Comparison of psychosocial and emotional consequences of childhood strabismus on the families from rural and urban India

Trends and patterns in pediatric ophthalmology and strabismus surgeries: a decade review from a leading Portuguese university hospital

PURPOSE

Strabismus and Pediatrics Ophthalmology surgeries are pivotal in addressing early-onset visual disorders. An 11-year retrospective study at a tertiary hospital center aimed to elucidate evolving surgical trends, focusing on esotropia cases.

METHODS

The surgical records from January 2009 to January 2020 were analyzed according to the baseline diagnosis. Esotropia cases were evaluated based on the patients' deviation types, surgical techniques, and pre-operative characteristics. A total of 2050 surgeries were performed over the study period.

RESULTS

Strabismus surgery accounts for 70% of the department's surgical activity. A trend toward a decrease in esotropia surgeries and a proportional increase in exotropia surgeries was noticeable. Esotropia cases, with a median surgical age of 6 years (p25-p75, 4-10) and uniform gender distribution (females, 54.8%), predominantly involved high angular deviations. Posterior fixation sutures emerged as the preferred surgical technique for esotropia.

CONCLUSION

The study's insights, while aligning with prior European research, introduce new dimensions to the understanding of strabismus surgeries, emphasizing the significance of early interventions, evolving surgical preferences, and the challenges posed by severe deviations.

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

Background

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

Methods

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

Results

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

Conclusions

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

The Case for Investing in Psychosocial Care and Rights of Children with Chronic Medical Conditions in India

This narrative review paper aims to build a common understanding of the vulnerabilities of children with chronic medical conditions who face exceptional challenges due to nature of the illness, deformity, injury, and traumatic healthcare encounters which could potentially lead to long-term psychological effects. The presence of chronic medical diagnoses in children and the subsequent impacts including social stigma, as well as their age and developmental level, may amplify adjustment challenges in parenting considerations, school, peer relations, career, and future relationships. Children may be traumatized by unfamiliar and painful healthcare experiences. Hospitalization can lead to increased feelings of isolation, fear, and self-doubt when children do not receive emotionally safe psychological support necessary to minimize the accompanying stress and anxiety. School experiences and parenting children with chronic illnesses have additional intersecting socialization characteristics. This paper highlights a vision for furthering the groundwork within Indian pediatric settings to promote emotional safety and psychosocial care. Principles from the United Nations Convention on the Rights of the Child and the World Health Organization's definition of health create an impetus for giving a voice to children with chronic medical conditions. While there are sporadic psychosocial services for children with chronic needs, they lack consistency, and this indicates a need and an opportunity for developing a unique career for human development and psychology professionals to address these concerns. As exemplars, two psychosocial care programs in India that help foster resilience in these children are highlighted. Although limited, extant research regarding the experiences of children with chronic medical conditions in India is discussed, and implications for future research and academic initiatives are interwoven within this paper.

Knowledge and attitude towards strabismus among adult residents in Woreta town, North West Ethiopia: A community-based study

BACKGROUND

Strabismus is a visual disorder where the eyes are misaligned and point in different directions. Untreated strabismus can lead to amblyopia, loss of binocular vision, and social stigma due to its appearance. Since it is assumed that knowledge is pertinent for early screening and prevention of strabismus, the main objective of this study was to assess knowledge and attitudes toward strabismus in Woreta town, Northwest Ethiopia. Providing data in this area is important for planning health policies.

METHODS

A community-based cross-sectional study was done in Woreta town from April-May 2020 with a sample size of 424. A systematic random sampling technique was employed to achieve the required sample size. A pre-tested self-administered questionnaire was used to collect the data. Data were entered using epi-data version 3.1, then processed and analyzed via SPSS version 20. Descriptive and analytical statistics were employed to summarize the data. A p-value of less than 0.05 was used to declare statistical significance.

RESULT

A total of 401 individuals aged over 18 years participated, with a response rate of 94.5%. Of those who responded, 56.6% were males. Of all the participants, 36.9% were illiterate. The proportion of people with poor knowledge of strabismus was 45.1%. It was shown that 53.9% of the respondents had a favorable attitude. Older age, higher educational level, having a history of eye examination, and a having a family history of strabismus were significantly associated with good knowledge of strabismus. A higher educational level, older age, and hearing about strabismus were significantly associated with a favorable attitude toward strabismus.

CONCLUSION AND RECOMMENDATION

The proportion of good knowledge and favorable attitude towards strabismus were lower than previously reported in Gondar City, Northwest Ethiopia. There is a need to provide health education and promotion campaigns on strabismus to the community: what strabismus is, its' possible treatments and the need to bring children to the eye care center for early diagnosis and treatment.

Patient reported outcomes for phosphomannomutase 2 congenital disorder of glycosylation (PMM2-CDG): listening to what matters for the patients and health professionals

Background

Congenital disorders of glycosylation (CDG) are a growing group of rare genetic disorders. The most common CDG is phosphomannomutase 2 (PMM2)-CDG which often has a severe clinical presentation and life-limiting consequences. There are no approved therapies for this condition. Also, there are no validated disease-specific quality of life (QoL) scales to assess the heterogeneous clinical burden of PMM2-CDG which presents a challenge for the assessment of the disease severity and the impact of a certain treatment on the course of the disease.

Aim and methods

This study aimed to identify the most impactful clinical signs and symptoms of PMM2-CDG, and specific patient and observer reported outcome measures (PROMs and ObsROMs, respectively) that can adequately measure such impact on patients’ QoL. The most burdensome signs and symptoms were identified through input from the CDG community using a survey targeting PMM2-CDG families and experts, followed by family interviews to understand the real burden of these symptoms in daily life. The list of signs and symptoms was then verified and refined by patient representatives and medical experts in the field. Finally, a literature search for PROMs and ObsROMs used in other rare or common diseases with similar signs and symptoms to those of PMM2-CDG was performed.

Results

Twenty-four signs/symptoms were identified as the most impactful throughout PMM2-CDG patients’ lifetime. We found 239 articles that included tools to measure those community-selected PMM2-CDG symptoms. Among them, we identified 80 QoL scales that address those signs and symptoms and, subsequently, their psychometric quality was analysed. These scales could be applied directly to the PMM2-CDG population or adapted to create the first PMM2-CDG-specific QoL questionnaire.

Conclusion

Identifying the impactful clinical manifestations of PMM2-CDG, along with the collection of PROMs/ObsROMs assessing QoL using a creative and community-centric methodology are the first step towards the development of a new, tailored, and specific PMM2-CDG QoL questionnaire. These findings can be used to fill a gap in PMM2-CDG clinical development. Importantly, this methodology is transferable to other CDG and rare diseases with multiple signs and symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02551-y.

A retrospective study of strabismus surgery in a tertiary eye hospital in the Chaoshan area in China from 2014 to 2020

BACKGROUND

To investigate the distribution pattern of strabismus surgery at an eye center in southern China.

METHODS

The data of all patients who underwent strabismus surgery at the Joint Shantou International Eye Center of Shantou University /Chinese University of Hong Kong from 2014 to 2020 were retrospectively analyzed. The type of strabismus and its relationship with age and sex were analyzed, and the trend in the number of strabismus surgeries was observed.

RESULTS

The data of 4640 patients included a total of 5,282 surgeries. Exotropia surgery was the most common, accounting for 54.0% of all strabismus surgeries, which tended to increase over time, but not significantly (P = 0.109). Constant exotropia was the most common exotropia, but its proportion decreased year by year. The next most common was intermittent exotropia. The percentage of surgeries for intermittent exotropia increased from 2016 to 2020. Surgery for esotropia accounted for 22.1% of all strabismus surgeries and became significantly less common from 2016 to 2020 (P < 0.01). Among patients with intermittent or constant exotropia, the proportion of patients younger than 12 years who underwent surgical intervention increased yearly, while this proportion amoung patients older 12 years old with constant exotropia decreased yearly.

CONCLUSION

Among exotropia surgeries, surgery for constant exotropia was the most common but decreased in prevalence annually. Children under 12 years old were the most affected population.

The predictive value of local to remote functional connectivity changes in comitant exotropia patients

BACKGROUND

Comitant exotropia (CE) is a common eye disease with abnormal eye movement, whereas altered synchronous neural activity in CE patients is poorly understood. The purpose of our study was to investigate local to remote functional connectivity of blood oxygen level-dependent (BOLD) signals changes in CE patients.

MATERIAL AND METHODS

Thirty-four patients and thirty-four healthy controls (HCs) underwent resting-state MRI scans. The ReHo and FC method was applied to investigate the local to remote functional connectivity changes in CE patients.

RESULTS

Compared to the HC group, CE patients showed significant increased ReHo values in the left cerebellar_crus2 and left middle frontal gyrus. Meanwhile, CE patients showed significant decreased ReHo values in the right middle temporal gyrus, left postcentral gyrus and right angular. Moreover, CE patients showed an increased FC between the cerebellar network, sensorimotor network (SMN) and default-mode network (DMN). The support vector machine (SVM) classification was up to a total accuracy of 94.12%. The AUC of the classification model was 0.99 on the basis of ReHo map.

CONCLUSION

Our result highlights that CE patients had abnormal local to remote functional connectivity in the cerebellar network, SMN, DMN, which might indicate the neural mechanism of eye movements and stereo vision dysfunction in CE patients. Moreover, the SVM algorithm reveals ReHo maps as a potential biomarker for predicting clinical outcomes in CE patients.

Diplopic versus nondiplopic strabismus: effects on functional vision and eye-related quality of life in adolescents

Twenty adolescents (12-17 years old) with diplopic strabismus and 20 with nondiplopic strabismus (matched to diplopic subjects for direction and magnitude of ocular deviation) completed the Pediatric Eye Questionnaire (PedEyeQ). Children completed the Child PedEyeQ, and one parent for each child completed the Proxy PedEyeQ and Parent PedEyeQ. PedEyeQ Rasch domain scores were calculated and converted to a scale of 0 (worst) to 100 (best). Distributions of domain scores were compared between diplopic and nondiplopic cohorts using Wilcoxon tests. Diplopic adolescents had significantly lower Child PedEyeQ scores on Functional Vision (72 vs 90; P = 0.008), Bothered by Eyes/Vision (65 vs 90; P = 0.009), and Frustration/Worry (53 vs 75; P < 0.001) domains. There was no difference on the Child Social domain (85 vs 90; P = 0.22). Proxy and Parent PedEyeQ scores were similar between diplopic and nondiplopic cohorts (P > 0.06 for each comparison). These findings highlight the importance of addressing diplopia when managing childhood strabismus.

Economizing strabismus surgery: Using half the double-armed suture for horizontal muscles

In a developing country like India, both availability and affordability of medical care are obstacles, leading to delay in seeking timely treatment. To reduce the cost incurred to the patients for strabismus surgery, we used half of a 6-0 polyglactin suture for performing common muscle weakening and strengthening procedures: a fixed and hang back recessions with plication and resection. We cut the 45-cm-long double-armed 6-0 polyglactin sutures in two halves, and with a modified approach, used one-half in each of two patients planned for monocular two horizontal muscles surgeries: fixed recession-plication and hang back recession-resection. By devising an intuitive manner of threading a single armed 22.5 cm suture we successfully carried out horizontal extraocular muscle surgeries on each of two patients of exotropia. We believe in the long run, this will reduce the cost to individual patients and sponsoring groups, and suggest that strabismus surgeons consider adopting this option.

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

Strabismus can hinder an individual's ability to perform daily functions and negatively affect their well-being. I examine the impact strabismus has on psychosocial health and quality of life in children and adults and evaluate the challenges confronted by parents of children with strabismus. Numerous misconceptions exist regarding the impact strabismus has on overall health. Negative attitudes persist toward those affected, resulting in difficulties with self-image. Individuals with strabismus are at increased risk for both visual system and psychiatric disorders. Misinformation regarding available treatment options for children and adults with strabismus continues to exist, resulting in decreased access to care. Improved education of health care providers can increase appropriate referrals and initiation of treatment. Treatment of strabismus is not merely cosmetic and has the potential to improve psychosocial health and quality of life for children and adults with and without diplopia.

Association of Strabismus With Functional Vision and Eye-Related Quality of Life in Children

Importance

Strabismus is common, affecting 2% to 4% of children, but how children and their families are affected in everyday life is poorly understood.

Objective

To evaluate the association of strabismus with functional vision and eye-related quality of life in children and their families using the Pediatric Eye Questionnaire (PedEyeQ).

Design, Setting, and Participants

This cross-sectional study was conducted between December 2017 and October 2019 and included 91 children with strabismus and 166 visually normal controls across 3 age groups (0-4, 5-11, and 12-17 years) who were enrolled at Mayo Clinic, Rochester, Minnesota, and Retina Foundation of the Southwest, Dallas, Texas.

Exposures

Children completed the child PedEyeQ (5 to 11- and 12 to 17-year versions: functional vision, bothered by eyes/vision, social, and frustration/worry domains); parents completed the proxy (0 to 4-, 5 to 11-, and 12 to 17-year versions: functional vision, bothered by eyes/vision, social, frustration/worry, and eye care domains) and the parent PedEyeQ (impact on parent and family, worry about child's eye condition, worry about child's self-perception and interactions, and worry about child's functional vision domains). Rasch-calibrated PedEyeQ scores were calculated for each domain and converted to 0 (worst) to 100.

Main Outcomes and Measures

PedEyeQ domain scores.

Results

Of 91 participants with strabismus, 41 (45.1%) were girls, 74 (81.3%) were white, 4 (4.4%) were Asian, 5 (5.5%) were more than 1 race, 5 (5.5%) were African American, and 2 (2.2%) were American Indian/Alaska Native. Child PedEyeQ domain scores were lower with strabismus vs visually normal controls among children ages 5 to 11 years and the greatest mean (SD) difference was in functional vision (12 [14] points; 95% CI, 6-18; P = .001), and among children ages 12 to 17 years, the greatest mean (SD) difference was in frustration/worry (27 [13] points; 95% CI, 18-36; P < .001). Proxy PedEyeQ domain scores were also lower with strabismus. The greatest difference among children ages 0 to 4 years was in functional vision (13 [9] points; 95% CI, 9-16; P < .001), among children ages 5 to 11 years was in functional vision (26 [10] points; 95% CI, 22-30; P < .001); and among children ages 12 to 17 years was in functional vision (21 [12] points; 95% CI, 12-30; P < .001), social (21 [13] points; 95% CI, 12-30; P < .001), and frustration/worry (21 [13] points; 95% CI, 12-30; P < .001). Parent PedEyeQ domain scores were lower with strabismus; the greatest difference was in worry about child's eye condition (38 [14] points; 95% CI, 34-42; P < .001).

Conclusions and Relevance

Strabismus is associated with reduced functional vision and eye-related quality of life in children. Parents of children with strabismus also experience a reduced quality of life. These findings advance our understanding of how strabismus affects children and their families and should be considered when defining patient management goals.

Assessment of Different Types of Strabismus Among Pediatric Patients in a Tertiary Hospital in Jeddah

Background Strabismus, also known as squint, is an ocular disorder in which the eyes do not align properly with each other when looking at an object. The estimated global prevalence of strabismus among children is between 1.3% and 5.7%. This study aimed to assess the various types of strabismus among pediatric patients in Jeddah, in the western region of Saudi Arabia. Methods The medical records of 281 patients with strabismus aged ≤18 years, who presented to the pediatric ophthalmology clinic in King Abdulaziz University Hospital between 2010 and 2019, were retrospectively reviewed. Data were analyzed using the Statistical Package for Social Sciences (SPSS; IBM Corp., Armonk, NY, USA). A p-value of 0.05 or less was considered statistically significant. Results Out of the 281 patients, 141 were (50.2%) female. The average age of the patients was 9.50 ± 4.24 years. The most common type of strabismus was esotropia (177 [63%] patients), followed by exotropia (96 [34.2%] patients), hypertropia (10 [3.6%] patients), and dissociated vertical deviation (four [1.4%] patients). Two-hundred thirty-one (82.8%) patients had bilateral strabismus. A total of 178 patients (63.3%) had no associated conditions with strabismus, whereas 103 (36.7%) had an associated condition. A significant relationship was observed between esotropia and prematurity (p = 0.024). Conclusion Esotropia was the most common type of strabismus among the patients, followed by exotropia. The results of this study showed that males were equally affected as females. We also found a significant relationship between esotropia and prematurity. Implementation of a compulsory nationwide pediatric ophthalmic screening program for children aged one, three, and five years is recommended to enable timely diagnosis of strabismus and any other refractive errors.

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

Purpose:

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

Methods:

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

Results:

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

Conclusion:

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

Automatic diagnosis of strabismus in digital videos through cover test

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Awareness and Perception of Strabismus Among the Youths and Women of Child-Bearing Age in a Local Government in South Western Nigeria: A Qualitative Study

Purpose To determine the awareness and perception of strabismus among the youths and women of child-bearing age in Ikenne Local Government Area (LGA) of Ogun State, South Western Nigeria. Methodology Fifteen focus group discussions (FGDs) were carried out in the LGA on the perceptions and attitudes of people to strabismus. Their responses were tape-recorded and later transcribed. A thematic phenomenological approach was used for the analysis. Result A total of 139 people participated in the FGDs, with a male:female ratio of 1:∼4. Although there was a fairly high level of awareness of strabismus in the populace, their knowledge and perception of the disease were poor. Attitudes toward the disease were based on unfounded fears and misconceptions of the disease. Conclusions We conclude that the perception and acceptance of people with strabismus by the people of Ikenne LGA was based on their poor knowledge of the disease. This in turn interfered with the uptake of health-care services for the condition.

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

Background:

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

Aim:

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

Settings and Design:

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

Materials and Methods:

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

Statistical Analysis:

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

Results:

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

Conclusions:

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

Awareness and Perception of Strabismus Among the Youths And Women of Child-Bearing Age in a Local Government in South Western Nigeria: A Qualitative Study

Purpose To determine the level of awareness, attitudes, and perceptions of strabismus among youth and women of child-bearing age in southwestern Nigeria. Methodology Fifteen Focus Group Discussions were carried out in Ogun State Nigeria on awareness, attitudes, and perceptions of people toward strabismus. A thematic phenomenological approach was used for the analysis. Results A total of 139 people participated in the Focus Group Discussions, with a male:female ratio of 1:∼4. Although there was a fairly high level of awareness of strabismus in the populace, their attitudes and perceptions of the disease were poor, based on unfounded fears and misconceptions of the disease. Conclusions We conclude that the negative perception and acceptance of people with strabismus by the people in southwestern Nigeria is based on poor knowledge of the disease. As a result, the stigma attached to the condition appears to interfere with accessing health-care services for treatment.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Establishing a surgical outreach program in the developing world: pediatric strabismus surgery in Guatemala City, Guatemala

PURPOSE

To report our experince in establishing a sustainable pediatric surgical outreach mission to an underserved population in Guatemala for treatment of strabismic disorders.

METHODS

A pediatric ophthalmic surgical outreach mission was established. Children were evaluated for surgical intervention by 3 pediatric ophthalmologists and 2 orthoptists. Surgical care was provided at the Moore Pediatric Surgery Center, Guatemala City, over 4 days. Postoperative care was facilitated by Guatemalan physicians during the second year.

RESULTS

In year 1, patients 1-17 years of age were referred by local healthcare providers. In year 2, more than 60% of patients were prescreened by a local pediatric ophthalmologist. We screened 47% more patients in year 2 (132 vs 90). Diagnoses included congenital and acquired esotropia, consecutive and acquired exotropia, congenital nystagmus, Duane syndrome, Brown syndrome, cranial nerve palsy, dissociated vertical deviation, and oblique muscle dysfunction. Overall, 42% of the patients who were screened underwent surgery. We performed 21 more surgeries in our second year (58 vs 37), a 57% increase. There were no significant intra- or postoperative complications.

CONCLUSIONS

Surgical outreach programs for children with strabismic disorders in the developing world can be established through international cooperation, a multidisciplinary team of healthcare providers, and medical equipment allocations. Coordinating care with local pediatric ophthalmologists and medical directors facilitates best practice management for sustainability.

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

PURPOSE

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

DESIGN

Cross-sectional, population-based study.

METHODS

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

RESULTS

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

CONCLUSION

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

Functional and psychosocial impact of strabismus on Singaporean children

PURPOSE

To quantify the effects of strabismus in Singaporean children using the Intermittent Exotropia Questionnaire (IXTQ) and the Adult Strabismus 20 Questionnaire (AS20).

METHODS

Consecutive strabismus patients 5-16 years of age were recruited along with an equal number of age-matched controls with eye conditions other than strabismus and amblyopia (group A) and controls with no known eye conditions (group B). All children completed the IXTQ; those 8-16 years of age also completed the AS20 questionnaire. Parents completed the parental proxy IXTQ (pp-IXTQ) and AS20 (pp-AS20) and a parental IXTQ (PIXT).

RESULTS

A total of 60 patients and 60 age-matched controls in each group were included. Children with strabismus had lower IXTQ (70.1 ± 19.0) and AS20 (80.0 ± 13.8) scores than those in group B (IXTQ, 90.3 ± 11.8 [P < 0.001]; AS20, 90.0 ± 10.9 [P < 0.001]) and group A (IXTQ, 80.6 ± 14.9 [P = 0.001]; AS20, 81.6 ± 18.3 [P = 0.691]). Among children with strabismus, child IXTQ scores were significantly lower than parental proxy scores (70.1 ± 19.0 vs 76.4 ± 15.8 [P = 0.026]), but there was no difference in control group scores or with AS20 scores. Item-level analysis suggested that children's worry focused on what others thought about them and their ability to make friends, whereas parents were more concerned about eyesight and whether surgery was required.

CONCLUSIONS

The IXTQ and AS20 were better at differentiating between children with strabismus and those with no eye condition than between children with strabismus and other eye conditions. Parental proxies were accurate in predicting child scores but parents were more likely to underestimate the psychosocial effects of their children's strabismus.

Awareness, perceptions and knowledge of strabismus among patients visiting a tertiary eye clinic in Southwest Nigeria

The purpose of this study was to assess the perceptions, knowledge of the causes, implications and treatment of strabismus in a black population. This was a descriptive cross-sectional study utilizing a total sampling technique. Face-to-face interviews were performed using a structured questionnaire. Socio-demographic characteristics, awareness, perceived causes, effect and treatment of squint were investigated. Data was analysed using descriptive and inferential (bivariate and binary regression) analysis. A total of 405 respondents (49.6 % male, 50.4 % female) were interviewed. Ages ranged from 11 ± 90 years (mean 41.26 ± 19.00). Modal age group was 17-44 (56 %). Levels of education showed that 22.0 % had no education, while primary, secondary and tertiary levels were 12.6, 31.6 and 33.8 %, respectively. Approximately 75 % of patients were aware of strabismus. Perceived causes were unknown to 53 % while 18.0 and 12 % mentioned eye disease and congenital-related, respectively. There was no knowledge of treatment in 54 % of patients, while 21 and 25 % knew about medical and surgical treatment, respectively. The effects on social and family life were stigmatization/social misfit (23 %), psychosocial/self pity/depression/inferiority complex (88 %), burden (economic/time) (7 %), and poor cosmesis (5 %). Females were significantly more aware than males (p = 0.043, OR 0.6, CI 0.399-0.986). Age (p = 0.187) and level of education (p = 0.321) had no significant relationship with the levels of awareness. Respondents who had no education were 1.25 times less likely to be aware of squint than those who had education (OR 0.8, CI 0.693-1.642). The awareness of the cause, effects and treatment of strabismus is poor in this population. Females were more aware than males.

Surgery versus Active Monitoring in Intermittent Exotropia (SamExo): study protocol for a pilot randomised controlled trial

BACKGROUND

Childhood intermittent exotropia [X(T)] is a type of strabismus (squint) in which one eye deviates outward at times, usually when the child is tired. It may progress to a permanent squint, loss of stereovision and/or amblyopia (reduced vision). Treatment options for X(T) include eye patches, glasses, surgery and active monitoring. There is no consensus regarding how this condition should be managed, and even when surgery is the preferred option clinicians disagree as to the optimal timing. Reports on the natural history of X(T) are limited, and there is no randomised controlled trial (RCT) evidence on the effectiveness or efficiency of surgery compared with active monitoring. The SamExo (Surgery versus Active Monitoring in Intermittent Exotropia) pilot study has been designed to test the feasibility of such a trial in the UK.

METHODS

DESIGN

an external pilot patient randomised controlled trial.

SETTING

four UK secondary ophthalmology care facilities at Newcastle NHS Hospitals Foundation Trust, Sunderland Eye Infirmary, Moorfields Eye Hospital and York NHS Trust.

PARTICIPANTS

children aged between 6 months and 16 years referred with suspected and subsequently diagnosed X(T). Recruitment target is a total of 144 children over a 9-month period, with 120 retained by 9-month outcome visit.Randomisation: permuted blocks stratified by collaborating centre, age and severity of X(T).

INTERVENTIONS

initial clinical assessment; randomisation (eye muscle surgery or active monitoring); 3-, 6- and 9-month (primary outcome) clinical assessments; participant/proxy completed questionnaire covering time and travel costs, health services use and quality of life (Intermittent Exotropia Questionnaire); qualitative interviews with parents to establish reasons for agreeing or declining participation in the pilot trial.

OUTCOMES

recruitment and retention rates; nature and extent of participation bias; nature and extent of biases arising from crossover or loss to follow-up; reasons for agreeing/declining participation; variability of cure rates (to inform power calculations for a definitive RCT); completion rates of outcome measures.

DISCUSSION

The SamExo pilot trial will provide important pointers regarding the feasibility of a full RCT of immediate surgery versus deferred surgery/active monitoring. The results of this pilot, including differences in cure rates, will inform the design of a definitive RCT.

TRIAL REGISTRATION

ISRCTN44114892.