Can the Red Reflex Test Detect Unequal Refractive Error?

OBJECTIVE: To determine the accuracy of the red reflex test in the detection of anisometropia. STUDY DESIGN: This prospective, single-masked study enrolled new patients younger than the age of 18 years who had not undergone pharmacologic pupillary dilation. A fellow who was masked to all clinical information illuminated both eyes with a direct ophthalmoscope in a darkened room from a distance of 1 m, assessing whether the red reflex between the 2 eyes was symmetric or asymmetric. The patient was then dilated, and cylcoplegic refraction was performed by an attending pediatric ophthalmologist. Exclusion criteria included the presence of strabismus, anisocoria, previous intraocular surgery, media opacity, leukocoria, or nystagmus. Sensitivity was compared with a null hypothesized value of 50% using a 1-sided binomial test. RESULTS: Ninety-two patients with a mean age of 7.3 years (range 3 months to 16 years) were enrolled. With spherical anisometropia greater than or equal to 0.125 diopters, the sensitivity of the red reflex test was 90.6% and the specificity was 58.3%. With cylindrical anisometropia greater than or equal to 0.25 diopters, the sensitivity of the red reflex test was 81.3% and the specificity was 70%. Anisometropia greater than 1.5 diopters in spherical equivalent (4 patients, range -10.625 to -2.625) or cylinder (3 patients, range 1.75-2.25) was accurately detected by red reflex testing in each case. CONCLUSIONS: The red reflex test can be an accurate screening tool to detect anisometropia when performed by an ophthalmologist.

Compliance with the prescribed occlusion treatment for amblyopia.

PURPOSE OF REVIEW: The present review article is an update on the current evidence about compliance to the prescribed occlusion treatment for amblyopia. In particular, the authors focus on the predictors and causes of noncompliance and possible interventions to increase it. RECENT FINDINGS: Compliance with prescribed occlusion treatment is often challenging. Reported rates of compliance range widely from 49% to 87%. Objective monitoring of occlusion has opened up new research opportunities and allow the design of effective therapeutic regimens. Also, predictors and causes of noncompliance have been investigated and their knowledge may help the clinician to improved compliance with prescribed occlusion treatment for amblyopia. SUMMARY: Although many of the studies assessing the effectiveness of interventions to increase compliance to patching treatment for amblyopia have many limitations, evidences support that use of educational supports, parents, and patient understanding on the importance of patching and written information should be considered to increase compliance with patching.

Amblyopia update: new treatments.

PURPOSE OF REVIEW: This review article is an update on the current treatments for amblyopia. In particular, the authors focus on the concepts of brain plasticity and their implications for novel treatment strategies for both children and adults affected by amblyopia. RECENT FINDINGS: A variety of strategies has been developed to treat amblyopia in children and adults. New evidence on the pathogenesis of amblyopia has been obtained both in animal models and in clinical trials. Mainly, these studies have challenged the classical concept that amblyopia becomes untreatable after the 'end' of the sensitive or critical period of visual development, because of a lack of sufficient plasticity in the adult brain. SUMMARY: New treatments for amblyopia in children and adults are desirable and should be encouraged. However, further studies should be completed before such therapies are widely accepted into clinical practice.

Four-muscle tenotomy surgery for nystagmus.

PURPOSE OF REVIEW: To describe the history and literature related to four-muscle tenotomy procedure for nystagmus. RECENT FINDINGS: The concept of four-muscle tenotomy surgery for nystagmus initially arose from objective eye movement recordings of patients with nystagmus and an eccentric face turn who had undergone the Anderson-Kestenbaum procedure. These eye movement recordings demonstrated secondary benefits, including broadening of the null region, improved visual acuity, and improved nystagmus waveforms. Studies initially performed in dogs validated the theory that such positive effects could be obtained by horizontal four-muscle tenotomy and reattachment without transposition. Subsequent studies in humans have demonstrated that the procedure results in improved visual acuity, broadening of the null zone, and improved target acquisition in patients with nystagmus. New theories have been described regarding techniques to augment the effects of the procedure and/or replicate its effects with a safer, less invasive alternative. SUMMARY: Horizontal four-muscle tenotomy has proven to be an effective procedure for reducing nystagmus, broadening the null position, and improving visual acuity in primary position for patients with nystagmus.

Review of the Disparities in Access to Pediatric Eye Care Among Low Socioeconomic Status and Underrepresented Racial Minority Groups Exacerbated by the Economic Downturn in Pediatric Ophthalmology.

PURPOSE: To explore the association between race and socioeconomic status on health disparities in pediatric eye care, characterize the status of diversity within the pediatric ophthalmology workforce, and propose potential solutions to improve access to vision care, particularly for children from vulnerable populations. METHODS: The major studies examining the socioeconomic and racial disparities in visual outcomes and the impact of diversity in the ophthalmology workforce were reviewed. RESULTS: Currently, the pediatric ophthalmology workforce has limited racial diversity, and increasing the number of underrepresented in medicine providers has potential to improve access to pediatric eye care, particularly for underserved populations. Mobile eye clinics, school-based vision programs, and health literacy initiatives may engage communities to bring eye care directly to children and enhance follow-up. CONCLUSIONS: Families with lower socioeconomic status may represent a vulnerable population facing significant access to pediatric eye care barriers, particularly for asymptomatic pediatric eye conditions. Emphasis on strategies that directly engage communities and bring free vision care to families should be given to improve disparities in visual health outcomes. Ophthalmologists and pediatric ophthalmologists should be aware of the current racial underrepresentation within the pediatric ophthalmology workforce, and the importance of workforce diversity in accelerating physician-patient concordance and access to eye care. [J Pediatr Ophthalmol Strabismus. 2024;61(3):172-178.].

Indications and Outcomes for Extraocular Muscle Disinsertion in Strabismus Surgery.

PURPOSE: To describe a case series of extraocular muscle (EOM) disinsertions, discuss the indications for muscle disinsertion, and examine deviation outcomes. METHODS: All consecutive patients who underwent EOM disinsertion by one surgeon from 2013 to 2021 were included in the study. Age, sex, best corrected visual acuity, diagnosis, preoperative deviation, postoperative deviation, and follow-up interval were recorded. RESULTS: Twelve patients (13 eyes) underwent EOM disinsertion. Ten were men and two were women. Eight eyes had an abducens nerve (cranial nerve 6) palsy, four had thyroid eye disease, and one had an oculomotor nerve palsy (cranial nerve 3). Preoperatively, the average age was 57.7 years, best corrected visual acuity was 0.24 logarithm of the minimum angle of resolution (logMAR) in the right eye and 0.35 logMAR in the left eye, and deviation was 56.4 prism diopters (PD). The average postoperative residual deviation was 5.3 PD with an average follow-up time of 290 days. Four patients underwent reoperation, one of whom underwent a third surgery. CONCLUSIONS: EOM disinsertion is an effective treatment in certain specific strabismus conditions. Patients who may benefit are those with a severe cranial nerve 6 palsy who cannot abduct the eye even to the midline and those with thyroid eye disease whose EOMs are so tight intraoperatively that even a small hook cannot be easily passed under the operative muscle adequately to perform a large recession technique. [J Pediatr Ophthalmol Strabismus. 2023;60(4):253-256.].

Is There a Path for an Economic Turnaround in Pediatric Ophthalmology?

PURPOSE: To create a survey that assesses potential solutions for an economic turnaround in pediatric ophthalmology and the frequency of their use. METHODS: A 12-question survey was distributed to United States-based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus discussion board and various social media fora. Demographic, economic, and workforce pattern data were collected and analyzed. RESULTS: Three hundred one pediatric ophthalmologists completed the survey. Thirty-one (10.3%) respondents used optical coherence tomography in children with amblyopia, 81 (26.9%) were a partner in an ambulatory surgery center, 133 (44.2%) had a retinopathy of prematurity financial contract arrangement with a neonatal intensive care unit to examine premature children, and 95 (31.6%) had a financial contract arrangement with an optical shop in their office. Twenty-four (8.0%) respondents were currently in the process of being or had been bought out by a private equity investor, 52 (17.3%) owned a Spot Vision Screener (Welch Allyn) for refraction, 158 (52.5%) had hired a pediatric ophthalmology extender (pediatric optometrist, technician, or orthoptist), 87 (29.5%) had recently increased their marketing profile, and 90 (29.9%) owned the property that their practice occupied. CONCLUSIONS: Potential for a revitalization and economic turnaround in pediatric ophthalmology depends on several income-generating suggestions that simultaneously improve workforce and manpower issues, thus increasing access to pediatric eye care. [J Pediatr Ophthalmol Strabismus. 2023;60(1):25-32.].

The Economic Downturn of Pediatric Ophthalmology and Its Impact on Access to Eye Care.

PURPOSE: To discuss the economic downturn of pediatric ophthalmology in the setting of an alarming decline in the number of residents pursuing pediatric ophthalmology and its impact on limiting access to eye care. METHODS: Survey studies and articles examining the recent economic impact of reimbursement cuts and practice pattern changes in pediatric ophthalmology were reviewed. Population data from the 2020 U.S. Census Bureau and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) were analyzed to illustrate provider-to-population relationships by state. RESULTS: Survey studies demonstrated a deteriorating economic situation marked by progression in reimbursement cuts, reductions in pediatric ophthalmologists accepting Medicaid patients, and dwindling numbers of residents pursuing pediatric ophthalmology fellowships. Provider-to-population relationships revealed that pediatric ophthalmologists are not evenly distributed to meet population demand, and that many states are suffering from a shortage of pediatric ophthalmologists. Furthermore, many states with high percentages of Medicaid coverage simultaneously have lower AAPOS members/million person ratios. CONCLUSIONS: The simple economic principles of supply and demand reveal a crisis in access to pediatric eye and adult strabismus care. The economic downtown and change in practice patterns may produce rippling effects outside pediatric ophthalmology in fields such as pediatrics and comprehensive ophthalmology. An interdisciplinary effort among health care providers and governmental officials is needed to revive the field of pediatric ophthalmology and improve access to eye care. [J Pediatr Ophthalmol Strabismus. 2023;60(1):18-24.].

Unanswered Questions Pertaining to the Economic and Workforce Issues in Pediatric Ophthalmology.

PURPOSE: To create a survey that examines remaining unanswered questions related to the economic and workforce issues in pediatric ophthalmology. METHODS: A 12-question survey was distributed to U.S.-based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) discussion board and various other social media forums. Statistical analysis was performed on the basis of practice setting groups. RESULTS: Two hundred eighty-seven pediatric ophthalmologists completed the survey. Of all respondents, 150 (52.3%) believed pediatric ophthalmology is a prestigious subspecialty, 137 (47.7%) thought that a hybrid fellowship combining pediatric ophthalmology and adult cataract surgery would increase the number of practicing pediatric ophthalmologists, 189 (65.9%) felt that early exposure during medical school would increase the number of residents who ultimately apply to pediatric ophthalmology fellowship, and 81 (28.2%) believed that the lobbyists hired by the AAPOS will be successful in preventing further Centers for Medicare and Medicaid Services reimbursement cuts. Medicaid patients comprised more than 25% of the total practice for 156 (54.4%) respondents. New patient, follow-up, and surgery wait times were greater than 2 months in 50.9%, 46.7%, and 38.7% of respondents, respectively. CONCLUSIONS: As the economic crisis in pediatric ophthalmology continues to worsen, questions related to increasing interest in the field through early exposure, hybrid fellowship, prestige, appointment wait times, and belief in the success of AAPOS lobbyists remain. Exceptional measures are required to revitalize the field and improve access to care. [J Pediatr Ophthalmol Strabismus. 2023;60(3):163-169.].

The Medicaid Dilemma and Its Profound Effect on the Economic and Workforce Issues in Pediatric Ophthalmology and Ultimately on Access to Pediatric Eye Care.

PURPOSE: To identify new patient, follow-up, and surgery appointment wait times for children seeking care at academic eye centers/children's hospitals (AEC/CHs) in the setting of very low Medicaid reimbursements and workforce issues in pediatric ophthalmology. METHODS: Each state in the United States with AEC/CHs was contacted by phone or email. Using a standardized script, the authors inquired about approximate wait times for non-emergency new patient, follow-up, and surgery appointment times, as well as percentage of patients insured by Medicaid seen at the AEC/CH. Medicaid reimbursements for new patient visits, follow-up visits, sensorimotor examinations, and one-muscle strabismus surgery were examined for each state. RESULTS: The mean percentage of children enrolled in Medicaid across the United States was 38.0%. Appointment and Medicaid inquiry calls were conducted across 41 states. Mean wait times across the United States for new patient, follow-up, and surgery appointments were 3.9, 3.4, and 2.7 months, respectively. Mean percentage of patients insured by Medicaid at AEC/CHs was 57.1%. High Medicaid-insured states offered longer wait times for new patient appointments than low Medicaid-insured states (4.4 versus 3.5 months; P = .20). The lowest Medicaid reimbursements for new patient visit, follow-up visit, sensorimotor examination, and one-muscle strabismus surgery occurred in Illinois, California, Ohio, and Michigan, respectively. CONCLUSIONS: Across the United States, states with higher percentages of patients insured by Medicaid exhibited longer new patient appointment wait times, suggesting that challenges related to Medicaid reimbursements directly contribute to disparities in access to pediatric eye care. [J Pediatr Ophthalmol Strabismus. 2023;60(3):170-177.].

What We Learned About the Economic and Workforce Issues in Pediatric Ophthalmology: Access to Eye Care and Possible Solutions.

PURPOSE: To provide a blueprint reviewing the major economic and workforce issues in pediatric ophthalmology and its effect on access to pediatric eye care, as well as potential solutions. METHODS: This was a systematic review of the landmark studies examining the economic and workforce issues in pediatric ophthalmology was performed. RESULTS: The number of residents pursuing pediatric ophthalmology fellowship has steadily declined since the early 2000s. Increasing overhead costs, low Medicaid reimbursements, practice pattern changes, and workforce shortages have all contributed to a significant crisis in access to pediatric eye care. CONCLUSIONS: Solutions to improve access to pediatric eye care involve pursuing more economical strategies within the confines of the pediatric ophthalmology practice, early exposure to the field during medical education, and enhancing residents' interest through faculty mentorship. Low reimbursements are a major driver contributing to extended appointment wait times for pediatric ophthalmology visits at major academic eye centers. Legislative changes at both the federal and state levels are needed to make appropriate increases in reimbursements, starting with states in the lowest quartile of Medicaid reimbursements. [J Pediatr Ophthalmol Strabismus. 2023;60(5):323-329.].

In the Setting of Heightened Economic and Workforce Issues, What Are Third-Year (PGY-4) Ophthalmology Residents' Perspectives of Pediatric Ophthalmology?

PURPOSE: To investigate the factors influencing residents' choice to pursue a pediatric ophthalmology fellowship. METHODS: A nine-question survey was distributed to third-year (PGY-4) ophthalmology residents of United States-based Accreditation Council for Graduate Medical Education residency training programs in ophthalmology. RESULTS: One hundred two of 502 residents completed the survey. Fifty percent of all respondents had no debt and 14.7% had more than $300,000 in debt. Forty-four (43.1%) rated the quality of pediatric ophthalmology teaching in their residency program as "excellent," 37 (36.3%) did not enjoy performing clinical ophthalmologic examinations on children, 83 (81.4%) had a clinical role model in pediatric ophthalmology, 29 (28.4%) believed pediatric ophthalmology is a prestigious subspecialty, 47 (46.1%) reported that economic factors influenced their post-residency decisions, 60 (58.8%) believed a hybrid fellowship combining adult cataract surgery and pediatric ophthalmology would be a popular fellowship, and 58 (56.9%) had a first-year (PGY-2) residency rotation of at least 1 month in pediatric ophthalmology. Enjoying the ophthalmologic examination of children most strongly predicted whether a resident would pursue a pediatric ophthalmology fellowship (Phi = 0.482). CONCLUSIONS: The desire to work with children overwhelmingly superseded other factors influencing a resident's decision to pursue a pediatric ophthalmology fellowship. Improving economic issues may be one of several factors that increase the attractiveness of the pediatric ophthalmology subspecialty. There is a dilemma in encouraging more residents to pursue pediatric ophthalmology in the setting of fewer technological advances consistent with lower perceived prestige. [J Pediatr Ophthalmol Strabismus. 2023;60(2):95-100.].

Practice Patterns of Pediatric Ophthalmologists During the COVID-19 Pandemic.

PURPOSE: To report the use of protective personal equipment (PPE) during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A 12-question multiple-choice survey was posted on a discussion board used by members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). Respondents provided information about their experience, PPE use, office equipment, and approach to care during the COVID-19 pandemic. RESULTS: One hundred twenty-eight pediatric ophthalmologists completed the survey. Eighty-seven (68.0%) identified as in private practice, whereas 41 (32.0%) identified as in an academic setting. Sixty-nine pediatric ophthalmologists (53.9%) reported routinely using N95 respirators, 72 (56.3%) reported wearing medical scrubs, 41 (32.0%) reported using disposable gloves, 33 (25.7%) reported wearing goggles, and 12 (9.4%) reported using face shields during office examinations. One hundred twenty-one pediatric ophthalmologists (94.5%) reported having slit lamps with plastic shields and 52 (40.6%) reported having phoropters with plastic shields. Ninety-nine (77.3%) responded that they would see a patient older than 2 years who refused to wear a mask for a nonemergency visit. CONCLUSIONS: Practice patterns of pediatric ophthalmologists have varied during the COVID-19 pandemic. [J Pediatr Ophthalmol Strabismus. 2022;59(3):145-150.].

The Economic Factors Impacting the Viability of Pediatric Ophthalmology.

PURPOSE: To create a survey that assesses the economic factors impacting the viability of pediatric ophthalmology between January 2021 and July 2022. METHODS: A 12-question survey was distributed to United States-based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus discussion board and various social media fora. Demographic, economic, and workforce pattern data were collected and analyzed. RESULTS: A total of 243 pediatric ophthalmologists completed the survey. One hundred seven (44.0%) respondents reported a surgical revenue decrease between 10% and 25%, 117 (48.1%) a clinical revenue decrease of less than 10%, 111 (45.6%) an overall income decrease of less than 10%, and 127 (52.2%) an overhead cost increase between 10% and 25%. Seventy-two (29.6%) respondents reported subsidizing income with pursuits outside of pediatric ophthalmology, 27 (11.1%) stopped operating due to reimbursement cuts, 75 (30.8%) limited the number of Medicaid or other public funded patients, 16 (6.5%) retired in the past 3 years, and 92 (37.8%) would not recommend a resident pursue a pediatric ophthalmology fellowship. CONCLUSIONS: There is a potential upheaval in the field of pediatric ophthalmology marked by increasing levels of disillusionment among current providers, a progressive decline in the number of trainees pursuing fellowship programs, and workforce issues suggestive of diversification of practice patterns outside of pediatric ophthalmology. The current economic crisis, in conjunction with these complex workforce issues, is and will continue to create a shortage of practicing pediatric ophthalmologists, seriously limiting access to pediatric and adult strabismus eye care. [J Pediatr Ophthalmol Strabismus. 2022;59(6):362-368.].

Economic Impact of the COVID-19 Pandemic Post-Mitigation on Pediatric Ophthalmologists.

PURPOSE: To create a survey to assess the economic impact that the coronavirus disease 2019 (COVID-19) pandemic post-mitigation (post-shutdown) has had on pediatric ophthalmologists. METHODS: A 14-question survey was disseminated to United States-based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) discussion board and on social media. Demographic data and data on the economic effect of the COVID-19 pandemic post-mitigation were collected. RESULTS: A total of 129 pediatric ophthalmologists completed the survey. Eighty-four (65.1%) respondents reported a clinical revenue decrease of greater than 10%, 83 (64.3%) a surgical decrease of greater than 10%, and 66 (51.2%) an income decrease of greater than 10%. Fifteen (11.6%) respondents reported limiting the number of Medicaid patients. This was more prevalent among those in private practice (P = .027). Twenty-seven (20.9%) pediatric ophthalmologists responded that they planned to retire earlier than anticipated because of the pandemic and 2 (1.6%) responded that they have retired since the start of the pandemic. Six (4.7%) respondents reported that they have sold their practice since the start of the COVID-19 pandemic. CONCLUSIONS: Pediatric ophthalmologists continue to face economic challenges introduced by the COVID-19 pandemic. Reduced revenue may represent a new normal for the near future in pediatric ophthalmology. These unprecedented economic upheavals come at a time when the field of pediatric ophthalmology already faces difficulties with low reimbursement and attracting new trainees. This multitude of issues may escalate into a crisis in providing appropriate pediatric ophthalmic care. [J Pediatr Ophthalmol Strabismus. 2022;59(5):291-295.].

Anterior Segment Optical Coherence Tomography in Locating the Insertion of Horizontal Extraocular Muscles After Strabismus Surgery.

PURPOSE: To evaluate the accuracy of anterior segment optical coherence tomography (AS-OCT) for locating horizontal extraocular muscle (EOM) insertion after strabismus surgery. METHODS: The distance from the limbus to the postoperative muscle insertion was measured with calipers intraoperatively and by AS-OCT during the postoperative visit of adults undergoing strabismus surgery. Images were collected by masked technicians. Intraclass correlation coefficients (ICC) were used to evaluate the agreement between measurements. RESULTS: Twenty-eight patients were recruited. Measurements were taken from 31 eyes, including 17 lateral and 14 medial rectus muscles. EOM insertion was successfully identified by AS-OCT for 14 (45%) cases. The ICC between intra-operative and AS-OCT measurement was 0.886 when the distance from the limbus to the insertion of EOM was less than 8 mm and 0.001 when the distance from the limbus was between 8 and 10 mm. EOM insertion was undetectable if distance to the limbus was greater than 10 mm. CONCLUSIONS: AS-OCT can accurately identify post-surgical horizontal muscle insertion if the insertion is less than 8 mm from the limbus. [J Pediatr Ophthalmol Strabismus. 2021;58(1):62-65.].

One muscle strabismus surgery.

PURPOSE OF REVIEW: To describe recent evidence from the literature regarding one muscle strabismus surgery for small- to moderate-angle horizontal deviations. RECENT FINDINGS: The use of one muscle surgery for comitant strabismus had been controversial because of concerns that it may result in a significant number of undercorrections and/or produce ocular incomitance. Recent evidence in unilateral lateral rectus recession for exotropia, unilateral medial rectus recession for esotropia, and unilateral rectus resections for undercorrected or recurrent strabismus and convergence or divergence insufficiency suggests that unilateral rectus muscle surgery is a safe, effective and predictable procedure for small- to moderate-angle horizontal deviations. Future prospective, comparative studies with larger samples in unilateral rectus muscle surgery are still needed. SUMMARY: Unilateral rectus muscle surgery is a safe, effective and predictable treatment for small- to moderate-angle horizontal deviations. This procedure limits surgery to one eye, leaves other muscles untouched for repeat surgery, and therefore, should be considered as a primary or alternative approach in the treatment of small- to moderate-angle strabismus.

Outcome study of unilateral lateral rectus recession for small to moderate angle intermittent exotropia in children.

PURPOSE: To report an outcome study of 100 consecutive children with intermittent exotropia treated by unilateral rectus recession for small to moderate angle exodeviation with a minimum follow-up of 6 months. METHODS: The records of patients with intermittent exotropia younger than 15 years who underwent 7-to-10-mm unilateral lateral rectus recession for exodeviation measuring 15 to 35 prism diopters (PD) from January 2000 to July 2008 were retrospectively reviewed. The surgery were performed accordingly to the amount of distance deviation. A successful alignment was defined as an exodeviation of 5 PD or less and absence of any esotropia in primary and lateral gaze while viewing distant or near targets. RESULTS: Successful alignment was achieved in 99%, 88%, and 76% of patients at early postoperative, 6-month, and final follow-up, respectively. One overcorrected patient had an esodeviation of 20 PD at 6 months. The results of the final follow-up did not depend on age or refraction at the level of 0.05, whereas the amount of initial exodeviation was found to be significantly correlated with success at the final examination (P = .041). There was a positive significant relationship between results at 6 months and final follow-up (P = .000, r = 0.449). Eleven of the 13 patients who had a second surgery and were observed more than 6 months had successful alignment. Eighty-nine percent of the patients achieved a successful outcome with the combined primary and secondary surgery at the final follow-up. CONCLUSION: Unilateral lateral rectus recession is a safe and effective treatment for small to moderate angle intermittent exotropia in children.

Workforce Issues in Pediatric Ophthalmology.

The fate of pediatric ophthalmology may be in jeopardy. For the past 20 years, there has been declining interest in the field compared to other subspecialties in ophthalmology, as fellowship positions and jobs remain unfilled. Of those fellows who do match in pediatric ophthalmology and strabismus, many are international medical graduates who often return to their native countries to practice, further diminishing the supply of pediatric ophthalmologists in the United States. In previous surveys, resident graduates have expressed disinterest in the field, reluctance to work with children, inadequate reimbursements, and insufficient interactions with faculty as reasons not to pursue this subspecialty. Millions of people throughout the United States do not have access to pediatric ophthalmologists, highlighting the issue of unequal distribution. As more pediatric ophthalmologists retire, there is concern that there will not be enough providers to meet the demands of this subspecialty. Although many of these factors deterring residents from entering this field have been resolved, the major issue of financial reimbursements has not been adequately addressed. [J Pediatr Ophthalmol Strabismus. 2020;57(1):9-11.].