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Wu C, Gaier ED, Nihalani BR, Whitecross S, Hensch TK, Hunter DG. Durable recovery from amblyopia with donepezil. Sci Rep 2023; 13:10161. [PMID: 37349338 PMCID: PMC10287641 DOI: 10.1038/s41598-023-34891-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 05/09/2023] [Indexed: 06/24/2023] Open
Abstract
An elevated threshold for neuroplasticity limits visual gains with treatment of residual amblyopia in older children and adults. Acetylcholinesterase inhibitors (AChEI) can enable visual neuroplasticity and promote recovery from amblyopia in adult mice. Motivated by these promising findings, we sought to determine whether donepezil, a commercially available AChEI, can enable recovery in older children and adults with residual amblyopia. In this open-label pilot efficacy study, 16 participants (mean age 16 years; range 9-37 years) with residual anisometropic and/or strabismic amblyopia were treated with daily oral donepezil for 12 weeks. Donepezil dosage was started at 2.5 or 5.0 mg based on age and increased by 2.5 mg if the amblyopic eye visual acuity did not improve by 1 line from the visit 4 weeks prior for a maximum dosage of 7.5 or 10 mg. Participants < 18 years of age further patched the dominant eye. The primary outcome was visual acuity in the amblyopic eye at 22 weeks, 10 weeks after treatment was discontinued. Mean amblyopic eye visual acuity improved 1.2 lines (range 0.0-3.0), and 4/16 (25%) improved by ≥ 2 lines after 12 weeks of treatment. Gains were maintained 10 weeks after cessation of donepezil and were similar for children and adults. Adverse events were mild and self-limited. Residual amblyopia improves in older children and adults treated with donepezil, supporting the concept that the critical window of visual cortical plasticity can be pharmacologically manipulated to treat amblyopia. Placebo-controlled studies are needed.
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Affiliation(s)
- Carolyn Wu
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA.
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.
| | - Eric D Gaier
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Bharti R Nihalani
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Sarah Whitecross
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA
| | - Takao K Hensch
- Center for Brain Science, Department of Molecular Cellular Biology, Harvard University, Cambridge, MA, USA
- International Research Center for Neurointelligence, University of Tokyo Institutes for Advanced Study, Tokyo, Japan
- FM Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - David G Hunter
- Department of Ophthalmology, Boston Children's Hospital, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- International Research Center for Neurointelligence, University of Tokyo Institutes for Advanced Study, Tokyo, Japan
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Master CL, Bacal D, Grady MF, Hertle R, Shah AS, Strominger M, Whitecross S, Bradford GE, Lum F, Donahue SP. Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment. Pediatrics 2022; 150:188533. [PMID: 35843991 DOI: 10.1542/peds.2021-056047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 01/24/2023] Open
Abstract
Visual symptoms are common after concussion in children and adolescents, making it essential for clinicians to understand how to screen, identify, and initiate clinical management of visual symptoms in pediatric patients after this common childhood injury. Although most children and adolescents with visual symptoms after concussion will recover on their own by 4 weeks, for a subset who do not have spontaneous recovery, referral to a specialist with experience in comprehensive concussion management (eg, sports medicine, neurology, neuropsychology, physiatry, ophthalmology, otorhinolaryngology) for additional assessment and treatment may be necessary. A vision-specific history and a thorough visual system examination are warranted, including an assessment of visual acuity, ocular alignment in all positions of gaze, smooth pursuit (visual tracking of a moving object), saccades (visual fixation shifting between stationary targets), vestibulo-ocular reflex (maintaining image focus during movement), near point of convergence (focusing with both eyes at near and accommodation (focusing with one eye at near because any of these functions may be disturbed after concussion. These deficits may contribute to difficulty with returning to both play and the learning setting at school, making the identification of these problems early after injury important for the clinician to provide relevant learning accommodations, such as larger font, preprinted notes, and temporary use of audio books. Early identification and appropriate management of visual symptoms, such as convergence insufficiency or accommodative insufficiency, may mitigate the negative effects of concussion on children and adolescents and their quality of life.
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Affiliation(s)
- Christina L Master
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine.,Minds Matter Concussion Program.,Pediatric and Adolescent Sports Medicine, Division of Pediatric Orthopaedics, Karabots Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Darron Bacal
- Department of Ophthalmology and Visual Science, Yale University, New Haven, Connecticut.,Eye Physicians and Surgeons, PC, New Haven, Connecticut
| | - Matthew F Grady
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine.,Pediatric and Adolescent Sports Medicine, Division of Pediatric Orthopaedics, Karabots Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Hertle
- Department of Surgery, College of Medicine, Northeast Ohio Medical College, Rootstown, Ohio.,Department of Specialty Medicine, Ohio University College of Osteopathic Medicine, Athens, Ohio; and Akron Children's Hospital Vision Center, Akron, Ohio
| | - Ankoor S Shah
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.,Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts.,Massachusetts Eye and Ear, Boston, Massachusetts
| | - Mitchell Strominger
- Departments of Surgery.,Ophthalmology.,Pediatrics.,Clinical Internal Medicine, University of Nevada Reno School of Medicine, Renown Medical Center, Reno, Nevada
| | - Sarah Whitecross
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts
| | - Geoffrey E Bradford
- Departments of Ophthalmology.,Pediatrics, West Virginia University, Morgantown, West Virginia
| | - Flora Lum
- Quality and Data Science Division, American Academy of Ophthalmology, San Francisco, California
| | - Sean P Donahue
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
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Master CL, Bacal D, Grady MF, Hertle R, Shah AS, Strominger M, Whitecross S, Bradford GE, Lum F, Donahue SP. Evaluation of the Visual System by the Primary Care Provider Following Concussion. Pediatrics 2022; 150:188534. [PMID: 35909153 DOI: 10.1542/peds.2021-056048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
Concussion is a common injury in childhood and has the potential for substantial impact on quality of life. Visual issues have been increasingly recognized as a common problem after concussion. Many children initially seek care for concussion with their pediatrician, making it even more important for pediatricians to recognize, evaluate, and refer children with visual issues after concussion. This clinical report is intended to support the recommendations in the companion policy statement on vision and concussion and provides definitions of some of the physiologic aspects of the visual system as they relate to concussion. A description of clinically feasible testing methodologies is provided in more detail to aid the clinician in assessing the visual system in a focused fashion after concussion. This guidance helps direct clinical management, including support for return to school, sports, and other activities, as well as potential referral for subspecialty care for the subset of those with persistent symptoms.
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Affiliation(s)
- Christina L Master
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Minds Matter Concussion Program, Pediatric and Adolescent Sports Medicine, Division of Pediatric Orthopaedics, Karabots Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Darron Bacal
- Department of Ophthalmology & Visual Science, Yale University, Eye Physicians & Surgeons, PC, New Haven, Connecticut
| | - Matthew F Grady
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Pediatric and Adolescent Sports Medicine, Division of Pediatric Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Hertle
- Department of Surgery, College of Medicine, Northeast Ohio Medical College, Rootstown, Ohio.,Department of Specialty Medicine, Ohio University College of Osteopathic Medicine; Athens, Ohio
| | - Ankoor S Shah
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.,Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts.,Department of Opthalmology, Massachusetts Eye & Ear, Boston, Massachusetts
| | | | - Sarah Whitecross
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts.,Clinical Internal Medicine, University of Nevada Reno School of Medicine, Renown Medical Center, Reno, Nevada
| | - Geoffrey E Bradford
- Departments of Ophthalmology.,Pediatrics, West Virginia University, Morgantown, West Virginia
| | - Flora Lum
- Quality and Data Science Division, American Academy of Ophthalmology, San Francisco, California
| | - Sean P Donahue
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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Nwanaji-Enwerem JC, Gateman T, Whitecross S, Whitman MC. First Visit Characteristics Associated with Future Surgery in Intermittent Exotropia. J Binocul Vis Ocul Motil 2022; 72:22-28. [PMID: 35049416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE Identify demographic and clinical characteristics at the first presentation associated with later having surgery for intermittent exotropia (IXT). METHODS Retrospective cohort study of 228 children with IXT and 5+ years of follow-up. Demographic and clinical data were extracted from medical records. A total 97 participants who underwent surgery during follow-up were compared to 131 participants who did not. Best subset regression was used to identify first visit variables associated with later having strabismus surgery. Surgery was then regressed on the selected variables using logistic models. RESULTS Age and control were the only first visit variables significantly associated with having surgery for IXT. Notably, neither angle of deviation nor stereopsis were associated with later surgery. In an adjusted logistic model, each one-month increase in age at presentation was associated with a 1% decrease in the odds of having surgery (OR = 0.991, 95% CI: 0.982-0.999, P = .04). Children with poor control at initial visit had almost five times greater odds of having surgery than those with good control (OR = 4.95, 95% CI: 2.31-10.98, P < .0001). CONCLUSIONS Age and control of IXT are important factors at presentation associated with future surgical intervention for IXT. The magnitude of deviation and stereopsis was not significantly associated with future surgical treatment for IXT.
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Affiliation(s)
- Jamaji C Nwanaji-Enwerem
- MD/PhD Program, Harvard Medical School, Boston, Massachusetts
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, California
| | - Taylor Gateman
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts
| | - Sarah Whitecross
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts
| | - Mary C Whitman
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
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Abstract
Concussion, or mild traumatic brain injury (mTBI), results from a force to the head and can cause acute physical, cognitive, and psychological symptoms. The majority of concussion symptoms will resolve within a month, but upward of a third of patients will have persistent, chronic symptoms. When these symptoms become chronic and persist beyond 1-3 months, this is termed post-concussion syndrome (PCS). Psychological changes associated with PCS may in part be due to a traumatic event and the injury itself and therefore post-traumatic stress reactions may contribute. In addition, alterations to daily life and alteration of lifestyle as a result of the injury can cause feelings of disconnection which in turn can feed anxiety and depression symptoms. A preinjury diagnosis or history of psychiatric or mood disorder, migraine, or family history of psychiatric illness is one the greatest risk factors for the development of PCS. It is recommended that evaluation of concussion and those with PCS take a multidisciplinary approach including evaluation by psychology, psychiatry, and/or neuropsychology. While most concussions do not require treatment, those with PCS will not likely see the resolution of their physical and psychological symptoms without intervention. Treatment is limited, but cognitive behavioral treatment has shown promise in the management of PCS symptoms. It is important to recognize the role psychology plays in the development and persistence of PCS and to recognize and seek collaborative care when treating these patients.
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Affiliation(s)
- Sarah Whitecross
- Department of Ophthalmology, Boston Children's Hospital , Boston, Massachusetts
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Abstract
BACKGROUND AND PURPOSE Orthoptic exercises are routinely prescribed to treat symptoms of convergence insufficiency (CI). The type and duration of treatment tends to vary among providers as until recently, few strong randomized control studies have addressed the efficacy of convergence insufficiency management. The aim of this paper is to address these studies and discuss their limitations. METHODS A review of the literature pertaining to convergence insufficiency was conducted. Articles relevant to the treatment of this disorder were analyzed, and those with adequate studies pertaining to CI treatment methods were included. RESULTS There are limited randomized control trials evaluating the effectiveness of vision therapy, and those that do exist have limitations: small patient populations, differing outcome measures, treatment length and intensity, and placebo effects, which are all confounding factors when assessing the validity of the current studies. CONCLUSION Despite the prevalence of convergence insufficiency, the known efficacy of vision therapy remains somewhat questionable. There is evidence to suggest that some form of therapy is effective in reducing symptoms and clinical findings of convergence insufficiency, but there is a lack of equal comparison in order to conclude which forms of treatment are best.
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MacKinnon S, Proctor MR, Rogers GF, Meara JG, Whitecross S, Dagi LR. Improving ophthalmic outcomes in children with unilateral coronal synostosis by treatment with endoscopic strip craniectomy and helmet therapy rather than fronto-orbital advancement. J AAPOS 2013; 17:259-65. [PMID: 23791406 DOI: 10.1016/j.jaapos.2013.01.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 01/22/2013] [Accepted: 01/29/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare long-term ophthalmic outcomes in infants treated for unilateral coronal synostosis (UCS) by endoscopic strip craniectomy (ESC) and helmet therapy with those treated by fronto-orbital advancement (FOA). METHODS Consecutive patients with UCS, uncomplicated by other suture synostosis, were identified by a retrospective review of medical records. Assessment of presence of amblyopia, cycloplegic refraction, strabismus, and strabismus surgical intervention at all visits was recorded. RESULTS Between 2004 and 2010, 22 patients were treated by FOA (mean follow-up, 21.5 months) and 21 patients with ESC and helmet therapy (mean follow-up, 23.5 months). The mean aniso-astigmatism was equal; however, the SD was greater for those treated by FOA (P < 0.05). A more severe pattern of strabismus developed in those treated by FOA (P < 0.0001). Those treated by FOA were more likely to have amblyopia (P = 0.0015) and to undergo surgical correction of their strabismus (odds ratio, 6.3:1). CONCLUSIONS Children with UCS treated with ESC and helmeting had less severe overelevation in adduction, amblyopia, extremes of astigmatism, and less need for strabismus surgery than those treated by FOA. Although the reason for these more favorable outcomes remains uncertain, we speculate that the earlier timing of ESC or differences in the anatomical changes resulting from the two procedures may play a role.
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Affiliation(s)
- Sarah MacKinnon
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Abstract
Forty-six female patients with pseudoseizures were compared with 50 female patients referred to a psychiatric outpatient clinic. Patients with convulsive pseudoseizures were more likely to be single and childless. An abnormal EEG was more frequently reported in patients with convulsive pseudoseizures, contributing to their earlier diagnosis of epilepsy. The defence mechanisms of patients with convulsive pseudoseizures using the Defense Mechanisms Inventory (DMI) were particularly characterized by higher scores on the 'reversal' scale and lower scores on the 'turning against self' scale. Mood disorders were more common in general psychiatric patients, while one-third of convulsive pseudoseizure patients did not complain of psychiatric symptoms.
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Affiliation(s)
- S S Jawad
- East Glamorgan General Hospital, Church Village, Mid Glamorgan, Wales, UK
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O'Rourke A, Lewin B, Whitecross S, Pacey W. The effects of physical exercise training and cardiac education on levels of anxiety and depression in the rehabilitation of coronary artery bypass graft patients. Int Disabil Stud 1990; 12:104-6. [PMID: 2096117 DOI: 10.3109/03790799009166262] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE to evaluate whether an exercise and education-based rehabilitation programme is sufficient treatment for individuals with clinically significant levels of anxiety or depression following coronary artery bypass graft (CABG) surgery. DESIGN follow-up and repeated assessment after surgery. SETTING outpatient cardiac rehabilitation programme. PATIENTS all 88 attenders after CABG surgery. ASSESSMENTS structured interview and Hospital Anxiety and Depression (HAD) scale (using 8 as the cut-off) administered by rehabilitation nurses at start of course and HAD repeated at 12 weeks and 6 and 12 months (by post after discharge). RESULTS return rates of 76 and 80% at 6- and 12-month assessments, respectively; statistically significant reductions in levels of anxiety and depression found between first and all subsequent assessments; subdividing into groups revealed significant reduction in anxiety and depression in the anxious and depressed groups at 12 weeks and 6 months, respectively, but at 12 months there was no significant reduction. CONCLUSIONS there is a need to address the problems of anxiety and depression directly by screening and treatment, and to provide more psychologically-orientated cardiac rehabilitation programmes.
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Affiliation(s)
- A O'Rourke
- Astley Ainslie Hospital, Edinburgh, Scotland, UK
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