Social and emotional impact of strabismus surgery on quality of life in children

Impact of Vision Impairment and Ocular Morbidity and Their Treatment on Quality of Life in Children: A Systematic Review

TOPIC

This review summarizes existing evidence of the impact of vision impairment and ocular morbidity and their treatment on children's quality of life (QoL).

CLINICAL RELEVANCE

Myopia and strabismus are associated with reduced QoL among children. Surgical treatment of strabismus significantly improves affected children's QoL.

METHODS

We conducted a systematic review and meta-analysis by screening articles in any language in 9 databases published from inception through August 22, 2022, addressing the impact of vision impairment, ocular morbidity, and their treatment on QoL in children. We reported pooled standardized mean differences (SMDs) using random-effects meta-analysis models. Quality appraisal was performed using Joanna Briggs Institute and National Institutes of Health tools. This study was registered with the International Prospective Register of Systematic Reviews (identifier, CRD42021233323).

RESULTS

Our search identified 29 118 articles, 44 studies (0.15%) of which were included for analysis that included 32 318 participants from 14 countries between 2005 and 2022. Seventeen observational and 4 interventional studies concerned vision impairment, whereas 10 observational and 13 interventional studies described strabismus and other ocular morbidities. Twenty-one studies were included in the meta-analysis. The QoL scores did not differ between children with and without vision impairment (SMD, -1.04; 95% confidence interval [CI], -2.11 to 0.03; P = 0.06; 9 studies). Myopic children demonstrated significantly lower QoL scores than those with normal vision (SMD, -0.60; 95% CI, -1.09 to -0.11; P = 0.02; 7 studies). Children with strabismus showed a significantly lower QoL score compared with those without (SMD, -1.19; 95% CI, -1.66 to -0.73; P < 0.001; 7 studies). Strabismus surgery significantly improved QoL in children (SMD, 1.36; 95% CI, 0.48-2.23; P < 0.001; 7 studies). No randomized controlled trials (RCTs) concerning refractive error and QoL were identified. Among all included studies, 35 (79.5%) were scored as low to moderate quality; the remaining met all quality appraisal tools criteria.

DISCUSSION

Reduced QoL was identified in children with myopia and strabismus. Surgical correction of strabismus improves the QoL of affected children, which supports insurance coverage of strabismus surgery. Further studies, especially RCTs, investigating the impact of correction of myopia on QoL are needed.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.].

Social-emotional issues among children with strabismus higher than among non-strabismus children in Western India

Purpose

Data on social-emotional aspects among children with strabismus in India are scanty. We compared the emotional symptoms (ES), loneliness and social dissatisfaction (LSD), and self-esteem (SE) and their associated risk factors among children with and without strabismus in India.

Methods

A cross-sectional case-control study design was used to recruit 101 children with strabismus aged 8 to 18 years and a control group of 101 children that were age- and gender-matched. Interviews were performed using standardized scales to assess ES, LSD, and SE. Variations in the intensity of ES, LSD, and SE were assessed using multiple classification analysis (MCA).

Results

A total of 202 children participated in the study. The mean ES, LSD, and SE scores were 3.4 (standard deviation [SD] 1.9), 48.4 (SD 3.2), and 22.1 (SD 3.8) for the strabismus group and 1.8 (SD 1.5), 33.3 (SD 3), and 31.3 (SD 2) for the non-strabismus group, respectively. Among the strabismus group, the highest levels of mean ES, LSD, and SE scores were observed among children facing problems in performing daily tasks. Amongst the non-strabismus group, children studying at the primary level and those facing neglect had the highest mean scores. In MCA, being affected with strabismus had the highest effect on the intensity of ES, LSD, and SE with a beta (β) value of 0.223 (P = 0.016), 0.922 (P < 0.001), and 0.853 (P < 0.001).

Conclusion

A significantly high proportion of children with strabismus deal with elevated levels of ES, LSD problems, and low SE as compared with non-strabismus children, highlighting the need to address the poor social-emotional health of children.

The effect of strabismus surgery on the learning abilities of school-aged children

PURPOSE

To evaluate whether strabismus surgery improves the learning performance - calculation, reading and drawing - of school-aged children.

METHODS

In a case-control study, patients between the ages of 7 and 10 years with horizontal strabismus, recommended for surgical correction, were prospectively included. Reading, calculating and drawing abilities were evaluated before and 3 months after corrective strabismus surgery using standardized tests. Cases were compared to control patients: patients with a surgical indication postponed due to the COVID lockdown.

RESULTS

Forty-two operated patients and 42 controls between the ages of 7 and 10 years with horizontal strabismus were included. The average reading speed was 65.8 words per minute pre-operatively compared to 80.6 words per minute post-operatively (p = 0.0038). The average drawing score was 71.1 pre-operatively compared to 84.3 post-operatively (p = 0.012). The average calculation score was 3.2 pre-operatively compared to 3.4 post-operatively (p = 0.363). Improvement given by strabismus surgery was confirmed avoiding the learning effect by comparison with the control group. The improvements observed were more significant in the youngest patients and esotropia.

CONCLUSIONS

This study highlights that strabismus surgery significantly improved the children's reading fluency and drawing task execution. These encouraging data should be taken into account when considering the indications for strabismus surgery.

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.

Knowledge, Attitude, and Practice Among Parents of Strabismic Children in Saudi Arabia: A Cross-Sectional Study

Background Strabismus is a reversible condition that must be identified and treated during the critical period of childhood. Thus, this study aims to evaluate the degree of knowledge, attitude, and practice among parents of strabismic children in Riyadh, Saudi Arabia. Method To this end, a cross-sectional study was conducted from August 2021 to November 2021 with a sample size of 424 parents of children with strabismus seeking ophthalmologic consultants in private and governmental ophthalmology clinics in Riyadh, Saudi Arabia. A self-administered questionnaire was used to collect the data. The questionnaire contains knowledge-related questions about strabismus, beliefs-related questions, questions addressing the barriers parents face regarding strabismus in a child, and sources of information about cross-eye and its management. Data were analysed using the SPSS database version 21 (IBM Corp., Armonk, NY, USA). P-values <0.5 was used for clinical significance. Result We found that most parents know there is a relationship between strabismus and refractive errors (69%) and cross eye can be corrected (55%). Moreover, strabismus causes psychosocial difficulties (55%), low self-esteem, and low school performance. Parents of strabismic children believed that their love for their children is not affected due to crossed eyes (53%) and that strabismic children should not be taken to traditional healers (59%). Barriers faced during the management of strabismus are parents' negligence (76%), fear of surgery (34%), and high cost (29%). Doctors are the most used and preferred source of information among parents of strabismic children. Conclusion This study identifies gaps in knowledge, wrong beliefs in society, and the barriers faced by parents of strabismic children. Thus, raising awareness of the importance of detecting and treating strabismus early, avoiding psychosocial complications, and improving children's quality of life.

Impact of Vision Impairment and Ocular Morbidity and Their Treatment on Depression and Anxiety in Children: A Systematic Review

TOPIC

This systematic review and meta-analysis summarizes existing evidence to establish whether vision impairment, ocular morbidity, and their treatment are associated with depression and anxiety in children.

CLINICAL RELEVANCE

Understanding and quantifying these associations support early detection and management of mental health symptoms in children with vision impairment and ocular morbidity. Additionally, this review provides evidence in favor of insurance coverage for timely strabismus surgery.

METHODS

We searched 9 electronic databases from inception through February 18, 2021, including observational and interventional studies assessing whether vision impairment, ocular morbidity, or both and their treatment are associated with depression, anxiety, or both in children. We used narrative synthesis and meta-analysis with the residual maximum likelihood method. A protocol was registered and published on The International Prospective Register of Systematic Reviews (identifier: CRD42021233323).

RESULTS

Among 28 992 studies, 28 956 studies (99.9%) were excluded as duplicates or unrelated content. Among 36 remaining studies, 21 studies (58.3%) were observational studies concerning vision impairment, 8 studies (22.2%) were observational studies concerning strabismus, and 7 studies (19.4%) were interventional studies. Vision impaired children demonstrated significantly higher scores of depression (standard mean difference [SMD], 0.57; 95% confidence interval [CI], 0.26-0.89; 11 studies) and anxiety (SMD, 0.62; 95% CI, 0.40-0.83; 14 studies) than normally sighted children. In particular, children with myopia demonstrated higher scores of depression (SMD, 0.58; 95% CI, 0.36-0.81; 6 studies) than normally sighted children. Strabismus surgery significantly improved symptoms of depression (SMD, 0.59; 95% CI, 0.12-1.06; 3 studies) and anxiety (SMD, 0.69; 95% CI, 0.25-1.14; 4 studies) in children.

CONCLUSION

Among children, vision impairment is associated with greater symptoms of depression and anxiety. Surgical treatment of strabismus improved these symptoms. Further randomized controlled trials exploring the impact of public health measures for myopia correction on mental health in children are needed. Scaling up access to strabismus surgery could improve the mental health of affected children.

Psychosocial Improvements in Children and Their Parents Following Strabismus Surgery

PURPOSE

To evaluate the psychosocial effects of strabismus surgery, the authors investigated the psychiatric symptoms and quality of life of children with strabismus and their parents.

METHODS

Children with strabismus between 6 and 18 years old (n = 39) and their parents (n = 39) were included. Psychiatric problems and the health-related quality of life were assessed with the Child Behavior Checklist and Pediatric Quality of Life Inventory, respectively. The State-Trait Anxiety Inventory for Children and Beck Anxiety Inventory were administered to children and parents, respectively. All assessments were conducted before and 3 months after strabismus surgery.

RESULTS

Compared with preoperative assessments, children with strabismus had significantly fewer psychiatric problems and a better quality of life after the surgery (P < .001). Following surgery, decreased symptom levels of anxiety scores were also obtained from children and their parents (P < .001). The amount of ocular realignment was directly correlated with improvement in social and attention problems among children (r = 0.354 and r = 0.324, respectively; P < .05).

CONCLUSIONS

Successful strabismus surgery has positive effects on psychosocial functioning and quality of life in children and their families. Surgical interventions seem beneficial for the management of strabismus in improving both physical and mental health. [J Pediatr Ophthalmol Strabismus. 2022;59(4):261-268.].

Association of Strabismus With Mood Disorders, Schizophrenia, and Anxiety Disorders Among Children

Importance

Children with strabismus have poorer functional vision and decreased quality of life than those without strabismus.

Objective

To evaluate the association between strabismus and mental illness among children.

Design, Setting, and Participants

This cross-sectional study analyzed claims data from the OptumLabs Data Warehouse, a longitudinal deidentified commercial insurance claims database, from 12 005 189 patients enrolled in the health plan between January 1, 2007, and December 31, 2017. Eligibility criteria included age younger than 19 years at the time of strabismus diagnosis, enrollment in the health plan between 2007 and 2018, and having at least 1 strabismus claim based on International Classification of Diseases, Ninth Revision, Clinical Modification and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification codes. Controls were children in the same database with no eye disease codes other than refractive error reported. Demographic characteristics and mental illness claims were compared. Statistical analysis was conducted from December 1, 2018, to July 31, 2021.

Main Outcomes and Measures

Presence of mental illness claims.

Results

Among the 12 005 189 patients (6 095 523 boys [50.8%]; mean [SD] age, 8.0 [5.9] years) in the study, adjusted odds ratios for the association of mental illnesses with strabismus were 2.01 (95% CI, 1.99-2.04) for anxiety disorder, 1.83 (95% CI, 1.76-1.90) for schizophrenia, 1.64 (95% CI, 1.59-1.70) for bipolar disorder, 1.61 (95% CI, 1.59-1.63) for depressive disorder, and 0.99 (95% CI, 0.97-1.02) for substance use disorder. There was a moderate association between each strabismus type (esotropia, exotropia, and hypertropia) and anxiety disorder, schizophrenia, bipolar disorder, and depressive disorder; odds ratios ranged from 1.23 (95% CI, 1.17-1.29) for the association between esotropia and bipolar disorder to 2.70 (95% CI, 2.66-2.74) for the association between exotropia and anxiety disorder.

Conclusions and Relevance

This cross-sectional study suggests that there was a moderate association between strabismus and anxiety disorder, schizophrenia, bipolar disorder, and depressive disorder but not substance use disorder. Recognizing that these associations exist should encourage mental illness screening and treatment for patients with strabismus.

A Retrospective Study on the Eye-Related Quality of Life, Functional Vision, and Their Determinants Among Children Following Congenital and Developmental Cataracts Surgery and Its Impact on Their Families Using the PedEyeQ

Objectives

To evaluate the eye-related quality of life (ER-QOL), functional vision, and their determinants in children following congenital and developmental cataract surgery, as the impact on their families, using the Pediatric Eye Questionnaire (PedEyeQ).

Materials and Methods

This was a retrospective cross-sectional study involving 107 children (aged 0–11 years) with congenital and developmental cataracts who had undergone surgery, as well as 59 visually healthy controls (aged 0–11 years). One parent for each child completed either the Proxy 0–4 PedEyeQ, the Proxy 5–11 PedEyeQ, or the Parent PedEyeQ, depending on their child's age. Mann-Whitney U and Kruskal-Wallis tests were then conducted to compare the differences between groups and to analyze their determinants.

Results

PedEyeQ scores were found to be lower in postoperative children with congenital and developmental cataracts compared with the control group across all study domains. The PedEyeQ Proxy 0 to 4 years' greatest mean difference was 27 points worse in the Functional Vision domain (95% CI −34 to −19; p &lt; 0.001). We also found that the occurrence of nystagmus (p &lt; 0.005) and strabismus (p &lt; 0.005) were the major factors affecting participants' functional vision. The PedEyeQ Proxy 5 to 11 years' greatest mean difference was 23 points worse in this same domain (95% CI −30 to −15; p &lt; 0.001), with nystagmus (p &lt; 0.05) being the main determinant herein. Parent PedEyeQ 0 to 4 years' greatest difference was 46 points worse on the Worry about their Child's Eye Condition domain (95% CI −57 to −36; p &lt; 0.001). Similarly, parents of children with ophthalmologic abnormalities, including nystagmus (p &lt; 0.001) and strabismus (p &lt; 0.05), were significantly more worried about their children's eye condition. Parent PedEyeQ 5 to 11 years' greatest difference was also found to be 30 points worse on the Worry about their Child's Eye Condition domain (95% CI −43 to −17; p &lt; 0.005).

Conclusions

Children who have undergone congenital and developmental cataract surgery experience a lower quality of life and reduced functional vision. Their families are also significantly and adversely affected herein. Thus, more attention is needed on these groups, with more focused measures being administered to both children and their families.

Altered Brain Structure and Spontaneous Functional Activity in Children With Concomitant Strabismus

Strabismus occurs in about 2% of children and may result in amblyopia or lazy eyes and loss of depth perception. However, whether/how long-term strabismus shapes the brain structure and functions in children with concomitant strabismus (CS) is still unclear. In this study, a total of 26 patients with CS and 28 age-, sex-, and education-matched healthy controls (HCs) underwent structural and resting-state functional magnetic resonance imaging examination. The cortical thickness and amplitude of low-frequency fluctuation (ALFF) were calculated to assess the structural and functional plasticity in children with CS. Compared with HCs group, patients with CS showed increased cortical thickness in the precentral gyrus and angular gyrus while decreased cortical thickness in the left intraparietal sulcus, parieto-occipital sulcus, superior and middle temporal gyrus, right ventral premotor cortex, anterior insula, orbitofrontal cortex, and paracentral lobule. Meanwhile, CS patients exhibited increased ALFF in the prefrontal cortex and superior temporal gyrus, and decreased ALFF in the caudate and hippocampus. These results show that children with CS have abnormal structure and function in brain regions subserving eye movement, controls, and high-order cognitive functions. Our findings revealed the structural and functional abnormalities induced by CS and may provide new insight into the underlying neural mechanisms for CS.

Health-related quality of life and anxiety associated with childhood intermittent exotropia before and after surgical correction

BACKGROUND

Intermittent exotropia (IXT) is the most common form of exotropia in children. In addition to cosmetic effects and loss of stereoscopic function, IXT may negatively impact the psychological well-being of children and their parents. The purpose of this study was to assess the patient-reported outcomes of Chinese children with IXT before and after strabismus surgery.

METHODS

The records of children with IXT who underwent strabismus surgery at the Zhongshan Ophthalmic Center of Sun Yat-sen University, China over the period from January 1, 2016 to December 31, 2018 were prospectively recruited. All children underwent ophthalmic and orthoptic examinations, including the prism and alternate cover test, fusion function by synoptophore, stereoacuity and Newcastle control score. Two patient-reported outcome measures were used: the intermittent Exotropia Questionnaire (IXTQ) to measure disease-specific health-related quality of life (HRQOL) and the Hospital Anxiety and Depression Scale (HADS) to measure anxiety and depression. Patient-reported outcome measurements were made before and after surgery with responses from children and their parents.

RESULTS

A total of 389 children were eligible for inclusion (47.8% male, 52.2% female, mean + SD age = 8.17 ± 2.81). Preoperative IXTQ scores in both children (48.21 ± 26.2) and their parents (44.6 ± 25.68) were significantly correlated with near stereoacuity (P = 0.029 and P = 0.015, respectively). The angle of deviation at near vision showed a negative linear relationship with visual function (P = 0.026) and psychological (P = 0.019) scores as well as opinions regarding surgery (P = 0.024). HADS scores (anxiety scale score: 11 ± 2.92, depression scale score: 10.44 ± 2.9) were also related to near stereoacuity (P < 0.05). After surgery, both children's (74.83 ± 16.59) and parents' (68.57 ± 17.06) IXTQ scores significantly improved (p<0.01). Children's IXTQ scores were related to the angle of deviation at distance, and their psychological and visual function scores showed a negative relationship with the angle of deviation at near vision (P < 0.05).

CONCLUSION

Children and parents' HRQOL and HADS were associated with near stereoacuity. Parents usually attend more readily to the angle of deviation at near in their IXT children. HRQOL improved significantly after surgery and can be used as one of the indices for preoperative evaluation but is not recommended as a criterion for surgical intervention.

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.

Saudi Children's Perception of Strabismus: A Hospital-Based Study

PURPOSE:

Children with strabismus may face difficulties interacting with their peers in elementary school. This study investigates the psychosocial effect of different types of strabismus on Saudi children's selection of a playmate.

METHODS:

Photographs of orthotropic children were digitally modified to simulate various magnitudes of strabismus. Orthotropic children with normal visual acuity viewed 18 sets of paired photographs and were asked to choose a playmate from each pair. Parents were asked to fill out a questionnaire on their socioeconomic background and to determine whether surgery should be indicated in strabismic patients for psychosocial reasons. Parents were also asked to rate their perception of seven personal characteristics of two images of the same child (one orthotropic and one strabismic).

RESULTS:

Two hundred and thirty-three children, aged 3–15 years (mean age: 9.94 [3.6] years), were studied. Children aged ≤6 years were significantly more likely not to distinguish between orthotropic children and those with strabismus (P < 0.001). Out of 233 participants, 69.6% were significantly in favor of orthotropic faces as opposed to 30.4% (P < 0.0001). Children perceived esotropia as less disturbing than exotropia and hypertropia (P < 0.001). Smaller magnitudes of strabismus were significantly preferred over larger angles (P < 0.001). Parents judged strabismic faces more negatively than orthotropic faces on all seven characteristics. Almost 88.4% of the adults thought that strabismic patients should undergo surgery for correction.

CONCLUSIONS:

Our findings suggest that children with apparent strabismus are perceived negatively and might be subjected to social alienation at a young age. Therefore, there is a need for strategies to address negative social bias toward children with strabismus and to enhance their peer acceptance in our society.

Influence of intermittent exotropia surgery on general health-related quality of life: different perception by children and parents

PURPOSE

To assess the general health-related quality of life (QOL) in children with intermittent exotropia (IXT) before and 3 months after surgery, by interviewing individual patients and their parents.

STUDY DESIGN

Prospective, interventional case series.

METHODS

Twenty-one patients undergoing IXT surgery and their parents were included. Using the Pediatric Quality of Life Inventory (PedsQL), children and parents were separately questioned about QOL of patients.

RESULTS

The mean patients' age was 8.6 ± 3.2 years (SD), with range of 5-16 years. The children responded that all PedsQL scores were significantly improved by surgery, and the highest improvement was observed in the school subscale score. When the parents rated the children's QOL, significant improvements were limited to 3 out of 7 subscales, including the emotional, psychosocial health summary, and total scores. The improvements in the PedsQL score were not correlated with age, size of deviation changes following surgery, nor the improvement in binocular vision.

CONCLUSIONS

The general health-related QOL significantly improved by surgery in pediatric patients with IXT, while the improvement was considerably underestimated by the parents. The children reported the greatest improvement in the school functioning subscale, whereas parents failed to discern this improvement. The discrepancy in children' and parents' views can be an important factor when considering indication of corrective surgery and evaluating surgical outcomes.

Psychosocial impacts of adult strabismus and strabismus surgery: a review of the literature

BACKGROUND

Patients with strabismus may suffer from both reduced visual functioning and the psychosocial effects of ocular misalignment. For adults with strabismus, there is a strong body of evidence supporting the advantages of surgical restoration of binocular visual function. However, even in the absence of binocular visual potential, patients may benefit from reconstructive surgery to restore an aesthetically acceptable ocular alignment.

OBJECTIVE

To review the psychosocial implications of strabismus in the adult population and to summarize the psychosocial impact of surgical correction.

METHODS

A Medline search (1946-2013) was conducted to identify the psychosocial implications of strabismus, its effects on employment, and the impact of surgical correction on strabismic adults using the following keywords: strabismus, surgery, quality of life, life style, employment/employability effects, job satisfaction, social support/social isolation/social marginalization, adaptation, stress, depression, family relations, interpersonal relations, friends, and peer group. The search was limited to patients older than 18 years and studies published in English. Of the initial 87 articles for which abstracts were reviewed, 20 studies were of sufficient relevance to be included in the review.

RESULTS

Eight studies examined the psychosocial impact of strabismus, 2 of which explored the effect of strabismus on finding partners, and 4 studies examined the effect of strabismus on employment. These studies examined perceptions of both patients with strabismus and the general population. Eight studies evaluated the impact of strabismus surgery. Strabismus was shown to have negative psychosocial functioning and employability in both patients' and the public's perceptions. Surgical correction was associated with long-lasting improvement in psychological and social functioning.

CONCLUSIONS

There is a fairly strong body of evidence in the literature to suggest that adult strabismus patients suffer significant social, psychological, and economic effects because of their condition. Surgery can be effective in improving these disadvantages. Clinicians should be aware of the importance of offering surgery to patients with significant strabismus, even in patients for whom it is not expected to improve visual function.

A dichoptic feedback-based oculomotor training method to manipulate interocular alignment

Strabismus is a prevalent impairment of binocular alignment that is associated with a spectrum of perceptual deficits and social disadvantages. Current treatments for strabismus involve ocular alignment through surgical or optical methods and may include vision therapy exercises. In the present study, we explore the potential of real-time dichoptic visual feedback that may be used to quantify and manipulate interocular alignment. A gaze-contingent ring was presented independently to each eye of 11 normally-sighted observers as they fixated a target dot presented only to their dominant eye. Their task was to center the rings within 2° of the target for at least 1 s, with feedback provided by the sizes of the rings. By offsetting the ring in the non-dominant eye temporally or nasally, this task required convergence or divergence, respectively, of the non-dominant eye. Eight of 11 observers attained 5° asymmetric convergence and 3 of 11 attained 3° asymmetric divergence. The results suggest that real-time gaze-contingent feedback may be used to quantify and transiently simulate strabismus and holds promise as a method to augment existing therapies for oculomotor alignment disorders.

Satisfaction with strabismus surgery based on the opinion of expert surgeons

PURPOSE

To assess the perception of strabismus surgeons in Spain regarding patient satisfaction after surgery, by analysing the types of strabismus with the most satisfied patients, as well as the causes of dissatisfaction.

METHODS

A survey was carried out among the members of the Spanish Strabology Society who were over 50 years of age, active in Spain, with more than 20 years of surgical experience, and whose main surgical activity was strabismus. The questionnaire consisted of 18 questions about the perception of patient satisfaction according to the type of strabismus, patient age, as well as the most frequent cause of dissatisfaction after surgery.

RESULTS

The questionnaires were completed by a total of 29 surgeons, with a mean of 31 years of surgical experience. The most frequent cause of perceived dissatisfaction was residual strabismus. No differences were found in the satisfaction index between children and adults. The surgery that was considered to produce greater satisfaction was endotropia, followed by decompensated 4th nerve palsy, and exotropia, while 3rd nerve palsy was the cause of the most dissatisfaction.

CONCLUSIONS

According to strabismus surgeons, endotropia is the most satisfactory surgery for the patient, followed by exotropia, vertical strabismus, and traumatic paralysis of the 4th cranial nerve.

Survey of Ehlers-Danlos Patients' ophthalmic surgery experiences

Background

Ehlers‒Danlos Syndrome (EDS) is a rare disease affecting approximately 1 in 5,000 people. Although ophthalmic conditions associated with EDS have been described, little data exist concerning ophthalmic surgical outcomes experienced by EDS patients.

Methods

Patients with EDS were surveyed via the EDS Society and asked about their ophthalmic surgical experiences including procedure, complications, and the timing with respect to receiving the EDS diagnosis. Complications were confirmed as such by subspecialists.

Results

Of 579 respondents, 467 reported confirmed EDS, and 112 of those had an ophthalmic procedure, including refractive surgery, cataract/lens surgery, retinal surgery, strabismus surgery, oculoplastic surgery, corneal surgery, and laser surgery for glaucoma. The rate of confirmed complications was: 23%‐refractive, 33%‐lens/cataract, 33%‐retina, 59%‐strabismus, 23%‐ oculoplastics, 0%‐cornea, and 25%‐glaucoma laser. In addition, 76% of patients underwent surgery prior to the EDS diagnosis.

Conclusions

Patients with EDS may have elevated risk of postoperative ophthalmic surgical complications. It would seem reasonable to systemically and prospectively explore how patients with EDS respond to ophthalmic surgery. Furthermore, it would seem circumspect to ask surgical candidates patients about whether they carry a diagnosis of EDS or have signs and symptoms of EDS prior to surgery.

Health-related quality of life and mental health in children and adolescents with strabismus - results of the representative population-based survey KiGGS

Background

To estimate the effect of strabismus (squinting) on mental health and health-related quality of life aspects in children and adolescents.

Methods

Data from the German Health Interview and Examination Survey for Children and Adolescents KiGGS (2003–2006 baseline survey; N = 14,835, aged 3 to 17 years, 49% girls) were examined. The presence of strabismus was derived by parental questionnaire, and health-related quality of life and mental health were investigated with the KINDL-R and Strengths and Difficulties Questionnaire. Associations between strabismus and outcomes were analyzed using multivariable linear and logistic regression models.

Results

Of 12,989 children without missing data, 579 children (4.5% of the sample) were reported to have strabismus. Children with strabismus had lower scores in the parent-reported KINDL-R total scale (adjusted beta = − 1.02; 95%CI: -1.86 to − 0.18; p = 0.018) and sub-scale ‘friends’ (adjusted beta = − 2.18; 95%CI: -3.56 to -0.80; p = 0.002) compared to children without strabismus. The presence of strabismus was also associated with more mental health problems like ‘hyperactivity/inattention’ (adjusted OR = 1.50; 95%CI: 1.14 to 1.98; p = 0.005), and ‘peer problems’ (adjusted OR = 1.35; 95%-CI: 1.05 to 1.74; p = 0.018) as reported by parents.

Conclusions

Strabismus in children and adolescents is associated with lower health-related quality of life.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1144-7) contains supplementary material, which is available to authorized users.

Arguments for the Adoption of a Nystagmus Care Pathway

Pathological nystagmus is a spontaneous oscillation of the eyes. It is a complex problem with many subtypes and causes ranging from the acute neurological emergency to chronic visual disorders. There is considerable variability in clinical management and patient experience across the UK. The Nystagmus Care Pathway (NCP) is a proposal to provide an evidence-based, consistent minimum standard of care across all eye services for patients with nystagmus. The NCP coordinates expertise from the various team members with a staged approach: 1) pathway entry; 2) nystagmus identification; 3) finding underlying causes/associations; 4) managing causes/associations; 5) managing the nystagmus and its effects; 6) support for patients and families; 7) pathway exit. Orthoptists are ideally placed to coordinate the NCP as they are trained in ocular motility and visual assessment. They are accustomed to providing continuity of care, multidisciplinary working and via the British and Irish Orthoptic Society (BIOS), they can provide consistency of care across the UK. Key performance indicators are proposed.

Visual functioning in adults with Idiopathic Infantile Nystagmus Syndrome (IINS)

PURPOSE

IINS is associated with mild/moderate visual impairment, strabismus and compensatory head postures (CHP), which can negatively impact quality of life. Standard visual acuity assessments tend to underestimate the effect of IINS on visual functioning. Published evidence on the effect of INS on quality of life is slowly emerging. Our study examines visual functioning of adults with IINS using the National Eye Institute Visual Function Questionairre-25 (VFQ-25).

METHODS

38 participants were recruited to participate in the study. All participants underwent detailed clinical examination, as well as appropriate investigations and were asked to complete the self administered VFQ-25.

RESULTS

35/38 participants completed the questionnaire. The mean age of the population was 35.1 years (range 17-64). Mean overall VFQ-25 score at baseline was 65 (SD 13, range 34-91). Participants specifically demonstrated lowest scores for the impact of IINS on mental health, role limitations and dependency. 26/35 of participants were not driving, either due to sub-normal vision, lack of confidence or difficulties with contrast sensitivity.

CONCLUSIONS

IINS can have a greater than expected impact on an individual's quality of life, without necessarily causing markedly reduced visual acuity. Our study showed lowest scores in the domains of mental health and wellbeing. Patients also reported reduced visual functioning in driving, which can impact adversely on employability and independence. Visual functioning questionnaires such as the VFQ-25 may provide more functional information on the impact of nystagmus on an individual's quality of life than objective measures such as high contrast Snellen and/or LogMAR visual acuity.

What Did They Know Then? A Journey Among the Giants of the Past

Dr. Richard Scobee has the honorary title "The Father of American Orthoptics." In addition to his numerous accomplishments in his academic career, he had hobbies that included collecting historical stamps. In tribute to his love of things past, this lecture will delve into the remote history of ophthalmology, to see what eminent pioneers knew and wrote about eye muscle disorders and binocular vision in their treatises. Our journey will include eight personalities and their works, ranging from the 7th century through to the early 19th century, and will encompass Europe, the Middle East, Great Britain, and North America. Analyzing the writings of these masters affords glimpses into the knowledge base and philosophies that were prevalent in different centuries. Many of these individuals were innovators who pushed the boundaries of knowledge. Some of them made advances using intuition and reason, mainly through case experience and case studies, while others used the scientific method to gain new information. In many cases, the words written by these luminaries centuries ago still resonate with us today and guide us in our everyday practices. It is hoped that this journey will be enlightening for orthoptists, ophthalmologists, and allied health personnel, and confirm, as in many areas of science, that we truly stand on the shoulders of giants, the masters from the recent and the distant past.

Plication as an alternative to resection in horizontal strabismus: A randomized clinical trial

Purpose:

Resections and plications tighten recti although the latter are less traumatic, potentially reversible, quicker, and vascularity preserving. To compare inflammation, scarring, and alignment in horizontal strabismus, operated uniocularly by either resections or plications (with recessions): recession and resection (R&R) or recession and plication (R&P) groups. This was a prospective, patient and assessor blind, randomized trial.

Methods:

All consenting strabismus patients qualifying for the first-time uniocular horizontal rectus surgeries underwent detailed ocular examination and were randomized into standard R&R or R&P groups. For the latter, we folded the tendon-muscle strap the desired amount using 6-0 polyglactin, suturing it to its insertion, entailing no disinsertion. We compared the groups for inflammatory grades (individually for congestion, chemosis, discharge, foreign-body sensation, and drop intolerance and aggregated to a total inflammatory score (TIS), scar visibility (SV) at 1 m, and successful alignment (≤10 prism diopter of orthotropia). We used Mann–Whitney and Fisher's exact tests, with significance at P ≤ 0.05.

Results:

We randomized 40 patients: 22 to R&R and 18 to R&P. The groups were comparable in age, strabismus onset and duration, and strabismus amount. The inflammatory scores, both individual and TIS, were comparable at all time-points: all P > 0.05. SV proportions were not significantly different: 16/22 in R&R versus 9/18 in R&P; P = 0.19. There were no significant differences in success rates: 14/22 versus 10/18, P = 0.74.

Conclusion:

Our study shows that plication is similarly effective as resection, when combined with recession in horizontal strabismus, and should be resorted to more frequently.

To assess knowledge and attitude of parents toward children suffering from strabismus in Indian subcontinent

Purpose:

Strabismus and anisometropia are the most common causes of amblyopia. It can be easily prevented or treated if detected early. With the changing socio-cultural-economic milieu of the society, the perspectives of strabismus in society are gradually changing but still adequate knowledge, awareness, and attitude of parents toward strabismus will help in preventing amblyopia and aid in the proper psychosocial adaptation of such children. This study aimed to assess knowledge and attitude of parents toward children suffering from strabismus.

Methods:

A prospective study was carried out from January 1 to February 29, 2016, through a structured questionnaire to assess the level of knowledge and attitude of parents of children suffering from strabismus.

Results:

One hundred and twenty parents of children with strabismus were interviewed through a questionnaire. Education level of 78 parents was less than graduation (60%) and of 42 parents (40%) was graduation or higher. The majority of the parents, i.e., 116 (96.67%) were bothered due to strabismus. One hundred and one (84.17%) parents felt that their child's strabismus was noticed by others during interaction. Seventy-four (61.67%) parents felt that their children will have difficulty in making friends. Ninety (75%) parents felt uncomfortable if someone asked something about their child's strabismus. One hundred and ten (91.67%) parents considered strabismus as cosmetic stigma.

Conclusion:

Some parents, especially from the lower educated segment, had poor understanding of strabismus, thus resulting in late presentation and ineffective countermeasures. The key to prevent strabismic amblyopia and its psychosocial impacts is to provide health education regarding strabismus.

Automatic diagnosis of strabismus in digital videos through cover test

BACKGROUND AND OBJECTIVE

Medical image processing can contribute to the detection and diagnosis of human body anomalies, and it represents an important tool to assist in minimizing the degree of uncertainty of any diagnosis, while providing specialists with an additional source of diagnostic information. Strabismus is an anomaly that affects approximately 4% of the population. Strabismus modifies vision such that the eyes do not properly align, influencing binocular vision and depth perception. Additionally, it results in aesthetic problems, which can be reversed at any age. However, the use of low cost computational resources to assist in the diagnosis and treatment of strabismus is not yet widely available. This work presents a computational methodology to automatically diagnose strabismus through digital videos featuring a cover test using only a workstation computer to process these videos.

METHODS

The method proposed was validated in patients with exotropia and consists of eight steps: (1) acquisition, (2) detection of the region surrounding the eyes, (3) identification of the location of the pupil, (4) identification of the location of the limbus, (5) eye movement tracking, (6) detection of the occluder, (7) identification of evidence of the presence of strabismus, and (8) diagnosis.

RESULTS

To detect the presence of strabismus, the proposed method achieved a specificity value of 100%, and (2) a sensitivity value of 80%, with 93.33% accuracy in diagnosis of patients with extropia. This procedure was recognized to diagnose strabismus with an accuracy value of 87%, while acknowledging measures lower than 1Δ, and an average error in the deviation measure of 2.57Δ.

CONCLUSIONS

We demonstrated the feasibility of using computational resources based on image processing techniques to achieve success in diagnosing strabismus by using the cover test. Despite the promising results the proposed method must be validated in a greater volume of video including other types of strabismus.

Difference of Self-identity Levels between Strabismus Patients and Normal Controls

Purpose

To evaluate differences in self-identity in patients diagnosed with strabismus, patients who underwent strabismus surgery, and healthy control individuals.

Methods

Self-identity testing was done during a military service physical examination. There were three subject groups: subjects with strabismus (group 1), subjects who had undergone corrective strabismus surgery (group 2), and subjects free of strabismus (group 3). The self-identity test was comprised of six sub-sections (subjectivity, self-acceptance, future confidence, goal orientation, initiative, and familiarity). Statistical significance of the sub-sections was compared across the three groups. Correlations in age at the time of surgery and across the six sub-sections were investigated in group 2.

Results

A total of 351 subjects were enrolled in the study; 96 subjects were in group 1, 108 subjects were in group 2, and 147 subjects were in group 3. Significant differences were evident in subjectivity, self-acceptance, initiative and familiarity between groups 1 and 3. No significant differences were found between groups 2 and 3. In group 2, statistical significance was evident between age at surgery and initiative and familiarity (r = −0.333, p < 0.001; r = −0.433, p < 0.001, respectively).

Conclusions

Self-identity is greater in non-strabismus subjects than strabismus subjects. Correction of strabismus may increase self-identity levels.

Gain beyond cosmesis: demonstration of psychosocial and functional gains following successful strabismus surgery using the adult strabismus questionnaire adult strabismus 20

Background:

Strabismus adversely affects psychosocial and functional aspects; while its correction impacts positively.

Aim:

The aim was to evaluate the gains in scores: Overall scores (OASs), psychosocial subscale scores (PSSs) and functional subscale scores (FSSs) following successful surgical alignment.

Settings and Design:

We evaluated changed scores in the adult strabismus 20 (AS-20) questionnaire, administered before and after successful surgery.

Materials and Methods:

Thirty adults horizontal strabismics, were administered the AS-20, at baseline, and at 6-week and 3-month. Group-wise analysis was carried out based on gender, strabismus type (esotropia [ET] or exotropia [XT]), back-ground and amblyopia.

Statistical Analysis:

We used Wilcoxon, and Mann-Whitney U-tests. Significance was set at P ≤ 0.05.

Results:

At baseline, there were no significant differences within the groups, except that those with amblyopia significantly scored less than nonamblyopes in OAS (median scores: 53.8 vs. 71.3; P = 0.009) and FSS (56.3 vs. 85.3; P = 0.009). OAS, PSS and FSS showed significant gains at 6-week and 3-month (all Wilcoxon P < 0.001). Compared with males, females showed significantly more gain at 3-month (OAS: 37.9 vs. 28.7; P = 0.02), on account of PSS gain (49.6 vs. 37.5; P = 0.01). The ET performed better than XT only on the FSS at 6-week (28.7 vs. 15.0; P = 0.02). Vis-à-vis the nonamblyopes, the amblyopes showed significantly more benefit at 6-week alone (OAS: 18.7 vs. 28.7; P = 0.04), largely due to gains in PSS.

Conclusions:

Successful strabismus surgery has demonstrated significant gains in psychosocial, functional and overall functions. There is some evidence that gains may be more in females; with a trend to better outcomes in ET and amblyopes up to 6-week.

The Impact of Congenital Strabismus Surgery on Quality of Life in Children

PURPOSE

To assess quality of life (QOL) in children undergoing strabismus surgery.

METHODS

This prospective cohort study included 87 children (including 41 boys, 47.1%) with mean age of 8.7 ± 4.1 years at three academic eye hospitals in Tehran. A modified version of the RAND Health Insurance Study QOL questionnaire was filled based on interviews with parents before and three months after surgery. The questionnaire consisted of 36 Likert scale items ranging in score from 0 to 100, with higher scores representing better function. Relevant items were averaged together and categorized into 11 distinct QOL dimensions.

RESULTS

The majority of QOL dimensions improved after strabismus surgery including functional limitation (92.36 ± 16.78 vs. 82.15 ± 20.92, P < 0.01), anxiety (68.61 ± 18.15 vs. 60.28 ± 19.19, P < 0.01), depression (82.31 ± 16.42 vs. 72.36 ± 17.72, P < 0.01), positive well-being (73.33 ± 14.69 vs. 70.56 ± 15.96, 0.048), social relations (79.43 ± 11.52 vs. 68.69 ± 30.98, 0.002), general health perception (76.4 ± 16.48 vs. 67.36 ± 18.9, P < 0.01), resistance/susceptibility (79.72 ± 13.4 vs. 71.02 ± 14.58, P < 0.01), satisfaction with development (73.81 ± 16.07 vs. 70.07 ± 14.98, P = 0.006), and eye alignment concerns (75.44 ± 15.89 vs. 53.14 ± 26.61, P < 0.01). Only self-reported prior health (71.73 ± 15.9 vs. 72.78 ± 15.29, P = 0.33) and parent-child closeness (72.92 ± 15.82 vs. 72.5 ± 17.99, P = 0.73) did not significantly improve. The amount of ocular realignment (more vs. less than 20 prism diopters [PD]) had a direct correlation with improvement in subscales of satisfaction with development (0.019) and eye alignment concerns (0.028).

CONCLUSION

Strabismus surgery positively impacts physical and psychosocial function in children. Children with a greater amount of correction experienced more QOL improvement after surgery.

An external pilot study to test the feasibility of a randomised controlled trial comparing eye muscle surgery against active monitoring for childhood intermittent exotropia [X(T)]

INTRODUCTION

The evidence base for the treatment of strabismus (squint) is poor. Our main aim is to improve this evidence base for the treatment of a common type of childhood squint {intermittent exotropia, [X(T)]}. We conducted an external pilot study in order to inform the design and conduct of a future full randomised controlled trial (RCT).

METHODS

Children of between 6 months and 16 years with a recent diagnosis of X(T) were eligible for recruitment. Participants were recruited from secondary care at the ophthalmology departments at four UK NHS foundation trusts. Participants were randomised to either active monitoring or surgery. This report describes the findings of the Pilot Rehearsal Trial and Qualitative Study, and assesses the success against the objectives proposed.

RECRUITMENT AND RETENTION

The experience gained during the Pilot Rehearsal Trial demonstrates the ability to recruit and retain sites that are willing to randomise children to both trial arms, and for parents to agree to randomisation of their children to such a study. One child declined the group allocation. A total of 231 children were screened (expected 240), of whom 138 (60%) were eligible (expected 228: 95%) and 49 (35% of eligible) children were recruited (expected 144: 63% of eligible). Strategies that improved recruitment over the course of the trial are discussed, together with the reasons why fewer children were eligible for recruitment than initially anticipated. Attrition was low. Outcome data were obtained for 47 of 49 randomised children.

TRIAL PROCESSES AND DATA COLLECTION

The Trial Management processes proved effective. There were high levels of completion on all of the data collection forms. However, the feedback from the treatment orthoptists revealed that some modifications should be made to the length and frequency of the health service assessment and travel assessment questionnaires, thus reducing the burden on participants in the main trial. Modifications to the wording of the questions also need to be made.

MONITORING OF BIAS

Children who recruited to the trial were older and had more severe strabismus than those children eligible but declining participation. Strategies to account for this in a full trial are proposed.

REASONS FOR PARTICIPATION OR DECLINING STUDY

These were identified using qualitative interviews. The principal reasons for declining entry into the study were strong preferences for and against surgical treatment.

HARMS

There were no serious unexpected adverse events. Two children had overcorrection of their X(T) with reduction in binocular vision following surgery, which is in line with previous studies. No children in the active monitoring arm developed a constant strabismus although two showed some reduction in control.

CONCLUSIONS

The SamExo study has demonstrated that it is possible to recruit and retain participants to a randomised trial of surgery compared with active monitoring for X(T). For longer-term full RCTs, in order to maximise the generalisability of future studies, consideration needs to be given to planning more time and clinic appointments to assess eligibility and to allow consideration of participation; the greater use of research nurses for recruitment; and accommodating the strong preferences of some parents both for and against surgical intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44114892.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 39. See the NIHR Journals Library website for further project information.

A functional MRI study of altered spontaneous brain activity pattern in patients with congenital comitant strabismus using amplitude of low-frequency fluctuation

OBJECTIVE

The aim of this study was to use amplitude of low-frequency fluctuation (ALFF) to investigate local features of spontaneous brain activity in patients with congenital comitant strabismus and clarify their relationship with emotional and psychosocial problems.

METHODS

A total of 20 patients with congenital comitant strabismus (ten males and ten females), and 20 healthy controls (ten males and ten females) closely matched in age, sex, and education underwent resting-state functional magnetic resonance imaging scans. The ALFF method was used to assess local features of spontaneous brain activity. Congenital comitant strabismus patients were distinguished from healthy controls by receiver operating characteristic curve. Correlation analysis was performed to explore the relationships between the observed mean ALFF signal values of the different areas and the Chinese version of the Hospital Anxiety and Depression Scale.

RESULTS

Compared with healthy controls, patients with congenital comitant strabismus had significantly lower ALFF in the bilateral medialfrontal gyrus and higher values in the bilateral cerebellum posterior lobe and left angular gyrus. In the congenital comitant strabismus group, the Hospital Anxiety and Depression Scale-depression score showed a negative correlation with the ALFF signal values of the bilateral medial frontal gyrus (r=-0.550, P=0.012) and a negative correlation was noted between the mean ALFF signal values of the left angular gyrus and strabismus duration (r=-0.515, P=0.020).

CONCLUSION

Congenital comitant strabismus mainly involves dysfunction in the bilateral medial frontal gyrus, bilateral cerebellum posterior lobe, and left angular gyrus, which may reflect the underlying pathologic mechanism of congenital strabismus.

Reprint of: Social phobia and other psychiatric problems in children with strabismus

OBJECTIVE

To investigate the rate of social phobia, anxiety, depression, and other psychiatric problems in children with strabismus.

DESIGN

Prospective, cross-sectional, case-control study.

PARTICIPANTS

Forty-two children with strabismus and 47 control subjects 8-13 years of age were enrolled in this study.

METHODS

After the ophthalmologist's examination, all cases were assessed by a psychiatrist based on the structured interview technique of Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version (Kiddie-SADS-PL). The Screen for Child Anxiety Related Emotional Disorders (SCARED) was administered to each subject to evaluate social phobia. All participants completed the Children's Depression Inventory (CDI).

RESULTS

Age as well as sex and income were comparable between the strabismus patients and control groups. Social phobia was diagnosed in 8 (19.04%) of the 42 strabismic children and in 1 (2.12%) of the control subjects. The CDI and SCARED (total score, social phobia, separation anxiety) scores of strabismus patients were significantly higher than the control group (p = 0.001, p = 0.004, p = 0.0001, p = 0.05, respectively).

CONCLUSIONS

A relationship between strabismus in children and social phobia, depression, and anxiety on a symptom basis was underlined by our data.

Surgical correction of childhood intermittent exotropia and the risk of developing mental illness

PURPOSE

To assess whether successful surgical intervention for intermittent exotropia, or the timing of intervention, has any effect on the development of mental illness.

DESIGN

Retrospective, observational case series.

METHODS

All patients (<19 years of age) diagnosed with intermittent exotropia in Olmsted County, Minnesota, from January 1, 1975, through December 31, 1994, were reviewed retrospectively. Potential cases were identified using the resources of the Rochester Epidemiology Project, a medical records database designed to capture data on any patient-physician encounter in Olmsted County, Minnesota. The main outcome measures were the occurrence and severity of mental illness among those who underwent strabismus surgery compared with those who did not.

RESULTS

Ninety-six (52%) of the 184 children identified were diagnosed with a mental illness at a mean age of 23.3 years (range, 6 to 41 years). Thirty-five (36%) of the 96 children in whom mental illness developed underwent strabismus surgery. Success at surgery (<10 prism diopters) was not associated with a decreased occurrence of mental illness (P = .30). Of the 88 patients in whom mental illness did not develop, strabismus surgery was not more commonly performed (P = .54), nor was it performed at a younger age (P = 1.0), when compared with the 96 patients in whom mental illness developed later.

CONCLUSIONS

Strabismus surgery for children with intermittent exotropia, regardless of success or age at surgery, did not alter the development of mental illness by early adulthood.

Effect of strabismus surgery on the reading ability of school-age children

AIM

To evaluate if strabismus surgery on children between the ages 5 and 14 years leads to an improvement in reading ability by comparing reading performance of patients before and after surgery.

METHODS

Pre- and postoperatively, the visual acuity, ocular alignment, and stereoacuity of 15 children with horizontal strabismus was recorded. The "3-Minute Reading Assessments: Word Recognition, Fluency, and Comprehension" for the appropriate age-group were used to assess children between the ages of 5 and 14 years. Thirteen of the 15 children presented with esotropic deviation, and the remaining 2 were exotropic.

RESULTS

Postoperatively, 12 patients were orthophoric and 3 had significant residual esotropia. The 15 patients had an average improvement in reading speed (10.3 words per minute), accuracy (4%), and fluency (2 points). For the 12 orthophoric patients, reading speed increased by 12.2 (P = .003), accuracy by 3% (P = .064), and fluency by 1.33 (P = .006).

CONCLUSION

Corrective strabismus surgery in school-age children showed an early improvement in reading ability that could translate into better academic performance. Our results suggest that reading ability could be an important factor when considering corrective surgery for children with strabismus.

Effects of corrective surgery on social phobia, psychological distress, disease-related disability and quality of life in adult strabismus patients

BACKGROUND

Corrective surgery is done for ocular alignment and disrupted facial expression in some cases of adult strabismus patients. The effects of corrective surgery on the presence of social phobia (SP) diagnosis, the severity of social anxiety symptoms, the disease-related disability and the quality of life (QoL) among strabismus patients have not been thoroughly studied yet.

METHODS

The study sample was composed of patients who had undergone corrective surgery for strabismus. Preoperative and postoperative evaluations made by using standardised measures of social phobia diagnosis (DSM-IV-TR) and severity (Liebowitz Social Anxiety Scale (LSAS)), anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), disability (Sheehan Disability Scale) and quality of life (short form-36).

RESULTS

Preoperatively, SP diagnosis was detected in 17 of 31 (54.8%) patients, whereas postoperatively 6 of 31 (19.4%) patients had SP (p=0.001). Participants showed a significant decrease in all subscale scores and total score of both LSAS and HADS compared with their preoperative scores. Significant improvements were observed in QoL and disability scores as well.

CONCLUSIONS

Adult strabismus patients seem to gain benefits from corrective surgery not only for their ocular misalignment but also for social anxiety levels that may be associated with improvements in their QoL and disability levels.

Alcohol use and positive screening results for depression and anxiety are highly prevalent among Chinese children with strabismus

PURPOSE

To study associations between strabismus and alcohol use, anxiety, and depression among 10- to 17-year-old children in Guangdong, southern China.

DESIGN

Cross-sectional, population-based study.

METHODS

Among 7537 children aged 6-17 years from 9 randomly selected primary and middle schools, ocular alignment was assessed with the Hirschberg light reflex, cover-uncover testing, and alternate cover testing at distance (6 m) and near (40 cm). Additionally, 4000 children (53.1%) aged 10+ years received self-administered questionnaires containing screening questions on alcohol use, anxiety, and depression.

RESULTS

Examinations were completed on 7464 of 7537 subjects (99.0%), including 3928 boys (52.6%), with a mean age of 11.1 ± 1.8 years. The prevalence of any strabismus, including exotropia (2.7%), esotropia (0.2%), and intermittent exotropia (3.9%), was 6.8%. Strabismus was more prevalent in urban students (7.3%) and female subjects (7.4%) compared to rural students (6.0%) and male subjects (6.2%) (all P < .05). In multivariate regression models, any strabismus was associated with older age and rural vs urban residence. Among 3903 children (97.6%) answering questionnaires, history of alcohol use (62.3% vs 36.3%) and positive screening responses for depression (26.0% vs 11.6%) and anxiety (10.3% vs 4.9%) were significantly (P < .01 for all) more common among children with strabismus.

CONCLUSION

These Chinese children with strabismus had a significantly higher prevalence of alcohol use and possible markers of emotional problems than children without strabismus. Further research should focus on the appropriateness of classifying surgical treatment for strabismus as "cosmetic" (ineligible for reimbursement) under China's rural health insurance.

Quality of life and emotional change for middle-aged and elderly patients with diabetic retinopathy

AIM

To evaluate the SF-36, Diabetes Specificity Quality of Life Scale (DSQL) and anxiety and depression symptoms and investigate its changes in proliferative diabetic retinopathy (PDR) by vitrectomy interventions.

METHODS

The present study included 108 diabetic retinopathy (DR) patients: 54 with PDR and 54 with non-proliferative diabetic retinopathy (NPDR). Each healthy control group (n=54) sociodemographically matched to DR groups was established respectively. The quality of life, anxiety and depression symptoms were evaluated and analyzed on preoperative and postoperative month 1 using SF-36, DSQL and Hospital Anxiety and Depression Scale (HADS).

RESULTS

DR patients described impaired HRQL (Health Related Quality of life, SF-36) in 6 out of 8 subscales, including 'Body Health', 'Body Role Function', 'General Health', 'Society Function', 'Emotion Role Function' and 'Mental Health'. Compared with controls, DR patients (NPDR and PDR) suffered from statistically significantly impaired HRQL (SF-36 Summary score) (P<0.05). By surgical intervention, the anxiety and depression score were significantly reduced, while the health and quality of life (SF-36 Summary scores and DSQL scores) was improved in patients with PDR (P<0.05).

CONCLUSION

DR patients were affected in mentation and quality of life. Surgery interventions can improve SF-36, DSQL, anxiety and depression in PDR patients.

Parent-reported symptoms of attention deficit hyperactivity disorder in children with intermittent exotropia before and after strabismus surgery

PURPOSE

To investigate the symptoms of attention deficit hyperactivity disorder (ADHD) as reported by parents in children with intermittent exotropia [X(T)] and to determine whether strabismus surgery for X(T) affects ADHD symptoms.

MATERIALS AND METHODS

Fifty-one consecutive children undergoing muscle surgery for X(T) were prospectively recruited. One parent of each child completed the ADHD rating scale IV (ADHD RS-IV) assessment consecutively before and one year after surgery. Patients whose preoperative scores were above the cut-off point, the 90th percentile based on a Korean sample, were regarded as demonstrating the ADHD trait. The impact of muscle surgery on ADHD symptoms was assessed by comparing the preoperative scores with the post-operative scores.

RESULTS

Eight (15.7%) of the 51 patients demonstrated the ADHD trait. ADHD RS-IV scores following strabismus surgery significantly decreased in patients with the ADHD trait (p=0.014), while they did not differ in patients without the ADHD trait. Seven (87.5%) of the 8 patients with the ADHD trait showed improvement in their ADHD RS-IV scores after surgery. There was no difference in surgical success rates between X(T) patients with and without the ADHD trait.

CONCLUSION

The ADHD trait was relatively common in children with X(T), and the parent-reported symptoms of the children with the ADHD trait improved after strabismus surgery. These results suggest that childhood X(T) may be one contributing factor to ADHD- related symptoms.

Testability of refraction, stereopsis, and other ocular measures in preschool children: the Sydney Paediatric Eye Disease Study

PURPOSE

To determine the testability and lower age limits for applying common eye tests to preschool children.

METHODS

Investigators from the Sydney Paediatric Eye Disease Study examined 2,461 children aged 6 to 72 months between 2007 and 2009. Cycloplegic autorefraction was measured with Retinomax and Canon autorefractors. Ocular biometry was measured by the use of IOLMaster in children aged >30 months. The Randot Preschool Stereoacuity test, Lang-Stereotest II, and the Stereo Smile II test were administered to assess stereoacuity. Fundus photography was performed with the subjects' pupils dilated. Testability was defined as the ability to successfully complete tests in both eyes.

RESULTS

There were 2,189 children with complete data. Most were testable with the Retinomax (71.8%) and Canon (66.0%) autorefractors. Testability improved with age (P for trend <0.0001) for both, and Retinomax achieved >70% testability when a subject was 24 months of age, half the age limit (48 months) found for Canon. IOLMaster was mostly testable in children aged 48+ months. Lang-Stereotest II could be used in children aged 6 months and achieved the greatest testability (94.4%) of all stereotests. White children performed better than children of some other ethnicities on Randot (P = 0.007), with girls performing better than boys (P = 0.01). Bilateral photography was achieved in >70% of preschool children 48 months of age.

CONCLUSIONS

The testability of all measures was strongly age related, with mostly no sex or ethnicity effects found. The handheld Retinomax could be tested in >70% of children aged 24 months, younger than that found for the stationary Canon autorefractor (48 months). Testability measures for most eye tests in this preschool sample are comparable to other preschool studies.

Negative social reaction to strabismus in school children ages 8-12 years

PURPOSE

To investigate children's willingness to sit next to a child with noticeable exotropia as a measure of social alienation.

METHODS

This was a cross-sectional, mixed-design study. Children in primary grades 3-6 (8-12 years old) were asked to view 8 digitally modified images of exotropic or orthotropic children in classroom settings and rate their willingness to sit next to the child in each image.

RESULTS

A total of 157 children participated. A 4 × 2 × 2 mixed-design analysis of variance revealed a significant main effect for primary level (F [3, 151] = 4.06, P = .01, partial η(2) = .08) and for image type, exotropic versus orthotropic, (F [1, 151] = 108.45, P = .00, partial η(2) = .42). The results of the main effects were qualified by a significant primary level X image type interaction (F [3, 151] = 4.00, P = .01, partial η(2) = .08). Children were less willing to sit next to a person with noticeable exotropia. Although this phenomenon was consistent across all primary levels, the magnitude of the effect diminished in strength for children in higher primary levels.

CONCLUSIONS

This study further strengthens existing evidence for strabismus-related prejudice that suggests that children with noticeable strabismus may be subjected to social alienation by other children.

Social phobia and other psychiatric problems in children with strabismus

OBJECTIVE

To investigate the rate of social phobia, anxiety, depression, and other psychiatric problems in children with strabismus.

DESIGN

Prospective, cross-sectional, case-control study.

PARTICIPANTS

Forty-two children with strabismus and 47 control subjects 8-13 years of age were enrolled in this study.

METHODS

After the ophthalmologist's examination, all cases were assessed by a psychiatrist based on the structured interview technique of Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version (Kiddie-SADS-PL). The Screen for Child Anxiety Related Emotional Disorders (SCARED) was administered to each subject to evaluate social phobia. All participants completed the Children's Depression Inventory (CDI).

RESULTS

Age as well as sex and income were comparable between the strabismus patients and control groups. Social phobia was diagnosed in 8 (19.04%) of the 42 strabismic children and in 1 (2.12%) of the control subjects. The CDI and SCARED (total score, social phobia, separation anxiety) scores of strabismus patients were significantly higher than the control group (p = 0.001, p = 0.004, p = 0.0001, p = 0.05, respectively).

CONCLUSIONS

A relationship between strabismus in children and social phobia, depression, and anxiety on a symptom basis was underlined by our data.

Is the pediatric quality of life inventory valid for use in preschool children with refractive errors?

PURPOSE

To determine the psychometric validity of the pediatric quality of life inventory (PedsQL 4.0) in assessing the impact of refractive errors on health-related quality of life (HRQoL) in preschool children in Singapore.

METHODS

Parents of toddlers (aged 25 to 48 months) and young children (49 to 72 months) completed the PedsQL 4.0, an HRQoL scale as part of population-based trial in Singapore. The outcome measures were the overall score, and the "physical"; "emotional"; "social"; and "school" functioning subscales. Rasch analysis was used to validate the PedsQL 4.0.

RESULTS

Parents of 939 (48.9%) toddlers and 982 (51.1%) young children completed the PedsQL 4.0 survey. The overall mean (±standard deviation) spherical equivalence for the right eye was 0.47 ± 1.13 diopter (D) for toddlers and 0.74 ± 1.22 D for young children. One hundred forty-nine (15.9%) toddlers and 90 (9.2%) young children were considered myopic (≥-0.50 D). Most participants (n = 1286, 89.6%) had presenting visual acuity 6/9 or better. Rasch analysis showed evidence of disordered category thresholds and poor person-item targeting for both groups. The separation reliability was 0.00 for toddlers and 0.03 for young children, indicating there was no variance in both samples. The PedsQL 4.0 overall and subscale scores displayed substantial multidimensionality as the variance values explained by the measures was <25% in both groups. A minimum value of 60% is usually considering acceptable.

CONCLUSIONS

The PedsQL 4.0 in its current state is not a valid psychometric scale to effectively evaluate the impact of refractive errors on HRQoL in preschool children in Singapore.

Influence of the direction of eye turn on the appearance of strabismus

PURPOSE

The purpose of this study was to determine whether an equal amount of exotropia (XT) or esotropia (ET) produces a more noticeable eye turn, which gives the better impression of eye contact, and how a positive angle kappa (K) affects this judgment.

METHODS

Images from a white male model were manipulated to simulate 0, 5, 10, and 15° of ET and XT for both 0 and +5° K. A series of image pairs was then created that juxtaposed XT and ET of equal angles for both 0 and +5° K. Forty-five optometry students then judged which image in each pair appeared to have the greater tropia and which gave the greater impression of eye contact.

RESULTS

When angle kappa was 0, there was no significant difference in whether XT or ET appeared to be more noticeable. However, when angle kappa was +5°, an XT of 5° or greater became more apparent than an equal ET (p < 0.001). However, when the criterion was eye contact, ET gave the greater impression that eye contact was being made when the deviation was 10° or more, and this was true for both 0 and +5° K (p < 0.001).

CONCLUSIONS

When a strabismus is to be evaluated or corrected purely for cosmetic reasons, the results may differ depending on the value of angle kappa and whether the criterion for good cosmesis is ocular deviation or eye contact.

The psychosocial effects of strabismus: effect of patient demographics on the AS-20 score

PURPOSE

The introduction of the AS-20 strabismus-specific quality-of-life questionnaire allows clinicians to quantify the effects of strabismus on adults for the first time. We correlated strabismic patients' demographic and clinical findings to their AS-20 scores.

METHODS

A consecutive cohort of patients from an ongoing prospective study of adults with manifest strabismus was recruited. The patients' age, sex, socioeconomic status (SES), magnitude, and direction of deviation were correlated to their AS-20 scores. Patients' zip codes were used to derive a score for their SES based on the English 2007 Index of Multiple Deprivation score (IMD2007).

RESULTS

A total of 61 questionnaires with all demographic and clinical data were available. The median magnitude of deviation was 20.4(Δ) in this group. The mean AS-20 score was 49.5 (SD 21.6). Women had significantly lower AS-20 scores than men (p = 0.02). There was no difference in AS-20 scores between individuals with eso- and exodeviations (p = 0.7). Multiple linear regression analysis shows female sex and lower SES to be significantly associated with lower AS-20 scores (p = 0.03 and p = 0.006, respectively).

CONCLUSIONS

Strabismic patients who are female or live in a more deprived area have a significantly lower AS-20 score.