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

Risk Factors for Acute Acquired Comitant Esotropia in Children and Young Adults: A Systematic Review

Background

Acute acquired comitant esotropia (AACE) is a rare subtype of esotropia that occurs after infancy. The exact pathogenesis of AACE remains unknown with aetiologies ranging from benign conditions to serious underlying neurological diseases being reported. Given the elusive characteristic of AACE, diagnostic and management guidelines remain unclear. This systematic review aims to contribute to this field by summarising the risk factors for AACE reported thus far.

Methods

A systematic review was conducted with papers found in CINAHL, MEDLINE, Cochrane library, PubMed databases and other sources. Eligible studies investigating the risk factors for, and clinical features of, AACE in children and young adults were critically appraised before relevant data were extracted and discussed via a narrative summary.

Results

Twelve studies were included in the final review, of which six and eight papers reported on benign and non-benign risk factors for AACE respectively. Identified benign risk factors varied among studies, while non-benign risk factors were associated with intracranial pathologies, multiple sclerosis and head trauma.

Conclusion

Given the low generalisability of study findings, no definitive conclusions can be drawn on the significance of each risk factor on AACE development. Further prospective research with more objective measurements of 'near work', larger sample sizes and control groups is required to better ascertain any cause-effect relationship, refine the diagnostic criteria for each AACE subtype and advise on appropriate management guidelines for AACE.

Maternal Hypertensive Disorder in Pregnancy and Childhood Strabismus in Offspring

Importance

Maternal hypertensive disorder in pregnancy (HDP) might affect ocular health in offspring; however, its association with strabismus remains unclear.

Objective

To examine the association of maternal HDP with overall and type-specific strabismus in offspring.

Design, Setting, and Participants

In the Jiangsu Birth Cohort study, a population-based study in China, pregnant women were recruited from April 24, 2014, to November 30, 2018. A total of 6195 offspring had maternal HDP diagnosis information, of whom 3078 were excluded due to having no information on ocular alignment or due to having ocular diseases other than strabismus or refractive error. Offspring underwent ocular examinations at 3 years of age, completed May 21, 2022. Data were analyzed from May 28, 2022, through December 15, 2023.

Exposure

Maternal HDP, categorized into hypertension and preeclampsia or with blood pressure (BP) well controlled (systolic BP, <130; diastolic BP, <80 mm Hg) and poorly controlled (systolic BP, ≥130; diastolic BP, ≥80 mm Hg).

Main Outcomes and Measures

The primary outcome was the incidence of strabismus in offspring. Poisson generalized linear mixed models were used to estimate the association between maternal HDP and strabismus.

Results

Among the included 3117 children (mean [SD] age, 36.30 [0.74] months; 1629 boys [52.3%]), 143 (4.6%) were exposed to maternal HDP and 368 (11.8%) had strabismus. Offspring exposed to maternal HDP had an 82% increased risk of overall strabismus (relative risk [RR], 1.82 [95% CI, 1.21-2.74]), an 82% increased risk of exophoria (RR, 1.82 [95% CI, 1.11-3.00]), and a 136% increased risk of intermittent exotropia (RR, 2.36 [95% CI, 1.13-4.93]) compared with unexposed offspring. When considering the type of maternal HDP, the risk for all strabismus was high for offspring exposed to preeclampsia (RR, 2.38 [95% CI, 1.39-4.09]) compared with unexposed offspring. When considering the BP control level of maternal HDP, the risk for all strabismus was high for offspring born to mothers with HDP and poorly controlled BP (RR, 2.07 [95% CI, 1.32-3.24]) compared with unexposed offspring.

Conclusions and Relevance

These findings suggest that maternal HDP is associated with an increased risk of offspring strabismus. Early screening of strabismus might be recommended for offspring with maternal HDP. Further exploration of the underlying mechanism of the association between HDP and strabismus is warranted.

The comparison of postoperative changes in subjective awareness of exodeviation between pediatric and adult patients with intermittent exotropia

To evaluate pre- and postoperative changes in the subjective awareness of exodeviation in patients with intermittent exotropia and compare pediatric and adult patients. This retrospective study included pediatric (6-17 years) and adult patients (≥18 years) with intermittent exotropia who underwent surgery. Patients with subjective awareness of exodeviation associated with exotropia were included. Postoperative improvement was defined as a decrease in the subjective awareness of exodeviation and alleviation of associated symptoms after surgery. Changes in subjective awareness of exodeviation after surgery were evaluated and compared between pediatric and adult patients. Clinical factors associated with postoperative improvement in subjective awareness of exodeviation were analyzed. A total of 195 patients (159 pediatric and 36 adult) were included. Among the included patients, 145 (74.4%, 145/195) reported postoperative improvements in their subjective awareness of exodeviation. A lower percentage of adult patients (15/36, 41.7%) showed postoperative improvement in subjective awareness of exodeviation than that of pediatric patients (130/159, 81.8%, P < .001). The level of distant control was significantly associated with postoperative improvement in subjective awareness of exodeviation in adult patients (odds ratio, 1.151; 95% confidence interval, 0.030-0.758; P = .022). There was a significant difference in the postoperative change in the subjective awareness of exodeviation between pediatric and adult patients with intermittent exotropia. Adult patients are less likely to exhibit postoperative improvement in subjective awareness of exodeviation than pediatric patients. Adult patients with a better level of distant control are more likely to show postoperative improvement in their subjective awareness of exodeviation.

Long-term visual and neurodevelopmental outcomes in children with Congenital Zika Syndrome after undergoing strabismus surgery

Purpose: To assess long-term visual and neurodevelopmental outcomes in children with congenital Zika syndrome (CZS) after strabismus surgery. Methods: A consecutive sample of five children with CZS who underwent strabismus surgery was enrolled. All children underwent a standardized pre- and postoperative protocol including binocular best-corrected visual acuity (BCVA) using the Teller Acuity Cards II (TAC II), ocular alignment, functional vision using the functional vision developmental milestones test (FVDMT), and neurodevelopmental milestone evaluation using the Bayley Scales of Infant Development-Third Edition (BSID-III). Scores of the FVDMT outcomes considering the child's developmental age based on the BSID-III score were compared with scores from postoperative assessment. Results: Five children with CZS (3 girls, 2 boys) were enrolled with a mean age at baseline (preoperative) of 35.0 ± 0.7 months (range, 34-36 months) and at final assessment of 64.4 ± 0.5 months (range, 64-65 months). Preoperative BCVA was 1.2 ± 0.5 logMAR and at final assessment 0.7 ± 0.1 logMAR. Successful strabismus surgery outcome was maintained in 4/5 (80.0%) of children at final assessment. The children's BSID-III scores showed significant neurodevelopment delay at the initial assessment (corresponding developmental mean age was 4.7 months) and at their final assessment (corresponding developmental mean age was 5.1 months). There was improvement or stability in 34/46 items evaluated in the FVDMT (73.9%) when comparing baseline with 2-year follow-up. Conclusions: Strabismus surgery resulted in long-term ocular alignment in the majority of children with CZS. All the children showed improvement or stability in more than 70.0% of the functional vision items assessed. Visual and neurodevelopmental dysfunction may be related to complex condition and associated disorders seen in CZS including ocular, neurological, and skeletal abnormalities.

Mental Health Conditions Associated With Strabismus in a Diverse Cohort of US Adults

Importance

Greater understanding of the association between strabismus and mental health conditions across sociodemographic backgrounds may inform strategies to improve mental well-being in this population.

Objective

To describe the association of strabismus with mental health conditions in a diverse cohort of US adults.

Design, Setting, and Participants

This cross-sectional study used data from the National Institutes of Health's All of Us Research Program, an ongoing program launched in 2015. The study included 3646 adults (aged ≥18 years) with strabismus and 3646 propensity score-matched controls. Statistical analysis was conducted from September 12, 2023, to January 29, 2024.

Main Outcomes and Measures

Adults with strabismus were propensity score matched on age, gender, race and ethnicity, income, educational level, and insurance status in a 1:1 ratio with adults without strabismus. The prevalences of anxiety, depression, substance use and addiction, bipolar disorder, and schizophrenia spectrum disorder among adults with strabismus were compared with controls. Logistic regression was used to evaluate the association of mental health conditions with sociodemographic factors in each group.

Results

This study included 3646 adults with strabismus (median age, 67 years [IQR, 53-76 years]; 2017 women [55%]) and 3646 propensity score-matched controls (median age, 67 years [IQR, 53-76 years]; 2017 women [55%]). Individuals with strabismus had higher prevalences of anxiety (1153 [32%] vs 519 [14%]; difference, 17%; 95% CI, 15%-19%; P < .001), depression (1189 [33%] vs 514 [14%]; difference, 19%; 95% CI, 17%-20%; P < .001), substance use and addiction (116 [3%] vs 51 [1%]; difference, 2%; 95% CI, 1%-3%; P < .001), bipolar disorder (253 [7%] vs 101 [3%]; difference, 4%; 95% CI, 3%-5%; P < .001), and schizophrenia spectrum disorder (103 [3%] vs 36 [1%]; difference, 2%; 95% CI, 1%-3%; P < .001) compared with individuals without strabismus. Among adults with strabismus, higher odds of mental health conditions were associated with younger age (odds ratio [OR], 1.11 per 10-year decrease; 95% CI, 1.06-1.16 per 10-year decrease), female gender (OR, 1.62; 95% CI, 1.41-1.85), Black or African American race and ethnicity (OR, 1.22; 95% CI, 1.01-1.48), low income (OR, 3.06; 95% CI, 2.56-3.67), and high school education or less (OR, 1.58; 95% CI, 1.34-1.85).

Conclusions and Relevance

In a diverse and nationwide cohort, adults with strabismus were more likely to have mental health conditions compared with adults without strabismus. Further investigation into the risk factors for poor mental health among adults with strabismus across sociodemographic backgrounds may offer novel opportunities for interventions to improve mental well-being in this population.

Treatment rate of strabismus and amblyopia is associated with the location of pediatric ophthalmologists in the United States

PURPOSE

To determine whether the geographic density of pediatric ophthalmologists is associated with the rate of children treated for strabismus and amblyopia.

METHODS

This cross-sectional study included children treated for strabismus and amblyopia 0-17 years of age with commercial insurance who were included in the Vision and Eye Health Surveillance System. Additionally, pediatric ophthalmologists by state were determined using the American Association for Pediatric Ophthalmology and Strabismus website. Unadjusted linear regression was used to compare the geographic density of pediatric ophthalmologists and the rate of children treated for strabismus and amblyopia by state in 2016. This was repeated using multivariable linear regression, controlling for race, poverty, non-English-speaking children, and insurance coverage for children by state.

RESULTS

New York and Mississippi had the highest and lowest rates of treatment of strabismus and amblyopia, with 3.97 and 0.83 children treated per 100 children, respectively. The geographic density of pediatric ophthalmologists was associated with the rate of children treated for strabismus and amblyopia in unadjusted analyses (β = 0.62, P < 0.001). Further, the geographic density of pediatric ophthalmologists was associated with the rate of children treated for strabismus and amblyopia in adjusted analyses (β = 0.61, P < 0.001).

CONCLUSIONS

The geographic density of pediatric ophthalmologists by state was positively associated with the rate of children treated for strabismus and amblyopia.

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.

Ophthalmology and oculoplastics for the rhinologist

PURPOSE OF REVIEW

As the management of ophthalmic and sinus disease advances, it is important to stay abreast of all current management options. This involves knowledge of adjacent anatomy and disease processes, and collaboration between multiple specialties. The authors provide a review of relevant ophthalmic and oculoplastic topics for the rhinologist.

RECENT FINDINGS

The scope and surgical skills of oculoplastic and rhinologist specialists have grown in conjunction with medical and technological advancements. Familiarity with the presentations of sinus disease in the orbit can decrease the time to disease recognition, and improve morbidity and mortality. Collaborative approaches provide improved access to areas of interest throughout the orbit and sinuses. Multiportal, transorbital, and endoscopic techniques can improve patient morbidity and mortality compared to conventional open approaches. Familiarity with all medical and surgical treatment options can help tailor treatments to patients' needs.

SUMMARY

Multidisciplinary approaches to sinus and orbit disease and the incorporation of new surgical technologies can improve patient options and outcomes.

Strabismic Adults' Experiences of Psychosocial Influence of Strabismus-A Qualitative Study

Introduction

Strabismus influences health-related quality of life. Individuals may have functional and psychosocial consequences of strabismus that impact their well-being. As strabismus is prevalent in all age groups, patients are seen in varied specialties in healthcare organizations. Therefore, healthcare professionals need to be aware of the psychosocial consequences when caring for strabismic individuals.

Objective

To describe strabismic adults' experiences of the psychosocial influence of strabismus.

Methods

Twelve strabismic adults participated in face-to-face or online semistructured individual interviews to share their experiences of the psychosocial influence of strabismus. The participants were selected purposefully. The data were analyzed using inductive content analysis.

Results

The participating adults described challenges with social environments, which showed stress in social situations and pressure in interactions. Strabismic adults had experienced staring from others, avoided social situations, and were uncomfortable with photography. They hid their strabismus, avoided eye contact, and struggled with intimate relationships. They also expressed struggles with mental well-being, which were emotional and psychological burdens. The adults described feeling negative emotions, worry, and irritation due to their condition. Struggles with self-confidence, difficulties with acceptance, negative thoughts about their appearance, experiences of bullying, and dealing with being different were described.

Conclusion

Strabismic adults experience psychosocial consequences of strabismus, influencing their psychosocial health-related quality of life. Further studies should focus on how healthcare professionals could support strabismic individuals' psychosocial well-being.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is There Gender Bias in Perceptions of Strabismus Among Adults?

PURPOSE

To investigate the effect of gender, type, and size of horizontal deviation on the perceived severity or need for intervention for strabismus among adults in the general population.

METHODS

Eight photographs of individuals aged 25 to 35 years were digitally manipulated to create 30 prism diopters (PD) of exotropia, 30 PD of esotropia, 50 PD of exotropia, and 50 PD of esotropia in both men and women. A survey asked respondents to rank these photographs by their severity or need for intervention from 1 (greatest need) to 8 (least need) to assess for unconscious bias for gender, strabismus type, or deviation size.

RESULTS

A total of 203 adult respondents completed the survey. Participants ranked men with both large esotropia and large exotropia (median rank = 1.5, interquartile range [IQR] = 1.5 to 1.5) as needing correction more urgently than similar women (median rank = 3.5, IQR = 3.5 to 4) (P < .0001). The median rank was 4 (IQR = 3.75 to 4.25) for all men combined and 5 (IQR = 4.75 to 5.25) for all women (P < .0001). Photographs with exotropia (median rank = 4, IQR = 3.75 to 4.5) were perceived as more severe than photographs with esotropia (median rank = 5, IQR = 4.5 to 5.25) (P < .0001). Respondents' gender, age, or history of strabismus did not significantly impact their rankings.

CONCLUSIONS

Male photographs were perceived as having a greater need for strabismus intervention than female photographs despite similar type and size of deviations. Exotropia was perceived as more severe than esotropia for smaller deviations only. More studies on the perceptions of strabismus are needed to understand whether unconscious bias affects patient care. [J Pediatr Ophthalmol Strabismus. 2023;60(6):396-401.].

The Role of Social Media in Strabismus Surgical Experience

PURPOSE

To understand patients' strabismus surgery experience, including its impact on patients' appearance and psychosocial factors such as anxiety and depression, via trends on popular social media platforms.

METHODS

TikTok and Instagram were searched for the following post hashtags: "#strabismus," "#strabismussurgery," "#crosseyed," and "#lazyeye." Data regarding date of post, username, gender, city, state, United States or international location, surgical status (preoperative, perioperative, or postoperative), tone (positive or negative), place of treatment, type of post (photo or video), number of likes/views, and number of followers were recorded for statistical analysis.

RESULTS

A total of 790 posts (400 TikTok, 390 Instagram) were included. The majority (87.8%) had a positive tone, particularly for Instagram (Instagram = 97.7%, TikTok = 78.3%, P < .01). TikTok had significantly more likes/follower (P < .01), as did negative posts (P < .01). #Lazyeye gained significantly more traction than other hashtags (range: P < .001 to .006). There were no differences in likes/follower for treatment phase (preoperative/perioperative/postoperative), gender, or relative age of poster (adult/parent/child).

CONCLUSIONS

These findings demonstrated that TikTok and Instagram users tend to share positive strabismus surgical experiences; however, negative posts were associated with more interactive responses from viewers. Colloquial hashtags (eg, #lazyeye) were more likely to gain traction than medical terms. TikTok posts were associated with more engagement than Instagram, which suggests TikTok may be a better platform going forward for patient outreach. [J Pediatr Ophthalmol Strabismus. 2023;60(6):402-405.].

Clinical significance of CTGF and Cry61 protein in extraocular muscles of strabismic patients

PURPOSE

To investigate the relationship between clinical features and protein amounts of Cysteine-rich 61 (Cyr61/CCN1) and connective tissue growth factor (CTGF/CCN2), which are vital components and regulators of the extracellular matrix in resected muscles from strabismus surgery.

METHODS

Strabismus patients who were diagnosed with horizontal concomitant strabismus or inferior oblique overaction (IOOA) and required extraocular muscles (EOMs) resection to correct eye position were included in this study. The protein amounts were measured by enzyme-linked immunosorbent assay (ELISA) in resected EOMs. Multivariable linear regression was used to investigate the associations, adjusting for gender, age (continuous), amblyopia, and disease duration.

RESULTS

A total of 141 muscles (including 38 lateral, 81 medial rectus, and 22 inferior oblique muscles) from 128 patients were collected in this study. The amount of Cry61 and CTGF per millimeter was significantly negatively associated with deviation angle in intermittent exotropia patients (Cry61: β, - 1.44; 95%CI, - 2.79 to - 0.10, p = 0.035; CTGF: β, - 3.14; 95%CI, - 5.06 to - 1.22, p = 0.002). The same relationship was also detected in the partially accommodative and non-accommodative esotropia patients, although it was not statistically significant (Cry61: β, - 2.40; 95%CI, - 5.05 to 0.24; p = 0.073; CTGF: β, - 3.47; 95%CI, - 9.18 to 2.87; p = 0.269). The amount of Cry61 and CTGF per millimeter showed significant associations with the degree of IOOA (p < 0.05).

CONCLUSIONS

Taken together, our results demonstrated a significant relationship between deviation angle and protein amount of Cry61 and CTGF and implied that Cry61 and CTGF may play important roles in modulation of EOM contractility, which provide new insights into strabismus pathogenesis.

Gender differences in horizontal strabismus: Systematic review and meta-analysis shows no difference in prevalence, but gender bias towards females in the clinic

Background

Strabismus is a misalignment of the visual axis that affects 2-3% of the population and can lead to loss of binocular vision. It is currently controversial whether there is a gender difference in the most common form of visual misalignment: horizontal strabismus. Some studies claimed that more females than males have an outward deviation (exotropia), while others concluded that there is no significant gender difference. No previous work has systematically explored gender differences in horizontal strabismus or has compared the results of population-based studies with those of clinic-based studies.

Methods

We conducted a systematic review and meta-analysis of studies reporting the prevalence of horizontal strabismus. We included 73 population-based studies and compared their disclosed gender population with that in 141 comparable clinical-based studies. We analysed the data according to gender, strabismus type (esotropia, exotropia), and geographic region/ethnicity.

Results

Summary statistics showed a nearly identical prevalence of horizontal strabismus (2.558% for males, 2.582% for females), esotropia (1.386% males vs. 1.377% females), and of exotropia (1.035% males vs. 1.043% females). Meta-analysis results showed that these differences between males and females were not statistically significant (odds ratio (OR) = 1.01; 95% confidence interval (CI) = 0.97-1.10), but that females were significantly more frequent (by 7.50%) in clinic-based studies than males, with 5.00% more females for esotropia, and 12.20% more females for exotropia when adjusted for the population's sex ratio. The extent of the female gender bias differed between geographic regions/societies, with Asians having the lowest bias towards females and Latin American countries having the strongest bias.

Conclusions

Males and females have the same prevalence of horizontal strabismus, including exotropia. Females with strabismus seek health care or are brought to clinics significantly more often than males. This is an example of gender bias in health care in favour of females rather than males, apparently because parents - erroneously fearing only cosmetic consequences - are more concerned about strabismus in their daughters than their sons. Societal attitudes towards females, as well as economic factors (insurance status), appear to be relevant factors that determine the magnitude of the gender bias in horizontal strabismus.

Cortical Reorganization After Optical Alignment in Strabismic Patients Outside of Critical Period

PURPOSE

To measure visual crowding, an essential bottleneck on object recognition and reliable psychophysical index of cortex organization, in older children and adults with horizontal concomitant strabismus before and after strabismus surgery.

METHODS

Using real-time eye tracking to ensure gaze-contingent display, we examined the peripheral visual crowding effects in older children and adults with horizontal concomitant strabismus but without amblyopia before and after strabismus surgery. Patients were asked to discriminate the orientation of the central tumbling E target letter with flankers arranged along the radial or tangential axis in the nasal or temporal hemifield at different eccentricities (5° or 10°). The critical spacing value, which is the minimum space between the target and the flankers required for correct discrimination, was obtained for comparisons before and after strabismus surgery.

RESULTS

Twelve individuals with exotropia (6 males, 21.75 ± 7.29 years, mean ± SD) and 15 individuals with esotropia (6 males, 24.13 ± 5.96 years) participated in this study. We found that strabismic individuals showed significantly larger critical spacing with nasotemporal asymmetry along the radial axis that related to the strabismus pattern, with exotropes exhibiting stronger temporal field crowding and esotropes exhibiting stronger nasal field crowding before surgical alignment. After surgery, the critical spacing was reduced and rebalanced between the nasal and temporal hemifields. Furthermore, the postoperative recovery of stereopsis was associated with the extent of nasotemporal balance of critical spacing.

CONCLUSIONS

We find that optical realignment (i.e., strabismus surgery) can normalize the enlarged visual crowding effects, a reliable psychophysical index of cortical organization, in the peripheral visual field of older children and adults with strabismus and rebalance the nasotemporal asymmetry of crowding, promoting the recovery of postoperative stereopsis. Our results indicated a potential of experience-dependent cortical organization after axial alignment even for individuals who are out of the critical period of visual development, illuminating the capacity and limitations of optics on sensory plasticity and emphasizing the importance of ocular correction for clinical practice.

Altered interhemispheric functional connectivity in patients with comitant exotropia before and after surgery: a resting-state fMRI study

Purpose

To assess the interhemispheric homotopic connectivity alterations in patients with comitant exotropia (CE) before and after surgery, using resting-state functional magnetic resonance imaging (rs-fMRI) with voxel-mirrored homotopic connectivity (VMHC).

Methods

Thirty-four patients with CE and twenty-four well-matched healthy controls (HCs) were enrolled to undergo a preoperative rs-fMRI scan. The rs-fMRI scan was performed again in twenty-four patients 1 month after surgery. The VMHC method was applied to evaluate the group differences of interhemispheric functional connectivity. The correlations between VMHC values and clinical variables were analyzed in the patient group.

Results

Compared with HCs, 34 patients with CE showed significantly increased VMHC values in occipital lobe (cuneus/superior occipital gyrus/middle occipital gyrus/calcarine), cerebellar area 8/cerebellar Crus1 area, and cerebellar Crus1 area. In CE group, VMHC in the cuneus was positively correlated with stereoacuity (r = 0.417, P = 0.014), meanwhile VMHC in the cerebellar Crus1 area was positively correlated with stereoacuity (r = 0.395, P = 0.021). One month after surgery, the 24 CE patients with follow-up showed decreased VMHC values in the cuneus and superior occipital gyrus compared with preoperative collection, meanwhile, non-significant difference compared with HCs.

Conclusion

Our study revealed the interhemispheric homotopic connectivity changes of patients with CE in the occipital lobe and cerebellum before and after surgery. The findings may provide a new perspective for the neurological alterations of CE.

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Visual Crowding Reveals Field- and Axis-Specific Cortical Miswiring After Long-Term Axial Misalignment in Strabismic Patients Without Amblyopia

Purpose

Inspired by physiological and neuroimaging findings that revealed squint-induced modification of cortical volume and visual receptive field in early visual areas, we hypothesized that strabismic eyes without amblyopia manifest an increase in critical spacing of visual crowding, an essential bottleneck on object recognition and reliable psychophysical index of cortical organization.

Methods

We used real-time eye tracking to ensure gaze-contingent display and examined visual crowding in patients with horizontal concomitant strabismus (both esotropia and exotropia) but without amblyopia and age-matched normal controls.

Results

Nineteen patients with exotropia (12 men, mean ± SD = 22.89 ± 7.82 years), 21 patients with esotropia (10 men, mean ± SD = 23.48 ± 6.95 years), and 14 age-matched normal controls (7 men, mean ± SD = 23.07 ± 1.07 years) participated in this study. We found that patients with strabismus without amblyopia showed significantly larger critical spacing with nasotemporal asymmetry in only the radial axis that related to the strabismus pattern, with exotropia exhibiting stronger temporal hemifield crowding and esotropia exhibiting stronger nasal hemifield crowding, in both the deviated and fixating eyes. Moreover, the magnitude of crowding change was related to the duration and degree of strabismic deviation.

Conclusions

Using visual crowding as a psychophysical index of cortical organization, our study demonstrated significantly greater peripheral visual crowding with nasotemporal asymmetry in only the radial axis in patients with strabismus without amblyopia, indicating the existence of hemifield- and axis-specific miswiring of cortical processing in object recognition induced by long-term adaptation to ocular misalignment.

Design and assessment of amblyopia, strabismus, and myopia treatment and vision training using virtual reality

Background

Virtual reality is a relatively new intervention that has the potential to be used in the treatment of eye and vision problems. This article reviews the use of virtual reality-related interventions in amblyopia, strabismus, and myopia research.

Methods

Sources covered in the review included 48 peer-reviewed research published between January 2000 and January 2023 from five electronic databases (ACM Digital Library, IEEE Xplore, PubMed, ScienceDirect and Web of Science). To prevent any missing relevant articles, the keywords, and terms used in the search included "VR", "virtual reality", "amblyopia", "strabismus," and "myopia". Quality assessment and data extraction were performed independently by two authors to form a narrative synthesis to summarize findings from the included research.

Results

Total number of 48 references were reviewed. There were 31 studies published on amblyopia, 18 on strabismus, and 6 on myopia, with 7 studies overlapping amblyopia and strabismus. In terms of technology, smartphone-based virtual reality headset viewers were utilized more often in amblyopia research, but commercial standalone virtual reality headsets were used more frequently in myopia and strabismus-related research. The software and virtual environment were mostly developed based on vision therapy and dichoptic training paradigms.

Conclusion

It has been suggested that virtual reality technology offers a potentially effective tool for amblyopia, strabismus, and myopia studies. Nonetheless, a variety of factors, especially the virtual environment and systems employed in the data presented, must be explored before determining whether virtual reality can be effectively applied in clinical settings. This review is significant as the technology in virtual reality software and application design features have been investigated and considered for future reference.

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.

Adverse Influences of Nonstrabismic Amblyopia on Quality of Life of Teenagers in China

The aim of this study was to explore the influences of nonstrabismic amblyopia on quality of life in adolescents. Health-related quality of life (HRQoL) scale, a multidimensional construct that indicates a fundamental health outcome, was used to measure physical and psychosocial functioning of the adolescents. Forty teenagers with nonstrabismic amblyopia and 40 control teenagers without nonstrabismic amblyopia were recruited between April 2019 and July 2021. The anthropometric measures, body image, physical activity outcome, and HRQoL scores including physical health, emotional functioning, social functioning, and school functioning were compared between the two groups. The results revealed that teenagers with nonstrabismic amblyopia had less weekly sedentary time (P < 0.001), weekly total steps (P < 0.001), and worse school functioning (P = 0.0211) than control teenagers. No significant difference was found in anthropometric measures and body image between the two groups (P > 0.05). This study implied the needs for teenagers with nonstrabismic amblyopia to enhance physical activities. Teachers and parents are encouraged to pay more attention to teenagers with nonstrabismic amblyopia to improve their school functioning.

Children with strabismus and amblyopia presented abnormal spontaneous brain activities measured through fractional amplitude of low-frequency fluctuation (fALFF)

Purpose

Based on fMRI technology, we explored whether children with strabismus and amblyopia (SA) showed significant change in fractional amplitude of low-frequency fluctuation (fALFF) values in specific brain regions compared with healthy controls and whether this change could point to the clinical manifestations and pathogenesis of children with strabismus to a certain extent.

Methods

We enrolled 23 children with SA and the same number matched healthy controls in the ophthalmology department of the First Affiliated Hospital of Nanchang University, and the whole brain was scanned by rs-fMRI. The fALFF value of each brain area was derived to examine whether there is a statistical difference between the two groups. Meanwhile, the ROC curve was made in a view to evaluate whether this difference proves useful as a diagnostic index. Finally, we analyzed whether changes in the fALFF value of some specific brain regions are related to clinical manifestations.

Results

Compared with HCs, children with SA presented decreased fALFF values in the left temporal pole: the superior temporal gyrus, right middle temporal gyrus, right superior frontal gyrus, and right supplementary motor area. Meanwhile, they also showed higher fALFF values in specific brain areas, which included the left precentral gyrus, left inferior parietal, and left precuneus.

Conclusion

Children with SA showed abnormal fALFF values in different brain regions. Most of these regions were allocated to the visual formation pathway, the eye movement-related pathway, or other visual-related pathways, suggesting the pathological mechanism of the patient.

Preliminary Study of Short-Term Visual Perceptual Training Based on Virtual Reality and Augmented Reality in Postoperative Strabismic Patients

The study aimed to explore the potential effect of short-term visual perceptual training based on virtual reality (VR) and augmented reality (AR) platforms in postoperative strabismic patients. We enrolled 236 postoperative strabismic patients, among whom 111 patients received VR-based training, and 125 patients received AR-based training. The stereoacuity of 1.5 m and dynamic stereopsis were improved by VR training; meanwhile, AR training exhibited more improvement in stereoacuity of 0.8 and 1.5 m, dynamic and coarse stereopsis. It was suggested that the visual perceptual training based on VR and AR technology can be potentially applied in postoperative strabismus treatment to promote the recovery of binocular vision.