Clinical Translation of Recommendations from Randomized Clinical Trials on Patching Regimen for Amblyopia

The impact of occlusion therapy and predictors on amblyopia dose-response relationship

This study aimed to calculate the dose-response relationship and predictors of visual acuity (VA) improvement following occlusion therapy at the IWK Health Center Eye Clinic and to add to amblyopia therapy dose-response relationship literature. A retrospective chart review was performed, considering patients who reached an occlusion therapy outcome at the IWK Eye Clinic between 2012 and 2019. The treatment outcome was defined as equal VA or stable VA for three consecutive clinical visits despite reported compliance. Subjective patching hours from parental reports, not prescribed hours, were used for statistical analyses. One hundred and thirty-four patients (66 females and 68 males) ages 2-11 years were included. Results showed a dose-response relationship of 224 hours/0.1logMAR increase in VA and total dose of 1344 hours for full-time occlusion and 504 hours for part-time occlusion was required to reach outcome VA. The fastest VA improvement occurred with younger age at treatment initiation, during the first 4 weeks of treatment, and in patients with strabismic and/or severe amblyopia. Classification of amblyopia, age, VA chart, initial distance VA (amblyopic eye), and treatment dose predicted the hour dose-response relationship. Dose-response relationship was faster in younger participants, in participants with strabismic and severe amblyopia, and during the first month of occlusion. Additionally, by creating a GLM model of dose-response relationship, relationship calculations can be performed. Therefore, an estimated timeline can be developed to allow allocation of clinical resources and to prepare patients for the treatment duration required and possibly increase treatment compliance.

Visual outcomes of photorefractive keratectomy in non-children with anisometropic amblyopia: One-year Follow-up Outcomes

OBJECTIVE

To evaluate the safety, efficiency, short term stability, and sensory results of photorefractive keratectomy (PRK) in anisometropic in non-compliant children with correction.

METHODS

Twelve eyes of 12 children with an age range: 6-17 years and anisometropic amblyopia who underwent PRK under general anesthesia to correct the dioptric difference between the eyes were included in this study. A complete ophthalmic assessment including refractive status, uncorrected and corrected distance visual acuity (UDVA & CDVA), and binocular vision status using the Worth 4-dot test and stereopsis were performed before and 1, 3, 6, and 12 months after PRK.

RESULTS

The mean preoperative CDVA was 0.34 ± 0.24 LogMAR which showed a statistically significant improvement at 12 months (0.20 ± 0.19, p = 0.024) after surgery compared to the preoperative assessment. (p = 0.003) The mean preoperative UDVA was 0.63 ± 0.24 LogMAR that increased to 0.44 ± 0.24, 0.32 ± 0.16, 0.25 ± 0.19, and 0.25 ± 0.19 LogMAR at 1, 3, 6, and 12 months after PRK, respectively. One to three lines improvement in UDVA and CDVA was seen in 10 (83.4%) and 8 eyes (66.7%); while one line UDVA and CDVA loss was seen in one (8.3%) and one (8.3%) eye and unchanged UDVA and CDVA was seen in 1 (8.3%) and 3 eyes (25%), respectively. The mean preoperative stereoacuity was 341.9 ± 245.7 s of arc, which significantly improved to 166.6 ± 87.5 s of arc 12 months after PRK. (p = 0.012).

CONCLUSION

PRK was an effective surgical alternative to improve visual acuity and stereopsis in anisometropic children who did not cooperate with conventional methods of amblyopia therapy.

Identifying Characteristics Predictive of Lost-to-Follow-Up Status in Amblyopia

PURPOSE

To identify demographic and disease-related characteristics predictive of Lost-to-Follow-Up (LTFU) status in amblyopia treatment and create a risk model for predicting LTFU status.

DESIGN

Retrospective cohort study METHODS: Setting: Single-center, ophthalmology department at Boston Children's Hospital (BCH).

PATIENTS

2037 patients treated for amblyopia at BCH between 2010 and 2014.

OBSERVATION PROCEDURE

LTFU was defined as patients who did not return after initial visit, excluding those who came for second opinion. Multiple variables were tested for association with LTFU status.

OUTCOME MEASURE

Odds ratio of LTFU risk associated with each variable. Multivariate logistic regression was used to create a risk score for predicting LTFU status.

RESULTS

A large proportion of patients (23%) were LTFU after first visit. Older age, nonwhite race, lack of insurance, previous glasses or atropine treatment, and longer requested follow-up intervals were independent predictors of LTFU status. A multivariable risk score was created to predict probability of LTFU (area under the curve 0.68).

CONCLUSIONS

Our comprehensive amblyopia database allows us to predict which patients are more likely to be LTFU after baseline visit and develop strategies to mitigate these effects. These findings may help with practice efficiency and improve patient outcomes in the future by transitioning these analyses to an electronic medical record that could be programmed to provide continually updated decision support for individual patients based on large data sets.

Development, Implementation, and Evaluation of Treatment Guidelines for Herpes Simplex Keratitis in Sydney, Australia

PURPOSE

To develop and measure the uptake of a local guideline for herpes simplex keratitis (HSK) and to standardize initial antiviral therapy in Australia.

METHODS

The Registered Nurses' Association of Ontario Toolkit: "Implementation of Best Practice Guidelines" was used to develop, implement, and evaluate the guideline at Sydney Eye Hospital. An implementation team was established to reach consensus on antiviral therapy guidelines through review of available evidence, identifying stakeholders, facilitators and barriers, creating strategies for implementation, and developing a sustainability plan. An audit of all adult HSK cases during a 6-month postguideline implementation period was conducted, and the results were compared with a preimplementation audit. A web-based survey was created to assess clinician awareness, usage, and level of knowledge of the guideline.

RESULTS

Clinicians, pharmacists, and administrative staff were identified as stakeholders. Changing clinician's behavior was the major barrier to implementation. Implementation strategies included printed and online materials and lectures to clinicians. A postimplementation audit included 85 patients, and 95 clinicians received a web-based survey. The dose of the prescribed antiviral medication was in alignment with the local guideline in 80% (51/64) of the patients compared with 73% (163/223) before implementation (P = 0.331). Stromal HSK with ulceration and keratouveitis were excluded because there were no recommendations before implementation. Over 70% of clinicians (30/41) were aware of the guideline and accessed them through educational resources.

CONCLUSIONS

Guidelines for the management of HSK may improve standardization of initial antiviral therapy in HSK. In practice, most clinicians were aware of and adhered to the local guideline.

Systematic review of the appropriateness of eye care delivery in eye care practice

BACKGROUND

Health care systems are continually being reformed, however care improvement and intervention effectiveness are often assumed, not measured. This paper aimed to review findings from published studies about the appropriateness of eye care delivery, using existing published evidence and/or experts' practice and to describe the methods used to measure appropriateness of eye care.

METHODS

A systematic search was conducted using Medline, Embase and CINAHL (2006 to September 2016). Studies reporting the processes of eye care delivery against existing published evidence and/or experts' practice were selected. Data was extracted from published reports and the methodological quality using a modified critical appraisal tool. The primary outcomes were percentage of appropriateness of eye care delivery. This study was registered with PROSPERO, reference CRD42016049974.

RESULTS

Fifty-seven studies were included. Most studies assessed glaucoma and diabetic retinopathy and the overall methodological quality for most studies was moderate. The ranges of appropriateness of care delivery were 2-100% for glaucoma, 0-100% for diabetic retinopathy and 0-100% for other miscellaneous conditions. Published studies assessed a single ocular condition, a sample from a single centre or a single domain of care, but no study has attempted to measure the overall appropriateness of eye care delivery.

CONCLUSIONS

These findings indicated a wide range of appropriateness of eye care delivery, for glaucoma and diabetic eye care. Future research would benefit from a comprehensive approach where appropriateness of eye care is measured across multiple conditions with a single methodology, to guide priorities within eye care delivery and monitor quality improvement initiatives.

Symptoms in noninfectious uveitis in a pediatric cohort: Initial presentation versus recurrences

PURPOSE

To describe the prevalence of symptoms with noninfectious uveitis (NIU) in a pediatric cohort and to assess the association between the presence of symptoms with first episode of uveitis (first-U) compared to symptoms at uveitis recurrence.

METHODS

The medical records of patients with NIU treated at a tertiary referral hospital from March 2008 to November 2107 were reviewed retrospectively. Symptomaticity (eye pain, eye redness, photosensitivity) was captured at initial uveitis activation and subsequent episodes. Univariate logistic regression modeling was used to identify clinical features associated with symptomatic first-U. Ordinal regression identified patient characteristics associated with symptomatic recurrence.

RESULTS

A total of 118 cases were reviewed; of these, 92 were followed for at least 6 months and had at least 1 reactivation. Juvenile idiopathic arthritis-related uveitis (JIAU) was the most common diagnosis (67/118 [57%]), followed by idiopathic uveitis (33%). In the majority, uveitis was restricted to the anterior chamber (82%). Of the 118 cases, 58 patients (49%) had symptomatic first-U, 34% JIA versus 69% non-JIA. Non-JIAU, age ≥7 years, and negative antinuclear antibody (ANA) test were significantly associated with symptomatic first-U; spondyloarthritis was not. With recurrence, half had symptoms: 41% JIA versus 66% non-JIA. Of those who had symptomatic first-U, 35% were asymptomatic at recurrence. Those with JIA had 50% or less odds of symptomaticity at reactivation. Complications did not vary based on having had symptoms at first-U.

CONCLUSIONS

Non-JIA diagnosis, older age, and ANA-negativity were associated with symptomatic first-U in our study cohort, but no patient characteristics were significantly associated with symptomatic recurrence. Clinical patterns may change during disease course, with uveitis switching from symptomatic to asymptomatic, which has implications for uveitis monitoring recommendations.

Compliance and patching and atropine amblyopia treatments

In the past 20 years, there has been a great advancement in knowledge pertaining to compliance with amblyopia treatments. The occlusion dose monitor introduced quantitative monitoring methods in patching, which sparked our initial understanding of the dose-response relationship for patching amblyopia treatment. This review focuses on current compliance knowledge and the impact it has on patching and atropine amblyopia treatment.

Use of atropine penalization to treat amblyopia in UK orthoptic practice

PURPOSE

To compare clinical practice patterns regarding atropine penalization use by UK orthoptists to the current evidence base and identify any existing barriers against use of AP as first-line treatment.

METHODS

An online survey was designed to assess current practice patterns of UK orthoptists using atropine penalization. They were asked to identify issues limiting their use of atropine penalization and give opinions on its effectiveness compared to occlusion. Descriptive statistics and content analysis were applied to the results.

RESULTS

Responses were obtained from 151 orthoptists throughout the United Kingdom. The main perceived barriers to use of atropine penalization were inability to prescribe atropine and supply difficulties. However, respondents also did not consider atropine penalization as effective as occlusion in treating amblyopia, contrary to recent research findings. Patient selection criteria and treatment administration largely follow current evidence. More orthoptists use atropine penalization as first-line treatment than previously reported.

CONCLUSIONS

Practitioners tend to closely follow the current evidence base when using atropine penalization, but reluctance in offering it as first-line treatment or providing a choice for parents between occlusion and atropine still remains. This may result from concerns regarding atropine's general efficacy, side effects, and risk of reverse amblyopia. Alternatively, as demonstrated in other areas of medicine, it may reflect the inherent delay of research findings translating to clinical practice changes.

A 1-Year Review of Amblyopia and Strabismus Research

PURPOSE

This current review highlights some of the literature published in the past year from April 2013 to May 2014.

DESIGN

Literature Review.

METHODS

The present review is based on an extended search for pertinent articles on amblyopia and strabismus published during the specified period.

RESULTS

Many articles are often not very comparable to one another because of a lack of randomized clinical trials with most of the studies being retrospective in nature. There is often disagreement on some terminology. Typically, the definition of binocular vision is rarely related to the tests used for evaluating it.

CONCLUSIONS

The authors conclude that 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 quality of life and disability levels.

One Year of Pediatric Ophthalmology and Strabismus Research in Review

PURPOSE

To highlight recent advances in amblyopia and strabismus.

DESIGN

Literature review.

METHODS

A literature search of articles published in the English language was performed in PubMed or MEDLINE between May 2012 and April 2013 using the terms amblyopia or strabismus. Articles deemed relevant were selected.

RESULTS

The review highlights articles that increase our understanding of strabismus and amblyopia as well as newer treatment strategies.

CONCLUSIONS

The review highlights some new information and possible future advances in amblyopia and strabismus.