Current trends among pediatric ophthalmologists to decrease myopia progression-an international perspective.

PURPOSE: To explore what the current worldwide preferred practice patterns of pediatric ophthalmologists are to decrease myopia progression among their patients. METHODS: A questionnaire was sent to all members of supranational and national pediatric ophthalmology and strabismus societies. RESULTS: The questionnaire was fully completed by most respondents 90.10% (847 of 940 responses). Fifty-seven percent (457) routinely treat to decrease myopia progression. The most common parameter to initiate treatment was a myopic increase of 1 diopter/year or more (74.8%, 246). Seventy percent (345) prescribed eye drops. Atropine 0.01% was the most popular (63.4%, 277) followed by atropine 1% (10.9%, 48) and atropine 0.5% (8.9%, 39). Eighty-six percent (394) of the respondents advised to spend more time outdoors, to reduce the amount of time viewing screens (60.2%, 277), and cutback the use of smart phones (63.9%, 294). CONCLUSIONS: Most pediatric ophthalmologists treat to decrease myopia. They employ a wide variety of means to decrease myopia progression. Atropine 0.01% is the most popular and safe modality used similarly to recent reports. However, there is no consensus when treatment should be initiated. Further prospective studies are needed to elucidate the best timing to start treatment and the applicability of recent studies in the Asian population to other ethnic groups. This will improve the ability to update pediatric ophthalmologist with evidenced-based treatment options to counter the myopia epidemic.

Correction to: Current trends among pediatric ophthalmologists to decrease myopia progression-an international perspective.

The published online version contains a mistake in the capturing of figures.

Macular structural characteristics in children with Down syndrome.

PURPOSE: This prospective study aimed to investigate macular structural characteristics in children with Down syndrome compared to those in healthy children. METHODS: Two groups of children (aged 6-16 years) were enrolled: children with Down syndrome (Down syndrome group, N = 17) and age-matched healthy children who were full-term at birth (control group, N = 18). Eligible patients had visual acuity of 20/100 or better and gestational age at birth of ≥ 36 weeks. Fourier domain optical coherence tomography was used for imaging of the macular retinal structure, and retinal volume scans centered on the macula were obtained. Central subfield thickness (CST) and the thickness of the inner and outer retinal layer regions were analyzed using the instrument's segmentation software. The analysis of data is provided for the right eye only, since there was no significant difference between right and left eyes for either the Down syndrome or control groups. RESULTS: Children in the Down syndrome group generally had identifiable retinal structure. The CST for the full retina and inner and outer retinal layers were all significantly greater in the Down syndrome group than the control group (independent t test, all p < 0.05). Despite the significantly thicker macula, only about 29 % (5 of 17) of the right eyes of patients with Down syndrome had macular thickness outside the normal range. Visual acuity in the Down syndrome group was not directly correlated with increased CST (t = 1.288, r = 0.326, p = 0.202). CONCLUSIONS: On average, CST in the Down syndrome group was greater than that in the control group, suggesting abnormal macular development in children with Down syndrome.

Update in pediatric optic neuritis.

PURPOSE OF REVIEW: Pediatric optic neuritis is an uncommon disorder with significant distinctions from its adult counterpart. Recognizing the features of this disorder and the potential association with progressive demyelinating processes is important for patients' evaluation and prognosis. RECENT FINDINGS: In the last few years, studies have expanded our understanding of demographic and presenting features for optic neuritis in the pediatric population. Emerging research on biomarkers and optical coherence tomography utility offers potential prognostic value in patient management. In addition, pooled research data have allowed for better understanding of the risks factors for progression from isolated optic neuritis to systemic demyelinating processes, such as multiple sclerosis. Although definitive evidence is lacking, corticosteroids remain the cornerstone of treatment. Various other immunosuppressive therapy studies have also reported success, particularly in refractory cases. SUMMARY: A comprehensive understanding of pediatric optic neuritis and its management remains elusive. A randomized clinical trial would potentially increase our knowledge and benefit the afflicted patients.

Practice patterns to decrease myopia progression differ among paediatric ophthalmologists around the world.

INTRODUCTION: Myopia is a worldwide epidemic. Plethora of treatments are offered to decrease myopia progression. In this study, we compared between different geographical areas worldwide the practice patterns used by paediatric ophthalmologists to decrease the progression of myopia. METHODS: Global responses to a questionnaire were analysed (n=794) for demographic variations. Pharmacological, optical and behavioural categories were defined as effective or ineffective based on the current scientific peer reviewed literature. RESULTS: Treatment rates varied significantly between geographical regions (mean 57%, range 39%-89%, p<0.001). Nearly all participants who treat myopia used at least one form of effective treatment, regardless of location (98%, p=0.16). Among those prescribing pharmacological treatments, European physicians offered the lowest rate of effective treatment compared with other regions (85% vs mean 97%). Rates of effective optical treatment varied significantly between locations (p<0.001), from 16% (Central-South America) to 56% (Far East). Most treating respondents advocated behavioural modifications (92%), between 87% (North America) and 100% (Central Asia). Nearly all respondents used combinations of treatment modalities (95%)-mostly pharmacological, optical and behavioural combination. However, combination rates varied significantly between regions (p<0.001). DISCUSSION: The utility of treatment to decrease myopia progression differs significantly across the world both in type, combination and efficacy. CONCLUSION: Paediatric ophthalmologists involvement and proficiency in myopia progression treatment varies around the world. This may entail promoting continuous medical education and other incentives to increase the number and proficiency of paediatric ophthalmologist to have a more effective impact to control the myopia epidemic in children.

Standard strabismus surgery in thyroid ophthalmopathy.

INTRODUCTION: Techniques for the surgical treatment of thyroid related strabismus vary and include non-adjustable (standard), [postop'] adjustable suture, and a newer procedure aimed at correcting restriction rather than using dose/response tables.This study reports the results utilizing standard strabismus procedures for the treatment of thyroid ophthalmopathy. METHODS: Charts of 31 consecutive patients who underwent surgery in the pst 5 years for restrictive strabismus secondary to thyroid ophthalmopathy were retrospectively reviewed. All surgery was performed by recession and reattachment of the muscle to the globe, allowing for no postoperative adjustment. Standard doses were used for all primary surgery and slightly modified in some cases of reoperation, but the general principal was from a standard published nomogram. RESULTS: All 31 patients had preoperative diplopia and restricted motility. 22 patients wore prisms prior to surgery. Of the 31 patients who underwent surgery 9 required a second operation. After reoperation 5 patients (16%) continued to have diplopia. However, 4 of these patients were able to achieve single binocular vision with a small amount of prism. Only 2 patients were unable to achieve single binocular vision with or without prism. 22 patients (71%) had full ocular motility after surgery. After one surgery, 25 of 31 patients (81%) were satisfied with the results of surgery. This increased to 29 patients (94%) after reoperation. CONCLUSION: The results of this study indicated that strabismus surgery for restrictive thyroid ophthalmopathy using standard technique and table amounts of surgery can provide excellent results and patient satisfaction.

Accuracy of biometry in pediatric cataract extraction with primary intraocular lens implantation.

PURPOSE: To determine the accuracy of predicted postoperative refractive outcomes in pediatric patients having cataract surgery with intraocular lens (IOL) implantation and to compare them with other variables historically considered important in cataract surgery. SETTING: Tertiary care referral hospital. METHODS: This retrospective review comprised 203 eyes of 153 consecutive pediatric patients (< or = 18 years old) having cataract extraction with primary posterior chamber IOL implantation in the capsular bag. All cases were performed by 1 of 2 surgeons, and all refractions were performed manually by an experienced pediatric ophthalmologist using a retinoscope. RESULTS: In all patients, the mean absolute value (MAE) of the prediction error was 1.08 diopters (D) +/- 0.93 (SD). Age at time of surgery and corneal (K) mean curvature were significantly correlated with the absolute value of the prediction error (P = .0006 and P = .0088, respectively). A multiple regression model showed that age at time of surgery and K mean curvature were the only 2 variables significantly associated with MAE; axial length, formula, surgeon, and A-scan type were not significantly associated with prediction error. CONCLUSIONS: Data from 203 consecutive primary pediatric IOL implantations showed the heterogeneous nature of the variables involved in predictions of refractive outcomes in this population. The complexities of this issue support the need for specific methods of measurement and an IOL calculation formula for the pediatric population.

Immediate Postoperative Alignment Measurements as a Predictor of Alignment Stability in Fixed Suture Strabismus Surgery.

PURPOSE: To evaluate the use of immediate postoperative alignment measurements as a predictor of future alignment stability in fixed suture strabismus surgery. METHODS: Forty-seven patients were prospectively evaluated after undergoing horizontal or vertical rectus muscle surgery using a fixed suture technique. Alignment measurements were taken approximately 1 hour, 1 to 3 weeks, and 2 to 3 months postoperatively. A Spearman correlation coefficient was used to compare measurements from the immediate postoperative period to the 2- to 3-month postoperative period. Patients with dissociated strabismus, only oblique muscle surgery, or poor vision in one or both eyes precluding precise alternate cover test were excluded. RESULTS: Mean age of all patients was 46.7 years (range: 12 to 86 years). Twenty-two patients underwent surgery for exotropia: 19 for esotropia and 6 for hypertropia. Mean alignment for all surgeries was 2 prism diopters (PD) undercorrection in the immediate postoperative period, which was similar to the mean of 4.6 PD undercorrection at 2 to 3 months postoperatively. However, the Spearman correlation between the immediate postoperative and 2- to 3-month postoperative measurements was 0.18 for all surgeries, 0.03 for exotropia, 0.56 for esotropia, and 0.40 for hypertropia. The overall success rate, defined as 8 PD or less of horizontal deviation and 4 PD or less of vertical deviation, was 77% at 2 to 3 months postoperatively. CONCLUSIONS: The relationship between immediate postoperative alignment and future alignment stability in fixed suture strabismus surgery has not been previously defined. The current study demonstrated that although the surgical success rate was reasonably good, poor correlation occurred between the alignment immediately postoperatively and 2 to 3 months postoperatively. [J Pediatr Ophthalmol Strabismus. 2018;55(4):240-244.].

Endoscopic diode laser cyclophotocoagulation in the management of aphakic and pseudophakic glaucoma in children.

INTRODUCTION: Endoscopic cyclophotocoagulation (ECP) has been shown to be a useful adjunct in the management of a variety of difficult pediatric and adult glaucomas. This study reports the efficacy and safety of this procedure for pediatric aphakic and pseudophakic glaucoma. METHODS: ECP was performed on 34 eyes of 25 patients under 16 years of age with aphakic or pseudophakic glaucoma between April 1994 and November 2004. Patients were followed for a minimum of 12 months or until a treatment failure had been declared. Treatment failure was defined as postoperative intraocular pressure (IOP) of >24 mm Hg and IOP lowering of less than 15% despite the addition of glaucoma medications or the occurrence of any visually significant complications. Aphakic eyes of patients with congenital glaucoma or an anterior segment dysgenesis were not included in the study group. RESULTS: Pretreatment IOP averaged 32.6 mm Hg in the 34 eyes, compared with a final postoperative average of 22.9 mm Hg. Mean follow-up period for study eyes was 44.4 months, and the average number of procedures per eye was 1.5. Overall success rate was 53% (18/34). Thirteen of the 34 eyes (38%) received one treatment only and were deemed a success. Retinal detachments developed in two eyes within the first postoperative month. CONCLUSIONS: ECP is a useful tool in the treatment of aphakic and pseudophakic glaucoma, with a low rate of visually significant complications. Retreatment of eyes improved the overall success rate, although experience with cases beyond two treatment sessions is limited. Hypotony was not encountered despite 8 of the 34 eyes receiving 360 degrees of total endocyclophotoablation to the ciliary processes.

Type 4 Duane syndrome.

PURPOSE: To identify cases of synergistic divergence whose characteristics suggest that this entity is a form of Duane syndrome. METHODS: The records of all patients with a Duane syndrome diagnosis, including standardized eye position photographs, from the E-Consultation program of Cybersight, Orbis International were analyzed. RESULTS: A total of 350 Duane syndrome cases were identified. Of these, 19 (5%) had features consistent with synergistic divergence, or type 4 Duane syndrome. Of the 19, 16 (84%) were male, 15 (79%) had palpebral fissure narrowing, all had anomalous head posture, and 18 (95%) were exotropic. Only 9 (47%) patients were reported to have undergone surgery. CONCLUSIONS: Synergistic divergence is a rare entity with features similar to those of Duane syndrome. We suggest that this entity be classified as type 4 Duane syndrome, because it has unique findings and an innervation pattern that differs from the other 3 recognized types.

A pilot randomized clinical trial of intermittent occlusion therapy liquid crystal glasses versus traditional patching for treatment of moderate unilateral amblyopia.

PURPOSE: To compare the effectiveness of intermittent occlusion therapy (IO therapy) using liquid crystal glasses and continuous occlusion therapy using traditional adhesive patches for treating amblyopia. METHODS: Children 3-8 years of age with previously untreated, moderate, unilateral amblyopia (visual acuity of 20/40 to 20/100 in the amblyopic eye) were enrolled in this randomized controlled trial. Amblyopia was associated with strabismus, anisometropia, or both. All subjects had worn any optimal refractive correction for at least 12 weeks without improvement. Subjects were randomized into two treatment groups: a 4-hour IO therapy group with liquid crystal glasses (Amblyz), set at 30-second opaque/transparent intervals (occluded 50% of wear time), and a 2-hour continuous patching group (occluded 100% of wear time). For each patient, visual acuity was measured using ATS-HOTV before and after 12 weeks of treatment. RESULTS: Data from 34 patients were available for analysis. Amblyopic eye visual acuity improvement from baseline was 0.15 ± 0.12 logMAR (95% CI, 0.09-0.15) in the IO therapy group (n = 19) and 0.15 ± 0.11 logMAR (95% CI, 0.1-0.15) in the patching group (n = 15). In both groups improvement was significant, but the difference between groups was not (P = 0.73). No adverse effects were reported. CONCLUSIONS: In this pilot study, IO therapy with liquid crystal glasses is not inferior to adhesive patching and is a promising alternative treatment for children 3-8 years of age with moderate amblyopia.

Strabismus in pediatric pseudophakia.

OBJECTIVE: To evaluate strabismus associated with pediatric pseudophakia. DESIGN: Retrospective case series. PARTICIPANTS: Charts of 94 pediatric patients who underwent cataract extraction with primary intraocular lens implantation from 1990 to 2003 at Indiana University School of Medicine were reviewed. Only those patients who had pre-cataract extraction and post-cataract extraction alignment measurements were included. METHODS: Data were collected on gender, race, age at presentation, age at time of cataract surgery, and type of cataract. Pre-cataract extraction and post-cataract extraction data on visual acuity (VA), alignment, and amblyopia were recorded. Results of strabismus surgery were also evaluated. MAIN OUTCOME MEASURES: Frequency, type and amount of strabismus, and results of strabismus surgery. RESULTS: Ninety-four pediatric pseudophakia patients were identified, and 37 (39%) had strabismus. Exotropia (46%) was more common than esotropia (41%). Factors not associated with the development of strabismus included age at presentation, interval between diagnosis and cataract extraction, race, and type of cataract. Factors statistically associated with the development of strabismus include pre-cataract extraction and post-cataract extraction VA, type of strabismus, and post-cataract extraction amblyopia. The mean pre-cataract extraction deviation of the group that had strabismus surgery was 22 prism diopters, and 75% were aligned at the last examination (mean follow up, 24 months). CONCLUSION: Strabismus occurs more frequently in pseudophakic pediatric patients than in the general pediatric population. Pseudophakic children should be monitored carefully for the development of strabismus, which in many cases can be successfully treated.

Refractive change in pediatric pseudophakia: 6-year follow-up.

PURPOSE: To evaluate the long-term evolution of refractive error changes in eyes of children who have primary intraocular lens (IOL) implantation to allow more accurate prediction of what IOL power should be implanted at a given age. SETTING: Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana, USA. METHODS: This study comprised all children between 2 and 15 years of age who had posterior chamber IOL implantation and who were followed for a minimum of 4 years postoperatively. Thirty-eight eyes of 27 patients with a mean follow-up of 6.1 years were evaluated. All refractions were performed manually by an experienced pediatric ophthalmologist. RESULTS: Children operated on at age 2 or 3 years had a mean myopic shift of 4.60 diopters (D) (range 0.50 to 10.75 D) over a mean of 5.8 years postoperatively. Children operated on at age 6 or 7 years had a mean myopic shift of 2.68 D (range 0.50 to 6.60 D) over a mean of 5.3 years. Children operated on at age 8 or 9 years had a mean myopic shift of 1.25 D (range -0.75 to 2.60 D) over a mean of 6.8 years. Patients operated on between ages 10 and 15 years had a mean shift of 0.61 D (range 0 to 1.90 D) over a mean of 5.7 years. CONCLUSIONS: The mean rate of myopic shift decreased throughout childhood, and the range of shift among individuals narrowed as patient age increased. However, the ability to predict future myopic shift for a given individual remains difficult, especially in younger patients.

Astigmatism after small-incision clear corneal cataract extraction and intraocular lens implantation in children.

PURPOSE: To investigate the magnitude of postoperative astigmatism in children having cataract extraction with intraocular lens (IOL) implantation through a 3.0 mm superior clear corneal incision. SETTING: Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana, USA. METHODS: This retrospective chart review comprised all pediatric patients having cataract surgery with IOL implantation through a 3.0 mm clear corneal incision from 1997 to 2002. One hundred two eyes of 75 patients were included. All refractions were performed manually by an experienced pediatric ophthalmologist. RESULTS: The mean postoperative retinoscopic cylinder in all patients was 0.63 diopter (D) (range 0.0 to 4.50 D) at 1 month, 0.40 D (range 0.0 to 1.75 D) at 6 months, and 0.51 D (range 0.0 to 2.50 D) at 1 year. Patients aged 0 to 36 months at the time of surgery had a mean postoperative cylinder of 0.22 D at 1 month, 0.03 D at 6 months, and 0.21 D at 1 year. Patients between 36 months and 6 years of age at surgery had a mean refractive cylinder of 0.50 D, 0.38 D, and 0.75 D, respectively. Patients older than 6 years at surgery had a mean refractive cylinder of 0.94 D, 0.75 D, and 0.76 D, respectively. CONCLUSIONS: Small-incision clear corneal cataract extraction with IOL implantation in children led to minimal postoperative astigmatism that remained stable over time. Less astigmatism was observed in children having surgery before they were 36 months old.