Plasma Levels of Bevacizumab and Vascular Endothelial Growth Factor After Low-Dose Bevacizumab Treatment for Retinopathy of Prematurity in Infants

Importance

Intravitreal bevacizumab effectively treats severe retinopathy of prematurity (ROP), but it enters the bloodstream and may reduce serum vascular endothelial growth factor (VEGF), potentially causing detrimental effects on developing organs in the premature infant.

Objective

To evaluate the association of intravitreal bevacizumab with plasma bevacizumab and VEGF concentrations at 2 and 4 weeks after predefined, de-escalating doses of intravitreal bevacizumab were administered to infants with severe ROP.

Design, Setting, and Participants

This phase 1 dose de-escalation case series study was conducted at 10 US hospitals of ophthalmology institutions from May 21, 2015, to May 7, 2019. Blood samples were collected 2 and 4 weeks after intravitreal bevacizumab injection. Participants included 83 premature infants with type 1 ROP in 1 or both eyes and no previous ROP treatment. Data were analyzed from April 2017 to August 2021.

Interventions

Study eyes received a single bevacizumab injection of 0.250 mg, 0.125 mg, 0.063 mg, 0.031 mg, 0.016 mg, 0.008 mg, 0.004 mg, or 0.002 mg. When the fellow eye required treatment, one dose higher was administered. Total dose administered at baseline was defined as the sum of doses given to each eye within 3 days of initial study-eye injection.

Main Outcomes and Measures

Plasma bevacizumab concentration at 2 and 4 weeks after injection and the percentage change in plasma VEGF concentrations from pretreatment levels.

Results

A total of 83 infants (mean [SD] age, 25 [2] weeks; 48 boys [58%]) were included in this study. Higher doses of bevacizumab administered at baseline were associated with higher plasma bevacizumab concentrations at 2 weeks (ρ, 0.53; 95% CI, 0.31-0.70) and 4 weeks (ρ, 0.44; 95% CI, 0.18-0.64). Plasma VEGF concentrations decreased by 50% or more from pretreatment levels in 40 of 66 infants (61%) at 2 weeks and 31 of 61 infants (51%) at 4 weeks, but no association was observed between the total dose of bevacizumab administered at baseline and percentage change in plasma VEGF concentrations 2 weeks (ρ, -0.04; 95% CI, -0.28 to 0.20) or 4 weeks (ρ, -0.17; 95% CI, -0.41 to 0.08) after injection.

Conclusions and Relevance

Results of this phase 1 dose de-escalation case series study revealed that bevacizumab doses as low as 0.002 mg were associated with reduced plasma VEGF levels for most infants at 2 and 4 weeks after intravitreal administration; however, no association was observed between total bevacizumab dose administered and reductions in plasma VEGF levels from preinjection to 2 weeks or 4 weeks. Additional studies are needed to evaluate the long-term effects of low-dose bevacizumab on neurodevelopment and retinal structure.

Developmental Improvement in Children With Intellectual Disability After Photorefractive Keratectomy for Severe Isoametropia

PURPOSE

To assess the impact of refractive error correction from photorefractive keratectomy on development in children with severe isoametropia, subnormal visual acuity, and intellectual disability unable to use refraction correction.

DESIGN

Prospective noncomparative interventional case series.

METHODS

Before and after photorefractive keratometry (PRK), subjects who had plateaued developmentally for 18 or more months were assessed using a battery of developmental tests. The primary outcome measure was the change in the developmental quotient (DQ) 6 months after PRK. Secondary outcomes were the change in the DQ, uncorrected visual acuity, cycloplegic refraction, and corneal status 12, 24, and 36 months after PRK.

RESULTS

Sixteen subjects aged 2 to 8 years were included. Twelve were highly myopic (mean, -9.69 ± 3.82 diopters [D]), 3 highly hyperopic (mean, +5.75 ± 0.59 D) and 1 highly astigmatic (mean, +3.50 D). Six months after PRK, the DQ significantly improved for expressive communication (mean, 4.51 ± 2.27 months; P = .04), interpersonal relationships (mean, 9.45 ± 4.18 months; P = .02) and coping (mean, 6.44 ± 2.10 months; P = .05). Twelve months after PRK, the DQ significantly improved for receptive communication (8.04 ± 1.80 months; P < .001), expressive communication (6.99 ± 2.27 months; P < .05), written communication (9.28 ± 3.72 months; P < .04), domestic skills (6.50 ± 2.43 months; P < .03), interpersonal relationships (10.57 ± 4.17 months; P < .02), and coping (8.41 ± 3.25 months; P < .5).

CONCLUSIONS

PRK significantly improves developmental abilities of children with intellectual disability, severe isoametropia, and previously plateaued development, in addition to improving visual acuity and refractive error.

Severe congenital chorioretinitis caused by congenital lymphocytic choriomeningitis virus infection

Purpose

To describe a case of congenital lymphocytic choriomeningitis virus (LCMV), a potentially severe and under-diagnosed etiology of congenital chorioretinitis.

Observations

A 5-month old boy presented with esotropia. Examination revealed light perception vision in the right eye and normal fixation and following behavior in the left eye, and a 50PD esotropia with full versions. The external, anterior segment, and pupil exams were normal. Fundus examination demonstrated slightly pale optic nerves, numerous geographic atrophic and hyperpigmented lesions along the vascular arcades in both eyes that extended into the fovea of the right eye. Head computed tomography (CT) imaging demonstrated bilateral cerebral volume loss with consequential ex vacuo dilation of the lateral ventricles and scattered intracranial calcifications. Serum IgG and IgM titers for toxoplasmosis, rubella, cytomegalovirus (CMV), herpes simplex virus (HSV), syphilis, and zika were all negative. Upon communication of negative TORCHS titers, the mother recalled a severe rat infestation of their home during the pregnancy. A LCMV antibody titer was then ordered and which resulted positive for IgG antibodies.

Conclusions and Importance

Congenital LCMV infection is an under-recognized cause of congenital chorioretinitis.

Band keratopathy in children previously treated with diode laser for type 1 retinopathy of prematurity

Band keratopathy is a corneal degeneration caused by chronic inflammation, systemic abnormalities, or, rarely, a primary biallelic SLC4A4 mutation leading to calcium hydroxyapatite deposition in Bowman's layer. We report a series of 16 eyes of 10 children with a remote history of diode laser treated retinopathy of prematurity who developed late-onset band keratopathy without evidence of other prior risk factors. The majority of patients developed band keratopathy bilaterally. Five eyes had visually significant central band keratopathy that required treatment with disodium ethylenediaminetetracetic acid (EDTA) chelation or phototherapeutic keratectomy. Band keratopathy may be an underreported late ophthalmic complication of diode-laser treated retinopathy of prematurity.

Corneal indices following photorefractive keratectomy in children at least 5 years after surgery

PURPOSE

To evaluate long-term corneal outcomes in pediatric patients who underwent photorefractive keratotomy (PRK) for the treatment of refractive amblyopia.

METHODS

In this prospective interventional case series, children with refractive amblyopia underwent PRK between January 1, 2007, and December 31, 2011, at Texas Children's Hospital's Department of Ophthalmology, a single tertiary eye center, and were followed for at least 5 years after surgery. Main outcome measures were 5+ years postoperative indices of corneal thickness, keratometry, degree of corneal haze, and presence or absence of keratectasia.

RESULTS

Twelve eyes of 8 subjects aged 3-9 years who underwent PRK and were followed for at least 5 years were included. The mean PRK treatment dose was 8.46 D for the myopic cohort and 4.49 D for the hyperopic cohort, which removed an average of 72 μm of corneal stromal tissue in addition to the 50 μm of corneal epithelium that was removed prior to laser ablation. The mean corneal thickness was 563 μm preoperatively, which decreased to 441 μm immediately following the PRK. The mean corneal thickness 5+ years after PRK was stable, at 498 μm, because of epithelial regrowth. None of the subjects developed visually significant corneal haze or topographic evidence of keratectasia.

CONCLUSIONS

In this study cohort, there were no topographic signs of keratectasia or corneal haze in children treated with PRK for high refractive error 5 years or more after surgery.

Cortical Visual Impairment in Congenital Cytomegalovirus Infection

PURPOSE

To describe the presentation, evolution, and long-term outcome of cortical visual impairment (CVI) in patients with symptomatic congenital cytomegalovirus (CMV) infection, and to identify risk factors for the development of CVI in patients with symptomatic congenital CMV.

METHODS

Retrospective subanalysis of a long-term prospective cohort study with data gathered from 1982 to 2013.

RESULTS

Eleven of 77 (14.3%) patients with symptomatic CMV, 0 of 109 with asymptomatic CMV, and 51 control patients had CVI. Overall, patients with symptomatic CMV had worse vision than patients with asymptomatic CMV, who in turn had worse vision than control patients. Microcephaly, intracranial calcification, dilatation of ventricles, encephalomalacia, seizure at birth, optic atrophy, chorioretinitis/retinal scars, strabismus, and neonatal onset of sensorineural hearing loss were risk factors associated with CVI.

CONCLUSIONS

CVI may result from symptomatic congenital CMV infection. The relationship of CVI and its risk factors in patients with CMV suggests the potential to predict the development of CVI through predictive modeling in future research. Early screening of CVI in children born with symptomatic congenital CMV can facilitate educational, social, and developmental interventions. [J Pediatr Ophthalmol Strabismus. 2019;56(3):194-202.].

Neural Plasticity Following Surgical Correction of Strabismus in Monkeys

Purpose

Although widely practiced, surgical treatment of strabismus has varying levels of success and permanence. In this study we investigated adaptive responses within the brain and the extraocular muscles (EOM) that occur following surgery and therefore determine long-term success of the treatment.

Methods

Single cell responses were collected from cells in the oculomotor and abducens nuclei before and after two monkeys (M1, M2) with exotropia (divergent strabismus) underwent a strabismus correction surgery that involved weakening of the lateral rectus (LR) and strengthening of the medial rectus (MR) muscle of one eye. Eye movement and neuronal data were collected for up to 10 months after surgery during a monocular viewing smooth-pursuit task. These data were fit with a first-order equation and resulting coefficients were used to estimate the population neuronal drive (ND) to each EOM of both eyes.

Results

Surgery resulted in a ∼70% reduction in strabismus angle in both animals that reverted toward presurgical misalignment by approximately 6 months after treatment. In the first month after surgery, the ND to the treated MR reduced in one animal and ND to the LR increased in the other animal, both indicating active neural plasticity that reduced the effectiveness of the treatment. Adaptive changes in ND to the untreated eye were also identified.

Conclusions

Active neural and muscle plasticity corresponding to both the treated and the untreated eye determines longitudinal success following surgical correction of strabismus. Outcome of surgical treatment could be improved by identifying ways to enhance “positive” adaptation and limit “negative” adaptation.

Heart rate variability changes and its association with the development of severe retinopathy of prematurity

PURPOSE

To evaluate differences in autonomic nervous system (ANS) activity associated with the development of retinopathy of prematurity.

METHODS

Heart rate variability (HRV) as an indicator of ANS activity was calculated in two groups of premature infants: (1) a treatment group of infants who developed type 1 ROP and underwent treatment and (2) a control group of infants who did not develop ROP more severe than stage 1 and who were matched to the treatment group in terms of age, weight, and similar risk factors, including similar frequency of intraventricular hemorrhage, bronchopulmonary dysplasia, and sepsis. HRV was analyzed during the first 5 days of life, within 5 days of initial ROP examination, and within 5 days of ROP treatment for the treatment group or, for controls, on the day of last electrocardiogram data prior to discharge. Calculations were performed for the high frequency, low frequency, and low frequency-high frequency values of the HRV components for all infants.

RESULTS

Between the initial ophthalmologic evaluation and the final evaluation, there was a tendency for reduction in both the low- and high-frequency components of the HRV indices in the treatment group, whereas there was a tendency for an increase in both components of the HRV indices in the control group. The difference in the rate of change of the high frequency between groups was statistically significant (P = 0.021).

CONCLUSIONS

Disruption in ANS activity may play an important role in the development and severity of ROP.

Longitudinal Evaluation of Eye Misalignment and Eye Movements Following Surgical Correction of Strabismus in Monkeys

Purpose

Strabismus correction surgery is well documented in both the literature and practice with varying levels of success and permanence. Our goal was to characterize longitudinal changes in eye alignment and eye movements following strabismus correction surgery in a monkey model for developmental strabismus.

Methods

We studied two juvenile rhesus monkeys with exotropia previously induced via an optical prism-rearing paradigm in infancy. Eye misalignment was corrected via a resection–recession surgery of the horizontal rectus muscles of one eye. Binocular search coils were used to collect eye movement data during smooth-pursuit, saccades, and fixation tasks before surgical treatment, immediately after surgery, and through 6 months after treatment.

Results

Both animals showed an immediate ∼70% reduction in misalignment as a consequence of surgery that regressed to a 20%–40% improvement by 6 months after treatment. Significant changes were observed in saccade and smooth-pursuit gain of the nonviewing eye after surgery, which also reverted to presurgical values by 6 months. A temporary improvement in fixation stability of the nonviewing eye was observed after surgery; naso-temporal (N/T) asymmetry of monocular smooth-pursuit remained unchanged.

Conclusions

Surgical realignment is followed by plastic changes that often lead to reversal of surgery effects. Immediate improvement in misalignment and changes in eye movement gains are likely a result of contractility changes at the level of the extraocular muscle, whereas longer-term effects are likely a combination of neural and muscle adaptation.

Complications of Strabismus Surgery

All surgeries carry risks of complications, and there is no way to avoid ever having a complication. Strabismus surgery is no different in this regard. There are methods to reduce the risk of a complication during or after surgery, and these steps should always be taken. When a complication occurs, it is important to first recognize it and then manage it appropriately to allow for the best outcome possible. This article will discuss some of the more common and/or most devastating complications that can occur during or after strabismus surgery as well as thoughts on how to avoid them and manage them should they happen.

Pharmacokinetics of bevacizumab and its effects on serum VEGF and IGF-1 in infants with retinopathy of prematurity

PURPOSE

To measure serum levels of bevacizumab and to compare serum levels of free vascular endothelial growth factor (VEGF) and insulin-like growth factor-1 (IGF-1) in infants who were treated with either intravitreal injection of bevacizumab (IVB) or laser for type 1 retinopathy of prematurity (ROP).

METHODS

Twenty-four infants with type 1 ROP were randomized into three treatment groups: IVB at 0.625 mg per eye per dose, IVB at 0.25 mg per eye per dose, and laser. Blood samples were collected prior to treatment and on posttreatment days 2, 14, 42, and 60. Weekly body weights were documented from birth until 60 days post treatment. Serum levels of bevacizumab, free VEGF, and IGF-1 were measured with enzyme-linked immunosorbent assay (ELISA).

RESULTS

Serum bevacizumab was detected 2 days after the injection, peaked at 14 days, and persisted for up to 60 days with half-life of 21 days. Area under the curve (AUC) analysis showed that systemic exposure to bevacizumab was variable among the subjects and was dose dependent. Serum free VEGF levels decreased in all three subgroups 2 days post treatment, with more significant reductions found in both IVB-treated groups, P = 0.0001. Serum IGF-1 levels were lower in both IVB-treated groups.

CONCLUSIONS

Clearance of bevacizumab from the bloodstream in premature infants takes at least 2 months. Although serum free VEGF levels decreased following either laser or bevacizumab treatment, the reductions were more significant in the IVB-treated groups. Potential long-term effects of systemic exposure to bevacizumab in infants need to be studied further.

Treatment of vertical deviations secondary to other causes

INTRODUCTION AND PURPOSE

Surgical treatment of vertical deviations secondary to other causes can be difficult and treatment approaches may vary. The purpose of this discussion is to present surgical treatment options for the management of vertical deviations secondary to other causes including dissociated vertical deviation, primary inferior oblique overaction, superior oblique overaction, and nonspecific eccentric gaze hypertropia with diplopia.

RESULTS

Surgical treatment of vertical deviations secondary to other causes is beneficial to patients. Treatment approaches may vary depending upon patient circumstances and surgeon preference. Side effects and complications from surgery to manage these conditions can occur but are usually of minor significance and not vision threatening.

CONCLUSIONS

Treatment of vertical deviations secondary to other causes is effective and results usually satisfactory.

An evidence-based approach to physician etiquette in pediatric ophthalmology

PURPOSE

Little objective evidence exists to guide physician etiquette in pediatric ophthalmology. This article describes the preferences of families visiting a pediatric ophthalmology clinic for the first time.

METHODS

Review of 149 questionnaires completed by the families of patients visiting a pediatric ophthalmology clinic in a tertiary care center. The Fisher exact and chi-square tests were used to compare subpopulations.

RESULTS

Most respondents preferred that their physician wear a white coat. Men preferred a handshake to a verbal greeting (P = .0264) and professional to business casual attire for both male and female physicians (P = .01, both). African-American parents were more likely to prefer being addressed by surname than other races (P = .008). No statistically significant differences were found comparing the preferences of parents with an advanced education (bachelor and graduate degrees) to those without.

CONCLUSION

Pediatric ophthalmologists may wish to consider wearing white coats and business casual attire in clinic and addressing parents informally as "mom" or "dad" or by their first name, although etiquette should ultimately be determined on an individual patient basis.

Periosteal Flap fixation of the Globe for Surgical Treatment of Severe Restrictive Strabismus: A Report of Eight Cases with Outcomes

PURPOSE

Severe paretic and restrictive strabismus presents a challenging surgical problem. Despite aggressive, and often multiple, surgical attempts, patients can have recurrence of large angle binocular misalignments. In this paper, we present a series of patients who underwent apically-based orbital bone periosteal flap fixation of the globe in cases of restrictive strabismus due to isolated third-nerve and sixth-nerve palsies, multiple cranial nerve palsies, and severe ocular fibrosis syndrome.

METHODS

We performed a retrospective study at our institution of patients who underwent a periosteal flap fixation. In all cases presented, the creation of the periosteal flap was performed by an orbital surgeon, and the strabismus surgery and follow-up data points were performed and collected by a strabologist.

RESULTS

A total of 8 patients underwent a periosteal flap fixation of the globe. The mean age was 48 years old. Three patients had a third cranial nerve palsy, one patient had congenital fibrosis, one patient had sixth cranial nerve palsy, and three patients had multiple cranial nerve palsies. Five patients had a medial periosteal flap constructed, and 3 patients had a temporal periosteal flap. Seven of the 8 patients had stable postoperative strabometry (binocular misalignment) measurements. A single patient required an additional procedure secondary to postoperative drift (a mild recurrence of binocular misalignment).

CONCLUSIONS

The surgical correction of severe paretic and restrictive strabismus is complex and can present a formidable challenge. The use of an orbital bone-based periosteal fixation flap, at our institution, has shown satisfactory outcomes not only with regard to improved postoperative deviation, but also, in that most patients required only this single procedure, usually after several prior unsuccessful interventions by standard strabismus surgery procedures.

The detection of simulated retinoblastoma by using red-reflex testing

OBJECTIVE

To determine the ability to detect simulated retinoblastoma by using the red-reflex test.

METHODS

Discs that simulated retinoblastoma lesions were affixed to the retina of model eyes with an 8- or 3-mm pupil. The diameter, height, and location of the discs varied. Five examiners evaluated the red reflex with direct ophthalmoscopy by using straight-on and oblique viewing. The generalized estimating equation was used to assess the effects of pupil dilation and observer viewing orientation on tumor detection.

RESULTS

Significant 3-way interactions between pupil dilation, observer orientation, and tumor diameter (P < .004) or height (P < .02) were detected; these relationships depended on tumor diameter and height. A similar 3-way interaction was found between pupil dilation, observer orientation, and tumor location in degrees from the fovea (P < .001). Oblique viewing and pupillary dilation improved the tumor-detection rate. With straight-on viewing, the degree of detection was <48% (95% confidence interval [CI]: 39%-57%) for even the largest lesions, compared with 96% (95% CI: 93%-98%) for oblique viewing. For peripheral lesions, the percentage detection for straight-on viewing was 35% (95% CI: 21%-50%) for 30 degrees from the fovea and 16% (95% CI: 2%-31%) for 60 degrees from the fovea; these detection rates significantly improved with oblique viewing to 70% or higher (P < .001).

CONCLUSIONS

Detection of simulated retinoblastoma was better when lesions were large and when oblique viewing and dilation were used. Peripheral location was negatively associated with detection. Red-reflex testing to detect leukocoria may be improved with oblique viewing and pharmacologic dilation.

Cul-de-sac incision for strabismus surgery in older patients

INTRODUCTION

A limbal surgical approach for strabismus surgery is often recommended for older patients, in the belief that the conjunctiva of older patients is too thin and prone to tear during surgery performed through a cul-de-sac incision. The purpose of this study was to evaluate the use of the cul-de-sac approach in patients more than 40 years of age.

METHODS

This is a retrospective analysis of consecutive patients more than 40 years of age who underwent strabismus surgery using a modified cul-de-sac approach to reduce manipulation of the conjunctiva during surgery.

RESULTS

A total of 32 cul-de-sac incisions were used to operate on 37 muscles in 19 consecutive patients more than 40 years old. The man age was 58 yeasr (41-77 years) with 8 patients (12 incisions) more than 60 years old. Absorbable sutures were used to close 28 of the incisions, with 19 incisions requiring 1 suture, 7 requiring 2 sutures, and 2 incisions in 2 patients requiring more than 2 sutures. Tears resulting in extension of the conjunctival incision occurred in several patients, but no other complications were encountered. One week following surgery, 28 (87.5%) of the incisions were well closed, while a small opening was noted with 4 (12.5%) of the incisions, but none required further intervention, and all healed well.

CONCLUSION

Strabismus surgery can be performed through a cul-de-sac incision in older patients. Slight modifications of the surgical technique to prevent excessive manipulation of the incision and to reduce the risk of tearing the conjunctiva are helpful. The cul-de-sac approach offers some important potential advantages to older patients undergoing strabismus surgery.

A survey of ophthalmology residents' attitudes toward pediatric ophthalmology

PURPOSE

To assess the level of ophthalmology resident interest in pediatric ophthalmology.

METHODS

An 18-item 5-point Likert scale was used to determine interest in pediatric ophthalmology among ophthalmology residents in the United States.

RESULTS

The response rate was 23% (316 of 1,341). Of the respondents, 74% agreed they had a clinical role model in pediatric ophthalmology, 66% perceived a good job market for this field, and 67% cited liking strabismus surgery. The majority of residents (56%) found pediatric patients difficult to examine and 50% stated income levels for pediatric ophthalmologists are low.

CONCLUSIONS

Although most residents have an overall positive view about pediatric ophthalmology, few indicate interest in pursuing a fellowship. Specifically, most residents reported having a clinical role model in pediatric ophthalmology, perceiving a good job market, and liking strabismus surgery, whereas few residents had interest in further pediatric training and many found pediatric patients difficult to examine and income levels low.

The timing of antibiotic administration in the management of infant dacryocystitis

PURPOSE

To report (1) the prevalence of bacteremia among infants with dacryocystitis and (2) the influence of timing of antibiotic administration on the need for repeat probing in the management of these patients.

METHODS

A retrospective analysis of the hospital records of 25 infants < or =6 weeks of age treated for acute dacryocystitis was conducted, including analysis of laboratory data and outcomes.

RESULTS

Of 22 infants who underwent blood cultures, 5 (22.7%) were bacteremic. Twenty-one of the 25 infants underwent nasolacrimal duct probing. Infants who received preoperative antibiotics were less likely to require a repeat probing than those who did not (6% vs. 80%), and this difference was statistically significant (p = 0.004).

CONCLUSIONS

The high rate of bacteremia in this series of patients and the significantly lower incidence of repeat probing among infants who received preprocedural antibiotics suggests that blood cultures and subsequent administration of intravenous antibiotics should be considered prior to probing of infants with dacryocystitis.

Pulsed mode versus near-continuous mode delivery of diode laser photocoagulation for high-risk retinopathy of prematurity

OBJECTIVE

To compare structural and functional outcomes and efficiency of diode laser photocoagulation for retinopathy of prematurity (ROP) when delivered in a pulsed mode versus a near-continuous mode.

METHODS

A retrospective study was conducted of 138 patients who underwent diode laser photocoagulation for threshold ROP using either pulsed or near-continuous delivery. Laser-related complications and structural and functional outcomes were analyzed. Prospectively, time efficiency and total energy used were evaluated in nine infants with bilateral symmetric high-risk prethreshold ROP in which one eye of each infant was randomized to pulsed and the fellow eye to near-continuous delivery.

RESULTS

There was no significant difference between groups with regards to prevalence of posterior disease (Zone 1 or posterior Zone 2) (p = 0.11), postoperative vitreous haze (p = 0.60), postoperative complications (p = 0.38), retinal detachment (p = 0.90), strabismus (p = 0.73), amblyopia (p = 0.69), or refractive error (p = 0.95). Mean time for treatment was 23 minutes using pulsed delivery versus 14 minutes per eye with near-continuous delivery (p < 0.001). The mean total power used per eye with pulsed mode delivery was 1.5 x 10(5) W versus 1.1 x 10(5) W with near-continuous delivery (p = 0.015).

CONCLUSIONS

No differences in complications, functional outcome, or structural outcome were found between using pulsed mode and near-continuous mode diode laser delivery for high-risk ROP. Near-continuous laser delivery, in our hands, was more time-efficient and used less total power.

Ultrasound biomicroscopy (UBM) characteristics of scleral tunnels created with suture needles commonly used during strabismus surgery

PURPOSE

To enhance the safety and efficacy of surgical treatment of strabismus, we sought to measure and determine the ultrasound biomicroscopy (UBM) profile of scleral tunnels created with needles commonly used during strabismus surgery, to determine which needles are less likely to create the complication of scleral perforation.

METHODS

Adult cadaver eyes were secured in a styrofoam head. Intraocular pressure was maintained between 15 and 21 mm Hg. Then S14, S24, S28 and TG100 needles were used to create scleral tunnels simulating those created during routine strabismus surgery. Ten scleral tunnels were created with each needle type at 3 different sites on the globe, for a total of 120 passes. The thickness of the sclera and the maximum depth and length of each scleral tunnel were measured using UBM.

RESULTS

The mean tunnel depth below the scleral surface (+/- SD) was 0.43 +/-0.11 mm, 0.37 +/-0.09, 0.40 +/-0.08 and 0.34 +/-0.07 mm, for the S14, S24, S28 and TG100 needles, respectively (P=0.002, One way ANOVA). For both the S14 and S28 needles, there was a "statistically significant" P 0.05) linear trend of an increase in the depth of the pass as the length of the pass increased (P=0.01 for the S14 and P=0.02 for the S28 {Pearson Correlation 2 tailed test}). A similar trend was found with the S24 needle but the trend was not "statistically significant" (P=0.35). No such trend was found with the TG100 needle.

CONCLUSIONS

Needle design had a definite impact on the characteristics of scleral tunnels created to simulate those made during strabismus surgery and may influence needle selection by the surgeon for different or various surgical circumstances, but the differences were not such as to predicate for or against the general use of any of these four needles for strabismus surgery.

Prevalence and course of strabismus in the first year of life for infants with prethreshold retinopathy of prematurity: findings from the Early Treatment for Retinopathy of Prematurity study

OBJECTIVE

To present strabismus data for premature infants with prethreshold retinopathy of prematurity (ROP) enrolled in the Early Treatment for Retinopathy of Prematurity study.

DESIGN

The prevalence of strabismus was tabulated for all of the infants with high-risk prethreshold disease who participated in the randomized trial of the Early Treatment for Retinopathy of Prematurity study and were examined at 6 and/or 9 months' corrected age as well as for all of the infants with low-risk prethreshold disease who were examined at 6 months' corrected age.

MAIN OUTCOME MEASURES

Presence or absence of strabismus at 6 and 9 months' corrected age.

RESULTS

The prevalence of strabismus at 6 months was higher for infants with high-risk prethreshold ROP than for those with low-risk prethreshold ROP (20.3% vs 9.6%, respectively; P<.001). Risk factors associated with the development of strabismus at 9 months include abnormal fixation behavior, presence of amblyopia, and outborn birth status (ie, born outside of a study-affiliated hospital). At 9 months, 30% of infants with high-risk prethreshold ROP had strabismus, although only 42% showed strabismus at 6 months. Thirty percent of infants with strabismus at 6 months showed normal alignment at 9 months.

CONCLUSIONS

Infants with high-risk prethreshold ROP show significant variability in the presence vs absence of strabismus in the first year of life; thus, conservative management is recommended.

APPLICATION TO CLINICAL PRACTICE

Ophthalmologists managing strabismus in infants who have high-risk prethreshold ROP should be aware of the significant variability in ocular alignment during the first year of life.

Visual outcomes after 3-port lens-sparing vitrectomy in stage 4 retinopathy of prematurity

OBJECTIVE

To assess the visual acuity of eyes successfully treated with 3-port lens-sparing vitrectomy for stage 4 retinopathy of prematurity.

METHODS

Of 102 consecutive eyes achieving at least posterior pole reattachment, 30 eyes of 26 patients were tested by Teller or Allen acuity measurements and were subsequently converted to logarithm of the minimum angle of resolution (logMAR). Visual outcomes were also examined as either favorable or unfavorable (Snellen equivalent >20/200).

RESULTS

Seventy-two eyes were not tested because of either inability to perform testing (age or neurologic sequelae related to prematurity) or loss of follow-up. Of those tested, mean +/- SD logMAR visual acuity for the stage 4A and stage 4B groups was 0.51 +/- 0.09 (Snellen approximate 20/62) and 1.03 +/- 0.19 (Snellen approximate 20/200), respectively (odds ratio, 0.39; 95% confidence interval, 0.24-0.64; P = .001). Of those eyes assessed by Teller measurements, 10 of 10 stage 4A eyes and 3 (37.5%) of 8 stage 4B eyes had favorable outcomes; among eyes assessed with Allen measurements, 4 of 4 stage 4A eyes and 0 of 8 stage 4B eyes had favorable outcomes.

CONCLUSIONS

The majority of eyes were not tested. Among eyes tested after successful 3-port lens-sparing vitrectomy, some eyes treated prior to macular detachment may be associated with a more favorable outcome and improved maintenance of functional visual acuity.

Long-term Outcomes of Photorefractive Keratectomy for Anisometropic Amblyopia in Children

PURPOSE

To evaluate the long-term visual acuity (VA) and refractive error responses to excimer laser photorefractive keratectomy (PRK) for treatment of anisometropic amblyopia in children.

DESIGN

Prospective interventional case-control study.

PARTICIPANTS

Eleven children, 2 to 11 years old, with anisometropic amblyopia who were noncompliant with conventional therapy with glasses or contact lenses and occlusion therapy were treated with PRK. A cohort derived retrospectively of 13 compliant and 10 noncompliant children with refractive errors similar to those of the PRK group who were treated with traditional anisometropic amblyopia therapy served as control groups.

INTERVENTION

Photorefractive keratectomy for the eye with the higher refractive error.

MAIN OUTCOME MEASURES

(1) Refractive error reduction and stability in the treated eye, (2) cycloplegic refraction, (3) VA, (4) stereoacuity, and (5) corneal haze up to 3 years after PRK. Compliant and noncompliant children with anisometropia amblyopia were analyzed as controls for refractive error and VA.

RESULTS

Preoperative refractive errors were -13.70 diopters (D) (+/-3.77) for the myopic group and +4.75 D (+/-0.50) for the hyperopic group. Mean postoperative refractive errors at last follow-up (mean, 31 months) were -3.55 D (+/-2.2.5) and +1.41 D (+/-1.07) for the myopic and hyperopic groups, respectively. At last follow-up, cycloplegic refractions in 4 (50%) of 8 myopes and all hyperopes (100%) were within 3 D of that of the fellow eye. Five (63%) of 8 myopic children achieved a refraction within 2 D of the target refraction. Two (67%) of 3 hyperopic patients maintained their refractions within 2 D of the target. Refractive regressions (from 1 year after surgery to last follow-up) were 0.50+/-1.41 D (myopes) and 0.60+/-0.57 D (hyperopes). Seven children (77%) were able to perform psychophysical VA testing preoperatively and postoperatively. Five (71%) of the 7 children had uncorrected VA improvement of at least 2 lines, and 4 (57%) of 7 had best spectacle-corrected VA improvement of at least 2 lines, with 1 improving 7 lines. Five (55%) of 9 children had improvement of their stereoacuity at last follow-up. Subepithelial corneal haze remained negligible. The mean final VA of the PRK group was significantly better than that of the noncompliant control group (P = 0.003). The mean final refractive error for both myopic and hyperopic groups was also significantly better that that of the control groups (P = 0.007 and P<0.0001, respectively).

CONCLUSIONS

Photorefractive keratectomy for severe anisometropic amblyopia in children resulted in long-term stable reduction in refractive error and improvement in VA and stereopsis, with negligible persistent corneal haze.

The management of strabismus in adults--III. The effects on disability

INTRODUCTION

This is the third article in a series on the various facets of the management of strabismus in adults. Here, we give a broad overview of the types and severity of disability and provide initial validation of an instrument (questionnaire) to assess these disability aspects.

METHODS

After undergoing strabismus surgery, 101 patients from 6 centers completed a 6-item questionnaire in which they rated both the before-surgery and after-surgery severity of problems associated with their strabismus, ranging from specific health, daily functioning, social interaction, concerns about the future, and self-image to job-related difficulties.

RESULTS

The before-surgery outcomes showed significant variation across the 6 types of problems (P < 0.001), with "specific health" and "daily tasks" yielding the highest problem rating. Patients with diplopia reported more severe problems with "daily tasks" (P = 0.004) and "concerns about the future" (P = 0.026) than patients without diplopia. Overall, all problem ratings declined after surgery (P < 0.001), but patients who were not successfully aligned were left with higher problem ratings on "specific health" (P = 0.005), "daily tasks" (P = 0.003), and "social interaction" (P = 0.024).

CONCLUSIONS

The results indicate a wide range of disability aspects in adult patients with strabismus, with moderate differences between patients with or without diplopia. Improvements in disability after surgery, as reflected by these ratings, should be taken into account when assessing the health value of adult strabismus management.

Involution of retinopathy of prematurity after laser treatment: factors associated with development of retinal detachment

PURPOSE

To identify specific features during the process of involution of retinopathy of prematurity after treatment at threshold that are associated with development of a retinal detachment.

DESIGN

Retrospective case series.

METHODS

The evolution of retinal detachments over time was analyzed retrospectively in 262 treated eyes of 138 infants. Specific features hypothesized to be associated with development of a retinal detachment were analyzed, including vitreous organization defined as clinically important, active stage 3 disease and active plus disease more than 21 days after treatment, and vitreous hemorrhage defined as clinically important.

RESULTS

A retinal detachment developed in 36 (13.7%) of 262 eyes. Vitreous organization meeting our clinically important definition was associated with a 31-fold (confidence interval [CI] 5.37-183.63; P < .0001) and 13-fold (CI 2.97-58.59; P < .0001) increase in the odds for retinal detachment for right and left eyes, respectively. Vitreous hemorrhage defined as clinically important was associated with a 38-fold (CI 2.69-551.19; P = .007) and 15-fold (CI 1.65-144.12; P = .02) increase in the odds for retinal detachment for right and left eyes, respectively. The timing of retinal detachment relative to vitreous hemorrhage was not determined. Prolonged activity of Stage 3 disease or plus disease more than 21 days after treatment was not associated with development of a retinal detachment.

CONCLUSIONS

Clinically important vitreous organization and vitreous hemorrhage were predictive for development of a retinal detachment. Evaluation of preemptive reintervention strategies for eyes at highest risk for developing a retinal detachment may be reasonable.

Reasons for Delay of Surgical Intervention in Adult Strabismus

BACKGROUND

It has been our impression that adult patients with strabismus frequently delay surgical intervention.

OBJECTIVES

To determine the length of time adult patients waited before undergoing strabismus surgery and to determine the reasons why these delays occurred.

DESIGN, SETTING, AND PARTICIPANTS

Prospective survey of consecutive patients who delayed strabismus surgery for more than 1 year.

INTERVENTION

Preoperative survey.

MAIN OUTCOME MEASURES

The primary outcome measure was time between the onset of strabismus and surgery and the reason why surgery had not been previously sought.

RESULTS

The mean age among 128 study participants was 45.7 years (age range, 18-86 years). The mean time between the onset of current strabismus and surgery was 19.9 years (range, 1-72 years). The major reasons for delay in seeking surgical treatment included the following: surgery was never offered by eye care specialist (35 patients [27%]), surgery was offered but declined by the patient (29 patients [23%]), the patient had received prior satisfactory nonsurgical care (17 patients [13%]), the patient had never sought care (14 patients [11%]), the patient had a previous poor surgical experience (8 patients [6%]), and the patient had been told by their eye specialist that nothing could be done or that surgery could make them worse (8 patients [6%]).

CONCLUSIONS

Strabismus surgery is often delayed for many years in adult patients who could potentially benefit from it. Almost half of such delays could be avoided by better education of the lay public and the medical community.

The management of strabismus in adults--II. Patient and provider perspectives on the severity of adult strabismus and on outcome contributors

PURPOSE

As part of a larger study intended to evaluate the management of strabismus in adults, we documented and compared patient and provider perspectives on the various factors that may contribute to treatment outcome and value of strabismus care.

METHODS

By completing a questionnaire, 170 patients with strabismus (ages 19 to 87 years) and 11 strabismus specialists who performed surgery on these patients each indicated the relative weight of several disease- and treatment-related contributors to the outcome and value of care. In addition, each respondent rated the severity of the strabismus before and after surgery.

RESULTS

Overall severity ratings improved as a result of surgery. The improvement perceived by the physicians was 5.1 +/- 1.7 on a 10-point scale and was larger than the 2.6 +/- 3.6 points improvement perceived by the patients ( P < 0.001). Patients and physicians expressed different views on the relative contributions to outcome and value (overall P < 0.001). Both groups indicated "the condition," "the physician," and "the procedures" as the largest contributors, but "condition" was perceived as more important by the physicians than by the patients ( P < 0.001), and "physician" was more important to the patients than to the physicians ( P < 0.001).

CONCLUSION

Although in approximate agreement on the main contributors to outcome and value, discrepancies exist between perspectives of patients and physicians on the relative weights of those contributors. Public information, education, and counseling may bring these perspectives better in line and ultimately improve both quality and patient satisfaction.

Retinopathy of prematurity: involution, factors predisposing to retinal detachment, and expected utility of preemptive surgical reintervention

PURPOSE

To characterize involution of retinopathy of prematurity (ROP) following treatment at threshold, to identify findings during involution that portend development of retinal detachment, and to assess the potential utility of preemptive vitrectomy for eyes with high-risk features.

METHODS

The probability of ROP involution and of retinal detachment evolution over time was analyzed in 262 treated eyes of 138 infants in a retrospective observational non-case controlled series. Expected utility of preemptive reintervention in eyes with high-risk features was evaluated using decision analysis. Modifications were devised to enhance classification of advanced ROP.

RESULTS

ROP fully involuted in approximately 80% of eyes within 28 days of treatment. Vitreous organization meeting the study's clinically important definition was associated with a 31-fold (5.37 to 183.63; P < .0001) and a 13-fold (2.97 to 58.59; P < .0001) increase in the odds for retinal detachment for right and left eyes, respectively. Vitreous hemorrhage defined as clinically important was associated with a 38-fold (2.69 to 551.19; P = .007) and a 15-fold (1.65 to 144.12; P = .02) increase in the odds for retinal detachment for right and left eyes, respectively. As modeled, an expected utility of 0.85 was calculated for preemptive vitrectomy compared with 0.79 for deferred vitrectomy for eyes with clinically important vitreous organization.

CONCLUSIONS

Acute-phase ROP involuted quickly in most eyes. Vitreous organization and vitreous hemorrhage were predictive of eyes that developed a retinal detachment. Decision analysis suggests that preemptive vitrectomy for eyes with vitreous organization meeting specific criteria is not likely to be worse than deferred vitrectomy, and it could be advantageous in some scenarios.

Corneal thickness in children

OBJECTIVE

To determine normal central and paracentral corneal thickness measurements in the pediatric population and to determine if these measurements are consistent across different pediatric age groups and different racial groups.

DESIGN

Prospective observational case series.

METHODS

Pachymetry measurements were performed on 198 eyes of 108 children. The measurements were taken centrally as well as at four paracentral sites 3 mm from the corneal center at the 3, 6, 9, and 12 o'clock positions. The two-tailed t test was used for comparison of the continuous means for values of corneal thickness. Analysis of variance (ANOVA) was performed to determine differences among age and ethnic groups

RESULTS

The mean central corneal thickness (CCT) was 549 +/- 46 microm. Paracentral corneal thickness mean values, as measured 3 mm from the corneal center, were as follows: superior, 575 +/- 52 microm; nasal, 568 +/- 50 microm; inferior, 568 +/- 51 microm; and temporal, 574 +/- 47 microm. The mean CCT values were significantly thinner than at each of the mean paracentral points (P < .05 for each comparison, paired t test). Paracentral corneal thickness measurements demonstrated no significant differences between locations (P > .05, variance analysis). The mean CCT +/- SD for each age group was as follows: 6 to 23 months, 538 +/- 40 microm; 2 to 4 years, 546 +/- 41 microm; 5 to 9 years, 566 +/- 48 microm; and 10 to 18 years, 554 +/- 35 microm (ANOVA P = .012). ANOVA performed on central pachymetry values demonstrated no significant differences among racial subgroups.

CONCLUSIONS

Pediatric central and paracentral corneal thicknesses increase slowly over time and reach adult thicknesses at 5 to 9 years of age.

Risk factors for treatment failure of anisometropic amblyopia

PURPOSE

This study sought to explore factors which might predict the lack of vision improvement following therapy of anisometropic amblyopia.

METHODS

We retrospectively reviewed the records of 104 children aged 3 to 8 years who had anisometropic amblyopia with a difference in the refractive power between the two eyes of at least 1 diopter, a difference in corrected visual acuity between the two eyes of at least 3 logMAR units, visual acuity in the amblyopic eye of 20/50 or worse, and no ocular structural abnormalities. Patients were treated with either patching or atropine penalization therapy. Patients with strabismus were included. Treatment failure was defined in two ways: (1) functional failure indicating a final visual acuity in the amblyopic eye worse than 20/40 and (2) relative failure indicating less than three lines of logMAR visual acuity improvement regardless of final vision.

RESULTS

Failure risk factors were as follows: age above 6 at the onset of treatment (adjusted odds ratio [OR] (95% confidence limits [CL] = 4.69 [1.55, 14.2]), the presence astigmatism of more than 1.50 diopters in the amblyopic eye (adjusted [OR] (95% CL) = 5.78 [1.27, 26.5]), poor compliance with treatment (adjusted [OR] (95% CL) = 5.47 [1.70, 17.6]), and initial visual acuity in the amblyopic eye of 20/200 or worse (adjusted [OR] (95% CL) = 3.79 [1.28, 11.2]). Strabismus was not found to be a significant risk factor. Neither the type or amount of refractive error nor the difference in the refractive power between the two eyes was a significant risk factor for treatment failure.

CONCLUSION

Eyes with poor initial visual acuity, the presence of significant astigmatism, and age over 6 years were less likely to achieve successful outcome. The clinical profile of patients with anisometropic amblyopia may be useful in predicting response to therapy, but compliance with treatment has a major effect on response to therapy.

A simple model for practicing surgery on the nasolacrimal drainage system

Practicing surgical techniques on models prior to operating on patients can be helpful in developing skills needed to perform surgery proficiently. A simple, inexpensive, and readily available model for instruction and practice of surgical maneuvers on the nasolacrimal drainage system is described.

Involution of threshold retinopathy of prematurity after diode laser photocoagulation

OBJECTIVE

To characterize the process of involution of threshold retinopathy of prematurity after transpupillary diode laser photocoagulation.

DESIGN

Retrospective case series.

PARTICIPANTS

Neonates with threshold retinopathy who underwent diode laser photocoagulation of the peripheral avascular retina.

METHODS

A retrospective chart review was done of the weekly examination records of infants treated for threshold disease. Features that were studied included the presence of residual stage 3 neovascularization, plus disease, and development of retinal detachment (RD).

MAIN OUTCOME MEASURES

Timing of full involution and/or development of an RD.

RESULTS

Of 262 eyes of 138 infants treated, full involution without RD was seen in 8%, 43%, 64%, 73%, and 86% of eyes at postoperative weeks 1, 2, 3, 4, and 9+/-3, respectively. Retinal detachments were diagnosed cumulatively in 0%, 1.5%, 4.2%, 6.5%, and 14% of eyes at weeks 1, 2, 3, 4, and 9+/-3, respectively.

CONCLUSIONS

Full involution of laser-treated threshold retinopathy of prematurity required more than 2 weeks in more than half of treated eyes. Most RDs were not detected until > or =3 weeks after treatment.

Herpes simplex virus keratitis in children

PURPOSE

To describe the spectrum and recurrence of herpes simplex virus (HSV) keratitis in children and adolescents.

DESIGN

Retrospective cohort study.

METHODS

Twenty-three patients younger than age 16 years were diagnosed with HSV keratitis at one institution.

RESULTS

All children presented with dendritic or punctate epithelial keratitis, and stromal keratitis occurred concurrently with epithelial keratitis in 14 patients (61%). Six patients (26%) had bilateral HSV keratitis. Eleven patients (48%) developed recurrent HSV keratitis at a median of 15 months after the first documented episode. Amblyopia occurred in three children.

CONCLUSION

Children with herpetic keratitis may have bilateral ocular involvement and are at risk for recurrent keratitis and amblyopia.

Parent-administered visual acuity testing: is it reliable and can it improve office efficiency?

PURPOSE

To evaluate the accuracy of a parent-administered visual acuity test, using the electronic visual acuity tester (EVA) (JAEB Center, Tampa, FL) and evaluate its use as a means to improve efficiency of office acuity testing.

METHODS

This was a prospective experimental study. Part I: Sixty-four children had their visual acuity determined using the EVA, first by their parents and then by an ophthalmic technician. Acuity scores were compared. Part II: Forty-four other children were randomly assigned to one of 2 groups. Group A (parent-prescreen) children had their visual acuity determined first by the parents using the EVA. The visual acuity result in that child was then rechecked by the technician using the Reinforcement Phase and Phase 2 of the Amblyopia Treatment Study (ATS) visual acuity testing protocol. Group B (full ATS protocol) children had their acuity determined by the technician using the full ATS protocol. The number of optotypes presented by the technician in order to determine the acuity in each group was compared.

RESULTS

Part I: Reliability of parent-determined visual acuity scores was high (r = 0.91 and 0.81 for right eyes (OD) and left eyes (OS), respectively), with 93% of right eye parent scores and 85% of left eye parent scores within 0.11 logarithm of minimal angle of resolution (logMAR) units (ie, within one line of vision) of the technician score. Part II: The parent prescreen group (Group A) required presentation of 66% fewer optotypes to the OD and 68% fewer optotypes to the OS than the full ATS protocol group (Group B) (OD: P = 5.4 x 10(-18); OS: P = 6.5 x 10(-18)).

CONCLUSIONS

Visual acuity testing results by parents using the EVA are reliable. Electronic visual acuity prescreening by parents reduces the number of optotype presentations required to be shown by the technician to accurately determine acuity. Use of a parent-assisted screening system in the waiting room may translate to increased office efficiency.

Strabismus surgery for adults: a report by the American Academy of Ophthalmology

OBJECTIVE

To describe the effectiveness and safety of surgical treatment of adult patients with strabismus, and to review the reported functional benefits and complications of strabismus surgery for adults.

METHODS

A literature search was conducted in September 2001. It was repeated and updated in April 2003, with retrieval of relevant citations. Panel members reviewed the articles and rated them according to their relevance to the topic and methodology.

RESULTS

The literature search identified 49 reports that describe the surgical treatment of strabismus in adult patients and meet predetermined review criteria. Of these reports, 2 were of randomized controlled trials, and 1 addressed the primary objective of this review. In this randomized study of adults with strabismus, direct comparison of surgical correction with botulinum toxin A chemodenervation indicated that surgical treatment was superior to botulinum toxin A in realigning the eyes (76.9% vs. 29.4%, P = 0.027). Several large case series of adults with strabismus (level III evidence) with successful surgical realignment rates of 68% to 85% have been reported. Functional benefits of surgical treatment are reported in many patients. These include elimination of diplopia, development of binocular fusion, expansion of binocular visual fields, and improvement of head position. Surgical complications, including new, postoperative diplopia (1%-14%) or scleral perforation (0.8%-1.8%), occur in a minority of patients. Unplanned reoperations (subsequent strabismus procedures that were not anticipated as part of a staged treatment) were needed in up to 21% of patients in large case series of comitant strabismus, and in up to 50% of patients with thyroid ophthalmopathy.

CONCLUSIONS

Despite the paucity of level I evidence from randomized controlled trials, the existing literature suggests that surgical treatment of adults with strabismus is safe and effective in improving ocular alignment. In many cases it improves visual function, based largely on level III evidence. Risks include unplanned reoperation, postoperative diplopia, and scleral perforation. Additional level I studies of surgical treatment of adult patients would help to document the effectiveness and substantiate the safety of this treatment.

The effect of off-the-visual-axis retinoscopy on objective refractive measurement

PURPOSE

To determine the effect of off-axis retinoscopy on objective refractive measurement.

DESIGN

Prospective experimental study.

METHODS

Eight volunteers underwent cycloplegic retinoscopy of their right eye on-the-visual-axis, and 5, 10, 15, and 20 degrees off-the-visual-axis in adduction. A single masked examiner performed all retinoscopy with random order of the patient and axis refracted.

RESULTS

The average spherical retinoscopic value at 0, 5,10,15, and 20 degrees of off-axis alignment was -0.40, -0.90, -1.00, -1.38, and -1.80 diopters, respectively. The average spherical equivalent retinoscopic value obtained for each of the above positions of eye alignment was -0.02, -0.59, -0.45, -0.64, and -0.98 diopters, respectively. The induced cylinder power increased by an average of 3% for each degree of off-axis retinoscopy, though the axis of the cylinder was not predictable.

CONCLUSION

Objective refractive measurement by retinoscopy is significantly altered by off-the visual-axis retinoscopy. The induced error may be clinically important even with small degrees of eccentricity.

Use of the RetCam 120 for fundus evaluation in uncooperative children

PURPOSE

To report our experience using the RetCam 120 to evaluate suspected retinal pathology in children who did not cooperate for standard in-office examination.

DESIGN

Interventional case series.

METHODS

We reviewed charts of eight consecutive uncooperative children with suspected fundus abnormalities that were photographed using the RetCam 120 as a routine part of patient care.

RESULTS

Three uncooperative children with suspected pathology required RetCam 120 photos because of inadequate fundus examination. Five had pathology or suspected pathology that required more detailed examination. In all of these children, we were able to reach or rule out a diagnosis.

CONCLUSION

The Retcam 120 digital fundus camera has utility as an in-office diagnostic tool for fundus examination of poorly cooperative children and may be a good alternative to examination under anesthesia or sedation in selected cases.

Accuracy of clinical estimation of abnormal head postures

PURPOSE

Correct diagnosis and analysis of an abnormal head posture (AHP) is critical in the clinical assessment of patients with strabismus and nystagmus. This study was performed to evaluate the accuracy and precision of clinicians estimating the degree of face turns and head tilts.

DESIGN

Experimental simulation study.

PARTICIPANTS

Two normal volunteers and 4 pediatric and 1 general ophthalmologists.

METHODS

Using a cervical range of motion (CROM) device, single axis head position (chin up, chin down, right and left face turn, and head tilts) were modeled, and clinical estimates of the amount of deviation were estimated by the four ophthalmologists. Each of the 4 examiners estimated 108 single axis AHPs in a randomized and masked pattern.

MAIN OUTCOME MEASURES

Accuracy of clinical estimation of AHP, intra- and inter- observer variability, and variability in terms of head position.

RESULTS

The examiners tended to overestimate the AHPs by an average of 5 degrees (P less than 0.001). Two "right" positions (right head tilt and face turn) were the worst. The average error was 10 +/-8 degrees for the right tilt and turn positions, while the error for all other positions, excluding these two, averaged 0 +/-10 degrees (P = 0.0001).

CONCLUSIONS

Clinical estimation of an AHP by ophthalmologists is in part remarkably accurate, even if imprecise, but some positions, notably right head tilt and right face turn in this study, were significantly overestimated. Objective methods of measuring AHPs such as the CROM may be preferable for these RHT and RFT AHPs and when maximum precision is needed for tracking changing AHPs or deviations.

Impact of patching and atropine treatment on the child and family in the amblyopia treatment study

OBJECTIVE

To assess the psychosocial impact on the child and family of patching and atropine as treatments for moderate amblyopia in children younger than 7 years.

METHODS

In a randomized, controlled clinical trial, 419 children younger than 7 years with amblyopic eye visual acuity in the range of 20/40 to 20/100 were assigned to receive treatment with either patching or atropine at 47 clinical sites. After 5 weeks of treatment, a parental quality-of-life questionnaire was completed for 364 (87%) of the 419 patients. Main Outcome Measure Overall and subscale scores on the Amblyopia Treatment Index.

RESULTS

High internal validity and reliability were demonstrated for the Amblyopia Treatment Index questionnaire. The overall Amblyopia Treatment Index scores and the 3 subscale scores were consistently higher (worse) in the patching group compared with the atropine-treated group (overall mean, 2.52 vs 2.02, P<.001; adverse effects of treatment: mean, 2.35 vs 2.11, P =.002; difficulty with compliance: mean, 2.46 vs 1.99, P<.001; and social stigma: mean, 3.09 vs 1.84, P<.001, respectively).

CONCLUSION

Although the Amblyopia Treatment Index questionnaire results indicated that both atropine and patching treatments were well tolerated by the child and family, atropine received more favorable scores overall and on all 3 questionnaire subscales.