Effects of Myo-inositol on Type 1 Retinopathy of Prematurity Among Preterm Infants <28 Weeks' Gestational Age: A Randomized Clinical Trial.

Importance: Previous studies of myo-inositol in preterm infants with respiratory distress found reduced severity of retinopathy of prematurity (ROP) and less frequent ROP, death, and intraventricular hemorrhage. However, no large trials have tested its efficacy or safety. Objective: To test the adverse events and efficacy of myo-inositol to reduce type 1 ROP among infants younger than 28 weeks' gestational age. Design, Setting, and Participants: Randomized clinical trial included 638 infants younger than 28 weeks' gestational age enrolled from 18 neonatal intensive care centers throughout the United States from April 17, 2014, to September 4, 2015; final date of follow-up was February 12, 2016. The planned enrollment of 1760 participants would permit detection of an absolute reduction in death or type 1 ROP of 7% with 90% power. The trial was terminated early due to a statistically significantly higher mortality rate in the myo-inositol group. Interventions: A 40-mg/kg dose of myo-inositol was given every 12 hours (initially intravenously, then enterally when feeding; n = 317) or placebo (n = 321) for up to 10 weeks. Main Outcomes and Measures: Type 1 ROP or death before determination of ROP outcome was designated as unfavorable. The designated favorable outcome was survival without type 1 ROP. Results: Among 638 infants (mean, 26 weeks' gestational age; 50% male), 632 (99%) received the trial drug or placebo and 589 (92%) had a study outcome. Death or type 1 ROP occurred more often in the myo-inositol group vs the placebo group (29% vs 21%, respectively; adjusted risk difference, 7% [95% CI, 0%-13%]; adjusted relative risk, 1.41 [95% CI, 1.08-1.83], P = .01). All-cause death before 55 weeks' postmenstrual age occurred in 18% of the myo-inositol group and in 11% of the placebo group (adjusted risk difference, 6% [95% CI, 0%-11%]; adjusted relative risk, 1.66 [95% CI, 1.14-2.43], P = .007). The most common serious adverse events up to 7 days of receiving the ending dose were necrotizing enterocolitis (6% for myo-inositol vs 4% for placebo), poor perfusion or hypotension (7% vs 4%, respectively), intraventricular hemorrhage (10% vs 9%), systemic infection (16% vs 11%), and respiratory distress (15% vs 13%). Conclusions and Relevance: Among premature infants younger than 28 weeks' gestational age, treatment with myo-inositol for up to 10 weeks did not reduce the risk of type 1 ROP or death vs placebo. These findings do not support the use of myo-inositol among premature infants; however, the early termination of the trial limits definitive conclusions.

Cataract Surgery in Children from Birth to Less than 13 Years of Age: Baseline Characteristics of the Cohort.

OBJECTIVE: To describe baseline characteristics, initial postoperative refractive errors, operative complications, and magnitude of the intraocular lens (IOL) prediction error for refractive outcome in children undergoing lensectomy largely in North America. DESIGN: Prospective registry study of children from birth to <13 years of age who underwent lensectomy for any reason within 45 days preceding enrollment. PARTICIPANTS: Total of 1266 eyes of 994 children; 49% female and 59% white. METHODS: Measurement of refractive error, axial length, and complete ophthalmic examination. MAIN OUTCOME MEASURES: Eye and systemic associated conditions, IOL style, refractive error, pseudophakic refraction prediction error, operative and perioperative complications. RESULTS: Mean age at first eligible lens surgery was 4.2 years; 337 (34%) were <1 year of age. Unilateral surgery was performed in 584 children (59%). Additional ocular abnormalities were noted in 301 eyes (24%). An IOL was placed in 35 of 460 eyes (8%) when surgery was performed before 1 year of age, in 70 of 90 eyes (78%) from 1 to <2 years of age, and in 645 of 716 eyes (90%) from 2 to <13 years of age. The odds of IOL implantation were greater in children ≥2 years of age than in those <2 years of age (odds ratio = 29.1; P < 0.001; 95% confidence interval: 19.6-43.3). Intraoperative complications were reported for 69 eyes (5%), with the most common being unplanned posterior capsule rupture in 14 eyes, 10 of which had an IOL placed. Prediction error of the implanted IOL was <1.00 diopter in 54% of eyes, but >2.00 diopters in 15% of eyes. CONCLUSIONS: Lensectomy surgery was performed throughout childhood, with about two-thirds of cases performed after 1 year of age. Initial surgery seemed safe, with a low complication rate. IOL placement was nearly universal in children 2 years of age and older. The immediate postoperative refraction was within 1 diopter of the target for about one-half of eyes.

Retinopathy of Prematurity: A Review of Current Screening Guidelines and Treatment Options.

With advancements in neonatal intensive care units, the early detection of retinopathy of prematurity in premature infants is extremely important. It is critical for physicians to recognize children at risk and ensure they receive appropriate screening and monitoring. This article will discuss risk factors, screening guidelines, classification and treatment of this disease in premature infants.

Management of infantile esotropia.

PURPOSE OF REVIEW: Surgical treatment has been the accepted mode of treatment for infantile esotropia for decades. The present review of recent literature evaluates the current standing of: type of surgery performed and best timing of surgery to achieve optimal results. RECENT FINDINGS: Recent studies suggest that early surgical intervention is of benefit by improving the probability of developing stereopsis. A significant advantage of the type of surgical intervention has yet to be demonstrated by the current studies. Botulinum toxin continues to be used for treatment of infantile esotropia, although it has not been shown to be a superior treatment. SUMMARY: Although many theories exist, the true cause of infantile esotropia remains unknown. The literature suggests that treatment before age 2 and perhaps even earlier improves the potential for binocular vision. After significant review of literature, it is clear that surgery is the treatment of choice for infantile esotropia but no method has a clear advantage. Efforts to define the best surgical procedure and timing of surgery through prospective, randomized multicenter trials are warranted.

Neurodevelopmental outcome of preterm infants enrolled in myo-inositol randomized controlled trial.

OBJECTIVE: This study evaluates the 24-month follow-up for the NICHD Neonatal Research Network (NRN) Inositol for Retinopathy Trial. STUDY DESIGN: Bayley Scales of Infants Development-III and a standardized neurosensory examination were performed in infants enrolled in the main trial. Moderate/severe NDI was defined as BSID-III Cognitive or Motor composite score <85, moderate or severe cerebral palsy, blindness, or hearing loss that prevents communication despite amplification were assessed. RESULTS: Primary outcome was determined for 605/638 (95%). The mean gestational age was 25.8 ± 1.3 weeks and mean birthweight was 805 ± 192 g. Treatment group did not affect the risk for the composite outcome of death or survival with moderate/severe NDI (60% vs 56%, p = 0.40). CONCLUSIONS: Treatment group did not affect the risk of death or survival with moderate/severe NDI. Despite early termination, this study represents the largest RCT of extremely preterm infants treated with myo-inositol with neurodevelopmental outcome data.

Intraocular lens use in challenging pediatric cases.

PURPOSE OF REVIEW: The technological advancement of intraocular lenses (IOLs) in recent years has increased their use in the pediatric population. This has led to the use of IOLs in children in whom they would not have been considered in the past. Yet, the majority of the literature looking at the use of specialty IOLs is in the adult literature. This review will look at the use of IOLs in special circumstances as reported in the pediatric population. RECENT FINDINGS: A Medline search of the use of IOLs in children reveals 27 articles published in the past year. The data available on the use of IOLs in special circumstances in children are significantly less. This paper will review the safety and efficacy of the use of IOLs in children with uveitis. Options available to treat aphakia in children with inadequate support for posterior chamber IOLs are explored. Finally, the role of using multifocal and other specialty IOLs is reviewed. SUMMARY: The use of IOL implantation in the pediatric population is evolving. There is much promise in using IOLs in specialty circumstances, but caution should be applied when using these new technologies in the pediatric population. Efforts must be made to study these areas within the pediatric population.

Visual outcome and success of amblyopia treatment in unilateral small posterior lens opacities and lenticonus initially treated nonsurgically.

PURPOSE: We sought to assess the success of amblyopia treatment in patients with small posterior lens opacities as well as the factors associated with a good visual outcome. METHODS: This was a retrospective study of patients with posterior lens opacities that initially were thought to be too small in size to warrant cataract surgery. The following variables were examined: cataract type, location, diameter, persistent hyaloid vessel, anisometropia, strabismus, and age of detection. Success of treatment of amblyopia was defined as improvement by at least 0.3 logMAR units. Good visual outcome was defined as 20/40 or better. Amblyopia was treated by glasses, patching, and/or atropine. Patients who failed with conservative treatment or had an increase in cataract size underwent surgery. RESULTS: Forty-eight (91%) of 53 eyes were amblyopic. Thirty amblyopic eyes had pre- and post-treatment Snellen acuities. Twenty (67%) had their visual acuity (VA) improved by 0.3 logMAR units or greater. None of the measured variables were associated with successful amblyopia treatment. Twenty-five (49%) of 51 patients had a final VA of 20/40 or better. The only variable associated with good visual outcome was cataract type: 18 of 25 (72%) posterior subcapsular cataract and 6 of 23 (32%) posterior lenticonus eyes achieved VA of 20/40 or better (P = 0.008). Six patients who went on to have cataract surgery experienced a larger improvement in BCVA (4.50 logMar units +/- 2.52 lines) compared with patients treated without cataract surgery (2.36 logMar units +/- 3.11 lines). DISCUSSION: Amblyopia treatment was successful in most cases. A small group of patients who underwent cataract surgery experienced a greater VA improvement; however, it was not statistically significant. Further studies are needed to determine which patients would benefit from cataract surgery.

Retinal involvement in patients with juvenile dermatomyositis.

The authors describe the clinical presentations and ophthalmic findings of two patients with juvenile dermatomyositis. The results of their dilated eye examinations proved to influence the treatment of the disease process because retinal pathology was used as a factor to escalate the degree of anti-inflammatory therapy. Therefore, an initial ophthalmic examination may be considered in patients with new-onset juvenile dermatomyositis.

Management of corneal abrasion in children: a randomized clinical trial.

STUDY OBJECTIVE: We compare percentage of healing, comfort, and complications in children with corneal abrasions treated with an eye patch versus no eye patch. METHODS: We performed a randomized clinical trial of patients aged 3 to 17 years who were diagnosed with isolated corneal abrasion. Patients were randomly assigned to an eye patch or no patch group. Abrasion size was documented with digital photographs and/or an eye template diagram at presentation and at 20- to 24-hour follow-up examination. A reviewer masked to treatment group determined percent healing by measuring presentation and follow-up abrasion sizes on the photographs/template. At follow-up, interference with activities of daily living (ADL) was measured with a visual analog scale and the number of pain medication doses taken since presentation was recorded. RESULTS: A total of 37 patients were enrolled: 17 with an eye patch and 18 with no eye patch. The mean patient age was 10 years, and two thirds of the patients were male. The majority (86%) of patients had 95% or more healing at follow-up, and there was no significant difference in percent healing between the 2 groups, even when adjusted for age and initial abrasion size (95% confidence interval [CI] for the difference in means -11 to 8 and -13 to 5, respectively). There was no difference between groups for number of pain medication doses required. Among measurements of interference with ADL, only the difficulty walking score was found to be significantly different between groups (patch mean 1.7 cm [SD 2.1 cm] versus no patch mean 0.3 cm [SD 0.7 cm]; 95% CI for the difference in means 0.3 to 2.5). CONCLUSION: This study suggests that eye patching in children with corneal abrasions makes no difference in the rate of healing. There was no difference in discomfort and interference with ADL, other than greater difficulty walking in the patch group, and there were no complications in either group.