpoints using descriptive statistics.

ETHICS/DISSEMINATION

This trial has been approved by the London-Brighton & Sussex Research Ethics Committee (18/LO/1204), National Health Service Health Research Authority and Medicines and Healthcare products Regulatory Agency. A lay advisory group will be involved with advising on and disseminating the results to non-professional audiences, including on websites of funder/participating institutions and inputting on healthcare professional audience children would like us to reach. Reporting to clinicians and scientists will be via internal and external meetings/conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03754153.

Medically unexplained visual loss in children and young people: an observational single site study of incidence and outcomes

PurposeTo determine the incidence of medically unexplained visual loss (MUVL) in children in an open access children's eye casualty.Patients and methodsWe collated demographic and clinical data of consecutive patients younger than 16 years who presented to the children's eye casualty at Moorfields Eye Hospital over a 12-month period and were diagnosed with MUVL or suspected MUVL. We reviewed the clinical records at least 3 months after initial presentation. We calculated the incidence using the number of 'new patient' attendances over the same period as denominator (n=2397). We used descriptive analysis.

MAIN OUTCOME MEASURES

number of patients diagnosed with MUVL, proportion of patients with a history of or present psychological problems, recovery rate, and improvement in visual acuity.ResultsWe identified 85 cases of MUVL (54 females; median age: 9 years (IQR 7-12)). The median duration of follow-up was 1.2 months (IQR 0-4.3). The estimated annual incidence was 3.5% (95% confidence interval 2.9-4.4%). Thirty-three per cent of children had a history of psychiatric disorders, reported a stressful life event, or showed signs of psychiatric disorder at the time of first presentation. The recovery rate was 25%. Median improvement in best-corrected visual acuity from presentation to last appointment was 0.22 (IQR 0.06-0.43) logMAR.ConclusionThe incidence of MUVL is higher and the rate of resolution lower than previously reported. MUVL may be associated with mental health problems. We recommend screening for psychological problems to facilitate access to psychological treatment.

Detecting optic nerve head swelling on ultrasound and optical coherence tomography in children and young people: an observational study

BACKGROUND

Following high-profile cases, referrals for evaluation of 'suspicious optic discs' to eye clinics in the UK have sharply increased, asking ophthalmologists to reliably distinguish between true and pseudopapilloedema. Optic nerve sheath dilatation (ONSD) on ocular ultrasound (US) is considered a reliable sign of true papilloedema, but this test is not widely available. Recently, anterior bowing of Bruch's membrane (BM) and increased retinal nerve fibre layer thickness on optical coherence tomography (OCT) have emerged as indicators of intracranial hypertension, and OCT is widely available. We aimed to evaluate safety and efficacy of the diagnostic workup in our service, with particular emphasis of diagnostic reliability of US and OCT.

METHODS

Retrospective service evaluation/cohort study of children and young people younger than 16 years investigated for 'suspicious discs' over a 7-month period in 2016 at a single eye care provider in London, UK. 61 children and young people underwent clinical assessment, US scan and OCT.

RESULTS

Of 61 cases, 3 had intracranial pathology. At presentation, only one had ONSD on US and anterior bowing of BM on OCT. Increased nerve fibre layer thickness in at least one of three relevant sectors was observed in two cases. All three cases of intracranial pathology, however, had significant points in their presenting or medical history.

CONCLUSION

Ophthalmologists and optometrists must not rely on funduscopy and ocular imaging when assessing a child for possible intracranial disease; history and basic neurological assessment are critical in the diagnostic workup.

Comparison of handheld rebound tonometry with Goldmann applanation tonometry in children with glaucoma: a cohort study

OBJECTIVE

To test agreement of two methods to measure intraocular pressure (IOP): rebound tonometry (RBT) and gold standard Goldmann applanation tonometry (GAT) in children with glaucoma.

DESIGN

Observational prospective cohort study.

SETTING

Tertiary paediatric glaucoma clinic at a single centre.

PARTICIPANTS

102 individuals attending a paediatric glaucoma clinic, mean (SD) age 11.85 (3.17), of whom 53 were male.

PRIMARY AND SECONDARY OUTCOME MEASURES

Intraocular pressure, central corneal thickness, child preference for measurement method.

RESULTS

Limits of agreement for intraobserver and interobserver were, respectively, (-2.71, 2.98) mm Hg and (-5.75, 5.97) mm Hg. RBT frequently gave higher readings than GAT and the magnitude of disagreement depend on the level of IOP being assessed. Differences of 10 mm Hg were not uncommon. RBT was the preferred method for 70% of children.

CONCLUSIONS

There is poor agreement between RBT and GAT in children with glaucoma. RBT frequently and significantly overestimates IOP. However, 'normal' RBT readings are likely to be accurate and may spare children an examination under anaesthesia (EUA). High RBT readings should prompt the practitioner to use another standard method of IOP measurement if possible, or consider the RBT measurement in the context of clinical findings before referring the child to a specialist clinic or considering EUA.

Strategies for optic nerve rescue and regeneration in glaucoma and other optic neuropathies

Glaucoma is the most common age-related optic nerve disease and also the most common neuropathy, affecting approximately 60 million people worldwide in its most common forms. This figure is expected to rise to 80 million by 2020. Glaucoma is a neurodegenerative disease in which various triggers induce cascades of secondary events, which ultimately lead to apoptotic retinal ganglion cell (RGC) death. The main risk factor for glaucomatous nerve damage is raised pressure in the eye. Understanding the cascades mediating optic nerve damage enables the development of new, neuroprotective treatment strategies that might not only target the initial insult but also prevent or delay secondary neurodegeneration. Furthermore, neuroregeneration and repopulation of the visual pathway by stem or neural precursor cells is becoming possible. Increasing understanding of the pathways involved in directed axon growth and manipulation of stem and progenitor cells towards an RGC fate have facilitated first successes in animal models of glaucoma.

Vision screening in children by Plusoptix Vision Screener compared with gold-standard orthoptic assessment

BACKGROUND/AIMS

To evaluate a new autorefractor, the Plusoptix Vision Screener (PVS), as a screening tool to detect risk factors for amblyopia by comparing it with gold-standard orthoptic vision screening in children.

METHODS

Community-based screening study including 288 children age 4-7 years who were screened with the PVS and by orthoptic assessment (distance acuity, cover test, extraocular movements, 20 PD prism test, Lang stereotest). Follow-up comprehensive eye examination of screening-positive children included manual cycloplegic retinoscopy.

RESULTS

Testability was high for both methods. Orthoptic screening identified 36 children with reduced vision and/or factors associated with amblyopia (referral rate 12.5%). The PVS identified 16 children with potential vision problems (referral rate 5.6%), indicating only moderate sensitivity (44%; 95% CI 27.9 to 61.9%), but high specificity (100%; 95% CI 98.5 to 100%) to detect factors associated with amblyopia. The PVS underestimated visually significant refractive errors.

CONCLUSIONS

Use of the PVS as single screening test in young children may miss a significant number of children with amblyopia or amblyogenic risk factors.

Plusoptix Vision Screener: the accuracy and repeatability of refractive measurements using a new autorefractor

BACKGROUND

The Plusoptix Vision Screener (PVS) is a new non-cycloplegic videoretinoscopy autorefractor. Refractive accuracy may affect its performance as a screening tool.

AIMS

Study 1: To determine the intra- and interobserver variability of PVS measurements. Study 2: To compare PVS measurements with gold-standard manual cycloplegic retinoscopy (MCR).

METHODS

Study 1: PVS refraction of 103 children with mean (SD) age 5.5 (0.6) years by two observers. Study 2: PVS and MCR refraction of 126 children with mean (SD) age 5.5 (1.5) years, including 43 children with manifest strabismus >/=5 PD, comparing mean spherical equivalent (MSE) and Jackson cross cylinders J(0) and J(45).

RESULTS

Study 1: Repeatability coefficients (observer 1): MSE: 0.63 D, J(0): 0.24 D, J(45): 0.18 D; those of observer 2 were nearly identical. The mean difference (95% limits of agreement) between the two observers for MSE, J(0) and J(45) were, respectively, 0.03 (-0.62 to 0.68 D), -0.008 (-0.25 to 0.23 D) and 0.013 (-0.18 to 0.20) D. Study 2: MSE tended to be lower on PVS than MCR, with differences of up to 8.00 D. Less than 20% of values were within +/-0.50 D of each other. Agreement was better for J(0) and J(45). Strabismus was associated with an odds ratio of 3.7 (95% CI 1.3 to 10.5) of the PVS failing to obtain a reading.

CONCLUSIONS

The PVS may underestimate children's refractive error.