National cross sectional study of detection of congenital and infantile cataract in the United Kingdom: role of childhood screening and surveillance. The British Congenital Cataract Interest Group

How ptosis affects the visual quality: an overview of visual quality impairments and contributing factors in ptotic eyes

BACKGROUND

The effect of ptosis on visual quality is a crucial consideration in the oculoplastic surgeon's practice that cannot be ignored before performing corrective surgery. The aim of this review is to summarize the manifestations and mechanisms of visual quality impairment in ptosis.

MAIN TEXT

A literature search was conducted in multiple databases to identify studies reporting changes in various visual quality parameters and mechanisms that affect visual quality loss in ptotic eyes. The studies included both retrospective and cross-sectional designs. This paper comprehensively describes the changes in a variety of subjective and objective visual quality parameters such as visual acuity, contrast sensitivity, visual field, refraction, higher-order aberrations, and OQAS parameters in the ptotic eye, and provides a detailed in-depth analysis of the specific mechanisms by which the eyelids, eyelashes, and ocular position interfere with visual quality.

CONCLUSIONS

The manifestations of the impact of ptosis on visual quality are diverse and influenced by multiple mechanisms. A comprehensive and objective assessment of the manifestations and specific mechanisms of visual quality impairment in patients with ptosis will provide an important reference for treatment selection and prognosis of visual function.

The outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa: a systematic review

IMPORTANCE

Cataract is one of the leading causes of childhood blindness in Africa. The management of this condition requires timely surgical extraction of the cataractous lens with immediate optical correction and long-term follow-up to monitor visual improvement and manage complications that may arise. This review provides an opportunity to benchmark outcomes and to shed light on the reasons for those outcomes.

OBJECTIVES

To review the published literature and report on the outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa.

DATA SOURCE

The EMBASE, PubMed, Scopus, and Web of Science were searched for relevant articles.

STUDY SELECTION

We included all published primary studies from sub-Saharan Africa on cataract surgery outcomes in children aged 0-16 years with primary intraocular lens implantation conducted between 1990 and 2020. Eligible studies were those published in English or for which an English translation was available. In addition, reviewers screened the reference lists of all studies included in the full-text review for eligible studies. During the review, studies fitting the inclusion criteria above except for having been conducted in middle and high-income countries were tagged and placed in a comparison arm.

DATA EXTRACTION AND SYNTHESIS

Study eligibility was determined by two independent reviewers, and data extraction was conducted by one reviewer with entries checked for accuracy by another reviewer. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data synthesis were followed. The Joanna Briggs Institute (JBI) critical appraisal checklist was used for quality appraisal of the studies. The statistical software R was used in the analysis, and data were pooled using a random-effects model. Forest plots were generated using the R package 'metafor'.

MAIN OUTCOMES AND MEASURES

The primary outcome was visual acuity (VA) after cataract surgery and the proportions of eyes that achieved good, borderline, or poor visual outcome according to the World Health Organisation (WHO) categorisation of post-operative visual acuity. The secondary outcome measures reported included lag time to surgery, rates of follow-up, and rate of complications.

RESULTS

Eight out of 4763 studies were eligible for inclusion in this review, and seven were included in the quantitative analysis. There was a male preponderance in the study population, and the mean age at the time of cataract surgery ranged from 3.4 to 8.4 years. Visual outcomes were available for short-term visual outcomes (1 to 6 months) as the studies had a significant loss to follow-up. The pooled proportion of eyes that achieved a good visual acuity (i.e. equal to or greater than 6/18) in the short-term period was 31% (CI, 20-42). The comparative studies from middle and high-income countries reported proportions ranging from 41 to 91%, with higher thresholds for good visual acuity of 6/12 and 6/15.

CONCLUSION AND RELEVANCE

This review reports that there is a lower proportion of eyes with good outcomes after undergoing paediatric cataract surgery in sub-Saharan Africa than in middle- and high-income countries. Furthermore, this review states that there is a high proportion of patients lost to follow-up and suboptimal refractive correction and amblyopia treatment after paediatric cataract surgery.

The clinical efficacy of preoperative flash visual evoked potential (VEP) for mature cataracts without a response to pattern VEP

BACKGROUND

This study aims to assess the effectiveness of the preoperative flash visual evoked potential (VEP) test in predicting postoperative visual acuity for monocular mature cataract cases when compared to the contralateral normal eye.

METHODS

The study included 60 patients, each with a monocular mature cataract diagnosis, who underwent preoperative flash VEP testing showing no pattern VEP response. Subsequently, phacoemulsification was performed. The relationship between the flash VEP test latency values (P1, N2, P2) and amplitude value (N2-P2), and the degree of visual acuity recovery 3 months post-cataract surgery, was evaluated using the LogMAR scale. Furthermore, a linear regression analysis was conducted to explore the connection between preoperative flash VEP components and postoperative visual acuity.

RESULTS

The average age of the patients was 65.4 ± 13.6 years, with a range of 43 to 87 years. The study included 36 males and 24 females. A significant disparity in visual acuity was observed between the preoperative and 3-month postoperative stages (p < 0.001). The preoperative flash VEP test for mature cataracts revealed significant delays in P1, N2, and P2 latency, as well as a reduction in N2-P2 amplitude potential when compared to the contralateral normal eye (p < 0.001). Notably, delayed P2 latency and reduced N2-P2 amplitude potential were particularly indicative of poor visual acuity prognosis after cataract surgery in the multiple regression analysis (p < 0.05). The N2-P2 amplitude potential was the important value that exhibited statistically significant results, with an area under the curve (AUC) of 80% sensitivity and 88% specificity, using a cutoff value of 6.07 μV.

CONCLUSIONS

In cases of monocular mature cataract, a reduction in N2-P2 amplitude potential compared to the contralateral normal eye emerged as the most reliable predictor of postoperative visual prognosis following cataract surgery.

Analysis of age at detection and outcomes of dense unilateral congenital cataract surgery for children on the paediatric cataract register

AIM

Analysis of age at time of detection and surgery of dense unilateral cataract and investigation of best-corrected visual acuity (BCVA) in a nationwide register-based cohort study, based on the routine of maternity ward eye screening.

METHODS

Data were derived from the Paediatric Cataract Register (PECARE). All children (n = 54) diagnosed with dense congenital unilateral cataract between January 2007 and September 2014 who had surgery before 1 year of age, and for whom 5-year follow-up records were available, were included.

RESULTS

The majority, 35/54 (65%), were detected and operated on before age 6 weeks and 30/35 (86%) were referred from maternity wards. Visual acuity (VA) ≥ 0.5 (decimal, 0.3 logMAR) was found in 7/53 (13%) of the cohort at age 5 years; further, 19 children achieved VA ≥ 0.1 (decimal, 1.0 logMAR) (36%) and 19 children VA < 0.05 (decimal, 1.30 logMAR) (36%). Ten-year follow-up records were available for 17/53 (32%) children; 1/17 (6%) achieved VA ≥ 0.5 (decimal, 0.3 logMAR), 4/17 (24%) VA ≥ 0.3-<0.5 (decimal, 0.52-0.30 logMAR), 3/17 (18%) VA ≥ 0.05-0.1 (decimal, 1.30-1.0 logMAR) and 10/17 (59%) VA < 0.05 (decimal, 1.30 logMAR).

CONCLUSION

A total of 90% of the children were detected with cataract within 100 days of birth and 80% were operated on within this period. This study showed better visual acuity in those treated for dense unilateral cataracts than previously reported in an earlier Swedish cohort study.

Age at recognition and age at presentation for surgery for congenital and developmental cataract in Kazakhstan

PURPOSE

To investigate the age at recognition and presentation for surgery for congenital and developmental cataract at Kazakh Eye Research Institute in Kazakhstan.

METHODS

A retrospective review of children aged 0-18 years, who presented with congenital and developmental cataract between January 1, 2010 and December 31, 2020. All medical records were reviewed. Gender, age at recognition, age at surgery, laterality, residential location (rural/urban) were recorded.

RESULTS

The study population included 897 patients of children presented with congenital and developmental cataract over a 10-year study period, 58% of them were boys and 44.6% were from rural areas. Cataract was bilateral in 621 (69.2%) and unilateral in 276 (30.8%) of patients. Median age at recognition for patients with congenital/developmental cataract was 12 months. Median age at surgery for congenital/developmental cataract was 51 months. Only 14.7% of children underwent surgery within first year of life. The urban citizens underwent surgery earlier than patients from rural areas. The median delay in presentation for surgery was 15 months.

CONCLUSION

The average age at cataract surgery in the population of Kazakhstan is much older than in developed countries. It is essential to study barriers that associated with delayed presentation to build strategies to overcome them.Key messagesIt is known that cataract surgery in children early in life provides favourable visual outcome.Children with congenital and developmental cataract in Kazakhstan experience delay in surgical treatment.Children from rural areas undergo cataract surgery later than urban citizens.

Universal newborn eye screening: a systematic review of the literature and review of international guidelines

Background

This systematic review assessed the effectiveness of universal screening for newborn eye abnormalities compared with no screening in improving infant vision and health outcomes.

Methods

We searched CENTRAL (Cochrane Library), MEDLINE, Embase, Global Health, Global Index Medicus, clinical trials databases, and bibliographies of relevant articles. We included randomized and observational studies of all newborns, regardless of illness or risk factors, that compared universal screening for any eye abnormality by eight weeks of age with no universal screening. Two authors independently selected studies, extracted data, and evaluated the risk of bias. We used GRADE to assess the certainty of evidence. We also reviewed available recommendations on newborn eye screening.

Results

Fourteen studies were identified but only three compared universal red reflex screening with no screening. Findings suggest that universal red reflex testing in maternity wards (MWs) may increase the number of newborns with congenital cataracts referred for eye care from MWs or well-baby clinics (WBCs) in the first year of life (risk ratio (RR) = 9.83, 95% confidence interval (CI) = 1.36-71.20; low certainty evidence). However, the effect of screening in WBC is uncertain (RR = 6.62, 95% CI = 0.87-50.09). The effect of MW or WBC screening on referral from any health care facility (MWs, WBCs, paediatrician clinic, other) in the first year is uncertain (MW screening: RR = 1.22, 95% CI = 0.63-2.39; WBC screening: RR = 0.97, 95% CI = 0.46-2.05). However, referral or surgery by 6 weeks of age may be higher with universal MW screening (early referral: RR = 4.61, 95% CI = 1.12-19.01; early surgery: RR = 8.23, 95% CI = 1.13-59.80; low certainty evidence). The effect of WBC screening on early referral and surgery is uncertain (early referral: RR = 1.98, 95% CI = 0.43-9.19; early surgery: RR = 3.97, 95% CI = 0.50-31.33; very low certainty evidence). Universal red reflex testing may increase clinical conjunctivitis (OR = 1.22, 95% CI = 1.01-1.47; low certainty evidence) but the effect on confirmed bacterial conjunctivitis is uncertain (OR = 1.20, 95% CI = 0.76-1.90; very low-certainty evidence). Nine guidelines recommended universal newborn eye screening using red reflex testing.

Conclusions

Evidence supports the role of red reflex testing shortly after birth to increase early identification, referral, and surgery for congenital cataracts.

Evaluation of childhood cataract characteristics at a tertiary referral center

PURPOSE

To examine the epidemiological characteristics of children undergoing cataract surgery at a referral center in Sao Paulo State, Brazil, as well as the facts surrounding treatment delays.

METHODS

In this transversal observational study, 240 operated eyes from 178 children undergoing cataract surgery were reviewed. The following aspects were analyzed: epidemiological and clinical characteristics, parental observations, red reflex test, operated eye, and age at cataract diagnosis and surgery.

RESULTS

The mean ages at the first visit and cataract surgery were 48.9 months (SD=50.0 months) and 64.5 months (SD= 55.4 months), respectively. The most critical sign adverted by parents was leukocoria. The red reflex test was performed on two-thirds of the children, with abnormal results in 28.0%. A family history of cataracts was evident in 30 (20,9%) children (n=144). Previous ocular surgery was found in 37 (16,6%) of the eyes (n=223), anterior segment disorders in 20 (9,0%) eyes (n=221), strabismus in 21 (9,5%) of the eyes (n=220), and nystagmus in 38 (24,4%) of the children (n=156).

CONCLUSIONS

One of the causes for the delay in admission may have been the failure to complete the red reflex. In terms of etiology, heredity was the most crucial component. The presence of strabismus and nystagmus in many of these children points to late diagnosis. The most significant impediments to adequate cataract treatment in children were the lack of referral programs and children's specialized ophthalmologic centers, in addition to the restricted number of support professionals trained in the field and pediatric ophthalmology specialists.

Descriptive and risk factor analysis of infantile cataracts: National Birth Defects Prevention Study, 2000-2011

Using National Birth Defects Prevention Study (NBDPS) data, we sought to estimate birth prevalence, describe clinical characteristics, and examine risk factors for infantile cataracts. We calculated birth prevalence using the numbers of NBDPS-eligible cataract cases and live births in the study area. We described case infants by the presence of associated ipsilateral eye defects (IEDs) and non-eye-related major birth defects. Using maternal exposure information collected via telephone interview, we conducted logistic regression analyses among the interviewed cases and controls. Birth prevalence of infantile cataracts was 1.07/10,000 live births. Unilateral cataracts were more often associated with IEDs, while infants with bilateral cataracts were more often preterm, full-term with low birth weight, or had non-eye-related major birth defects. Unilateral cataracts were positively associated with maternal nulliparity (adjusted odds ratio [aOR] = 1.61, 95% confidence interval [CI] = 1.18, 2.20; reference: multiparity), whereas bilateral cataracts were positively associated with maternal education <12 years (aOR = 2.08, 95% CI = 1.13, 3.82; reference: education >12 years), and foreign-born nativity (aOR = 1.92, 95% CI = 1.04, 3.52; reference: U.S.-born nativity). The current analysis can inform future epidemiological studies aimed at identifying mechanisms underlying the associations between infantile cataracts and complex maternal exposures, such as lower levels of education and foreign-born nativity.

Referral patterns for infantile cataracts in two regions of the United States

BACKGROUND

Delayed treatment of congenital or infantile cataracts can cause deprivation amblyopia. Prompt diagnosis and surgical intervention is critical for optimal outcomes. This study assessed referral patterns for congenital or infantile cataracts in two regions of the United States.

METHODS

The medical records of children 0-1 years of age with congenital or infantile cataracts at Stanford University (2008-2018) and Emory University (2010-2015) were reviewed retrospectively.

RESULTS

A total of 111 children were included. Of these, 82 (74%) were initially evaluated by a primary care doctor, of whom 40 (49%) were referred directly to a pediatric cataract surgeon. Of 61 newborns 0-2 months of age, 9 (15%) were initially referred to an eye care provider before 6 weeks of age, but the initial evaluation by a pediatric cataract surgeon was delayed until after 6 weeks of age. Referral patterns were similar between the two institutions (P = 0.06).

CONCLUSIONS

Many children with congenital of infantile cataracts are initially referred by a primary care doctor to an eye care provider who does not perform pediatric cataract surgery. Nevertheless, the majority of newborn infants with cataracts were evaluated by a pediatric cataract surgeon before 6 weeks of age.

The Utility of Universal Newborn Eye Screening: A Review

Universal newborn eye screening can identify ocular abnormalities early and help mitigate long-term visual impairment. Traditional neonatal and infant eye screening is administered by neonatologists and pediatricians using the red reflex test. If this test identifies an ocular abnormality, then the patient is examined by an ophthalmologist. Notably, the red reflex test may be unable to detect amblyogenic posterior segment pathology. Recent studies using fundus imaging and telemedicine show reduced cost of human resources and increased sensitivity compared with traditional approaches. In this review, the authors discuss universal newborn eye screening pilot programs with regard to disease prevalence, referral-warranted disease, and cost-effectiveness. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:S6-S16.].

Comparison between wide-field digital imaging system and the red reflex test for universal newborn eye screening in Brazil

PURPOSE

To compare neonatal eye screening using the red reflex test (RRT) versus the wide-field digital imaging (WFDI) system.

METHODS

Prospective cohort study. Newborns (n = 380, 760 eyes) in the Maternity Ward of Irmandade Santa Casa de Misericórdia de São Paulo hospital from May to July 2014 underwent RRT by a paediatrician and WFDI performed by the authors. Wide-field digital imaging (WFDI) images were analysed by the authors. Validity of the paediatrician's RRT was assessed by unweighted kappa [κ] statistic, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).

RESULTS

While WFDI showed abnormalities in 130 eyes (17.1%), RRT was only abnormal in 13 eyes (1.7%). Wide-field digital imaging (WFDI) detected treatable retina pathology that RRT missed including hyphema, CMV retinitis, FEVR and a vitreous haemorrhage. The sensitivity of the paediatrician's RRT to detect abnormalities was poor at 0.77% (95% confidence interval, CI, 0.02%-4.21%) with a PPV of only 7.69% (95% CI, 1.08%-38.85%). Overall, there was no agreement between screening modalities (κ = -0.02, 95% CI, -0.05 to 0.01). The number needed to screen to detect ocular abnormalities using WFDI was 5.9 newborns and to detect treatable abnormalities was 76 newborns.

CONCLUSION

While RRT detects gross abnormalities that preclude visualization of the retina (i.e. media opacities and very large tumours), only WFDI consistently detects subtle treatable retina and optic nerve pathology. With a higher sensitivity than the current gold standard, universal WFDI allows for early detection and management of potentially blinding ophthalmic disease missed by RRT.

A novel instrument for assessing the retinal red reflex for non‐ophthalmic health professionals

BACKGROUND

The direct ophthalmoscope is the standard instrument for assessing retinal red reflexes when screening for cataract, however, it is expensive and often not available to non-ophthalmic health professionals. The pen torch ophthalmoscope is a new economic alternative for this purpose. This study aimed to determine its accuracy in assessing retinal red reflexes and to compare it to the direct ophthalmoscope. It is anticipated that this instrument will be useful in detecting both congenital and adult type cataracts.

METHODS

Eighteen health professionals evaluated the retinal red reflexes of 68 subjects at the Dunedin Hospital Eye Clinic with both the direct ophthalmoscope and the pen torch ophthalmoscope. Three groups of seven, six and five observers assessed both eyes of 24, 21 and 23 subjects, respectively, resulting in 1,574 examinations.

RESULTS

Compared to the direct ophthalmoscope, the pen torch ophthalmoscope exhibited lower sensitivity (68 per cent versus 75 per cent), but higher specificity (72 per cent versus 63 per cent) and lower over-referral (false positive) rates by nine per cent. The positive predictive value in respect to identifying for cataract was better for the pen torch ophthalmoscope (71 per cent) than for the direct ophthalmoscope (66 per cent), while the negative predictive value was slightly worse (70 per cent and 73 per cent, respectively). When compared to the direct ophthalmoscope, 15/18 observers felt the pen torch ophthalmoscope was accurate enough, one felt it was just as good and two did not respond.

CONCLUSIONS

This pilot study demonstrates that the pen torch ophthalmoscope is comparable to the direct ophthalmoscope in detecting abnormal retinal red reflexes in adults with cataracts. At six per cent of the cost of a direct ophthalmoscope, it may appeal to non-ophthalmic health professionals in developed and developing countries. It may also increase the frequency of screening for cataract in children and adults. Further development and study of this pen torch ophthalmoscope prototype is warranted.

Detection of anomalies in the red reflex test requires adequate training

CLINICAL RELEVANCE

Midwives should receive appropriate training to enable them to reliably detect an abnormality in the red reflex, so as to detect potentially sight- (and possibly life-) threatening visual anomalies in newborns.

BACKGROUND

Midwives who had completed the relevant Newborn and Infant Physical Examination (NIPE) training in the UK, were tested to determine whether they could reliably detect an abnormality in the red reflex of a model eye. Their results were compared to a group of undergraduate optometry students in their final year, who had considerably more experience with ophthalmoscopy.

METHODS

Two groups of adult participants, 27 post-graduate midwives and 10 undergraduate optometry students with different levels of experience in ophthalmoscopy were recruited. Participants were required to perform the red reflex test repeatedly on a set of 10 model eyes with interchangeable simulated retinas, that produced both normal and abnormal 'red' reflexes, under controlled conditions.

RESULTS

A total of 1,810 observations were recorded across both groups of participants. Both the sensitivity and the specificity for distinguishing between normal and abnormal reflexes were higher for the optometry students (sensitivity 77.5 per cent and specificity 96.7 per cent) than the midwives (sensitivity 53.9 per cent and specificity 75.4 per cent). The positive predictive values were 21.7 per cent and 67.4 per cent for the midwives and optometry students, respectively. The negative predictive values were 92.8 per cent for the midwives and 98.0 per cent for the optometry students.

CONCLUSION

Despite completion of required training on the red reflex test, optometry students outperformed midwives in the detection of anomalous red reflex test simulations from a model eye. This result is likely due to differences in training in ophthalmoscopy between the two groups of participants. Additional training in the conduct of the red reflex test for midwives is therefore recommended.

Age at detection and age at presentation of childhood cataract at a tertiary facility in Ibadan, Southwest Nigeria

BACKGROUND

To describe factors which influence the age at detection and age at presentation of patients with childhood cataract at a tertiary eye care facility in Southwest Nigeria.

METHODS

A retrospective review of children who presented with cataract between 2011 and 2015. Case notes were reviewed and data on age at detection and presentation as well as other clinical information was collected and analyzed using Stata 12 statistical software.

RESULTS

A total of 164 cases were reviewed, 52.4% of them were boys. Median age at presentation was 48 months while the median age at detection was 13.5 months. Seventy-four (45.1%) children had congenital cataract, 31.1% had developmental cataract, and 21.3% had traumatic cataract. The child's mother detected the cataract in 116 (70.7%) of the patients. Median age at presentation for patients with congenital cataract was 18 months and 84 months for developmental cataract. The median age at presentation for congenital cataracts that were noticed by the mother was 17 months compared with 72 months for those noticed by other caregivers (p = 0.0085). The median age at presentation for developmental cataracts that were noticed by the mother was 72 months compared with 114 months for those noticed by other caregivers (p = 0.0065). Gender of the child did not significantly influence the age at detection or presentation. The source of referral and the location of domicile did not significantly affect the time interval between detection of the cataract and presentation to hospital.

CONCLUSION

The average age of children presenting with cataracts in our setting is older than in high income countries. Detection of the cataract by the mother increases the likelihood of early presentation; thus, focused maternal education may promote earlier detection and presentation.

The infrared reflex: a potential new method for congenital cataract screening

OBJECTIVE

To compare the accuracy of infrared (IR)-reflex assessment using a prototype imaging device to standard non-mydriatic red-reflex screening with direct ophthalmoscope (DO) in the diagnosis of neonatal and childhood cataract.

METHODS

The comparison of the techniques was made in two distinct cohorts: in the first, newborns underwent IR and red-reflex testing by a medical student, with results compared to a reference red-reflex examination by an experienced midwife. In the second, an enriched cohort of children attending a specialist paediatric ophthalmology clinic had IR and red-reflex testing by a medical student to reference examination by a paediatric ophthalmologist. The medical students were considered inexperienced screeners due to their limited exposure to ophthalmology. The sensitivity and specificity of the IR and red-reflex assessments in respect to reference examination were calculated. Diagnostic accuracy was compared in Caucasian and non-Caucasian eyes.

RESULTS

IR and red-reflex imaging were possible in all 180 neonatal eyes examined. A total of 5% of newborn eyes were found to have embryological remnants in the anterior segment of the eye with IR-reflex imaging which were not detected on reference red-reflex examination. IR-reflex assessment had significantly better sensitivity (100 vs 71%, p < 0.05) and specificity (100 vs 63%, p < 0.01) than red-reflex assessment in the diagnosis of childhood cataract. Red-reflex specificity was particularly poor in non-Caucasian eyes compared to Caucasian eyes (32 vs 72%, p < 0.05).

CONCLUSION

This pilot study indicates that IR-reflex imaging has the potential to improve the diagnostic accuracy of eye screening for cataract by inexperienced healthcare staff, particularly in non-Caucasian children.

Prospective observational study of universal newborn eye screening in a hospital and community setting in New Zealand

OBJECTIVE

Early detection of ocular abnormalities in newborn infants is essential for timely diagnosis and treatment. This study aimed to assess wide-field digital imaging for universal newborn eye screening (UNES) to determine the prevalence of ocular abnormalities, including retinal haemorrhages, in newborn infants in New Zealand.

DESIGN

Prospective ocular screening study of infants.

SETTING

A public hospital maternity ward and a community birth centre in Auckland, New Zealand.

PATIENTS

A total of 350 infants were enrolled in UNES, those with birth weight <1250 g or gestational age <30 weeks were excluded.

METHODS

Wide-field digital images of the external eye and retina were captured by RetCam (Natus Medical, San Carlos, California, USA) and reviewed by an ophthalmologist via an established telemedicine methodology.

MAIN OUTCOME MEASURES

Detection of ocular abnormalities, including retinal haemorrhages. Correlation between haemorrhages and maternal, obstetric and neonatal factors.

RESULTS

A total of 346 infants completed screening (median age 2 days). Retinal haemorrhages were present in 50 cases (14.5%), two cases exhibited persistent retinal haemorrhages at 6-week follow-up. A significant increase in the odds of retinal haemorrhages was present for vaginal delivery compared with caesarean section. Other ocular abnormalities, including congenital cataract and optic nerve hypoplasia, were present in 1.4% of infants.

CONCLUSIONS

Ocular abnormalities were detected by UNES including congenital cataract and optic nerve hypoplasia. However, retinal haemorrhages, significantly associated with delivery modality, were the most common abnormality detected. The majority of retinal haemorrhages resolved spontaneously.

Delay in presentation to hospital for childhood cataract surgery in India

Purpose

Cataract is one of the major causes of avoidable visual disability in children and the aim of this study was to investigate the age at which children with cataract present for surgery at tertiary hospitals across India.

Methods

A prospective multicenter study collected data from 9 eye hospitals in 8 states in India. All children admitted for cataract surgery between Nov 2015 and March 2016 were considered eligible. Parents were interviewed at the hospital by trained personnel and socio demographic information, age at diagnosis and at surgery and the relevant clinical data were obtained from the medical records. Mean age, age range at surgery were used and performed logistic regression analyses.

Results

Parents of 751 consecutive cases were interviewed, of which 469(63%) were boys and 548 (73%) were from rural areas. Cataract was bilateral in 493 (66%) and unilateral in 258 (34%); of the unilateral cases, 179 (69%) were due to trauma. The mean age at surgery for ‘congenital’ and ‘developmental’ cataract was 48.2 ± 50.9 and 99.7 ± 46.42 months, respectively and the mean age was lower in the southern region compared to other regions. Children with 2 or more siblings at home were five times more likely to undergo surgery within 12 months (OR, 4.69; 95% CI: 2.04–10.79; p = < 0.001).

Conclusions

Late surgery for childhood cataract remains a major challenge and the factors determining this issue in India are pertinent also to several other countries and need to be addressed for every child with cataract to achieve full visual potential.

The impact of the National Institute for Health Research Health Technology Assessment programme, 2003-13: a multimethod evaluation

BACKGROUND

The National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme supports research tailored to the needs of NHS decision-makers, patients and clinicians. This study reviewed the impact of the programme, from 2003 to 2013, on health, clinical practice, health policy, the economy and academia. It also considered how HTA could maintain and increase its impact.

METHODS

Interviews (n = 20): senior stakeholders from academia, policy-making organisations and the HTA programme. Bibliometric analysis: citation analysis of publications arising from HTA programme-funded research. Researchfish survey: electronic survey of all HTA grant holders. Payback case studies (n = 12): in-depth case studies of HTA programme-funded research.

RESULTS

We make the following observations about the impact, and routes to impact, of the HTA programme: it has had an impact on patients, primarily through changes in guidelines, but also directly (e.g. changing clinical practice); it has had an impact on UK health policy, through providing high-quality scientific evidence - its close relationships with the National Institute for Health and Care Excellence (NICE) and the National Screening Committee (NSC) contributed to the observed impact on health policy, although in some instances other organisations may better facilitate impact; HTA research is used outside the UK by other HTA organisations and systematic reviewers - the programme has an impact on HTA practice internationally as a leader in HTA research methods and the funding of HTA research; the work of the programme is of high academic quality - the Health Technology Assessment journal ensures that the vast majority of HTA programme-funded research is published in full, while the HTA programme still encourages publication in other peer-reviewed journals; academics agree that the programme has played an important role in building and retaining HTA research capacity in the UK; the HTA programme has played a role in increasing the focus on effectiveness and cost-effectiveness in medicine - it has also contributed to increasingly positive attitudes towards HTA research both within the research community and the NHS; and the HTA focuses resources on research that is of value to patients and the UK NHS, which would not otherwise be funded (e.g. where there is no commercial incentive to undertake research). The programme should consider the following to maintain and increase its impact: providing targeted support for dissemination, focusing resources when important results are unlikely to be implemented by other stakeholders, particularly when findings challenge vested interests; maintaining close relationships with NICE and the NSC, but also considering other potential users of HTA research; maintaining flexibility and good relationships with researchers, giving particular consideration to the Technology Assessment Report (TAR) programme and the potential for learning between TAR centres; maintaining the academic quality of the work and the focus on NHS need; considering funding research on the short-term costs of the implementation of new health technologies; improving the monitoring and evaluation of whether or not patient and public involvement influences research; improve the transparency of the priority-setting process; and continuing to monitor the impact and value of the programme to inform its future scientific and administrative development.

[Epidemiologic and etiological characteristics of congenital cataract: study of 59 cases over 10 years]

OBJECTIVE

The goal of this study was to analyze the epidemiology and maternal, prenatal and perinatal risk factors for congenital cataracts.

MATERIALS AND METHODS

We conducted a retrospective study of all consecutive cases of congenital cataracts diagnosed and managed at hôpital Nord Marseille, France. We describe demographic, personal, maternal and familial characteristics of these patients.

RESULTS

We identified 59 children with congenital cataract. The group consists of 31 girls (53%) and 28 boys (47%). Cataract was bilateral in 71% of cases and unilateral in 29% of cases. This group is first divided according to etiological forms. Idiopathic cataract accounts for 63% of patients. Genetic and infectious cataract accounts for 34% and 3%, respectively. According to the clinical presentation, congenital cataract was an isolated finding in 51% of cases. It was associated with ocular abnormalities in 27% of cases and with systemic abnormalities in 22% of cases. The diagnosis was made upon routine screening in 41% of cases. Leucoria and strabismus led to the diagnosis in 24% and 19%, respectively. The average age of diagnosis was 19.7 months.

CONCLUSION

Congenital cataract is a relatively rare condition. The description of a series of 59 cases is important as well as the comparison of our results to large epidemiological data previously published. The elucidation of novel risk factors requires consideration at a national or even global scale.

Congenital cataract: prevalence and surgery age at Zhongshan Ophthalmic Center (ZOC)

Congenital cataract (CC) is the primary cause of treatable childhood blindness. Population-based assessments of prevalence and surgery age of CC, which are critical for improving management strategies, have been unavailable in China until now. We conducted a hospital-based, cross-sectional study of the hospital charts of CC patients younger than 18 years old from January 2005 to December 2010 at Zhongshan Ophthalmic Center (ZOC) in Guangzhou, China. Residence, gender, age at surgery, hospitalization time, and the presence of other ocular abnormalities were extracted and statistically analyzed in different subgroups. The search identified 1314 patients diagnosed with CC from a total of 136154 hospitalizations, which accounted for 2.39% of all the cataract in-patients and 1.06% of the total in-patients over the six-year study period. Of the identified CC patients, 9.2% had ≥ 2 hospitalizations due to the necessity of additional surgeries, with a total ratio of boys to girls of 1.75 ∶ 1. Based on a subgroup analysis according to age, patients 2-6 years old constituted the highest proportion (29.22%) of all hospitalized CC patients, and those 13-18 years old constituted the lowest proportion (13.47%) of the total number. The average age at surgery was 27.62 ± 23.36 months, but CC patients ≤ 6 years old (especially ≤ 6 months old) became increasingly prevalent throughout the 6-year study period. A total of 276 cases (20.93%) of CC were associated with one or more other ocular abnormalities, the highest incidence rates were observed for exotropia (6.24%), nystagmus (6.16%), and refractive error (3.65%). In conclusion, CC patients accounted for 2.39% of all cataract in-patients in a review of 6 years of hospitalization charts from ZOC. The age at the time of surgery decreased over the 6-year study period, which probably reflects the continuing improvement of public awareness of children's eye care in China.

Amblyopia in childhood eyelid ptosis

PURPOSE

To report the prevalence and causes of amblyopia among children with ptosis diagnosed in a well-defined population over a 40-year period.

DESIGN

Retrospective, population-based cohort study.

METHODS

We retrospectively reviewed the charts of 107 patients younger than 19 years for the prevalence and causes of amblyopia who were diagnosed with childhood ptosis and were residents of Olmsted County, Minnesota, from January 1, 1965, through December 31, 2004.

RESULTS

Amblyopia was diagnosed in 16 (14.9%) of the 107 patients with childhood ptosis. Fourteen (14.6%) of 96 patients diagnosed with a congenital form of ptosis demonstrated amblyopia. Twelve (14.8%) of the 81 patients diagnosed with simple congenital ptosis had amblyopia, 7 (8.6%) cases of which solely were the result of eyelid occlusion of the visual axis. The causes of amblyopia in the remaining 5 patients were significant refractive error in 3 patients and strabismus in 2 patients.

CONCLUSIONS

Amblyopia occurred in 1 in 7 children diagnosed with ptosis in this population-based cohort. In approximately half of those with amblyopia, or less than 10% of all patients, the disease solely was the result of eyelid occlusion of the visual axis.

Parenting stress in the infant aphakia treatment study

OBJECTIVE

To evaluate parenting stress following infants' cataract extraction surgery, and to determine if levels of stress differ between 2 treatments for unilateral congenital cataract in a randomized clinical trial.

METHODS

At surgery, an intraocular lens (IOL) was implanted or children were left aphakic, treated with contact lens (CL). Stress measures were administered 3 months after surgery and at the first visit after the visual acuity (VA) assessment done at 12 months of age.

RESULTS

Caregivers in the IOL group reported higher levels of stress than those in the CL group 3 months after surgery, but there were no group differences in stress scores at the post-VA assessment. Stress scores did not change differentially for participants assigned to IOL versus CL treatments.

CONCLUSIONS

Treatment assignment did not have a significant impact on caregiver stress during infancy or on the change in stress during the child's first 2 years of life.

Improving detection of blindness in childhood: the British Childhood Vision Impairment study

OBJECTIVES

In industrialized countries, there are established programs of childhood vision screening and surveillance, but little is known about their performance. We investigated the patterns of presentation/detection and early treatment of a nationally representative cohort of children with severe visual impairment or blindness (SVI/BL) in 1 year (2000) in the United Kingdom.

METHODS

All children who were younger than 16 years and had a new diagnosis of SVI/BL were identified by active surveillance through the British Ophthalmological and Pediatric Surveillance Units. Data that were collected up to 1 year after diagnosis included sociodemographic characteristics, detection of SVI/BL, nonophthalmic disorders/impairments, ophthalmic findings, and early management.

RESULTS

Of 439 identified children, 65% were younger than 1 year at diagnosis, 28% were of nonwhite ethnicity, and 40% in the worst quintile of deprivation score. A total of 77% had associated nonophthalmic disorders/impairments. Although 70% had established symptoms or signs at diagnosis by a health professional, parents had suspected blindness in only 47%. A quarter of isolated SVI/BL was detected through routine vision screening; however, 46% of children's SVI/BL and associated nonophthalmic disorders/impairments were diagnosed through a clinical surveillance examination undertaken because of high risk for a specific eye disease.

CONCLUSIONS

The "patient journey" of children with visual impairment is markedly influenced by the presence of additional impairments/chronic diseases. Parents' understanding of normal visual development needs to be improved. Increasingly, new evidence-based formal programs of clinical (ophthalmic) surveillance are needed in response to the changing population of children who are at risk for blinding eye disease.

Visual impairment and delay in presentation for surgery in chinese pediatric patients with cataract

PURPOSE

To report visual impairment and blindness and delay in presentation for surgery in Chinese pediatric patients with cataract.

DESIGN

Retrospective case series.

PARTICIPANTS

A total of 196 children (309 eyes) with congenital or developmental cataract.

METHODS

Surgery was performed in all patients. Visual impairment and blindness were defined as best-corrected visual acuity < 20/60. The characteristics, visual acuity, and time delay to surgery of these children were evaluated.

MAIN OUTCOME MEASURES

Incidence of visual impairment and blindness, ages at disease recognition and at surgery, and duration of delay in presentation for surgery.

RESULTS

Visual acuity was 20/25 or better in 22 eyes (7.1%), between 20/25 and 20/40 in 72 eyes (23.3%), and between 20/40 and 20/60 in 87 eyes (28.2%). Visual impairment and blindness occurred in 41.4% of eyes, 52.0% of patients, 35.4% of patients with bilateral cataract, and 74.7% of patients with unilateral cataract. The frequency of visual impairment and blindness in eyes with combined nystagmus, combined strabismus, total cataract, nuclear cataract, and posterior polar cataract was 84.4%, 75%, 63.8%, 48%, and 48.3%, respectively. Severe postoperative complications resulted in 14.8% of visual impairment and blindness. The mean ages at disease recognition and at surgery were 22.6 ± 30.4 months and 68.3 ± 40.0 months, respectively. The mean delay of presentation for surgery was 49.6 ± 39.8 months in all patients and 35.7 ± 32.2 months in the patients with congenital cataract. The disease was recognized within 6 months of age in 46 children (40.7%) with bilateral cataract and 10 children (12.0%) with unilateral cataract. Among these children, only 18 (15.9%) with bilateral cataract and 1 (1.2%) with unilateral cataract underwent surgery between 3 and 6 months of age. No patients received surgical intervention within 3 months.

CONCLUSIONS

Severe visual impairment is common in pediatric patients with cataract in China. Delayed presentation to the hospital and late surgical treatment are the major reasons and deserve greater attention.

Simultaneous vs sequential bilateral cataract surgery for infants with congenital cataracts: Visual outcomes, adverse events, and economic costs

OBJECTIVES

To compare the incidence of adverse events and visual outcomes and to compare the economic costs of sequential vs simultaneous bilateral cataract surgery for infants with congenital cataracts.

METHODS

Retrospective review of simultaneous vs sequential bilateral cataract surgery for infants with congenital cataracts who underwent cataract surgery when 6 months or younger at our institution.

RESULTS

Records were available for 10 children who underwent sequential surgery at a mean age of 49 days for the first eye and 17 children who underwent simultaneous surgery at a mean age of 68 days (P = .25). We found a similar incidence of adverse events between the 2 treatment groups. Intraoperative or postoperative complications occurred in 14 eyes. The most common postoperative complication was glaucoma. No eyes developed endophthalmitis. The mean (SD) absolute interocular difference in logMAR visual acuities between the 2 treatment groups was 0.47 (0.76) for the sequential group and 0.44 (0.40) for the simultaneous group (P = .92). Payments for the hospital, drugs, supplies, and professional services were on average 21.9% lower per patient in the simultaneous group.

CONCLUSIONS

Simultaneous bilateral cataract surgery for infants with congenital cataracts is associated with a 21.9% reduction in medical payments and no discernible difference in the incidence of adverse events or visual outcomes. However, our small sample size limits our ability to make meaningful comparisons of the relative risks and visual benefits of the 2 procedures.

Delayed presentation of anorectal malformations: the possible associated morbidity and mortality

AIM

Anorectal malformations (ARMs) are one of the most common congenital anomalies dealt by pediatric surgeons with reported incidence of approximately 1 in 5,000 live births. The majority of patients usually presents during the neonatal period. However a significant number of patients report later during infancy or even late childhood. Such delayed presentation may affect the surgical management and contribute to functional and psychological problems for both babies and their parents. The aim of this study is to highlight the frequency of this problem, cause of delayed presentation, and how this delayed presentation of ARM contributes to morbidity and mortality.

PATIENTS AND METHODS

During the 3-year study period, 104 cases with ARM (74 males and 30 females) were presented to pediatric surgery unit in Assiut university children's hospital. Delayed presentation means that the child came after the first 48 h or after 3 months of age in case of low ARM in females.

RESULTS

Out of 104 cases, 20 fulfil the criteria of delayed presentation (11 females and 9 males). Their age at presentation ranged from 4 days to 14 years. Fourteen classified as low ARM (6 male and 8 female), whereas six classified as high ARM (3 male and 3 female). The causes of delayed presentation were delayed detection, wrong advice to the parents, inadequate treatment offered, and social causes. The associated morbidities encountered were chronic constipation, mega rectum, and unnecessary colostomy. Two mortalities were encountered; both were males presented on days 4 and 14 after birth.

CONCLUSIONS

Delayed ARMs is not uncommon. Every neonate should be carefully examined and screened for such anomaly to avoid the possible morbidity and mortality which are directly related to this delayed presentation.

Assessment of risk factors for infantile cataracts using a case-control study: National Birth Defects Prevention Study, 2000-2004

OBJECTIVE

To identify risk factors for infantile cataracts of unknown etiology.

DESIGN

Case-control study.

PARTICIPANTS

Case infants (n = 152) and control infants (n = 4205) enrolled in the National Birth Defects Prevention Study for birth years 2000-2004.

METHODS

Multivariate analysis was performed exploring associations for risk factors for bilateral and unilateral infantile cataracts of unknown etiology.

MAIN OUTCOME MEASURES

Infantile cataracts of unknown etiology.

RESULTS

Maternal interviews were completed for 43 case infants with bilateral and 109 with unilateral infantile cataracts of unknown etiology. Very low birth weight (<1500 g) was associated with both unilateral (adjusted odds ratio [OR], 6.0; 95% confidence interval [CI], 2.2-16.3) and bilateral (OR, 13.2; 95% CI, 4.2-41.1) cataracts, whereas low birth weight (1500-2499 g) was only associated with bilateral cataracts (OR, 3.3; 95% CI, 1.3-8.1). Infants with unilateral cataracts were more likely to be born to primigravid women (OR, 1.6; 95% CI, 1.0-2.7) than women with > or =2 previous pregnancies, although this was of borderline significance. Although not significant, effect estimates were elevated suggesting a possible association between unilateral cataracts and maternal substance abuse during pregnancy, and between bilateral cataracts and urinary tract infection during pregnancy and aspirin use during pregnancy.

CONCLUSIONS

Very low birth weight is associated with both bilateral and unilateral cataracts, whereas low birth weight is associated with bilateral cataracts and primigravidity with unilateral cataracts. Other associations, although not statistically significant, suggest risk factors that merit further research.

A safety assessment of tumor necrosis factor antagonists during pregnancy: a review of the Food and Drug Administration database

OBJECTIVE

To present any congenital anomalies with respect to tumor necrosis factor (TNF) antagonists reported to the US Food and Drug Administration (FDA) to determine if there are common findings.

METHODS

A review of the FDA database of reported adverse events with etanercept, infliximab, and adalimumab from 1999 through December of 2005 was performed. Key words for congenital anomalies were employed as search tools. Duplicate reports were eliminated. Any concomitant medicines were recorded.

RESULTS

Our review of > 120,000 adverse events revealed a total of 61 congenital anomalies in 41 children born to mothers taking a TNF antagonist. Of these mothers, 22 took etanercept and 19 took infliximab. There were no reports in women taking adalimumab. The most common reported congenital anomaly was some form of heart defect. Twenty-four of the 41 (59%) children had one or more congenital anomalies that are part of vertebral abnormalities, anal atresia, cardiac defect, tracheoesophageal, renal, and limp abnormalities (VACTERL) association. There were 34 specific types of congenital anomalies in total, and 19 (56%) of those are part of the VACTERL spectrum. Nine of these 19 (47%) types of VACTERL anomalies were observed statistically significantly more than historical controls (p < 0.01); in 4 of these 9 the p value was < or = 0.0001. Thirteen (32%) of the children had more than one congenital anomaly; 7 of these 13 children had 2 defects that are part of the VACTERL spectrum. However, only 1 child was diagnosed with VACTERL. In 24/41 cases (59%) the mother was taking no other concomitant medications.

CONCLUSION

A seemingly high number of congenital anomalies that are part of the VACTERL spectrum have been reported. These congenital anomalies are occurring at a rate higher than historical controls. This commonality raises concerns of a possible causative effect of the TNF antagonists.

Clinical outcomes of surgical techniques in congenital cataracts

PURPOSE

To investigate the general clinical features of congenital cataracts and to determine their relationship to visual prognosis and surgical complications according to age at operation and surgical procedure adopted.

METHOD

We retrospectively evaluated 92 eyes in 61 patients with congenital cataracts who underwent cataract surgery between January 1996 and December 2006. The demographic data, surgical technique, post-operative complications, and final visual prognosis were evaluated.

RESULTS

The average age at surgery was 3.17 years (range 1 month to 11 years), and the mean follow-up was 40.02 months (range 6 to 46 months). Of the 56 eyes that could be checked for visual acuity after cataract extraction, 29 (51.7%) had a BCVA of > or = 0.5 at last visit. Unilateral congenital cataracts (p=0.025) and congenital cataracts with strabismus (p=0.019) showed significantly poorer visual outcomes. Patients with nystagmus also experienced a poor visual outcome; 6 patients (67%) had a BCVA of <0.1. Posterior cataracts had the worst visual prognosis (p=0.004). No statistically significant differences in posterior capsular opacity (p=0.901) or synechia formation (p=0.449) were observed between surgical techniques, but children younger than one year showed a higher tendency for PCO and synechia formation.

CONCLUSIONS

Anterior vitrectomy did not reduce postoperative complications. Higher rates of complications (PCO, posterior synechia) developed in children younger than one year of age.

Incidence of and factors associated with glaucoma after surgery for congenital cataract: findings from the British Congenital Cataract Study

PURPOSE

To report the incidence of and factors associated with postoperative open-angle glaucoma in a nationally representative group of children undergoing surgery for congenital or infantile cataract.

DESIGN

Noncomparative interventional cohort study.

PARTICIPANTS

All children in the United Kingdom who were newly diagnosed with congenital or infantile cataract in a 12-month period in 1995 and 1996 (the British Congenital/Infantile Cataract Study) were eligible for this study. One hundred sixty-five children with congenital or infantile cataract underwent cataract surgery.

METHODS

All the children were traced through their managing ophthalmologists. Standardized outcome data were collected at least 6 years after diagnosis. For children undergoing cataract extraction, Cox regression analysis was performed to determine incidence of postoperative open-angle glaucoma and the effect of key factors considered, a priori, potentially to be associated with it (i.e., age at detection and surgery, type of cataract surgery, primary intraocular lens implantation, severe postoperative uveitis, and microphthalmia).

MAIN OUTCOME MEASURES

Development of open-angle glaucoma after cataract surgery.

RESULTS

Postoperative glaucoma developed in 27 of 275 eyes of 165 children who underwent cataract surgery. The overall annual incidence of postoperative glaucoma was 5.25 per 100 cataract operations. The median time to development of postoperative glaucoma was 1.34 years (range, 0.39 months-6.73 years). Younger age at detection of cataract was the only factor independently associated with the development of glaucoma when all other factors of interest (which were all statistically associated with age at detection) were accounted for. A 10-fold increase in the age at detection (for example, 30 days compared with 3 days) was associated with a 64% decrease in the hazard ratio (95% confidence interval, 41%-79%; P<0.001).

CONCLUSIONS

Median time to development of postoperative open-angle glaucoma in the present study was lower than that reported previously, emphasizing the need for vigilance from the early postoperative period. Earlier detection of cataract was the only significant factor associated with the development of glaucoma after surgery for congenital cataract.

The health-related quality of life of children with congenital cataract: findings of the British Congenital Cataract Study

BACKGROUND

There is increasing emphasis on patient-based assessment of healthcare outcomes, but evaluation of the impact of ophthalmic disorders on quality of life is undertaken infrequently.

AIM

To report on the health-related quality of life (HRQOL) of children with congenital cataract.

METHODS

At least 6 years after diagnosis, 41 children (representative of a national cohort) and their parents completed the child and proxy (parental) versions of PedsQL 4.0, a generic multidimensional paediatric HRQOL instrument, independently. This provided a physical health summary score, a psychosocial health summary score and an overall score (range 0-100, higher scores indicating better HRQOL).

RESULTS

Questionnaires were completed by 33 parent-child pairs and by 8 parents alone. The mean (SD) total score self-reported by children was 75.85 (15.56) and that reported by parents was 75.91(16.79). The mean (SD) physical health score self-reported by children was 80.76 (8.61), which was higher than the psychosocial health score of 72.93 (16.06). There was considerable variation in agreement of scores reported by individual child-parent pairs (the largest difference was 56.3 points). Notably, the PedsQL scores of children with congenital cataract were comparable with those reported for some children with severe systemic diseases such as rheumatological disease and some cancers.

CONCLUSIONS

These findings serve to characterise the significant broader impact of congenital cataract on patients and their families. The PedsQL 4.0 proved to be an acceptable instrument for assessing generic HRQOL, permitting valuable reporting by children and their parents. However, to capture the subjective experience of ophthalmic disease in childhood fully, specific vision-related quality of life measures for children are needed.

Birth characteristics of different ocular congenital abnormalities in hungary

AIMS

The aim of the study was to estimate the prevalence at birth of different ocular congenital abnormalities and to describe their birth characteristics in Hungary.

METHODS

Two data sets were evaluated: the national-based Hungarian Congenital Abnormality Registry and the Hungarian Case-Control Surveillance of Congenital Abnormalities which include cases with ocular abnormalities and patient controls with other (non-ocular) congenital abnormalities, and population controls without abnormalities from the National Birth Registry.

RESULTS

Seven hundred twelve cases were found with ocular abnormalities in the data set of the Hungarian Congenital Abnormality Registry (2.62 per 10,000 live births), while that of the Hungarian Case-Control Surveillance of Congenital Abnormalities included 314 cases with ocular defects among 2.7 million live births in Hungary between 1980 and 2002. There was an obvious underascertainment and/or notification of cases with ocular defects because an extra effort to ascertain all cases with ocular abnormalities resulted in a birth prevalence of 6.31 per 10,000 live births in 1999. The main birth characteristics of cases were male excess, shorter mean gestational age and smaller mean birth weight with a larger proportion of preterm birth and low birthweight.

CONCLUSIONS

Earlier diagnosis of ocular abnormalities is necessary with a more complete notification of these cases to the Hungarian Congenital Abnormality Registry. The birth characteristics of cases with ocular abnormalities may have some associations with the origin of ocular defects; therefore, these variables will require further studies in case-control approach.

Changes in refraction and ocular dimensions after cataract surgery and primary intraocular lens implantation in infants

PURPOSE

To study refraction and axial length changes after cataract extraction and primary intraocular lens (IOL) implantation in children younger than 1 year of age.

SETTING

Two regional hospitals.

METHODS

After determining the IOL power for emmetropia, 80% of the value was used to choose the IOL for implantation to counter anticipated myopic shift with age. The main outcome measures were changes in refraction and axial length 3 years after surgery.

RESULTS

Thirty-four eyes of 20 children (mean age 6.7 months +/- 3.9 [SD]) were studied. Refraction in the immediate postoperative period was +4.53 +/- 1.45 diopters (D). Three years after surgery, the mean refraction was -2.49 +/- 3.08 D (P<.001). Twenty-two eyes (64.7%) had surgery during the first 6 months of life (group 1) and had a shorter axial length at surgery (mean 18.92 +/- 1.32 mm) compared with 12 eyes (35.3%) that received surgery between 7 and 12 months (group 2, mean 20.29 +/- 1.00 mm) (P = .007). However, the final axial length was greater in group 1 (mean 22.67 +/- 1.04 mm) than in group 2 (mean 21.23 +/- 0.26 mm) (P = .019).

CONCLUSIONS

Primary IOL implantation is an option for children having cataract surgery in the first year of life. Significant myopic shifts occurred, and this seemed to be more pronounced in younger children. It appears that rethinking current strategies for IOL power calculation may be required to achieve more optimal refractive outcomes.

Using multiple sources to improve and measure case ascertainment in surveillance studies: 20 years of the British Paediatric Surveillance Unit

BACKGROUND

The British Paediatric Surveillance Unit (BPSU) was established in 1986 to facilitate national surveillance of uncommon paediatric disorders. This study investigated the effectiveness of using multiple source reporting and capture-recapture analysis to maximize case ascertainment in studies undertaken through the BPSU.

METHODS

Structured review of all surveillance studies completed through the BPSU. Quantitative and qualitative analysis of the effectiveness of multiple reporting sources and capture-recapture methods was made.

RESULTS

Of 71 studies undertaken through the BPSU, 59 were included in this review and 38 used additional data sources. Established national sources were most readily adapted for use as secondary data sources, including routine health data, communicable disease and specialty-specific surveillance units, whilst the involvement of parent groups and the media was less successful. Six studies employed capture-recapture techniques to estimate the completeness of case ascertainment.

CONCLUSIONS

Active surveillance through the BPSU remains a timely and reliable primary source of cases, but employing additional reporting sources is effective in enhancing case ascertainment. When the assumptions for its valid use are met, capture-recapture analysis allows the estimation of completeness of ascertainment. It is essential to define the purpose of an additional source at the outset of a study and to ensure that subsequent analysis is appropriate.

Amblyopia

Results from recent randomised clinical trials in amblyopia should change our approach to screening for and treatment of amblyopia. Based on the current evidence, if one screening session is used, screening at school entry could be the most reasonable time. Clinicians should preferably use age-appropriate LogMAR acuity tests, and treatment should only be considered for children who are clearly not in the typical range for their age. Any substantial refractive error should be corrected before further treatment is considered and the child should be followed in spectacles until no further improvement is recorded, which can take up to 6 months. Parents and carers should then be offered an informed choice between patching and atropine drops. Successful patching regimens can last as little as 1 h or 2 h a day, and successful atropine regimens as little as one drop twice a week. Intense and extended regimens might not be needed in initial therapy.

A population-based case-control study of isolated anophthalmia and microphthalmia

The purpose of the study was to reveal the etiological factors in the origin of isolated an/microphthalmia. The dataset of the Hungarian Case-Control Surveillance of Congenital Abnormalities, 1980-2002 containing 56 cases with isolated an/microphthalmia and 22,744 malformed controls with other non-ocular defects from the Hungarian Congenital Abnormality Registry, in addition of 56 matched control pairs and 37,837 population controls without defects from the National Birth Registry, was evaluated. Exposure data and family history were collected (i) prospectively by prenatal logbook and other medical records, (ii) retrospectively through a structured questionnaire filled-in by mothers, and (iii) information obtained by regional nurses at home visit of non-respondent mothers. The autosomal recessive origin of isolated an/microphthalmia was indicated in about 10% of cases on the basis of sib recurrence. Cases with isolated an/microphthalmia had a much shorter mean gestational age and smaller mean birth weight, a much larger proportion of preterm birth and low birthweight. Their mothers were younger with a predominance of first birth order, frequently unmarried with low socioeconomic status. These findings are in agreement with a much higher prevalence at birth of cases with isolated an/microphthalmia in the gypsy population probably due to the interaction of inbreeding effect and low socioeconomic status. Further molecular genetic studies are needed to identify gene mutations of isolated an/microphthalmia in the Hungarian gypsy population.

Delay in presentation to hospital for surgery for congenital and developmental cataract in Tanzania

BACKGROUND

Childhood cataract is a leading cause of blindness in children in eastern Africa. High quality surgical services have been established at a few tertiary facilities in the region; however, there appears to be delay in presentation to hospital.

METHODS

Parents or guardians of all children presenting to KCMC Hospital or CCBRT Hospital with congenital (recognised since birth or within the first year) or developmental (cataract leading to reduction in vision after 1 year of age) cataract were interviewed regarding the actions taken (and timing of these) before coming to hospital. Demographic information was also collected. For analysis children were grouped as either late presenters (more than 12 months after recognition) or not late presenters (within 12 months of recognition) and predictors of late presentation were assessed.

RESULTS

Among 178 children (74 congenital cataract and 104 developmental cataract) analysed, the mean delay between recognition by the caregiver and presentation to hospital was 34 months, almost 3 years. The median delay was 18 months-9 months for congenital cataract and 24 months for developmental cataract. Long delay in presentation was associated with having developmental cataract, living far from the hospital, and low socio-educational status of the mother. Among children with congenital cataract, having another sibling increased the likelihood of early presentation.

CONCLUSION

Delay in presentation remains a significant problem for children needing surgery for congenital or developmental cataract. Parents who have multiple children may be more likely to seek early treatment, possibly because their expectations of achievable sight at a young age are based on previous experience of their older children. Educational efforts should aim to reach the most "unreachable" (those living the furthest from the hospital and having the lowest socio-educational status of the mother).

Screening for congenital cataracts: a cost-consequence analysis of eye examination at maternity wards in comparison to well-baby clinics

AIM

To estimate, on a national basis in Sweden, the costs versus consequences of combined maternity ward and well-baby clinic eye screening compared to well-baby clinic screening alone.

METHODS

Two scenarios were created and compared regarding healthcare costs: visual acuity development and quality-adjusted life-years (QALYs). One scenario represented early management (combined maternity ward and well-baby clinic screening); the other represented less early management (well-baby clinic screening only). Each scenario was based on 100,000 births, and the healthcare costs were calculated from detection until age 18 y. All estimates of prevalence, visual outcome, postoperative complications and screening procedures were based on previous, recently published studies. Estimated costs were obtained from St. Erik's Eye Hospital in Stockholm and the University Hospital of Lund, at 2001 prices.

RESULTS

Total cost of the maternity ward/well-baby clinic screening scenario was 7.9 million SEK, and that of the maternity ward screening scenario was 6.9 million SEK. The incremental cost-effectiveness ratio was estimated at 234,000 SEK/QALY provided three more children per year were detected in Sweden by mandatory maternity ward/well-baby clinic screening.

CONCLUSION

The incremental expense of introducing combined maternity ward/well-baby clinic eye screening on a nationwide basis is cost effective and within acceptable levels of cost/QALY when compared with other widely accepted therapies across diverse medical specialties.

Scope for improving congenital cataract blindness prevention by screening of infants (red reflex screening) in a New Zealand setting

OBJECTIVE

To assess the coverage and quality of routine red reflex screening in a single region and to consider the results in the context of the current New Zealand guidelines.

METHODS

All the health practitioners partaking in routine Well Child - Tamariki Ora checks in the Nelson-Tasman region were asked to complete a simple one-page questionnaire on red reflex screening.

RESULTS

Out of 127 providers potentially involved in routine infant examinations, the response rate was 92%. Red reflex screening was not being performed at the appropriate routine infant check with an ophthalmoscope by 16% (10/61) of the general practitioners and 29% (10/35) of the midwives. Eighteen per cent of the doctors and 47% of the midwives did not understand why red reflex screening was important or what was being looked for.

CONCLUSIONS

There is substantial scope for improving the coverage and quality of red reflex screening in this region to meet national guidelines. The importance and technique of examining the red reflex should be stressed in the training of both doctors and midwives who are lead maternity carers in New Zealand.

Is early surgery for congenital cataract a risk factor for glaucoma?

AIMS

To estimate the risk of aphakic glaucoma after lensectomy for congenital cataract and its association with surgery within the first month of life.

METHOD

A retrospective case notes review was conducted of all patients who had lensectomy for congenital cataract during their first year of life at Great Ormond Street Hospital between 1994 and 1997. Patients with pre-existing glaucoma, anterior segment dysgenesis, and Lowe syndrome were excluded. The risk of aphakic glaucoma after surgery was estimated using Kaplan-Meier survival analysis.

RESULTS

80 patients, undergoing 128 lensectomies were eligible. Of these, six patients (nine eyes) were lost to follow up. Based on eye count, the risk of glaucoma by 5 years after lensectomy was 15.6% (95% CI 10.2 to 23.4). Based on patient count, the 5 year risk of glaucoma in at least one eye following bilateral surgery was 25.1% (95% CI 15.1 to 40.0). The incidence of glaucoma remained at a constant level for the first 5 years after surgery. After early bilateral lensectomy, within the first month of life, the 5 year risk of glaucoma in at least one eye was 50% (95% CI 27.8 to 77.1) compared to 14.9% (95% CI 6.5 to 32.1) with surgery performed later (log rank test, p = 0.012). There was no significant difference (Kolmogorov-Smirnov test: unilateral lensectomy p = 0.587, bilateral lensectomy p = 0.369) in 5 year visual outcomes between eyes operated before and after 1 month of age.

CONCLUSION

Bilateral lensectomy during the first month of life is associated with a higher risk of subsequent glaucoma than with surgery performed later. The reason for this is unclear but it may be prudent, in bilateral cases, to consider delaying surgery until the infant is 4 weeks old. As the incidence of glaucoma is similar for each year after surgery, long term glaucoma surveillance is mandatory.

Parenting stress among caregivers of children with congenital cataracts

OBJECTIVE

To examine parenting stress among caregivers of young children with congenital cataracts and to assess whether diagnostic and/or treatment differences are associated with differences in perceived parenting stress.

METHODS

Parents of 41 preschool-age children with congenital cataracts (13 with bilateral cataracts [BCCs] and 28 with unilateral cataracts [UCCs], of whom 14 were aphakic and 14 were pseudophakic) completed the Parenting Stress Index (PSI) and/or a disease-specific parental stress measure, ie, the Ocular Treatment Index (OTI).

RESULTS

The 28-item OTI had excellent internal consistency (alpha = 0.94) and supported three of four a priori validity hypotheses. Parents of children with congenital cataracts reported normal parenting stress levels on the PSI. Parents of children with UCCs tended to report higher levels of stress, but not significantly so, than did parents of children with BCCs. Among parents of children with UCCs, those whose children were aphakic reported higher levels of stress on the OTI and all of the PSI subscales than did parents of pseudophakic children. These differences were statistically significant for two subscales (Adaptability [P =.03] and Mood [P =.01]).

CONCLUSIONS

Although parents of children with congenital cataracts generally did not report increased parenting stress levels, clinicians should be aware that parenting stress can adversely impact patients' families. We did observe higher stress levels in parents with children who had UCCs and did not receive an intraocular lens-particularly stress related to their child's reaction to sensory stimulation and mood-compared with parents of pseudophakic children. Thus, clinicians may want to consider parenting stress levels when choosing a treatment for children with UCCs, especially because such stress has been associated with poor treatment compliance for children with other chronic conditions.