Incidence of Glaucoma-Related Adverse Events in the First 5 Years After Pediatric Lensectomy

Importance

Glaucoma can develop following cataract removal in children.

Objective

To assess the cumulative incidence of glaucoma-related adverse events (defined as glaucoma or glaucoma suspect) and factors associated with risk of these adverse events in the first 5 years after lensectomy prior to 13 years of age.

Design, Setting, and Participants

This cohort study used longitudinal registry data collected at enrollment and annually for 5 years from 45 institutional and 16 community sites. Participants were children aged 12 years or younger with at least 1 office visit after lensectomy from June 2012 to July 2015. Data were analyzed from February through December 2022.

Exposures

Usual clinical care after lensectomy.

Main Outcomes and Measures

The main outcomes were cumulative incidence of glaucoma-related adverse events and baseline factors associated with risk of these adverse events.

Results

The study included 810 children (1049 eyes); 443 eyes of 321 children (55% female; mean [SD] age, 0.89 [1.97] years) were aphakic after lensectomy, and 606 eyes of 489 children (53% male; mean [SD] age, 5.65 [3.32] years) were pseudophakic. The 5-year cumulative incidence of glaucoma-related adverse events was 29% (95% CI, 25%-34%) in 443 eyes with aphakia and 7% (95% CI, 5%-9%) in 606 eyes with pseudophakia; 7% (95% CI, 5%-10%) of aphakic eyes and 3% (95% CI, 2%-5%) of pseudophakic eyes were diagnosed as glaucoma suspect. Among aphakic eyes, a higher risk for glaucoma-related adverse events was associated with 4 of 8 factors, including age less than 3 months (vs ≥3 months: adjusted hazard ratio [aHR], 2.88; 99% CI, 1.57-5.23), abnormal anterior segment (vs normal: aHR, 2.88; 99% CI, 1.56-5.30), intraoperative complications at time of lensectomy (vs none; aHR, 2.25; 99% CI, 1.04-4.87), and bilaterality (vs unilaterality: aHR, 1.88; 99% CI, 1.02-3.48). Neither of the 2 factors evaluated for pseudophakic eyes, laterality and anterior vitrectomy, were associated with risk of glaucoma-related adverse events.

Conclusions and Relevance

In this cohort study, glaucoma-related adverse events were common after cataract surgery in children; age less than 3 months at surgery was associated with elevated risk of the adverse events in aphakic eyes. Children with pseudophakia, who were older at surgery, less frequently developed a glaucoma-related adverse event within 5 years of lensectomy. The findings suggest that ongoing monitoring for the development of glaucoma is needed after lensectomy at any age.

Plasma Levels of Bevacizumab and Vascular Endothelial Growth Factor After Low-Dose Bevacizumab Treatment for Retinopathy of Prematurity in Infants

Importance

Intravitreal bevacizumab effectively treats severe retinopathy of prematurity (ROP), but it enters the bloodstream and may reduce serum vascular endothelial growth factor (VEGF), potentially causing detrimental effects on developing organs in the premature infant.

Objective

To evaluate the association of intravitreal bevacizumab with plasma bevacizumab and VEGF concentrations at 2 and 4 weeks after predefined, de-escalating doses of intravitreal bevacizumab were administered to infants with severe ROP.

Design, Setting, and Participants

This phase 1 dose de-escalation case series study was conducted at 10 US hospitals of ophthalmology institutions from May 21, 2015, to May 7, 2019. Blood samples were collected 2 and 4 weeks after intravitreal bevacizumab injection. Participants included 83 premature infants with type 1 ROP in 1 or both eyes and no previous ROP treatment. Data were analyzed from April 2017 to August 2021.

Interventions

Study eyes received a single bevacizumab injection of 0.250 mg, 0.125 mg, 0.063 mg, 0.031 mg, 0.016 mg, 0.008 mg, 0.004 mg, or 0.002 mg. When the fellow eye required treatment, one dose higher was administered. Total dose administered at baseline was defined as the sum of doses given to each eye within 3 days of initial study-eye injection.

Main Outcomes and Measures

Plasma bevacizumab concentration at 2 and 4 weeks after injection and the percentage change in plasma VEGF concentrations from pretreatment levels.

Results

A total of 83 infants (mean [SD] age, 25 [2] weeks; 48 boys [58%]) were included in this study. Higher doses of bevacizumab administered at baseline were associated with higher plasma bevacizumab concentrations at 2 weeks (ρ, 0.53; 95% CI, 0.31-0.70) and 4 weeks (ρ, 0.44; 95% CI, 0.18-0.64). Plasma VEGF concentrations decreased by 50% or more from pretreatment levels in 40 of 66 infants (61%) at 2 weeks and 31 of 61 infants (51%) at 4 weeks, but no association was observed between the total dose of bevacizumab administered at baseline and percentage change in plasma VEGF concentrations 2 weeks (ρ, -0.04; 95% CI, -0.28 to 0.20) or 4 weeks (ρ, -0.17; 95% CI, -0.41 to 0.08) after injection.

Conclusions and Relevance

Results of this phase 1 dose de-escalation case series study revealed that bevacizumab doses as low as 0.002 mg were associated with reduced plasma VEGF levels for most infants at 2 and 4 weeks after intravitreal administration; however, no association was observed between total bevacizumab dose administered and reductions in plasma VEGF levels from preinjection to 2 weeks or 4 weeks. Additional studies are needed to evaluate the long-term effects of low-dose bevacizumab on neurodevelopment and retinal structure.

Reactive infectious mucocutaneous eruption – repeat etanercept after intravenous immunoglobulin: A case report

Reactive infectious mucocutaneous eruption is a recently distinguished mucosal-predominant blistering eruption triggered by respiratory infections. We describe a previously healthy 11-year-old Black female with rapidly progressive mucocutaneous blistering after prodromal respiratory infection symptoms. Reactive infectious mucocutaneous eruption was suspected and treated with systemic corticosteroids followed by etanercept. Twenty-four hours after etanercept, the diagnosis of multisystem inflammatory syndrome in children was raised and intravenous immunoglobulin was given. Rapidly worsening mucocutaneous disease ensued but was controlled by a second dose of etanercept. Our case highlights the following: (1) the novel observation of possible interaction/neutralization of etanercept by intravenous immunoglobulin, (2) the challenging differential diagnosis of multisystem inflammatory syndrome in children for reactive infectious mucocutaneous eruption patients in the Coronavirus disease 2019 (COVID-19) pandemic, and (3) the role of early treatment to prevent dyspigmentation.

Postoperative glaucoma following infantile cataract surgery: an individual patient data meta-analysis

IMPORTANCE

Infantile cataract surgery bears a significant risk for postoperative glaucoma, and no consensus exists on factors that may reduce this risk.

OBJECTIVE

To assess the effect of primary intraocular lens implantation and timing of surgery on the incidence of postoperative glaucoma.

DATA SOURCES

We searched multiple databases to July 14, 2013, to identify studies with eligible patients, including PubMed, MEDLINE, EMBASE, ISI Web of Science, Scopus, Central, Google Scholar, Intute, and Tripdata. We also searched abstracts of ophthalmology society meetings.

STUDY SELECTION

We included studies reporting on postoperative glaucoma in infants undergoing cataract surgery with regular follow-up for at least 1 year. Infants with concurrent ocular anomalies were excluded.

DATA EXTRACTION AND SYNTHESIS

Authors of eligible studies were invited to contribute individual patient data on infants who met the inclusion criteria. We also performed an aggregate data meta-analysis of published studies that did not contribute to the individual patient data. Data were pooled using a random-effects model.

MAIN OUTCOMES AND MEASURES

Time to glaucoma with the effect of primary implantation, additional postoperative intraocular procedures, and age at surgery.

RESULTS

Seven centers contributed individual patient data on 470 infants with a median age at surgery of 3.0 months and median follow-up of 6.0 years. Eighty patients (17.0%) developed glaucoma at a median follow-up of 4.3 years. Only 2 of these patients had a pseudophakic eye. The risk for postoperative glaucoma appeared to be lower after primary implantation (hazard ratio [HR], 0.10 [95% CI, 0.01-0.70]; P = .02; I(2) = 34%), higher after surgery at 4 weeks or younger (HR, 2.10 [95% CI, 1.14-3.84]; P = .02; I(2) = 0%), and higher after additional procedures (HR, 2.52 [95% CI, 1.11-5.72]; P = .03; I(2) = 32%). In multivariable analysis, additional procedures independently increased the risk for glaucoma (HR, 2.25 [95% CI, 1.20-4.21]; P = .01), and primary implantation independently reduced it (HR, 0.10 [95% CI, 0.01-0.76]; P = .03). Results were similar in the aggregate data meta-analysis that included data from 10 published articles.

CONCLUSIONS AND RELEVANCE

Although confounding factors such as size of the eye and surgeon experience are not accounted for in this meta-analysis, the risk for postoperative glaucoma after infantile cataract surgery appears to be influenced by the timing of surgery, primary implantation, and additional intraocular surgery.

Acute infectious conjunctivitis in childhood

OBJECTIVE

To review the etiology, clinical features and management of acute infectious conjunctivitis in children after the newborn period.

DATA SOURCES

Articles obtained from MEDLINE published before March 2000.

DATA SELECTION AND EXTRACTION

Representative articles on the etiology and clinical features were selected. Twenty-four clinical trials were also selected. From these articles, the main findings from three placebo controlled trials and two comparative clinical trials involving children are summarized in detail. The main findings from 19 comparative clinical trials in adults are briefly summarized.

DATA SYNTHESIS AND CONCLUSIONS

Acute infectious conjunctivitis caused by bacteria or viruses is a very common problem in children after the neonatal period. The most common bacterial pathogens are nontypable Haemophilus influenzae and Streptococcus pneumoniae. Diagnostic microbiology tests are not indicated for uncomplicated cases but may be useful for very young or very ill children if there is no response to initial therapy; for nosocomial cases; for cases suspected to be caused by sexually transmitted pathogens; and for outbreaks. Conjunctivitis is usually a mild, self-limited disease, but topical antibiotics are superior to placebo in reducing the duration and severity of symptoms. Most topical agents have equivalent efficacy; therefore, the selection of first-line agents should include inexpensive drugs with few adverse effects. Good choices include polymyxin/gramicidin, polymyxin/trimethoprim or sulfacetamide. Referral to an ophthalmologist should be considered in situations in which the diagnosis of uncomplicated conjunctivitis is in doubt or if there is no prompt response to therapy.

Effect of age on response to amblyopia treatment in children

OBJECTIVE

To determine whether age at initiation of treatment for amblyopia influences the response among children 3 to less than 13 years of age with unilateral amblyopia who have 20/40 to 20/400 amblyopic eye visual acuity.

METHODS

A meta-analysis of individual subject data from 4 recently completed randomized amblyopia treatment trials was performed to evaluate the relationship between age and improvement in logMAR amblyopic eye visual acuity. Analyses were adjusted for baseline amblyopic eye visual acuity, spherical equivalent refractive error in the amblyopic eye, type of amblyopia, prior amblyopia treatment, study treatment, and protocol. Age was categorized (3 to <5 years, 5 to <7 years, and 7 to <13 years) because there was a nonlinear relationship between age and improvement in amblyopic eye visual acuity.

RESULTS

Children from 7 to less than 13 years of age were significantly less responsive to treatment than were younger age groups (children from 3 to <5 years of age or children from 5 to <7 years of age) for moderate and severe amblyopia (P < .04 for all 4 comparisons). There was no difference in treatment response between children 3 to less than 5 years of age and children 5 to less than 7 years of age for moderate amblyopia (P = .67), but there was a suggestion of greater responsiveness in children 3 to less than 5 years of age compared with children 5 to less than 7 years of age for severe amblyopia (P = .09).

CONCLUSIONS

Amblyopia is more responsive to treatment among children younger than 7 years of age. Although the average treatment response is smaller in children 7 to less than 13 years of age, some children show a marked response to treatment.

Laser-assisted subepithelial keratectomy and photorefractive keratectomy for post-penetrating keratoplasty myopia and astigmatism in adults

PURPOSE

To evaluate whether laser-assisted subepithelial keratectomy (LASEK) and photorefractive keratectomy (PRK) achieve effective targeted correction and the extent of post-treatment corneal haze after corneal transplantation.

SETTING

Nonhospital surgical facility, Calgary, Alberta, Canada.

DESIGN

Evidence-based manuscript.

METHODS

This study evaluated visual acuity, refractive error correction, and potential complications after LASEK or PRK to eliminate refractive error differences after penetrating keratoplasty in adults. A Nidek EC-5000 or Technolas 217 excimer laser was used in all treatments.

RESULTS

At last follow-up (mean 20.50 months post laser), the mean spherical equivalent (SE) decreased from -2.71 diopters (D) ± 4.17 (SD) to -0.54 ± 3.28 D in the LASEK group and from -4.87 ± 3.90 D to -1.82 ± 3.34 D in the PRK group. The mean preoperative uncorrected distance visual acuity (UDVA) was 1.63 ± 0.53 and 1.45 ± 0.64, respectively, and the mean postoperative UDVA, 0.83 ± 0.54 and 0.90 ± 0.55, respectively. The improvement in SE and UDVA was statistically significant in both groups (P < .01). The mean haze (0 to 3 scale) at the last follow-up was 0.46 ± 0.708 in the LASEK group and 0.58 ± 0.776 in the PRK group.

CONCLUSIONS

The UDVA improved and refractive errors were effectively reduced after LASEK or PRK in eyes with previous PKP. There was no significant difference in the change in SE, UDVA, or corrected distance visual acuity between LASEK and PRK. Some patients had evidence of corneal haze, although the difference between the groups was not significant.

Survey on allied health personnel in Canadian ophthalmology: the scalpel for change

OBJECTIVE

To determine the recruiting and training needs for ophthalmic medical personnel (OMP), assess the value of their certification, and compare the ophthalmic practice productivity and performance of non-certified and certified OMP, as rated by both ophthalmologists and OMP.

DESIGN

Comparative analysis.

PARTICIPANTS

One hundred and sixteen Canadian ophthalmologists and 98 OMP.

METHODS

An invitation to complete an online survey on OMP recruitment, training, certification, and productivity performance in a clinical setting was sent to 1081 ophthalmologists and OMP.

RESULTS

Fifteen percent of ophthalmologists and 31% of OMP completed the survey. Ophthalmologists (61%) reported difficulty hiring OMP; employee referrals was the best method (40%). Awareness of formal OMP training programs was high and 50% of respondents supported developing additional training programs; 55% of OMP were encouraged by their employers to obtain certification. Personal challenge and achievement (79%) and improved skills (71%) were the main reasons for OMP to obtain certification. The majority of OMP and ophthalmologists felt that certified OMP enhanced most practice productivity measures. Higher wages associated with certification were reported by 73% of respondents.

CONCLUSIONS

Training of qualified OMP was identified as a need by ophthalmologists. Ophthalmic practices can increase their overall productivity by adding certified OMP to their staff.

Monocular oral reading performance after amblyopia treatment in children

PURPOSE

To evaluate the monocular oral reading rate, accuracy, fluency, and comprehension in 10-year-old children previously treated for amblyopia.

DESIGN

Prospective, observational case series.

METHODS

Seventy-nine children (mean age, 10.3 years) previously treated in a multicenter randomized trial comparing patching and atropine were tested at seven sites using a modification of the Gray Oral Reading Test, Fourth Edition (GORT-4).

RESULTS

The mean visual acuities (VA) in the amblyopic and fellow eyes at the time of the reading assessment were 0.17 logarithm of the minimum angle of resolution (logMAR) units (approximately 20/32) and -0.03 logMAR units (approximately 20/20), respectively. Compared with the sound eye, amblyopic eye performance was worse when reading orally with respect to rate (P < .001), accuracy (P = .03), and fluency (P < .001). Reading comprehension scores were similar with the amblyopic and fellow eyes (P = .45). Similar results were found with respect to original treatment group assignment (atropine or patching). There was a modest correlation between interocular difference (IOD) of VA at age 10 years and IOD in reading rate (r = 0.37; 95% confidence interval [CI], 0.18 to 0.56) and fluency (r = 0.28; 95% CI, 0.08 to 0.49). There was no correlation between the IOD in VA and IOD in accuracy (r = 0.08; 95% CI, -0.14 to 0.30) or comprehension (r = 0.16; 95% CI, -0.05 to 0.37).

CONCLUSIONS

The monocular oral reading ability when measured with the GORT-4 was slightly worse when reading with previously treated amblyopic eyes compared with fellow eyes in terms of rate, accuracy, and fluency, but reading comprehension testing was similar.

A randomized trial of atropine vs patching for treatment of moderate amblyopia: follow-up at age 10 years

OBJECTIVE

To determine the visual acuity outcome at age 10 years for children younger than 7 years when enrolled in a treatment trial for moderate amblyopia.

METHODS

In a multicenter clinical trial, 419 children with amblyopia (visual acuity, 20/40-20/100) were randomized to patching or atropine eyedrops for 6 months. Two years after enrollment, a subgroup of 188 children entered long-term follow-up. Treatment after 6 months was at the discretion of the investigator; 89% of children were treated.

MAIN OUTCOME MEASURE

Visual acuity at age 10 years with the electronic Early Treatment Diabetic Retinopathy Study test.

APPLICATION TO CLINICAL PRACTICE

Patching and atropine eyedrops produce comparable improvement in visual acuity that is maintained through age 10 years.

RESULTS

The mean amblyopic eye acuity, measured in 169 patients, at age 10 years was 0.17 logMAR (logarithm of the minimum angle of resolution) (approximately 20/32), and 46% of amblyopic eyes had an acuity of 20/25 or better. Age younger than 5 years at entry into the randomized trial was associated with a better visual acuity outcome (P < .001). Mean amblyopic and sound eye visual acuities at age 10 years were similar in the original treatment groups (P = .56 and P = .80, respectively).

CONCLUSIONS

At age 10 years, the improvement of the amblyopic eye is maintained, although residual amblyopia is common after treatment initiated at age 3 years to younger than 7 years. The outcome is similar regardless of initial treatment with atropine or patching.

Treatment of strabismic amblyopia with refractive correction

PURPOSE

To report data on the response of previously untreated strabismic amblyopia to spectacle correction.

DESIGN

Prospective, interventional case series.

METHODS

Twelve patients with previously untreated strabismic amblyopia were prescribed spectacles and examined at five-week intervals until visual acuity was not improved from the prior visit.

RESULTS

Amblyopic eye acuity improved by 2 lines or more from spectacle-corrected baseline acuity in nine of the 12 patients (75%), resolving in three (interocular difference <or=1 line). Mean change from baseline to maximum improvement was 2.2 +/- 1.8 lines. Improvement continued for up to 25 weeks.

CONCLUSIONS

These results support the suggestion from a prior study that strabismic amblyopia can improve and even resolve with spectacle correction alone. Larger studies with concurrent controls are needed to confirm or refute these findings.

Paediatric pseudophakia: analysis of intraocular lens power and myopic shift

BACKGROUND

At the Alberta Children's Hospital, the authors have been performing paediatric cataract extraction with intraocular lens (IOL) implant for over 10 years. The authors examined the amount of myopic shift that occurs in various age groups and cataract types, in order to evaluate the success of predicting the appropriate power of IOL to implant.

METHODS

This study is a retrospective review children undergoing small incision posterior chamber foldable IOL implantation between age 1 month and 18 years, from 1995 to 2005. 163 eyes of 126 patients underwent surgery. All patients were followed for a minimum of 6 months postoperatively. The children were divided into four groups at time of surgery: Group A: 1-24 months, Group B: 25-48 months, Group C: 49-84 months, Group D: 85 months-18 years.

RESULTS

The mean target refraction for the groups were: Group A: +6.37 D, Group B: +4.66 D, Group C: +1.95 D, and Group D: +0.97 D. Children under 4 years experienced the most myopic shift and the largest mean rate of refractive change per year. Mean change Group A: -5.43 D, Group B: -4.16 D, Group C: -1.58 D, Group D: -0.71 D. Eighty-nine per cent of patients with unilateral cataracts had a postoperative refraction within 3.00 D of the fellow eye at last follow-up visit (mean=3.16 years).

CONCLUSIONS

The rate of myopic shift is high in children under age 4 years at time of surgery, shifting as much as -12.00 D. The mean postoperative target refraction should probably be increased from previous literature recommendations. The patient's age at time of cataract surgery and the refractive power of fellow eye are all factors to consider when deciding what power IOL to surgically implant in a paediatric patient.

Trachoma control in Southern Zambia--an international team project employing the SAFE strategy

PURPOSE

To determine the prevalence of trachoma and to measure the impact of the SAFE strategy (World Health Organization GET 2020 strategy) for treating trachoma in the Gwembe District of Southern Zambia.

DESIGN

This is an observational study of the introduction of the SAFE strategy employing a collaborative approach and its impact on trachoma in the area.

PARTICIPANTS

Three thousand eight hundred ninety two persons in communities at 26 well sites in the Gwembe district of Southern Zambia were included in this study.

METHODS

New, clean water wells were drilled under local supervision for each of 26 identified villages. All people living in villages near the wells were screened for trachoma and then treated with antibiotic if required. Education on personal and environmental hygiene was provided by trained volunteers. Patients affected by trichiasis and corneal scarring received surgery, locally if possible. Attempts to control fly populations by cleaning villages, penning livestock, and digging latrines were undertaken. This was performed under advisement and consultation with local villagers and government officials. Data was collected on variables normally associated with trachoma and others relating to demographics, water quality, environment and hygiene.

MAIN OUTCOME MEASURES

Prevalence of trachoma in the area at two years post introduction of SAFE strategy.

RESULTS

The overall prevalence of trachoma in the area was 47% in 2001; however, the prevalence was 55% among children under 10 years. At two years post intervention, the overall prevalence of trachoma reduced to 7.6%, and decreased to 10.6% in children under 10 years, and 5.9% among adults.

CONCLUSIONS

Continued monitoring and risk factors will need to continue to be addressed in order to sustain this trachoma control project in this area of Zambia.

Treatment of anisometropic amblyopia in children with refractive correction

OBJECTIVE

To evaluate the effectiveness of refractive correction alone for the treatment of untreated anisometropic amblyopia in children 3 to <7 years old.

DESIGN

Prospective, multicenter, noncomparative intervention.

PARTICIPANTS

Eighty-four children 3 to <7 years old with untreated anisometropic amblyopia ranging from 20/40 to 20/250.

METHODS

Optimal refractive correction was provided, and visual acuity (VA) was measured with the new spectacle correction at baseline and at 5-week intervals until VA stabilized or amblyopia resolved.

MAIN OUTCOME MEASURES

Maximum improvement in best-corrected VA in the amblyopic eye and proportion of children whose amblyopia resolved (interocular difference of < or =1 line) with refractive correction alone.

RESULTS

Amblyopia improved with optical correction by > or =2 lines in 77% of the patients and resolved in 27%. Improvement took up to 30 weeks for stabilization criteria to be met. After stabilization, additional improvement occurred with spectacles alone in 21 of 34 patients observed in a control group of a subsequent randomized trial, with amblyopia resolving in 6. Treatment outcome was not related to age, but was related to better baseline VA and lesser amounts of anisometropia.

CONCLUSION

Refractive correction alone improves VA in many cases and results in resolution of amblyopia in at least one third of 3- to <7-year-old children with untreated anisometropic amblyopia. Although most cases of resolution occur with moderate (20/40-20/100) amblyopia, the average 3-line improvement in VA resulting from treatment with spectacles may lessen the burden of subsequent amblyopia therapy for those with denser levels of amblyopia.

A randomized trial to evaluate 2 hours of daily patching for strabismic and anisometropic amblyopia in children

OBJECTIVE

To compare 2 hours of daily patching (combined with 1 hour of concurrent near visual activities) with a control group of spectacle wear alone (if needed) for treatment of moderate to severe amblyopia in children 3 to 7 years old.

DESIGN

Prospective randomized multicenter clinical trial (46 sites).

PARTICIPANTS

One hundred eighty children 3 to 7 years old with best-corrected amblyopic-eye visual acuity (VA) of 20/40 to 20/400 associated with strabismus, anisometropia, or both who had worn optimal refractive correction (if needed) for at least 16 weeks or for 2 consecutive visits without improvement.

INTERVENTION

Randomization either to 2 hours of daily patching with 1 hour of near visual activities or to spectacles alone (if needed). Patients were continued on the randomized treatment (or no treatment) until no further improvement was noted.

MAIN OUTCOME MEASURE

Best-corrected VA in the amblyopic eye after 5 weeks.

RESULTS

Improvement in VA of the amblyopic eye from baseline to 5 weeks averaged 1.1 lines in the patching group and 0.5 lines in the control group (P = 0.006), and improvement from baseline to best measured VA at any visit averaged 2.2 lines in the patching group and 1.3 lines in the control group (P<0.001).

CONCLUSION

After a period of treatment with spectacles, 2 hours of daily patching combined with 1 hour of near visual activities modestly improves moderate to severe amblyopia in children 3 to 7 years old.

Refractive laser surgery in children with coexisting medical and ocular pathology

PURPOSE

To report the visual, refractive, and functional outcomes of photorefractive keratectomy (PRK) and of laser-assisted subepithelial keratectomy in a group of children with significant refractive error and underlying medical conditions or ocular pathology who were noncompliant with traditional management.

SETTING

Nonhospital surgical facility and a hospital clinic.

METHODS

This case series comprised 5 individual cases of anisometropic amblyopia and/or high myopia. Underlying medical and ocular conditions were as follows: upper eyelid hemangioma with oblique myopic astigmatism, Pelizaeus-Merzbacher leukodystrophy with nystagmus, Klippel-Trenaunay-Weber syndrome with glaucoma, incontinentia pigmenti with unilateral optic nerve atrophy, and Goldenhar syndrome with unilateral optic nerve hypoplasia. Photorefractive keratectomy or LASEK was performed in 6 eyes of 5 patients. Age range at the time of surgery was 1.0 to 7.0 years. All procedures were performed under general anesthesia.

RESULTS

Best corrected visual acuity improved by 2 lines in 2 patients and 1 line in 2 patients by 6 months after surgery. Stereopsis and/or fusional status improved in 3 patients. Amblyopia treatment compliance improved in 1 patient. Alignment improved without strabismus surgery in 2 cases. A functional vision survey demonstrated a positive effect on the ability of all 5 children to function in their environment.

CONCLUSION

During the period of visual cortical plasticity, refractive surgery, by eliminating the refractive component of amblyopia and by promoting fusional ability, provides considerable improvement in children, even those with underlying medical conditions associated with ocular pathology.

Laser-assisted subepithelial keratectomy in children

PURPOSE

To evaluate whether laser-assisted subepithelial keratectomy (LASEK) achieves effective targeted myopic correction with less post-treatment corneal haze than observed with photorefractive keratectomy (PRK) in children who fail traditional forms of treatment for myopic anisometropic amblyopia and high myopia.

SETTING

Nonhospital surgical facility with follow-up in a hospital clinic setting.

METHODS

This prospective study comprised 36 eyes of 25 patients. The mean patient age at treatment was 8.27 years (range 1.0 to 17.4 years). Patients were divided into 3 groups: those with myopic anisometropic amblyopia (13 patients/13 eyes), those with bilateral high myopia (11 patients/22 eyes), and those with high myopia post-penetrating keratoplasty (1 patient/1 eye). All patients were treated with LASEK under general anesthesia using the Visx 20/20 B excimer laser and a multizone, multipass ablation technique. Although the myopia was as high as -22.00 diopters (D) spherical equivalent (SE) in some eyes, no eye was treated for more than -19.00 D SE.

RESULTS

At 1 year, the mean SE decreased from -8.03 D to -1.19 D. Forty-four percent of eyes were within +/-1.0 D of the targeted correction; 78% of eyes had clear corneas with no haze. In the entire group, the mean best corrected visual acuity improved from 20/80 to 20/50. A functional-vision survey demonstrated a positive effect on the patients' ability to function in their environments after LASEK.

CONCLUSIONS

Laser-assisted subepithelial keratectomy in children represents another method of providing long-term resolution of bilateral high myopia and myopic anisometropic amblyopia with minimal post-laser haze. The reduction in post-laser haze with LASEK compared to that with the standard PRK technique may represent an advantage in treating these complex patients.

Risk of amblyopia recurrence after cessation of treatment

BACKGROUND

Although amblyopia can be successfully treated with patching or atropine, there have been few prospective studies of amblyopia recurrence once treatment is discontinued.

METHODS

We enrolled 156 children with successfully treated anisometropic or strabismic amblyopia (145 completed follow-up), who were younger than 8 years of age and who received continuous amblyopia treatment for the previous 3 months (prescribed at least 2 hours of daily patching or prescribed at least one drop of atropine per week) and who had improved at least 3 logMAR levels during the period of continuous treatment. Patients were followed off treatment for 52 weeks to assess recurrence of amblyopia, defined as a 2 or more logMAR level reduction of visual acuity from enrollment, confirmed by a second examination. Recurrence was also considered to have occurred if treatment was restarted because of a nonreplicated 2 or more logMAR level reduction of visual acuity.

RESULTS

Recurrence occurred in 35 (24%) of 145 cases (95% confidence interval 17% to 32%) and was similar in patients who stopped patching (25%) and in patients who stopped atropine (21%). In patients treated with moderately intense patching (6 to 8 hours per day), recurrence was more common (11 of 26; 42%) when treatment was not reduced prior to cessation than when treatment was reduced to 2 hours per day prior to cessation (3 of 22; 14%, odds ratio 4.4, 95% confidence interval 1.0 to 18.7).

CONCLUSIONS

Approximately one fourth of successfully treated amblyopic children experience a recurrence within the first year off treatment. For patients treated with 6 or more hours of daily patching, our data suggest that the risk of recurrence is greater when patching is stopped abruptly rather than when it is reduced to 2 hours per day prior to cessation. A randomized clinical trial of no weaning versus weaning in successfully-treated amblyopia is warranted to confirm these observational findings.

Telemedicine approach to screening for severe retinopathy of prematurity: a pilot study

PURPOSE

To evaluate the use of remote reading of digital retinal photographs in the diagnosis of severe (referral-warranted) retinopathy of prematurity (ROP) during longitudinal screening for ROP.

STUDY DESIGN

Prospective, longitudinal cohort study.

SUBJECTS

Forty-four consecutive premature infants at risk for ROP.

METHODS

All infants were examined longitudinally, over a series of examinations, by indirect ophthalmoscopy (gold standard) and digital photography using the RetCam-120 Digital Retinal Camera (Massie Research Laboratories Inc., Dublin, CA) equipped with an ROP lens. Images were stored and read remotely by a masked reader. Referral-warranted ROP was defined as ROP in zone 1, the presence of plus disease or the presence of any stage 3 ROP. We determined whether and when referral-warranted ROP was diagnosed for each eye, of each infant, on each examination, during the course of each of the infant's screening.

RESULTS

Severe (referral-warranted) ROP was diagnosed in 23 eyes by indirect ophthalmoscopy during their series of examinations. Digital photography had a sensitivity of 100% and a specificity of 96% in detecting referral-warranted ROP. The positive predictive value of digital photography was 92%, and the negative predictive value was 100%. In 87% of eyes, referral-warranted ROP was diagnosed by digital photography before or at the same time as indirect ophthalmoscopy.

CONCLUSIONS

Longitudinal remote reading of digital photographs using the RetCam-120 system has excellent specificity and sensitivity in detecting referral-warranted ROP. This pilot study has shown that remote reading of digital photographs has promise for telemedicine strategies in ROP screening.

Congenital absence of the inferior rectus muscle--diagnosis and management

BACKGROUND

Congenital absence of the inferior rectus muscle is a rare cause of apparent inferior rectus palsy especially in the absence of associated cranial facial anomalies.

METHODS

We report three cases of isolated congenital absence of the inferior rectus muscle and its successful surgical management.

RESULTS

Failure of the normal embryologic development of the mesodermal complex around the eye can lead to agenesis of the extraocular muscles. In apparent palsies of the inferior rectus muscle and no definite cause, a high index of suspicion and orbital imaging can confirm the diagnosis of congenitally absent inferior rectus preoperatively. Surgical correction may involve inferior transposition of the horizontal rectus muscles.

CONCLUSIONS

Although rare, congenital absence of the inferior rectus muscle is a possible cause of apparent inferior rectus muscle palsy particularly in the absence of another identifiable cause. Strabismus surgery in conjunction with intramuscular botulinum toxin injection can offer significant improvement in function and cosmesis of these patients.

Photorefractive keratectomy in children

PURPOSE

To evaluate photorefractive keratectomy (PRK) in pediatric patients who fail traditional methods of treatment for myopic anisometropic amblyopia and high myopia.

SETTING

Nonhospital surgical facility with follow-up in a hospital clinic setting.

METHODS

Photorefractive keratectomy was performed in 40 eyes of 27 patients. The patients were divided into 4 groups based on the type of myopia: myopic anisometropic amblyopia (15 eyes/13 patients), bilateral high myopia (20 eyes/10 patients), high myopia post-penetrating keratoplasty (3 eyes/2 patients), and combined corneal scarring and anisometropic amblyopia (2 eyes/2 patients). All procedures were performed under general anesthesia using the VISX 20/20 B laser and a multizone, multipass ablation technique. Appropriate corneal fixation was achieved with appropriate head positioning (turn and tilt) and an Arrowsmith fixation ring. Myopia was as high as -25.00 diopter (D) spherical equivalent (SE), but no treatment was for more than -17.50 D SE.

RESULTS

The mean SE decreased from -10.68 D to -1.37 D at 1 year, a mean change of -9.31 D. At 1 year, the mean best corrected visual acuity improved from 20/70 to 20/40 in the entire group. Forty percent of eyes were within +/-1.0 D of the targeted refraction. There was no haze in 59.5% of eyes. Three eyes initially had 3+ haze; 1 improved to 2+ and 2 required repeat PRK with significant haze reduction. Five eyes (3 patients) with greater than -17.00 D SE myopia before PRK (range -17.50 to -25.00 D) had 3.42 D more effect than predicted (range 0.50 to 5.50 D). A functional vision survey demonstrated a positive effect on the children's ability to function in their environments after the laser treatment.

CONCLUSION

Photorefractive keratectomy in children represents another method of providing long-term resolution of bilateral high myopia and myopic anisometropic amblyopia.

Multiple CYP1B1 mutations and incomplete penetrance in an inbred population segregating primary congenital glaucoma suggest frequent de novo events and a dominant modifier locus

Primary congenital glaucoma (PCG) is an autosomal recessive disorder associated with unknown developmental defect(s) in the anterior chamber. Recently, we reported three distinct mutations in CYP1B1, the gene for cytochrome P4501B1, in 25 Saudi families segregating PCG. For this report, we analyzed 37 additional families and confirmed the initial finding of decreased penetrance. Mutations and intragenic single-nucleotide polymorphisms (SNPs) were also analyzed from direct sequencing of all CYP1B1 coding exons. Eight distinct mutations were identified: G61E, R469W and D374N, the most common Saudi mutations, account for 72, 12 and 7%, respectively, of all the PCG chromosomes. Five additional homozygous mutations (two deletions and three missense mutations) were detected, each in a single family. Affected individuals from five families had no CYP1B1 coding mutations, and each family had a unique SNP profile. The identification of eight distinct mutations in a single gene, on four distinct haplotypes, suggests a relatively recent occurrence of multiple mutations in CYP1B1 in Saudi Arabia. These data demonstrate decreased penetrance of the PCG phenotype in the Saudi population, because 40 apparently unaffected individuals in 22 families have mutations and haplotypes identical to their affected siblings. Two individuals were subsequently diagnosed with glaucoma and two others had abnormal ocular findings that are consistent with milder forms of glaucoma. Analysis of these 22 kindreds suggests the presence of a dominant modifier locus that is not linked genetically to CYP1B1. Linkage and Southern analyses excluded three candidate modifier loci.

Anomalies of motion perception in infantile esotropia

PURPOSE

To quantify motion sensitivity in patients with infantile esotropia who, as a subgroup, have been previously reported to have abnormal oculomotor control. In addition, to probe abnormal binocular development as a factor underlying abnormal motion perception in infantile esotropia (IE), motion sensitivity was compared among participants with and without stereopsis.

METHODS

Monocular sensitivity to leftward and rightward motion was assessed across the horizontal meridian, using partially coherent random dot kinematograms. Participants included 11 observers with IE, 5 observers with acquired esotropia, and 11 observers with normal eye alignment.

RESULTS

Participants with IE showed no deficits in motion sensitivity to any visual field locations when motion thresholds were collapsed across direction. However, they showed an abnormal variation in directional anisotropy. Although sensitivity to centripetal motion was superior in both hemifields of control participants and in the temporal hemifields of participants with IE, a centrifugal bias was revealed in the nasal hemifields of IE. Stereoblind observers with acquired esotropia showed a normal centripetal directional anisotropy, whereas binocular observers with acquired esotropia showed directional anisotropy similar to that in the IE group.

CONCLUSIONS

Motion perception, like oculomotor function in IE, is characterized by a variation of directional anisotropy for stimuli presented to the nasal hemifields. This finding supports the hypothesis that abnormal oculomotor control and motion perception in IE reflect a common disruption of the visual system. A similar variation of directional sensitivity in patients with acquired esotropia with normal stereopsis suggests that the interruption of binocularity is not the underlying cause of abnormal motion perception in IE.

Mutations in CYP1B1, the gene for cytochrome P4501B1, are the predominant cause of primary congenital glaucoma in Saudi Arabia

The autosomal recessive disorder primary congenital glaucoma (PCG) is caused by unknown developmental defect(s) of the trabecular meshwork and anterior chamber angle of the eye. Homozygosity mapping with a DNA pooling strategy in three large consanguineous Saudi PCG families identified the GLC3A locus on chromosome 2p21 in a region tightly linked to PCG in another population. Formal linkage analysis in 25 Saudi PCG families confirmed both significant linkage to polymorphic markers in this region and incomplete penetrance, but it showed no evidence of genetic heterogeneity. For these 25 families, the maximum combined two-point LOD score was 15.76 at a recombination fraction of .021, with the polymorphic marker D2S177. Both haplotype analysis and homozygosity mapping in these families localized GLC3A to a 5-cM critical interval delineated by markers D2S2186 and D2S1356. Sequence analysis of the coding exons for cytochrome P4501B1 (CYP1B1) in these 25 families revealed three distinctive mutations that segregate with the phenotype in 24 families. Additional clinical and molecular data on some mildly affected relatives showed variable expressivity of PCG in this population. These results should stimulate a study of the genetic and environmental events that modify the effects of CYP1B1 mutations in ocular development. Furthermore, the small number of PCG mutations identified in this Saudi population makes both neonatal and population screening attractive public health measures.

A gene for primary congenital glaucoma is not linked to the locus on chromosome 1q for autosomal dominant juvenile-onset open angle glaucoma

BACKGROUND

Primary congenital glaucoma is an uncommon autosomal recessive condition that results from a developmental defect in the trabecular meshwork and anterior chamber angle, manifesting in the neonatal or infantile period with increased intraocular pressure, corneal enlargement and edema, and optic nerve cupping with consequent loss of vision. Nothing is known about its genetic location.

PATIENTS AND METHODS

Linkage analysis was performed in 25 primary congenital glaucoma Saudi Arabian families with six polymorphic DNA markers on chromosome 1q in a region that has shown tight linkage to a locus for autosomal dominant juvenile-onset open angle glaucoma (GLC1A). Twenty-four of these families are highly consanguineous.

RESULTS

Each family was shown separately to exclude the 8-centimorgan (cM) interval containing the GLC1A locus. Four families independently demonstrated overlapping regions of exclusion (theta < or = -2) that spanned the entire 8-cM interval. Assignment of a primary congenital glaucoma locus in this region could be excluded by a cadre of 21 families because a primary congenital glaucoma disease locus did not segregate in an autosomal recessive manner on haplotypes constructed with markers in this region. For all families, no affected individuals demonstrated homozygosity of alleles in regions tightly linked to the GLC1A locus.

CONCLUSION

These results exclude the 8-cM region on chromosome 1q shown to contain the GLC1A locus from containing a disease locus for primary congenital glaucoma in this population of 25 Saudi Arabian families.

Experiences in developing countries an ophthalmologist's "dream come true"

Images

Recession of the superior oblique tendon for inferior oblique palsy and Brown's syndrome

Superior oblique tendon recession of 12 to 14 mm was performed in five patients with inferior oblique muscle palsy and three patients with Brown's syndrome. The angle of deviation was decreased by an average of 18 prism dioptres in the worst field of gaze for the former group and by 17.3 delta for the latter group. As a secondary benefit of the procedure for the patients with inferior oblique palsy, any associated preoperative A-pattern was collapsed an average of 10 delta postoperatively. The procedure eliminated all abnormal head postures and improved versions and ductions for both groups. Symptoms of diplopia and torsion were resolved, and full fusional ability was maintained at preoperative levels in all fields of gaze for all patients. After an average follow-up period of 18 months none of the patients had manifested superior oblique palsy or other notable postoperative surgical complications. Theoretical advantages of superior oblique tendon recession include the potential for reversibility and reoperation if required, the possibility of asymmetric surgery and the potential to perform the procedure with an adjustable suture. The technique is an advantageous approach in the surgical treatment of these complicated cases.

Juvenile xanthogranuloma of the corneoscleral limbus

Juvenile xanthogranuloma presenting as an isolated corneoscleral lesion is rare. We report such a case in a 5-year-old boy who required lamellar sclerokeratectomy to the level of Descemet's membrane. Ten months after treatment by total excision and lamellar corneoscleral grafting with donor tissue there was no evidence of recurrence. We discuss the clinical and histologic features of this disorder, the differential diagnosis and treatment options.

Recession of the superior oblique tendon in A-pattern strabismus

We performed 9 to 12 mm of recession of the superior oblique tendon for A-pattern strabismus in 10 patients. The average preoperative A-pattern measured 29.4 prism dioptres (PD), and the average pattern correction was 29.3 PD. All patients had a residual pattern of 6 PD or less (average 2.3 PD). No patient experienced significant underaction of the superior oblique, and other surgical complications, such as ptosis, Brown's syndrome, and laceration of the vortex vein or superior rectus, did not occur. The procedure corrected 14 to 40 PD of A-pattern. The amount of pattern corrected was correlated with the size of the preoperative A-pattern but not with the total amount of recession done. No significant shift in esodeviation in primary position was noted in the patients who underwent only superior oblique recession. The procedure appears to be of particular value in patients with moderate superior oblique overaction. The advantages of recession of the superior oblique tendon include the potential for reversibility and reoperation, low risk of induced superior oblique palsy, allowance for asymmetric surgery and potential for adjustable suture technique.

Superior oblique and inferior rectus muscle injury following frontal and intranasal sinus surgery

Chronic inflammatory sinus disease is a common process, sometimes requiring nasal and paranasal sinus surgery. Extraocular muscle dysfunction is a rare surgical complication of sinus surgery, but has been reported. Previous studies have been concerned with trauma to the medial rectus muscle resulting in severe paralysis or restriction. This study reports five patients with acquired strabismus and symptomatic vertical diplopia secondary to sinus surgery. In all patients, the resultant diplopia was disabling. Four patients had frontal sinus window surgery performed, with incisions placed in the supero-nasal quadrant of the orbit, below the eyebrow (a modified Lynch incision). Three patients acquired a superior oblique paresis and the fourth developed a Brown's syndrome. The location of the skin incision was critical to injury in the trochlear area. The fifth patient underwent a nasal polypectomy and antrostomy with secondary orbital hemorrhage and proptosis. A mild inferior rectus paresis was the result.

Familial congenital fourth cranial nerve palsy

Few reports of hereditary transmission patterns in congenital superior oblique palsy have been made in the past. In this study, three families with congenital superior oblique palsies have been identified and examined. Two members of each family had a superior oblique palsy. After full history, eye examination, and sensory testing, the patterns in each family have been analyzed. Deviations varied from binocular fusion and orthophoria to large vertical deviations, especially in adduction. Sensory patterns were compatible with the congenital nature of the palsy. A discussion of possible causes for a congenital superior oblique palsy is offered and the congenital superior oblique palsies are analyzed. A definite genetic transmission pattern could not be found, but possible explanations are considered. Regardless of etiology, therapy for this problem is unchanged from that for all superior oblique palsies. Occurrences of congenital trochlear palsies in multiple family members should be considered when a patient with this problem is diagnosed.