Optical coherence tomography in pediatric ophthalmology: current roles and future directions

Impact of social determinants of health on follow-up adherence, testing completion, and outcomes among pediatric glaucoma patients at a tertiary care center

PURPOSE

To identify patient characteristics associated with visit attendance, treatment outcomes, and optical coherence tomography (OCT) testing in pediatric glaucoma patients at an urban tertiary care center.

METHODS

The records of patients with childhood glaucoma seen from 2015 to 2021 were reviewed. Primary outcomes were the proportion of scheduled visits completed, visual acuity and intraocular pressure (IOP) at most recent follow-up, and rates of OCT testing. Social determinants of health evaluated included race and ethnicity, distance of residence from clinic, insurance carrier type and residence within Baltimore City County, the latter two serving as proxies for socioeconomic status.

RESULTS

A total of 99 patients met inclusion criteria: 61% were male; 47%, White (non-Hispanic); 25%, Black (non-Hispanic); 11%, Hispanic/Latino; and 7% Asian/Pacific Islander. Mean distance from clinic was 45.3 miles. Mean visit completion rate was 90.4%; there was no statistically significant variation in visit completion rates by patient characteristics. IOP outcomes did not vary across patient groups, but visual acuity outcomes in affected eyes were significantly worse among Baltimore City County residents compared with non-residents. Only 22% of the cohort received ≥1 OCT per year, and patients living 0-29.9 miles from clinic had significantly lower odds of reaching the threshold than more distant patients. Patients with state-based insurance had significantly lower odds of being ≥50th percentile for rate of OCTs received compared to patients with commercial insurance.

CONCLUSIONS

In children with glaucoma, residence within Baltimore City County was associated with significantly worse visual acuity outcomes, and close proximity to clinic was an independent predictor of lower rates of OCT testing, despite similar visit attendance rates and IOP outcomes across all groups.

Outcome measures in childhood glaucoma: a systematic review of randomized controlled trials

PURPOSE

To synthesize the outcome measures used by randomized controlled trials (RCTs) for childhood glaucoma.

METHODS

MEDLINE, EMBASE, and Scopus were searched from inception to February 17, 2023. Randomized controlled trials and observational studies related to childhood glaucoma were included. Primary and secondary outcomes were extracted and the data was used to generate a literature review.

RESULTS

This review identified 42 unique reports pertaining to childhood glaucomas. Most of the studies originated from Egypt, India, and the USA. Intraocular pressure (IOP) outcomes were the most frequent outcomes studied, followed by clinical outcomes and safety outcomes. Clinical outcomes were the most common secondary outcomes studied, followed by IOP outcomes and safety outcomes.

CONCLUSIONS

This systematic review found heterogenous outcomes with IOP outcomes as the most studied primary outcome. As the remaining outcomes were not consistently utilized, this review highlights the need for a consensus on studies of pediatric glaucoma.

Ganglion cell complex thickness with spectral domain optical coherence tomography and correlations in a normative pediatric South Asian cohort

Spectral domain optical coherence tomography (SD-OCT) was used to assess the perifoveal Ganglion cell complex (GCC) thickness in healthy Pakistani children. 174 eyes of 87 healthy children (3 to 16 years) were included after a thorough eye examination. Significant refractive error was excluded (>± 5 DS), glaucoma, ocular pathology, intraocular surgery, trauma, and systemic ailments. The perifoveal GCC analysis was done by Optopol Revo 80® high resolution SD-OCT. The average age was 11.1 ± 3.12 years. The average GCC thickness globally was 120.01 ± 76.74 μm, superiorly; 117.51 ± 8.77 μm, superonasally; 120.47 ± 8.78 μm, superotemporally, 103.83 ± 8.25 μm, inferiorly; 117.41 ± 8.71 μm, inferonasally 120.57 ± 8.88 μm, and inferotemporally; 107.15 ± 7.69 μm. The average GCC thickness was positively correlated with axial length (p = .02) and the GCC thickness in all sectors was significantly higher amongst males as compared to females (p < .05). Our study provides normative data for the macular GCC thickness in healthy children of our population. GCC thickness estimation is an important diagnostic parameter in glaucoma and optic neuropathies. Establishing a normative database for our pediatric population would help immensely in the diagnosis and monitoring of optic nerve disorders. RESEARCH HIGHLIGHTS: Spectral domain optical coherence tomography guided measurement of the ganglion cell complex thickness of the Pakistani pediatric population has not been done before. Our study provides normative data for the macular ganglion cell complex in healthy children of our population and studies its correlations with age, gender, intraocular pressure, axial length, refractive status, and corneal thickness. This will guide us in optic nerve and neurological disease diagnosis and monitoring.

Anterior segment parameters on optical coherence tomography in healthy South Asian children

PURPOSE

High resolution spectral domain optical coherence tomography (SD-OCT) was used to assess the anterior segment structure parameters in healthy South Asian children.

METHODS

108 eyes of 54 healthy children ≤ 16 years were recruited after a thorough eye exam. The anterior segment analysis was be done by Optopol Revo 80 high resolution SD-OCT. Central corneal thickness (CCT), Angle opening distance (AOD), Anterior chamber (AC) angle, Trabecular iris space area (TISA), Trabecular iris angle (TIA), iris thickness at 2 mm, internal AC diameter and lens vault were evaluated.

RESULTS

Mean age was 11.38 years. Mean IOP was 13.63 mmHg, mean axial length, 22.82 mm, mean spherical equivalent, -0.14 D, mean CCT, 532.6 µm and mean CDR was 0.31. The mean internal AC diameter was 11609.15 µm. The nasal and temporal AC angles was 53.54° and 50.37°, respectively [P = .033]. The nasal and temporal AOD500 were 0.9 mm and 0.85 mm, respectively [P = .629]. The nasal and temporal AOD750 were 1.21 mm and 1.06 mm, respectively [P = .583]. The nasal TIA was 41.75°; the temporal TIA; 40.24° [P = .325]. The nasal TISA500 was 0.33 mm²; the temporal TISA500, 0.31 mm² [P = .012]. The nasal TISA750 was 0. 59 mm²; the temporal TISA750, 0.56 mm² [P = .746]. The nasal iris thickness at 2 mm was 483.54 µm; the temporal iris thickness, 505.8 µm [P = .273]. The mean lens vault was -519.58 µm.

CONCLUSIONS

Our study data depicts the normal anterior segment parameters in healthy Pakistani children.

OCT Imaging in Infants

Optical coherence tomography (OCT) is widely applied in diagnosis and management of retina diseases particularly macular diseases in adult retina practices. However, it has been under-utilized in pediatric retinal diseases especially in neonates and infants. Utilization of OCT in primary macular diseases in this age group is also uncommon and is less reported. Challenges involved in image acquisition and limitations with available devices technique can explain the limited research and accurate data availability in the literature in this field. Purpose of this review article is to summarize the use of OCT and its importance in various infantile retinal pathologies such as vascular diseases, tumors, retinal dystrophies, and optic nerve pathologies with primary focus on neonates and infants, along with infant choroid. In addition, we also discuss about future directions including OCT angiography for infants.

Optical coherence tomography in paediatric clinical practice

Optical coherence tomography is a non-invasive ocular imaging technique that is frequently used in the diagnosis and monitoring of optic nerve or retinal disease. Advances in optical coherence tomography speed and image processing capability allow increased use of the modality in clinical practice, especially in younger children. This review outlines the challenges involved in imaging children, highlights the technological progress, the importance of acquiring normative data and, finally, focuses on the clinical applicability of optical coherence tomography in our paediatric population with various ocular conditions.

Optical Coherence Tomography in Children With Microtropia

PURPOSE

To assess whether optical coherence tomography (OCT) could be useful for detecting and documenting fixation in patients with microtropia.

METHODS

Retinal fixation observation was performed using spectral-domain OCT on amblyopic children with microtropia. The position between the retinal fixation point and the anatomical fovea was measured, in microns, using the system software tools. Only patients with a high level of cooperation, OCT scan quality signal of 7 or better, and visual acuity of 0.70 logarithm of the minimum angle of resolution (logMAR) or worse in the amblyopic eye were included.

RESULTS

A total of 25 patients were included: 15 with microtropia (study group) and 10 without tropia and with foveal fixation and stereopsis (control group). In the study group, microtropia was previously diagnosed in 67% of cases through the cover test, and was predominantly in the left eye (73%). The average visual acuity of the sound eye was 0.03 decimal and 0.18 logMAR in the amblyopic eye. The microtropia was 3.73 ± 3.34 prism diopters and eccentric fixation (387 ± 199 µm) with OCT was observed in all cases except one. Eccentricity was predominantly in the superonasal quadrant (57%). Both eyes in the control group and the contralateral eyes of the study group showed foveal fixation.

CONCLUSIONS

OCT can play an important role in the diagnosis and measurement of eccentric fixation in eyes with microtropia, providing high sensitivity. [J Pediatr Ophthalmol Strabismus. 2018;55(3):171-177.].

Clinical and Genetic Evaluation of a Cohort of Pediatric Patients with Severe Inherited Retinal Dystrophies

We performed a clinical and genetic characterization of a pediatric cohort of patients with inherited retinal dystrophy (IRD) to identify the most suitable cases for gene therapy. The cohort comprised 43 patients, aged between 2 and 18 years, with severe isolated IRD at the time of presentation. The ophthalmological characterization also included assessment of the photoreceptor layer integrity in the macular region (ellipsoid zone (EZ) band). In parallel, we carried out a targeted, next-generation sequencing (NGS)-based analysis using a panel that covers over 150 genes with either an established or a candidate role in IRD pathogenesis. Based on the ophthalmological assessment, the cohort was composed of 24 Leber congenital amaurosis, 14 early onset retinitis pigmentosa, and 5 achromatopsia patients. We identified causative mutations in 58.1% of the cases. We also found novel genotype-phenotype correlations in patients harboring mutations in the CEP290 and CNGB3 genes. The EZ band was detectable in 40% of the analyzed cases, also in patients with genotypes usually associated with severe clinical manifestations. This study provides the first detailed clinical-genetic assessment of severe IRDs with infantile onset and lays the foundation of a standardized protocol for the selection of patients that are more likely to benefit from gene replacement therapeutic approaches.

The use of handheld spectral domain optical coherence tomography in pediatric ophthalmology practice: Our experience of 975 infants and children

Purpose:

Optical coherence tomography (OCT) is an important imaging tool assessing retinal architecture. In this article, we report a single centers experience of using handheld spectral domain (SD)-OCT in a pediatric population using the Envisu 2300 (Bioptigen Inc., Research Triangle Park, NC, USA).

Methods:

We studied SD-OCT images from 975 patients imaged from January 2011 to December 2014. The variety of cases that underwent an SD-OCT was analyzed. Cases examples from different case scenarios were selected to showcase unique examples of many diseases.

Results:

Three hundred and sixty-eight infants (37.7%) were imaged for retinopathy of prematurity, 362 children (37.1%) underwent the test for evaluation of suboptimal vision or an unexplained vision loss, 126 children (12.9%) for evaluation of nystagmus or night blindness, 54 children (5.5%) for an intraocular tumor or a mass lesion such as retinoblastoma, and 65 children (6.7%) for other diseases of the pediatric retina. The unique findings in the retinal morphology seen with some of these diseases are discussed.

Conclusion:

The handheld SD-OCT is useful in the evaluation of the pediatric retinal diseases. The test is useful in the assessment of vision development in premature children, evaluation of unexplained vision loss and amblyopia, nystagmus and night blindness, and intraocular tumors (including retinoblastoma).

Normative Spectral Domain Optical Coherence Tomography Data in Healthy Turkish Children

PURPOSE

To determine the normative database of macular and retinal nerve fiber layer (RNFL) thickness parameters in healthy Turkish children by OCT.

METHODS

318 eyes of 318 children (138 boys, 183 girls) aged between 3 and 17 years were evaluated. The children were scanned by Cirrus HD-OCT (Carl Zeiss Meditec) to measure the macula, RNFL, and optic nerve head parameters.

RESULTS

Axial length (AL) (p < 0.001, R²= 0.08), spherical equivalent (SE) (p < 0.001, R²= 0.12), and rim area (p < 0.001, R²= 0.15) were the strongest predictors of RNFL thickness. All of the macular measurements were significantly related to age (p < 0.001, R²> 5%). Average macular thickness (p < 0.01) and outer macula (p = 0.002) showed significant relationship with the AL and SE.

CONCLUSION

This study ensures an age-adjusted pediatric normative database using OCT to diagnose and monitor macular diseases, optic nerve diseases, and glaucoma in children.

Reduced retinal nerve fibre layer thickness in children with severe obesity

BACKGROUND

Some optic nerve diseases are silent and insidious. Recently, reduced thickness of retinal nerve fibre layer (RNFL) has been associated with increasing body mass index in adults.

OBJECTIVES

To investigate the association of childhood obesity with RNFL measured by optical coherence tomography imaging.

METHODS

Ninety-seven children aged 5-14 years classified according to standard deviation score of body mass index (SDS-BMI) were included. Parameters of metabolic risk, adipocytokines (leptin, adiponectin) and interleukin-6 were analyzed. All subjects underwent a comprehensive ophthalmologic examination with direct ophthalmoscopy. Evaluation of RNFL with optical coherence tomography of the head of the nerve was performed.

RESULTS

RNFL thickness on the average and inferior, superior and nasal quadrants were decreased in severely obese children (SDS-BMI > 4) with respect to the other groups. However, no statistically significant association was found between the different groups of children and RNFL thickness in the temporal quadrant. There was a significant inverse correlation of RNFL thickness with adiposity indices (P = 0.016), leptin (P = 0.029) and interleukin-6 (P = 0.030) in overweight and obese children.

CONCLUSIONS

These findings suggest that adiposity and obesity-related inflammatory factors may be associated with the loss of retinal ganglion cells in children.

Real-time automated thickness measurement of the in vivo human tympanic membrane using optical coherence tomography

BACKGROUND

Otitis media (OM), an infection in the middle ear, is extremely common in the pediatric population. Current gold-standard methods for diagnosis include otoscopy for visualizing the surface features of the tympanic membrane (TM) and making qualitative assessments to determine middle ear content. OM typically presents as an acute infection, but can progress to chronic OM, and after numerous infections and antibiotic treatments over the course of many months, this disease is often treated by surgically inserting small tubes in the TM to relieve pressure, enable drainage, and provide aeration to the middle ear. Diagnosis and monitoring of OM is critical for successful management, but remains largely qualitative.

METHODS

We have developed an optical coherence tomography (OCT) system for high-resolution, depth-resolved, cross-sectional imaging of the TM and middle ear content, and for the quantitative assessment of in vivo TM thickness including the presence or absence of a middle ear biofilm. A novel algorithm was developed and demonstrated for automatic, real-time, and accurate measurement of TM thickness to aid in the diagnosis and monitoring of OM and other middle ear conditions. The segmentation algorithm applies a Hough transform to the OCT image data to determine the boundaries of the TM to calculate thickness.

RESULTS

The use of OCT and this segmentation algorithm is demonstrated first on layered phantoms and then during real-time acquisition of in vivo OCT from humans. For the layered phantoms, measured thicknesses varied by approximately 5 µm over time in the presence of large axial and rotational motion. In vivo data also demonstrated differences in thicknesses both spatially on a single TM, and across normal, acute, and chronic OM cases.

CONCLUSIONS

Real-time segmentation and thickness measurements of image data from both healthy subjects and those with acute and chronic OM demonstrate the use of OCT and this algorithm as a robust, quantitative, and accurate method for use during real-time in vivo human imaging.