Quality of life in adults with strabismus

Strabismus Surgery for Psychosocial Reasons-A Literature Review

Introduction

Strabismus surgery may be undertaken for visual benefit, to improve or eliminate diplopia symptoms, or to restore or improve binocular single vision (BSV). In patients without visual symptoms or expected visual benefit, strabismus surgery may still be undertaken if the presence of strabismus causes the patient psychosocial symptoms. To evaluate strabismus surgery undertaken for psychosocial reasons, evidence of postoperative outcomes in this specific cohort is needed.

Methods

A systematic search of the literature was conducted (1946-2023) to identify evidence where postoperative outcomes were reported for adult patients (age 18 years and above) who had undergone strabismus surgery for psychosocial reasons.

Results

Sixty-nine papers were included in the literature review. Most sources of evidence included patients within heterogeneous cohorts of strabismus surgery outcomes, with a range of symptoms and differing surgical aims.

Discussion

In adults who underwent strabismus surgery for psychosocial reasons, improved postoperative ocular alignment and/or improved health related quality of life (HRQoL) were common. Strabismus surgery outcomes appeared to be measured satisfactorily at three months postoperatively. Additional surgical outcomes, including an expanded field of vision, unexpected BSV, improved binocular summation, improved task performance and improved eye movements have been reported, but not fully investigated. There was a lack of consensus on how postoperative success should be defined and measured. A core outcome set for strabismus has been suggested and there is potential to add to the available evidence by investigating which outcome measures are most relevant to those with strabismus and psychosocial symptoms. There is a growing need for robust evidence in this specific subgroup of patients due to a lack of evidence specifically reporting postoperative outcomes in adults with strabismus and psychosocial symptoms.

Strabismus is more than a misalignment; a cross-sectional pilot study of HRQOL in Finnish strabismic adults referred to a university hospital

PURPOSE

To evaluate associations between the health-related quality of life (HRQOL) and demographic, self-reported strabismus-related and orthoptic status variables in Finnish strabismic adults.

METHODS

Participants (n = 137) of this study were adult patients who previously participated in the pilot study to translate and validate Adult Strabismus Questionnaire (AS-20) into Finnish. For this study, the participants' orthoptic status were collected among the previously obtained self-reported demographic and strabismus-related data. The refined AS-20 structure of 18 items and four subscales of self-perception, interaction, reading function and general function was used. Low scores on AS-20 indicate low HRQOL. The associations were evaluated with cross-tabulation and nonparametric methods of Mann-Whitney U and Kruskal-Wallis tests. Statistical significance was set at p < 0.05.

RESULTS

Interaction subscale scores were the highest of all subscale scores among the participants. Age had an association with HRQOL in self-perception and the youngest participants had the lowest scores. Importantly, participants who did not experience diplopia suffered from lower self-perception and interaction but reported higher scores on reading function and general function subscales compared to the participants who experienced diplopia. Exotropia with or without vertical strabismus were most common types among the participants. The education background was not associated with HRQOL.

CONCLUSION

Impacts of strabismus are similar in Finnish strabismic adults compared to international studies. Healthcare professionals and decision-makers should always consider the psychosocial impact of strabismus on patients without diplopia when making decisions on strabismus treatment and care processes.

Medical Student Perception of Strabismus in Race Implicit Association Test

PURPOSE

To determine whether the appearance of strabismus is noted in a race implicit association test by medical students.

METHODS

Medical students participated in a survey evaluating for the appearance of strabismus in photographs from a commonly used race implicit association test. Analysis was performed to determine whether strabismus was perceived equally between both groups tested.

RESULTS

Photographs of six individuals of African descent were perceived as having strabismus more frequently (62%) than photographs of individuals of European descent (31%; odds ratio: 3.85; 95% CI: 3.34 to 4.44; P < .0001). Participants who identified as Black or African American similarly perceived strabismus more frequently in individuals of African descent (58%) than those of European descent (24%; odds ratio: 4.36; 95% CI: 2.13 to 8.96; P < .0001).

CONCLUSIONS

Photographs used in a common race implicit association test appear to differ not only in ethnicity but also in extraocular alignment. Because extraocular alignment is a known cause of negative prejudice, results of this particular implicit association test should be interpreted with caution. [J Pediatr Ophthalmol Strabismus. 2023;60(5):372-376.].

Surgical outcomes following strabismus surgery for abducens nerve palsy

PURPOSE

To assess ocular alignment outcomes and their stability for patients who underwent strabismus surgery for abducens nerve palsy and to identify preoperative patient variables that predict surgical success or repeated surgeries.

METHODS

We retrospectively reviewed the medical records of patients diagnosed with abducens nerve palsy and who subsequently underwent strabismus surgery.

RESULTS

A total of 209 patients (386 procedures) were included. The mean number of surgeries for patients was 1.9 ± 1.4. Success was achieved after a single surgery for 112 patients (53.6%), and success was achieved for an additional 42 patients, for a total of 154 patients (73.7%), following all surgeries. Preoperative abduction deficit severity was the only variable predictive of surgical success, with mild deficits having the highest odds of both initial success (OR = 5.555; CI, 2.722-11.336) and final success (OR = 5.294; 95% CI, 1.931-14.512). When analyzing survival time until additional surgery, the median survival was 406 days; abduction deficit severity, older age, other coincidental motility abnormalities, greater magnitude esotropia, and surgical technique were predictive of repeat surgical incidence.

CONCLUSIONS

In our patient cohort, preoperative abduction deficit was an important predictor of both surgical success and repeat surgical incidence for abducens nerve palsy. Older patient age, additional motility abnormalities, and greater amounts of baseline strabismus were also associated with greater likelihood of multiple surgeries.

A review of patient-reported outcome measures used in uveitis

We review patient-reported outcome measures (PROMs) used to evaluate the quality of life (QoL) in uveitis and provide a quality assessment of the psychometric properties of the PROMs, making it easier to choose the best questionnaire for uveitis. Our review included 158 articles. A total of 98 PROMs were used to measure QoL in uveitis and the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ -25) was the most frequently used PROM in these studies. There were 5 uveitis-specific PROMs, but they were meant for either birdshot choroidopathy or cytomegalovirus retinitis or paediatric uveitis. There are no PROMs developed explicitly for the more common, anterior uveitis, intermediate uveitis, panuveitis, and chronic uveitis. The uveitis-specific PROMs performed better in our quality assessment criteria compared to other PROMs. However, these PROMs were constructed using traditional classical test theory and have not been assessed using the modern family of psychometric assessment methods such as Rasch analysis. As new therapeutic modalities for uveitis such as the new biological agents and steroid implants, continue to evolve, a comprehensive PROM will be increasingly valued in clinical trial settings to compare the effects of treatments from the patient's perspective.

Translation and transcultural adaptation of the AS-20 scale to measure quality of life in adults with strabismus in Colombia, a pilot study

BACKGROUND

Strabismus generates a negative psychosocial impact on adult patients, affecting aspects such as self-perception and quality of life. There is no scale in Colombian Spanish that measures these impacts.

OBJECTIVE

To carry out the translation and cross-cultural adaptation of the AS-20 instrument into Colombian Spanish.

MATERIALS AND METHODS

Pilot test of a cross-sectional Study for the translation, reverse translation, and cross-cultural the AS-20 instrument from its original language, English, to Colombian Spanish, in adult patients with strabismus in Bogotá, Colombia.

RESULTS

16 patients were assessed. The age range was between 18 and 68 years with a mean age of 41 years. The scale was answered in an average time of 10.62min. Difficulty was reported in three individuals for understanding two items (questions 8 and 14), which were resolved.

CONCLUSION

The translation and pilot test of AS-20 scale into Colombian Spanish was carried out, identifying and solving translational difficulties. Is the first step in the cross-cultural adaptation process. Based on the results, the validation and cross-cultural adaptation can be completed in a future study.

Health-Related Quality of Life in Adult Patients with Strabismus-Translation and Psychometric Testing of the Adult Strabismus Questionnaire (AS-20) into Finnish

(1) Strabismus has an impact on individuals' health-related quality of life. The impact should be assessed with valid patient-reported outcome measures such as the Adult Strabismus Questionnaire (AS-20). The AS-20 was further refined using a Rasch analysis for the American population. The aims of the study were to translate and culturally adapt the AS-20 into Finnish and to evaluate the psychometric properties of the Finnish AS-20. (2) The guidelines of the Professional Society for Health Economics and Outcomes Research steered the process and four items were added from the original data as Finnish additions. The construct and convergent validity and internal consistency were evaluated via psychometric testing for three potential Finnish AS-20 structures. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was applied. (3) The participants (n = 137) reported that the translation was clear and understandable. All structures showed high reliability and internal consistency as measured using Cronbach alpha values. The convergent validity assessed using Spearman's correlation coefficients between the structures and one item of Satisfaction with Life Scale indicated very low to moderate positive correlations. The construct validity evaluated using a confirmatory factor analysis revealed the refined AS-20 structure to be satisfactory. (4) The refined AS-20 can be used in clinical practice and research, but further validation is recommended.

Strabismus and amblyopia in Africa - a systematic review and meta-analysis

The objective of this review was to estimate the prevalence of strabismus and amblyopia in Africa. A systematic online literature search was conducted for articles on strabismus and amblyopia in Africa. Meta-analysis was performed, using the Freeman-Tukey double arcsine transformation, to estimate the prevalence of strabismus and amblyopia in Africa. Subgroup analyses were conducted according to age, gender, study year, and type of amblyopia. Meta-regression was used to evaluate the influence of predetermined factors on the prevalence of amblyopia. 8 (1 population-based & 7 school-based) and 21 (3 population-based & 18 school-based) studies on strabismus and amblyopia with sample sizes of 22,355 and 46,841, respectively, were included in the review. Overall prevalence of strabismus in Africa was estimated to be 0.8% (95% CI: 0.4% - 1.4%); exotropia was 0.2% (95% CI: 0.1% - 0.5%) and esotropia was 0.5% (95% CI: 0.1% - 1.2%). Overall prevalence of amblyopia was estimated to be 0.6% (95% CI: 0.3% - 0.9%); refractive and strabismic amblyopia were 1.1% (95% CI: 0.2% - 2.5%) and 0.4% (95% CI: 0.2% - 0.6%), respectively. Prevalence estimate of amblyopia in males was 1.8% (95% CI: 0.7% - 3.3%) and in females was 1.3% (95% CI: 0.4% - 2.6%). There was a significant association between the prevalence of amblyopia and the type of amblyopia (p = .007) and the study year (p = .006). Although there appears to be a relatively low prevalence of strabismus and amblyopia in Africa, there is a dearth of well-designed population-based studies on strabismus and amblyopia in Africa, resulting in the lack of epidemiological information on strabismus and amblyopia within the general African population. Information about the prevalence of strabismus and amblyopia across Africa can inform policy making and design and implementation of public health intervention program.

Development and 5-year Evaluation of Diagnosis-Specific Protocols for Visual Neuro-Rehabilitation in a Multicenter Inpatient Rehabilitation Network

Objective

To provide a retrospective evaluation of a new eye and vision rehabilitation care pathway in a U.S. multi-site inpatient rehabilitation network involving the occupational therapy (OT) staff and a consulting doctor of optometry (OD) specializing in vision rehabilitation.

Design

Retrospective study.

Setting

Two Inpatient Rehabilitation Facilities (IRFs) and 1 Long Term Acute Care Hospital (LTACH).

Participants

There were 2083 records reviewed (44% women, avg. age 59 years). The most common diagnoses were hemispatial neglect (19.2%), homonymous field defects (18.5%), and oculomotor cranial nerve palsies (16.7%) (N=2083).

Interventions

Clinical care was reviewed where diagnosis-specific protocols were developed and training was provided to OTs in order to reinforce OD-prescribed interventions during daily treatment sessions, including (1) third, fourth, and sixth ocular cranial nerve palsies (OCNPs) with prisms fitted for full time, postural adaptation training, and oculomotor re-education using pursuits, saccades, head-rotations, and binocular vision exercises including alternate cover and vergence; (2) homonymous hemianopia with training awareness of field loss, eccentric viewing, and fitting of Peli lens for optical field expansion; and (3) prism adaptation therapy (PAT) for left hemispatial neglect.

Main Outcome Measures

Frequency of diagnoses.

Hypothesis

Diagnoses with developed protocols were most common. Secondarily, feasibility and efficacy by anonymous OT survey.

Results

2083 vision consults were performed over 5 years. The most common diagnoses were hemispatial neglect (n=399, 19.2%), homonymous field defects (n=386, 18.5%), and OCNPs (n=347, 16.7%). None of the OTs reported the protocols were infeasible and 63% (IQR 38%-69%) reported their patients benefited from the interventions. The survey suggested prism for OCNPs helped in 42%, and Peli lens and PAT both helped in 38%.

Conclusions

Data support the feasibility of this inpatient eye and vision rehabilitation care pathway which may be used as a foundation for creating or refining similar programs elsewhere. Uniform administration of IRF-based visual neuro-rehabilitation care could provide a substrate for future clinical trials to evaluate efficacy.

Vision-related quality of life amongst patients with low vision and blindness in a resource-limited country

PURPOSE

To evaluate the significance of sociodemographic and clinical variables on the quality of life of low-vision patients in a tertiary hospital in Enugu, Nigeria, and also determine the causative ocular pathologies and their vision-related quality of life.

METHODS

A cross-sectional study of adults 18 years and above with low vision/blindness. They were consecutively enrolled and clinically evaluated. The WHO-NEI-VFQ-25 questionnaire for quality of life was administered. Descriptive statistics were used to summarize variables. Kruskal-Wallis test, analysis of variance, and post hoc tests were done where appropriate.

RESULTS

Of the 400 participants, 81% were above 40 years. Mean age was 57.27 ± 16.34 years. Males (52.0%) and females (48.0%). 225 (56.25%) had Moderately Severe Visual Impairment. Low vision/blindness negatively affected the different domains of quality of life significantly, except ocular pain and dependency. Glaucoma and Cataract were the major disease conditions that affected most of the domains significantly. These conditions when poorly managed, due to poor and limited health resources, progress to low vision/blindness. Of all the socio-demographic factors and clinical variables studied, only age and severity of low vision were significant predictors of quality of life.

CONCLUSION

There is the need for prompt and proper treatment of low-vision patients and advocacy for the establishment of adequate and functional rehabilitation services. Quality of life which measures the overall impact of a disease on an individual was low in people with low vision and blindness. Low-vision services, which include rehabilitation, will provide comprehensive eye-care services and thus improve their quality of life.

Ocular Manifestations in Primary Immunodeficiency Disorders: A Report From the United States Immunodeficiency Network (USIDNET) Registry

BACKGROUND

Few published studies address eye disease in primary immunodeficiency (PID) despite ocular infections and autoimmune disease being known manifestations of immunodeficient states.

OBJECTIVE

Data from the USIDNET Registry provide a resource to study ocular ailments in subjects with PID.

METHODS

Ocular manifestations and patient characteristics were determined using data from 4624 patients with PID enrolled in the US Immunodeficiency Network (USIDNET) Registry.

RESULTS

A total of 519 (11.2%) patients had recorded ocular diseases. Those with autoinflammatory disorders (n = 4 of 7 [57.1%]), intrinsic and innate immunity defects (n = 9 of 44 [20.5%]), and immune dysregulation (n = 27 of 142 [19.0%]) had the highest percentage of ocular diseases for the PID diagnosis category. Of the 67.6% with infections, 85.5% had conjunctivitis. Bacteria (56.2%) and viruses (27.4%) were the most common microorganisms reported, with Staphylococcus (31.7%), Haemophilus (26.8%), and Streptococcus (22.0%) being the most common bacteria isolated. Those with a history of eye infections had lower immunoglobulin levels, lower CD19 B-cell percentages, and a lower number of protective pneumococcal titers. In patients with noninfectious ocular complications, 30.8% had vision changes, with retina (n = 20 [8.0%]), cataract (n = 16 [6.4%]), and nerve diseases (n = 16 [6.4%]) also being common. Many patients with ocular disease had serious sequelae, with 12.7% undergoing eye surgery and 10.6% having a vision-based disability.

CONCLUSIONS

Vision loss and conjunctivitis were the most commonly reported ocular complications and pose large quality-of-life issues. Learning more about ocular disease in PID will increase awareness about the importance of addressing and evaluating for these ailments.

Outcomes and risk factors of surgical management of thyroid eye disease-related diplopia

OBJECTIVES

To evaluate the outcomes of strabismus surgery in patients with thyroid eye disease (TED) and to assess the influence of preceding treatments such as steroid administration, orbital decompression and radiotherapy.

METHODS

Retrospective study on a cohort of patients with TED undergoing strabismus surgery. Data collection included clinical features, smoking status, preceding steroid therapy, orbital radiation therapy and orbital decompression. Qualitative evaluation, assessing diplopia and quality of life and quantitative evaluation, assessing the eye misalignment were analysed 1 year after the last squint surgical procedure.

RESULTS

Seventy-nine patients were identified. Ninety-five surgical procedures were performed on 92 eyes. A significant overall improvement of ocular motility was registered (p < 0.001, paired t-test). Forty-five (57%) patients had excellent outcomes, twenty-three (29%) had good outcomes and eleven (14%) had poor outcomes. The average number of muscles operated was significantly greater in patients who underwent orbital bone decompression (1.58 ± 0.63; p = 0.0082; 95% CI 1.413-10.214). Quantitative and qualitative outcomes were not associated with the preceding therapy: steroid (p = 0.75), radiotherapy (p = 0.95) or orbital bone decompression (p = 0.25). The success rate was no different between adjustable and fixed sutures (p = 0.8).

CONCLUSION

Strabismus surgery in TED patients resulted in a high success rate in reducing diplopia and improving ocular motility. The success rate was not negatively associated with previous therapies. Indeed, resolution of diplopia required more squint procedures in patients who have previously undergone to orbital decompression.

Psychosocial needs of Spanish schoolchildren with visual impairment: a mixed methods research

Abstract This study investigates the psychosocial needs of a group of schoolchildren with visual impairments. Based on a CUAN+CUAL mixed methods, it analyzed 26 children, with and without visual impairment, who attended a pediatric ophthalmology consultation with their parents. Several descriptive, mean and variance tests of independence between variables were performed using Pearson’s Chi-square (χ²) and Mann-Whitney U tests. The interviews conducted with the children and/or parents on the impact of their visual impairment on education, leisure activities and peer interaction, as well as the feelings derived from the impairment, underwent discourse analysis. Results show that schoolchildren with severe visual impairments experience greater difficulties regarding physical and emotional well-being, school performance, and peer interaction when compared with those without. These findings suggest the importance of developing comprehensive and joint health and socio-educational interventions to improve these areas.

Assessing the quality of life in age-related macular degeneration patients: a cross-sectional study in Kazakhstan

AIM

The goal of this study was to assess Vision-Related Quality of Life (VRQoL) in patients with Age-Related Macular Degeneration (AMD) and identify its significant predictors.

METHODS

458 AMD patients from four eye clinics in three major cities of Kazakhstan were recruited for this study. Data were collected using a structured questionnaire on sociodemographic and visual information and the National Eye Institute-Visual Function Questionnaire-39 (NEI-VFQ-39).

RESULTS

The study sample included 181 male patients who were 64.9 years on average (SD±8.4), and 277 female patients who were 68.7 years on average (SD±10.7). The majority of patients had stage 2 (43.7%) or stage 3 (40.2%) AMD according to the Age-Related Eye Disease Study (AREDS) classification. The mean (SD) NEI-VFQ-39 total score was 58.0 (23.8), range (9.8 - 100). The multiple linear regression model showed that the VRQoL of AMD patients correlated with the AMD stage according to the AREDS classification, age of the patients, visual acuity, number of years since the AMD diagnosis, and the city of residence.

CONCLUSIONS

AMD causes severe vision impairment and daily functioning problems, reducing the quality of life of patients. To diagnose and treat degenerative eye disorders at an early stage, it is essential to inform patients about regular ophthalmological checkups to diagnose and treat degenerative eye disorders at an early stage.

Identificación de necesidades psicosociales de un grupo de escolares españoles con problemas visuales: un estudio con metodología mixta

Resumen Este estudio presenta un análisis de las necesidades psicosociales de un grupo de escolares españoles que padecen problemas visuales. La investigación utiliza metodología mixta aplicada en una muestra de 26 menores que acuden con sus progenitores a una consulta de oftalmología pediátrica con y sin problemas visuales. Se realizan entrevistas a los niños, adolescentes y/o progenitores sobre las repercusiones de su problema visual en el ámbito educativo, en la realización de actividades de ocio y tiempo libre y en la interacción con sus iguales, además de los sentimientos que les produce su problema visual. A los datos obtenidos se aplican análisis descriptivos, de medias, de varianza y pruebas de independencia entre variables, mediante las pruebas de chi-cuadrado de Pearson (χ²) y de U de Mann-Whitney. Los resultados encontrados indican que el grupo de escolares con problemas visuales graves tienen mayores dificultades que los que no los tienen en el bienestar físico y emocional, en el rendimiento escolar y en la interacción con los otros. Estos resultados sugieren la importancia de programar intervenciones integrales y conjuntas de carácter sanitario y socioeducativo que incidan en la mejora en cada una de las áreas de necesidad.

Causes of concomitant strabismus surgery delay in teenagers and adults

To reveal the reasons for strabismus surgery delay and motivations for seeking surgical treatment in adulthood. Prospective survey among 91 adult patients, suffering from concomitant strabismus acquired in the childhood that underwent delayed strabismus surgery. The mean age of participants was 24 years (from 16 to 58 years); 48 females (52.7%), and 43 males (47.3%). Strabismus surgery has been delayed for about 20 years in adult patients who could potentially benefit of it in childhood. The most common reasons for strabismus surgery delay, reported by patients, included the following: lack of awareness about surgery (37.4%); surgery was recommended but declined by patients' parents/guardians in their childhood (6.6%); fear of surgery (17.6%); eye specialists affirmation that surgery would not lead to strabismus improvement (27.5%); previous poor surgical experience (6.6%); and non-affordability (4.4%). The main motivations for seeking strabismus surgery in adulthood among our patients were the following: appearance improvement (38.5%), strengthening of self-confidence (30.8%), better social relationship (16.5%), better job opportunities (7.7%), and advice from family and friends (6.6%). About 80% of strabismus surgery delays in teenagers and adults were caused by lack of awareness regarding strabismus surgery and even the misconception among primary health-care practitioners and some eye doctors who considered that surgery would not lead to strabismus correction. The main reasons for seeking strabismus surgery in adulthood were: esthetical ones, self-confidence strengthening, and building better social relationship. All factors mentioned below confirmed the negative impact of oculomotor disorders on patient's psychological condition. The focus on patient's individual concerns and needs was especially important for recovery and well-being of adult patients with strabismus and formed a central feature of patient centered medical approach.

Evaluation of nutritional adjustment program on quality of life in children with chronic liver disease

BACKGROUND

Chronic liver disease is associated with decreased quality of life. The quality of life of children with chronic liver disease is related to their quality of life. Malnutrition is associated with death from cirrhosis, development of complications, and health-related quality of life in people with liver disease. Therefore, this study was conducted to determine the effect of nutritional adjustment program on quality of life in children with chronic liver disease.

MATERIALS AND METHODS

This clinical trial study was performed on children with chronic liver disease referred to the nutrition clinic of Ghaem Educational-Research Center in Mashhad in 2015. In this study, 77 children with chronic liver disease were randomly divided into two groups. Before and after the intervention, patients' quality of life was assessed with the PedsQL™ 4.0 generic core scale questionnaire. Data analysis was performed using SPSS16 software.

RESULTS

In the postintervention stage, the mean total score of quality of life in the experimental group was 1965.0 ± 270.9 and in the control group was 1522.5 ± 321.3 (P < 0.001). The difference in quality of life score of physical, social, and school performance in the two groups was significant.

CONCLUSION

According to the results of this study, it seems that interventions that can improve the quality of life of children with chronic liver disease can be an important step in advancing these people toward a healthy and quality life. As a result, it is possible to take steps to improve the quality of life of patients by encouraging children with liver disease and providing information about diet.

Evaluation of a Hirschberg Test-Based Application for Measuring Ocular Alignment and Detecting Strabismus

Purpose: Photographic Hirschberg test applications are practical options for screening in areas where a specialist is not available. A semi-automated Hirschberg test-based application was developed and evaluated on its ability to detect and measure strabismus at distance and near fixation.Methods: This is a prospective cross-sectional inter-rater agreement study conducted at a tertiary hospital. Study A evaluated the ability of the application to determine the presence or absence of strabismus in subjects of unknown strabismus status (n = 28). Study B evaluated the ability of the application to measure the deviation of strabismic subjects (n = 8). All subjects underwent alternate prism cover test (APCT) at distance and near fixation. Facial photographs at distance and near fixation were taken. Each photograph underwent automated face and eye detection, manual limbus and corneal reflex identification, and strabismus detection and measurement.Results: The application obtained a matching rate of 95.14% for the face and eyes. The application yielded a sensitivity of 92.86% for horizontal strabismus at distance and near fixation, however, with low specificity values (7.692%, 14.81%, and 8%). The Bland-Altman plots derived from Study B showed bias values of application measurements between 3.625Δ and 6.125Δ with wide intervals of the limits of agreement. Repeatability of the measurements yielded bias values of -0.625Δ and 2.5Δ for horizontal and vertical strabismus at distance and 4.375Δ and 1.25Δ at near fixation, respectively.Conclusion: This semi-automated Hirschberg test-based application can effectively determine the face and eye location and shows potential as a screening tool for horizontal strabismus.

The impact of strabismus on psychosocial heath and quality of life: a systematic review

Strabismus can hinder an individual's ability to perform daily functions and negatively affect their well-being. I examine the impact strabismus has on psychosocial health and quality of life in children and adults and evaluate the challenges confronted by parents of children with strabismus. Numerous misconceptions exist regarding the impact strabismus has on overall health. Negative attitudes persist toward those affected, resulting in difficulties with self-image. Individuals with strabismus are at increased risk for both visual system and psychiatric disorders. Misinformation regarding available treatment options for children and adults with strabismus continues to exist, resulting in decreased access to care. Improved education of health care providers can increase appropriate referrals and initiation of treatment. Treatment of strabismus is not merely cosmetic and has the potential to improve psychosocial health and quality of life for children and adults with and without diplopia.

Inpatient Virtual Vision Clinic Improves Access to Vision Rehabilitation Before and During the COVID-19 Pandemic

OBJECTIVE

To describe and evaluate a secure video call system combined with a suite of iPad vision testing apps to improve access to vision rehabilitation assessment for inpatients.

DESIGN

Retrospective.

SETTING

Two acute care inpatient rehabilitation hospitals and 1 long-term acute care (LTAC) hospital.

PARTICIPANTS

Records of inpatients seen by the vision service.

INTERVENTIONS

Records from a 1-year telemedicine pilot performed at acute rehabilitation (AR) hospital 1 and then expanded to AR hospital 2 and LTAC hospital during coronavirus disease 2019 (COVID-19) were reviewed. In the virtual visits, an occupational therapist measured the patients' vision with the iPad applications and forwarded results to the off-site Doctor of Optometry (OD) for review prior to a video visit. The OD provided diagnosis and education, press-on prism application supervision, strategies and modifications, and follow-up recommendations. Providers completed the telehealth usability questionnaire (10-point scale).

MAIN OUTCOME MEASURES

Vision examinations per month at AR hospital 1 before and with telemedicine.

RESULTS

With telemedicine at AR hospital 1, mean visits per month significantly increased from 10.7±5 to 14.9±5 (P=.002). Prism was trialed in 40% of cases of which 83% were successful, similar to previously reported in-person success rates. COVID-19 caused only a marginal decrease in visits per month (P=.08) at AR1, whereas the site without an established program (AR hospital 2) had a 3-4 week gap in care while the program was initiated. Cases at the LTAC hospital tended to be more complex and difficult to manage virtually. The telehealth usability questionnaire median category scores were 7 for Ease of Use, 8 for Interface Quality, 6 for Reliability, and 9 for Satisfaction and Future Use.

CONCLUSIONS

The virtual vision clinic process improved inpatient access to eye and visual neurorehabilitation assessment before and during the COVID-19 quarantine and was well accepted by providers and patients.

Measuring health-related quality of life in individuals with cyclodeviation using the Adult Strabismus 20 (AS-20) questionnaire

PURPOSE

To assess health-related quality of life (HRQoL) in patients diagnosed with cyclodeviation and to evaluate subjective change following surgical treatment using the Adult Strabismus-20 (AS-20) questionnaire.

METHODS

A prospective cohort study was performed from 2014 to 2019 on 29 adult patients with cyclodeviation and cyclodiplopia who were due to undergo corrective strabismus surgery by the same surgeon. The group was divided into two subgroups, according to the type of surgery required for fusion. All scores were analyzed for the whole sample and subgroups. Preoperative scores were compared with those of control patients.

RESULTS

Pre- and postoperative QoL scores were successfully collected from 26 patients (mean age, 56 years; 8 female) using the AS-20 questionnaire. Scores were significantly higher for control subjects than for patients in the cyclodeviation group (P = 0.0001). Postoperative scores for all 20 questionnaire questions were significantly improved for all patients (P = 0.002). There was a significant improvement in the functional subscale score (P = 0.001), but not in the psychosocial subscale score (P = 0.23). Results were enhanced by Rasch analysis.

CONCLUSIONS

Cyclodeviation patients demonstrated significantly lower scores than controls. The functional scores were significantly lower than the psychosocial scores, in contrast to other forms of strabismus. Strabismus surgery had a significant effect on quality-of-life scores in this group of adults.

Management of strabismus related to infantile glaucoma: Case series

OBJECTIVE

To evaluate the different modalities of treatment of the strabismus related to infantile glaucoma, its complications, and results.

METHODS

The clinical history of 7 patients with infantile glaucoma which required strabismus surgical treatment were analyzed. Age at onset of glaucoma, type of glaucoma, glaucoma surgeries, type of strabismus, strabismus surgical treatment and postoperative results were studied.

RESULTS

Four patients required strabismus surgery, two were treated with botulinum toxin and one required both. Primary congenital glaucoma was the most common (71,42%), 14,28% had an anterior segment dysgenesis and 14,28% had secondary glaucoma. Regarding strabismus, 4 patients had exotropia and 3 had esotropia. The main difficulty involved the management of the conjunctiva and the filtering blebs.

CONCLUSION

Strabismus is a frequent complication in infantile glaucoma. The management of these patients should be individualized. In our case series, treatment of strabismus improved eye alignment. Surgery should be the mainstay of treatment while preserving the conjunctiva and interfere the less with glaucoma surgeries. Botulinum toxin is a reasonable option when conservative treatment is needed.

Management of strabismus related to infantile glaucoma: Case series

OBJECTIVE

To evaluate the different modalities of treatment of the strabismus related to infantile glaucoma, its complications, and results.

METHODS

The clinical history of 7 patients with infantile glaucoma which required strabismus surgical treatment were analyzed. Age at onset of glaucoma, type of glaucoma, glaucoma surgeries, type of strabismus, strabismus surgical treatment and postoperative results were studied.

RESULTS

Four patients required strabismus surgery, two were treated with botulinum toxin and one required both. Primary congenital glaucoma was the most common (71,42%), 14,28% had an anterior segment dysgenesis and 14,28% had secondary glaucoma. Regarding strabismus, 4 patients had exotropia and 3 had esotropia. The main difficulty involved the management of the conjunctiva and the filtering blebs.

CONCLUSION

Strabismus is a frequent complication in infantile glaucoma. The management of these patients should be individualized. In our case series, treatment of strabismus improved eye alignment. Surgery should be the mainstay of treatment while preserving the conjunctiva and interfere the less with glaucoma surgeries. Botulinum toxin is a reasonable option when conservative treatment is needed.

Influence of prenatal environment and birth parameters on amblyopia, strabismus, and anisometropia

PURPOSE

To report the prevalence of amblyopia, strabismus, and anisometropia in a young adult population at a single center in Australia and to investigate the underlying prenatal and early-life risk factors.

METHODS

Participants in the Raine Study have been followed from mid-gestation (n = 2,868 newborns) to young adulthood. At age 20 years, 1,344 participants had a comprehensive eye examination, including visual acuity and a detailed orthoptic assessment. Risk factors were determined from medical records and questionnaires completed by the mothers at 18 weeks' gestation. The main outcome measures were the proportions of participants with amblyopia, esotropia, exotropia, or anisometropia (defined as >1 D difference).

RESULTS

Of the 1,125 white participants, 12 (1.1%) had amblyopia, 39 (3.5%) had strabismus, and 33 (2.9%) had anisometropia. In multivariable logistic regression, amblyopia was associated with a maternal history of pregnancy-induced hypertension (OR = 3.80; 95% CI, 1.19-12.13); esotropia, with lower gestational age (OR = 0.97; 95% CI, 0.95-0.97) and a heavier placenta (OR = 1.02; 95% CI, 1.00-1.04); exotropia, with a maternal history of previously treated hypertension (OR = 4.00; 95% CI, 1.06-15.03) and maternal use of recreational drugs during early pregnancy (OR = 3.61; 95% CI, 1.06-15.03); and anisometropia, with older maternal age (OR = 1.07; 95% CI, 1.01-1.14) and an abnormal umbilical cord (OR = 2.39; 95% CI, 1.04-5.47).

CONCLUSIONS

The prevalence of amblyopia, strabismus, and anisometropia in this cohort was similar to that in other studies. Preterm birth and maternal health may have adverse effects on eye development.

Maternal smoking during pregnancy and the risk of strabismus in offspring: a meta-analysis

The effect of maternal smoking during pregnancy on strabismus in offspring remains unclear. We conducted a meta-analysis to summarize epidemiological evidences on the association between maternal smoking during pregnancy and the risk of offspring strabismus. Eligible studies were searched from the PubMed, Ovid, Embase and CNKI databases up to May 2018. The qualities of included articles were assessed with the Newcastle-Ottawa Scale and the assessment scale recommended by the Agency for Healthcare Research and Quality. Odds ratios (ORs) corresponding with its 95% confidence intervals (CIs) were pooled to estimate the effects of maternal cigarette smoking on the risk of offspring strabismus. Subgroup analyses and meta-regression were performed to explore the potential sources of heterogeneity. The Begg's test and Egger's test were used to assess the publication bias. Eleven articles involving 4,833 patients with strabismus were included. The pooled OR showed that maternal smoking during pregnancy was significantly associated with strabismus in offspring (OR = 1.46, 95% CI = 1.32-1.60). Compared with less than 10 cigarettes per day (OR = 1.17, 95% CI = 1.06-1.29), maternal smoking 10 cigarettes or more per day during pregnancy significantly increased the risk of offspring strabismus (OR = 1.79, 95% CI = 1.39-2.31). The risk of developing esotropia and exotropia for smoking pregnant women, respectively, increased by 65% (OR = 1.65, 95% CI = 1.31-2.09 and OR = 1.65, 95% CI = 1.24-2.19) than those who did not smoke during pregnancy. Additionally, the increased risk of maternity smoking associated with offspring strabismus was stable across all subgroup analyses. Overall, maternal smoking during pregnancy was associated with a significantly increased risk of offspring strabismus and the result was persistent in subgroup analyses, suggesting the importance in changing smoking habit or smoking cessation for women who are pregnant or preparing to.

Comparison of vision-related quality of life and mental health between congenital and acquired low-vision patients

Purpose

To evaluate the impact of the age of onset of low vision on patients’ vision-related quality of life (VR-QoL) and mental health.

Methods

Low-vision patients who visited Chung-Ang University hospital from January 2012 to December 2014 were included. Patients were divided into the congenital low-vision (CLV) and acquired low-vision (ALV) groups according to the age of disease onset. People with normal visual function comprised the control group. VR-QoL was estimated with the National Eye Institute Visual Function Questionnaire (NEI VFQ-25), while mental health was assessed through the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI). The mean scores of each questionnaire were compared between the groups in independent t-tests.

Results

Overall, 125 low-vision patients (55 CLV and 70 ALV) and 71 control subjects were included. Although the subscale and composite scores of the NEI VFQ-25 were lower in the ALV group than in the CLV group, the differences were not significant. However, the BDI and BAI scores were significantly higher in the ALV group than in the CLV group (12.07 ± 11.97 vs. 7.67 ± 9.04, P = 0.021; 9.11 ± 10.51 vs. 5.69 ± 6.85, P = 0.030, respectively). Also, the number of patients requiring expert consultation for depression was higher in the ALV group than in the CLV group (P = 0.010).

Conclusion

ALV patients have more vulnerable mental health states than CLV patients. Therefore, assessment of the age of onset of low vision and mental health plays a critical role in successful rehabilitation.

Update on the Clinical Approach to Spatial Neglect

PURPOSE OF REVIEW

Spatial neglect is asymmetric orienting and action after a brain lesion, causing functional disability. It is common after a stroke; however, it is vastly underdocumented and undertreated. This article addresses the implementation gap in identifying and treating spatial neglect, to reduce disability and improve healthcare costs and burden.

RECENT FINDINGS

Professional organizations published recommendations to implement spatial neglect care. Physicians can lead an interdisciplinary team: functionally relevant spatial neglect assessment, evidence-based spatial retraining, and integrated spatial and vision interventions can optimize outcomes. Research also strongly suggests spatial neglect adversely affects motor systems. Spatial neglect therapy might thus "kick-start" rehabilitation and improve paralysis recovery. Clinicians can implement new techniques to detect spatial neglect and lead interdisciplinary teams to promote better, integrated spatial neglect care. Future studies of brain imaging biomarkers to detect spatial neglect, and real-world applicability of prism adaptation treatment, are needed.

Development and Preliminary Evaluation of a Smartphone App for Measuring Eye Alignment

Purpose

We evaluate a smartphone application (app) performing an automated photographic Hirschberg test for measurement of eye deviations.

Methods

Three evaluation studies were conducted to measure eye deviations in the horizontal direction. First, gaze angles were measured with respect to the ground truth in nonstrabismic subjects (n = 25) as they fixated monocularly on targets of known eccentricity covering an angular range of approximately ±13°. Second, phoria measurements with the app at near fixation (distance = 40 cm) were compared with the modified Thorington (MT) test in normally-sighted subjects (n = 14). Third, eye deviations using the app were compared to a cover test with prism neutralization (CTPN; n = 66) and Synoptophore (n = 34) in strabismic subjects. Regression analyses were used to compare the app and clinical measurements of the magnitude and direction of eye deviations (prism diopters, Δ).

Results

The gaze angles measured by the app closely followed the ground truth (slope = 1.007, R² = 0.97, P < 0.001), with a root mean squared error (RMSE) of 2.4Δ. Phoria measurements with the app were consistent with MT (slope = 0.94, R² = 0.97, P < 0.001, RMSE = 1.7Δ). Overall, the strabismus measurements with the app were higher than with Synoptophore (slope = 1.15, R² = 0.91, P < 0.001), but consistent with CTPN (slope = 0.95, R² = 0.95, P < 0.001). After correction of CTPN values for near fixation, the consistency of the app measurements with CTPN was improved further (slope = 1.01).

Conclusions

The app measurements of manifest and latent eye deviations were consistent with the comparator clinical methods.

Translational Relevance

A smartphone app for measurement of eye alignment can be a convenient clinical tool and has potential to be beneficial in telemedicine.

Clinical profiles and surgical outcomes of adult esotropia

OBJECTIVE

The aim of this study was to describe the clinical features and surgical outcomes of teenage and adult patients with esotropia undergoing strabismus surgery with adjustable sutures.

METHODS

Seventy-three patients were included in this retrospective, cohort study. Patients were stratified into group 1 (35 with childhood-onset esotropia [CET]) and group 2 (38 with adult-onset esophoria-tropia [EPT]). Preoperative immediate, 2-week, and 4-6-month postoperative measurements of ocular alignment, as well as fusional testing, were performed. Postoperative success was defined as distant (6 m) and near (33 cm) alignment within 12 prism diopters (PDs) of orthotropia in the primary position at 2 weeks and at 4-6 months with a single surgery.

RESULTS

Patients with CET more frequently had hyperopia and amblyopia and were more likely to present for surgery because of psychosocial strabismus-related problems. Patients with EPT predominantly had myopia and were more likely to experience diplopia and asthenopia. In group 1, the mean preoperative distance deviation improved from 30 PDs to 4 PDs at 2 weeks and to 4 PDs at 4-6 months (p < 0.001). In group 2, mean preoperative distance alignment improved from 22 to 3 PDs at 2 weeks and to 3 PDs at 4-6 months (p < 0.001). The mean objective, single-surgery success rate at 2 weeks was 88% and 97% in groups 1 and 2, respectively. At 4-6 months, postoperative success was 71% in group 1 and 80% in group 2. The majority of patients reported subjective improvement.

CONCLUSIONS

There are distinct preoperative differences between CET and EPT patients. Adjustable, strabismus surgery in this cohort is safe and effective in achieving subjective and objective success.

Prognostic indicators for the development of strabismus among patients with graves' ophthalmopathy

Objective

Thyroid eye disease (TED), an autoimmune inflammatory process involving the orbital tissues around the eye, is the most common extra-thyroidal manifestation of Graves’ disease (GD). Due to changes in the patient’s appearance, TED is a socially and visually disabling condition with significant impacts on quality of life. The aim of this study is to assess predictors of strabismus, a severe manifestation of TED.

Design

Single-institution retrospective case-control study. Cases of Graves’ ophthalmopathy patients with strabismus were matched 1:1 to controls of Graves’ ophthalmopathy patients without strabismus by age and sex.

Patients

Patients ≥18 years old with severe Graves’ ophthalmopathy who received their medical care at UCLA with strabismus between 2012 and 2015.

Measurements

Eligibility criteria for cases was a diagnosis of Graves’ ophthalmopathy with a subsequent diagnosis of strabismus. Using conditional logistic regression, the odds ratios of developing strabismus following the diagnosis of Graves’ disease were assessed. The prognostic indicators assessed include race, ethnicity, cigarette smoking (active), serum thyroid peroxidase (TPO) antibody positivity, serum thyroglobulin (Tg) antibody positivity, antithyroidal medication use, and steroid use.

Results

The study sample (45 cases 1:1 matched against 45 controls) was comprised primarily of non-Hispanic, non-Latino Caucasian women with TED (mean ± SD age 63.0 ± 13.1 years). There were no significant predictors for the development of strabismus, including cigarette smoking (active), serum thyroid peroxidase (TPO) antibody positivity, serum thyroglobulin (Tg) antibody positivity, antithyroidal medication, and steroid use.

Conclusions

No significant predictors of strabismus, a severe manifestation of Graves’ ophthalmopathy, were identified following a diagnosis of TED in this study.

Health-Related Quality of Life (HRQoL) in Young Adults with Strabismus in India

INTRODUCTION

Strabismus has negative psycho-social and functional effects in adults. The impact can be minimised with surgery. However, in a low-income setting, it is important to evaluate the level of impact and prioritise the target population for intervention. The Adult Strabismus (AS-20) questionnaire is a reliable tool for assessment of Health-Related Quality of Life (HRQoL) in strabismic adults.

AIM

To assess the HRQoL in young adults with manifest strabismus through psychosocial and functional scores according to gender and direction of deviation using the AS-20 questionnaire.

MATERIALS AND METHODS

In this cross-sectional cohort study, 132 young adults who manifest horizontal strabismus were recruited and the AS-20 questionnaire was administered. Patient's demographic profile and type of strabismus were noted and compared with the overall mean scores of psycho-social and functional subscales. Data was analyzed using SPSS 21 and p-value less than 0.05 was considered statistically significant.

RESULTS

The participants comprised of 70 (53.03%) males and 62 (46.97%) females with a mean age of 24.5±3.57 years (range 18 to 38 years). The overall mean AS-20 score of young adults with strabismus was 61.62±12.61. The overall mean score for male and female were 65.54±13.53 and 57.68±13.46, respectively. Similarly, the mean scores for esotropes was 57.03±11.66 and 66.19±15.30 for exotropes. The overall mean scores were statistically significantly reduced (decreased QoL) in females as compared to males (CI 95%; p=0.002) and in esotropes as compared to exotropes (CI 95%; p=0.001). However, there was no significant difference between the psychosocial and functional score for all types of strabismus and genders (for all, p>0.05).

CONCLUSION

The Quality of Life (QoL) is affected through psychosocial and functional factors in adults with strabismus. Females and adults with esotropia faced greater difficulties in the QoL. We recommend clinicians to consider the impact on QoL while managing adult with strabismus.

Vision-Related Quality of Life Before and After Deep Anterior Lamellar Keratoplasty

OBJECTIVES

To determine changes in the vision-related quality of life in patients undergoing deep anterior lamellar keratoplasty (DALK) by using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25).

METHODS

Thirty-five patients who were scheduled for DALK between March 1, 2013, and March 1, 2014 were asked to complete the NEI VFQ-25. NEI VFQ-25 was administered again at 6 months and at 1 year postoperatively. Data on patients' age, sex, preoperative diagnosis, preoperative and postoperative best-corrected visual acuity, and postoperative astigmatism were recorded.

RESULTS

Successful DALK with the Anwar big bubble technique was achieved in 23 of 35 (65.7%) patients. The indications for surgery were keratoconus in 15 patients (62.2%), stromal corneal dystrophies in 4 (17%), and corneal scar in 4 (17%). The mean preoperative NEI VFQ-25 composite score (55.2±19.7) improved significantly (76.9±11.6) at 6 months after DALK and continued to improve (84.3±6.6) at 1 year postoperatively (Friedman test, P=0.001). All NEI VFQ-25 subscale item scores increased significantly after surgery. The patients' age was significantly correlated with the NEI VFQ-25 subscale score of mental health at 6 month and at 1 year postoperatively (r=0.92, P=0.008 and r=0.94, P=0.005, respectively). There was a negative relationship between postoperative astigmatism at 1 year and NEI VFQ-25 ocular pain, social functioning, peripheral vision, and mental health subscale scores (r=-0.76, P=-0.07; r=-0.53, P=0.2; r=-0.53, P=0.27; r=-0.80, P=0.05).

CONCLUSION

Vision-related quality of life improved significantly after DALK and continued to improve after suture removal.

Strabismus in Adults Older Than 60 Years

PURPOSE

To describe the epidemiology of adult strabismus, its etiology, and treatment methods in patients 60 years and older presenting to a tertiary care center.

METHODS

This retrospective chart review study of patients with strabismus was performed at the Ratner Eye Center, University of California-San Diego. Data collected included demographics, etiology of misalignment, alignment in the primary position, binocularity, previous surgical intervention, and treatment methods.

RESULTS

A total of 291 patients were included. The majority of patients (87.9%) had an acquired underlying etiology of misalignment (neurological, non-neurological, thyroid eye disease, or myotoxic). The most common presenting complaint was diplopia (77%). A total of 38.8% of patients had previous strabismus surgery. Surgical interventions were pursued in 32% of patients.

CONCLUSIONS

This article provides insight into the epidemiology of strabismus in patients older than 60 years. The characterization and greater understanding of strabismus in this age group can be used to enhance prevention, diagnosis, and treatment of these patients. [J Pediatr Ophthalmol Strabismus. 2016;53(6):365-368.].

Contractile Force of Human Extraocular Muscle: A Theoretical Analysis

Aim. The length-contractile force relationships of six human extraocular muscles (EOMs) in primary innervations should be determined during eye movement modeling and surgery of clinical EOMs. This study aims to investigate these relationships. Method. The proposal is based on the assumption that six EOMs have similar constitutive relationships, with the eye suspended in the primary position. The constitutive relationships of EOMs are obtained by optimizing from previous experimental data and the theory of mechanical equilibrium using traditional model. Further, simulate the existing experiment of resistance force, and then compare the simulated results with the existing experimental results. Finally, the mechanical constitutive relationships of EOMs are obtained. Results. The results show that the simulated resistance forces from the other four EOMs except for the horizontal recti well agree with previous experimental results. Conclusion. The mechanical constitutive relationships of six EOMs in primary innervations are obtained, and the rationality of the constitutive relationships is verified. Whereafter, the active stress-strain relationships of the six EOMs in the primary innervations are obtained. The research results can improve the eye movement model to predict the surgical amounts of EOMs before EOM surgery more precisely.