A Pilot Randomized Clinical Trial of Base-in Relieving Prism Spectacle Treatment of Intermittent Exotropia.

SIGNIFICANCE: This pilot randomized trial, the first to evaluate a specific base-in relieving prism treatment strategy for childhood intermittent exotropia, did not support proceeding to a full-scale clinical trial. Defining and measuring prism adaptation in children with intermittent exotropia are challenging and need further study. PURPOSE: This study aimed to determine whether to proceed to a full-scale trial of relieving base-in prism spectacles versus refractive correction alone for children with intermittent exotropia. METHODS: Children 3 years old to those younger than 13 years with distance intermittent exotropia control score of ≥2 points on the Intermittent Exotropia Office Control Scale (Strabismus 2006;14:147-150; 0 [phoria] to 5 [constant]), ≥1 episode of spontaneous exotropia, and 16 to 35∆ by prism-and-alternate-cover test, who did not fully prism adapt on a 30-minute in-office prism-adaptation test were randomized to base-in relieving prism (40% of the larger of distance and near exodeviations) or nonprism spectacles for 8 weeks. A priori criteria to conduct a full-scale trial were defined for the adjusted treatment group difference in mean distance control: "proceed" (≥0.75 points favoring prism), "uncertain" (>0 to <0.75 points favoring prism), or "do not proceed" (≥0 points favoring nonprism). RESULTS: Fifty-seven children (mean age, 6.6 ± 2.2 years; mean baseline distance control, 3.5 points) received prism (n = 28) or nonprism (n = 29) spectacles. At 8 weeks, mean control values were 3.6 and 3.3 points in prism (n = 25) and nonprism (n = 25) groups, respectively, with an adjusted difference of 0.3 points (95% confidence interval, -0.5 to 1.1 points) favoring nonprism (meeting our a priori "do not proceed" criterion). CONCLUSIONS: Base-in prism spectacles, equal to 40% of the larger of the exodeviations at distance or near, worn for 8 weeks by 3- to 12-year-old children with intermittent exotropia did not yield better distance control than refractive correction alone, with the confidence interval indicating that a favorable effect of 0.75 points or larger is unlikely. There was insufficient evidence to warrant a full-scale randomized trial.

A Randomized Trial of Binocular Dig Rush Game Treatment for Amblyopia in Children Aged 7 to 12 Years.

PURPOSE: To compare visual acuity (VA) improvement in children aged 7 to 12 years with amblyopia treated with a binocular iPad game plus continued spectacle correction vs. continued spectacle correction alone. DESIGN: Multicenter randomized clinical trial. PARTICIPANTS: One hundred thirty-eight participants aged 7 to 12 years with amblyopia (33-72 letters, i.e., approximately 20/200 to 20/40) resulting from strabismus, anisometropia, or both. Participants were required to have at least 16 weeks of optical treatment in spectacles if needed or demonstrate no improvement in amblyopic-eye visual acuity (VA) for at least 8 weeks prior to enrollment. METHODS: Eligible participants (mean age 9.6 years, mean baseline VA of 59.6 letters, history of prior amblyopia treatment other than spectacles in 96%) were randomly assigned to treatment for 8 weeks with the dichoptic binocular Dig Rush iPad game (prescribed for 1 hour per day 5 days per week) plus spectacle wear if needed (n = 69) or continued spectacle correction alone if needed (n = 69). MAIN OUTCOME MEASURES: Change in amblyopic-eye VA from baseline to 4 weeks, assessed by a masked examiner. RESULTS: At 4 weeks, mean amblyopic-eye VA letter score improved from baseline by 1.3 (2-sided 95% confidence interval [CI]: 0.1-2.6; 0.026 logMAR) with binocular treatment and by 1.7 (2-sided 95% CI: 0.4-3.0; 0.034 logMAR) with continued spectacle correction alone. After adjusment for baseline VA, the letter score difference between groups (binocular minus control) was -0.3 (95% CI: -2.2 to 1.5, P = 0.71, difference of -0.006 logMAR). No difference in letter scores was observed between groups when the analysis was repeated after 8 weeks of treatment (adjusted mean: -0.1, 98.3% CI: -2.4 to 2.1). For the binocular group, adherence data from the iPad indicated that slightly more than half of the participants (58% and 56%) completed >75% of prescribed treatment by the 4- and 8-week visits, respectively. CONCLUSIONS: In children aged 7 to 12 years who have received previous treatment for amblyopia other than spectacles, there was no benefit to VA or stereoacuity from 4 or 8 weeks of treatment with the dichoptic binocular Dig Rush iPad game.

Home tonometry in childhood glaucoma: clinical indications and physician and parental attitudes.

Home rebound tonometry is a beneficial tool for the management of childhood glaucoma, yet is not commonly used. In this study, 29 childhood glaucoma patients were recruited for twice daily home intraocular pressure (IOP) monitoring using an Icare rebound tonometer. Home rebound tonometry data prompted and/or validated glaucoma-related surgery in 16 patients (55%) and medication change in 22 patients (76%). According to survey responses, 84% of parents or patients (n = 83) would be interested in home tonometry, and 80% of physicians (n = 48) agreed that home tonometry would improve their ability to manage patients; however, only 14% of physicians currently lend tonometers for this purpose, largely due to financial concerns.

Comparison of Objective and Subjective Techniques of Strabismus Measurement in Adults With Normal Retinal Correspondence.

PURPOSE: Accurate measurement of strabismus is vital to proper diagnosis and treatment. Objective and subjective measurement techniques can be used. The authors hypothesized that subjective measurement techniques would measure larger deviations than objective ones. METHODS: Adults with strabismus, visual acuity greater than 20/50 in each eye, and normal retinal correspondence were measured in primary gaze at distance and near using the alternate prism and cover test and the red glass test. RESULTS: Seventy-three patients were prospectively enrolled. Objective mean deviations were 9.1 (distance horizontal), 5.1 (distance vertical), 10.0 (near horizontal), and 2.6 (near vertical) prism diopters (PD). Subjective mean deviations were 10.2 (distance horizontal), 6.8 (distance vertical), 12.2 (near horizontal), and 3.2 (near vertical) PD. Subjective measurements were larger by a statistically significant margin and were more likely to show the presence of a vertical deviation not measured objectively (19 occurrences vs 2 at near, P = .008; 15 occurrences vs 0 at distance, P = .004). The measured deviations were within 5 PD horizontally and 3 PD vertically most of the time (range: 66.7% to 83.6%). CONCLUSIONS: The red glass test was more likely to measure a larger deviation at distance and near and to identify a vertical deviation not seen objectively at both distance and near. The mean difference between the tests was usually not large enough to affect surgical treatment, but could potentially result in different amounts of prescribed prism for patients treated optically. [J Pediatr Ophthalmol Strabismus. 2017;54(4):216-220.].

Long-term home monitoring of intraocular pressure in pediatric glaucoma.

PURPOSE: Diurnal fluctuation of intraocular pressure (IOP), implicated in progression of adult glaucoma, has been reported in children only in the context of office and short-term home monitoring. The purpose of this study was to evaluate long-term patterns of IOP fluctuation and changes resulting from outflow-enhancing intervention in pediatric glaucoma. METHODS: Parent-measured home-based rebound tonometry (Icare, Finland Oy) in pediatric glaucoma patients was studied prospectively. IOP was monitored for more than 1 month, with requested measurements at least 3 times daily. Demographic and glaucoma-related information were collected for each participant. IOP was recorded at home on electronic data sheets. It was then evaluated for trends including mean overall IOP, IOP pre- and post-planned IOP-lowering interventions, and IOP spikes over determined time intervals. RESULTS: IOP was measured in 14 eyes of 7 children (mean age, 9.3 ± 2.4 years) over a mean of 164.3 days (range, 75-341), with a mean of 2.46 readings daily. Six eyes of 5 children underwent attempted outflow improvement, with improved mean IOP before versus after intervention (26.6 vs 15.5 mm Hg, P < 0.0001) and decreased mean daily IOP fluctuation (8.4 vs 4.6 mm Hg, P < 0.001) for each. An IOP reading 20% greater than mean for an individual eye over the entire period (a pressure "spike") occurred in 19.3 ± 6.7% over 1 day, 62.9 ± 18.0% over 3 days, 80.8 ± 12.2% over 7 days, and 92.9 ± 9.4% over 14 days. CONCLUSIONS: Long-term home monitoring in pediatric glaucoma proved feasible in this study population and often demonstrated large IOP fluctuations. A 14-day period of home monitoring provided >90% chance of identifying an IOP spike. Successful outflow improvement lowered both mean IOP and mean daily IOP fluctuations.