Comparison of Congenital Rubella Syndrome Cases at a Philippine Tertiary Hospital from 2009-2012 to 2019-2022

Background and Objective@#The Philippines does not have a national congenital rubella syndrome (CRS) surveillance or registry. Regular monitoring of CRS cases in hospitals, including in a Philippine tertiary hospital, helped in the past to provide clinico-epidemiologic data on CRS. This study aimed to continue providing clinico-epidemiologic data on CRS cases seen in the Philippine tertiary hospital from 2009-2012 and 2019-2022 and compare the cases seen from said timelines.@*Methods@#A cross-sectional study was used, employing chart review of patients newly diagnosed with CRS from 2009-2012 and 2019-2022 in the Department of Ophthalmology and Visual Sciences at the Philippine tertiary hospital.@*Results@#Forty-two patients newly diagnosed with CRS from 2009-2012 and 2019-2022 were included. Only 14 (33%) were serologically-confirmed cases (albeit qualitatively). Median age (first and third interquartile ranges) at consult was 1 year (0.4, 2.5). Twenty-four (57%) patients had maternal history of rashes and/or fever. Trimester of pregnancy when mother became symptomatic was not significantly correlated with chief complaint (p=0.20) and numbers of ophthalmic (p=0.68) and systemic manifestations (p=0.32). Cataract was the most common ophthalmic manifestation present in 40 (95%) patients. Twenty-six (62%) patients had other associated systemic findings of which hearing loss was the most common. Only 29 of 40 patients with cataract underwent lensectomy, with 23 patients having poor visual prognosis prior to surgery (5 with nystagmus alone, 10 with nystagmus and strabismus, and 8 with strabismus alone). @*Discussion@#Using ophthalmic manifestations as primary indicator, this study provided an update on the CRS cases in the country. Laboratory confirmation remains a challenge in diagnosing CRS as the tests are costly and not widely available. There was increase from 2009-2012 compared to 2019-2022 in number of patients who underwent surgical treatment for cataract but visual outcomes were suboptimal due to delay in consultation. Although there was a decrease in number of CRS cases seen in the Philippine tertiary hospital, this cannot be attributed to increased rubella-containing vaccine (RCV) coverage alone. @*Conclusion@#Provision of data from individual hospital-based studies similar to this highlights the need for a national CRS surveillance system or registry. This can better gauge the burden of CRS and identify the gap in RCV coverage.

Effects of prolonged waiting time on visual outcomes of patients with pediatric cataract in a Tertiary Public Hospital

Background@#Pediatric cataract is one of the most common preventable cause of childhood blindness worldwide. Early and timely intervention of pediatric cataract is important to maximize the visual outcomes and start prompt visual rehabilitation.@*Objectives@#This study aimed to determine the average time from the day of initial consult at the outpatient clinic to the day of the cataract surgery and compare the effects of delayed surgery on visual outcomes of patients.@*Methods@#This is a retrospective chart review of medical records from January 2015 to June 2022. The dates of the different steps in the process up to the day of intervention were noted and the average interval duration and the total waiting time were determined. Patients operated on within 2 weeks from initial consult was defined as no delay while those operated >2 weeks had delayed surgery. Pre-operative and post-operative best corrected log MAR visual acuity were compared within each group to determine if delay in surgical intervention has a significant effect on the visual outcomes of patients.@*Results@#Median age at initial consult was 4.9 years while median age at surgery was 5.2 years. Ninety-nine (99) patients had developmental cataract and 123 patients had bilateral cataract. Leukocoria was the most common chief complaint (63.45%). Pre-operatively, 94 patients had strabismus, 49 had eye preference, 48 had nystagmus, and 43 had amblyopia in the diagnosis. There was significantly faster admission to cataract surgery during the pandemic compared to pre-pandemic period but there was no difference in the total waiting time. Patients with congenital cataract had the least total waiting time followed by developmental, and rubella cataract. There is no significant difference in visual outcomes between patients operated without delay and with delay.@*Conclusion@#There is delayed age at diagnosis and surgery of pediatric cataract patients in the Philippine General Hospital. Early surgery did not reflect better visual outcomes compared to delayed surgery probably due to delay in consultation of patients.

Spontaneous consecutive exotropia after conservative management of accommodative esotropia

@#Spontaneous consecutive exotropia (SCXT) in conservatively managed accommodative esotropia is not widely discussed. The author presents a case series of 4 patients with SCXT describing patient characteristics and possible risk factors. Management modifications based on this series are proposed. Four cases of patients who initially presented with accommodative esotropia and later developed SCXT are presented. The age range at presentation was between 4 months to 3 years, with total follow-up ranging between 8–15 years. All four cases presented with esotropia on or before the age of 3 years, with initial hyperopia ranging between +1.50 to +4.25. The SCXT occurred between ages 2–7 years. Possible risk factors identified include amblyopia, dissociated vertical deviation, rapid control of esodeviation, inferior oblique overaction, and poor follow-up during the course of their strabismus. The author recommends earlier tapering of hyperopia correction following initial control with full cycloplegic refraction. Identified risk factors should alert the specialists to be wary of SCXT.

Ocular manifestations of two Filipinos with congenital fibrosis of the extraocular muscles

@#Congenital fibrosis of the extraocular muscles (CFEOM) is a rare, congenital, non-progressive disorder presenting with partial or total ophthalmoplegia, with variable degrees of ptosis in both eyes. We present the clinical manifestations of congenital fibrosis of the extraocular muscles in two patients. Both patients presented with bilateral ptosis and variable ophthalmoplegia with a chin-up posture. The ocular deviations have been noted since birth. No patient demonstrated a Marcus-Gunn jaw-winking phenomenon. Both patients had a mild refractive error with with-the-rule astigmatism. Deviation for both patients revealed exotropia with varying amounts of hypotropia and limitations in the movement of extraocular muscles. Both patients presented no abnormalities in the pupils. Neuroimaging revealed atrophy of the extraocular muscles. Diagnosis of CFEOM in a resource-poor setting is also challenging due to inaccessible gene testing. Manifestations of CFEOM vary across affected patients. CFEOM proposes challenges to the ophthalmologist with regards to management.

Outcome of strabismus surgery for exotropia in a 4-year-old with silver-russell syndrome (SRS): A case report

@#Silver-Russell Syndrome (SRS) is a rare disorder associated with prenatal and postnatal growth retardation with associated characteristic facial and ocular features including strabismus. We report the outcome of strabismus surgery performed for exotropia in a 4-year-old patient with SRS. The patient presented with decreased visual acuity and constant exotropia of the right eye noted since 3 months of age. Systemic SRS characteristics consisted of relative macrocephaly, short stature, forehead prominence and stunted growth pattern. An X-pattern exotropia is consistent with bilateral tight lateral recti muscles with overelevation in adduction of the left eye was present. Patient underwent unilateral right lateral rectus recession and right medial rectus resection for a 50-prism diopter constant exotropia. Patient had a favorable outcome of within 8 prism diopters from orthotropia at 1st, 3rd-, 6th- and 12th-month post-operatively.

Validation of the Filipino translation of the impact of vision impairment for children (IVI_C) questionnaire among school children

Background@#Quality of life questionnaires provide valuable information in assessing the effects of health interventions and public health campaigns. In the Philippines, we only have a few validated questionnaires targeted specifically for children.@*Objective@#To translate to Filipino and validate the translated Impact of Vision Impairment for Children Questionnaire (IVI_C).@*Methods@#This is a translation and validation study of the IVI_C. The IVI_C was translated following international guidelines of forward–translation and back-translation methods. After completion of the Filipino IVI_C version, pretesting was performed on school-aged children 8 to 18 years old through convenience sampling in the outpatient department and Pediatric Ophthalmology and Motility Clinic at Sentro Oftalmologico Jose Rizal, Philippine General Hospital from January 1 to August 31, 2018.@*Results@#We included 130 participants in the study. The calculated Cronbach’s alpha coefficient of 0.88 for the translated Filipino version of the IVI_C suggested high reliability and internal consistency. Rasch analysis showed comparability of the Filipino translation to the original English version of the questionnaire.@*Conclusion@#Our study showed that the Filipino version of IVI_C questionnaire was of high reliability and validity.

Pandemic challenge accepted: The Philippine Board of Ophthalmology shifts to online administration of its certifying examinations

@#The ongoing global COVID-19 pandemic triggered a series of events that resulted in the disruption of the delivery of various certifying examinations including that which was given by the Philippine Board of Ophthalmology (PBO). This paper shares the experience of the PBO using digital technology in administering its first ever online delivery of its certifying examinations. Online platform requirements used for delivering the examination are enumerated, online proctoring described, as well as the conduct of oral panel examinations and skills evaluation via video submission. Challenges encountered, feedback reported by both examinee and examiner, lessons learned from this endeavor, and future directions are discussed.

Long term follow-up of retropupillary fixation of iris-clipped intraocular lens for children with inadequate capsular support

@#Children with weak or absent capsular support requiring lens removal and intraocular lens implantation present as one of the more challenging cases in pediatric ophthalmology practice. The authors present a case series with postoperative follow-up of at least five years after retropupillary fixation of iris-clipped lenses. All cases had improved visual acuity with only minor focal iris atrophy as complication in one case. Retropupillary fixation of iris-clipped IOL should be included in an ophthalmologist's armamentarium when operating on cases with weak or absent capsular support.

Changes in Corneal Topography and Clinical Refraction Following Horizontal Rectus Muscle Surgery

Objectives@#Refractive changes have been studied after muscle surgery in literature but most results are inconsistent. It has been postulated that changes in corneal tension after muscle surgery may cause a change in corneal curvature resulting in the change in refraction postoperatively. This study investigated changes in corneal topography and clinical refraction after horizontal rectus muscle surgery.@*Methods@#Twenty-one eyes of 13 patients underwent horizontal rectus muscle surgery via limbal approach. Manifest refraction, cycloplegic refraction, and corneal topography were measured preoperatively, and postoperatively at day 1 and weeks 1, 2, 4 and 8. The proportion of subjects with at least 0.5 D change from preoperative measurements and the proportion of subjects that needed new prescription postoperative were also computed. Analysis of the results were done using the Friedman test to identify significant differences among measurements at different time periods with post-hoc analysis utilized to identify specific time periods with significant changes from preoperative measurements.@*Results@#Mean corneal keratometry, horizontal, vertical, and oblique astigmatism, obtained topographically showed no significant difference from preoperative measurements. The statistically significant difference in corneal astigmatism in the recession group at day 1, week 4 and week 8 postoperatively was not confirmed when converted to power vectors in both vertical/horizontal (J0) and oblique (J45) astigmatism. Clinical refraction showed a transient myopic shift in spherical equivalent, statistically significant only on postoperative day 1 in the recession group. There was no statistically significant difference in clinical astigmatism. There was ≥ 0.5 D change in spherical equivalent in 60% in both study groups by the end of follow-up. The shift in J0 was more than 10% in the recession group. More than fifty percent (52.4%) needed new prescription for glasses.@*Conclusion@#No statistically significant change in corneal topography and clinical refraction following horizontal rectus muscle surgery were found. Patients should still be refracted at least 2 weeks postoperatively to check if there is a need for change in prescription glasses to improve alignment and/or improve vision.

Postoperative changes in alignment in patients surgically corrected for Esotropia and Exotropia in a Tertiary Government Hospital

Objective@#To compare the postoperative alignment of patients surgically corrected for esotropia or exotropia 6 weeks and 6 months after surgery.@*Method@#This retrospective study reviewed clinical records of patients who underwent horizontal muscle surgery at the University of the Philippines-Philippine General Hospital from 2010 to 2014. The changes in alignment from 1 week to 6 weeks and from 1 week to 6 months after surgery were compared for overcorrection, undercorrection, and adequate correction groups. ANOVA and Pearson correlation were used.@*Results@#Twenty two esotropia and 10 exotropia patients were included. Overcorrected esotropia patients had an esotropic change in alignment (15.50+13.44 PD after 6 weeks, p=0.026; 25+18.38 PD after 6 months, p=0.008). Under corrected esotropia patients had an exotropic change in alignment (-1.25+5.91 PD after 6 weeks, p=0.026;-4.38+14.16 PD after 6 months, p=0.008). Undercorrected exotropia patients had an esotropic change in alignment (6.67+6.35 PD after 6 weeks, p=0.028; 6+9.85 PD after 6 months, p=0.024). The presence of vertical deviations in esotropia caused an exotropic change in alignment after 6 months (p=0.03).@*Conclusion@#Although an exotropic drift is more commonly reported, fusional vergences may account for postoperative alignment changes towards orthotropia.

Translation and validation of a Filipino version of the children’s visual function questionnaire

Objective@#The objectives of this study were to translate into Filipino the Children’s Visual Function Questionnaire for children 3 years and above (CVFQ3plus), and to validate the translated CVFQ3plus to be used locally to assess the quality of life (QoL) of Filipino children aged 3 to 7 years old with visual impairment. @*Methods@#Study Design: The study was a single-center, non-randomized translation and validation study. Translation: The CVFQ3plus translation into Filipino involved translation, reconciliation, pretesting, and small group discussion, based on the KIDSCREEN Group Translation and Validation procedures. Participants and Sampling: Convenience sampling was done to select the participants of the study. Participants were included in the study if they were parents or primary caregivers of children aged 3-7 years old who were noncompliant with treatment and/or those with non-treatable visual impairment defined as mild, moderate, severe unilateral, and severe bilateral. Procedure: All patients underwent complete ophthalmologic examination, including determination of the visual acuity using either the LEA chart or HOTV chart, prior to the administration of both the Filipino and English versions of the CVFQ3plus to their parents or caregivers. Participants were also asked to do a self-rating of their English proficiency, and their preferred version of the CVFQ. Statistical Analysis: Chronbach’s Alpha with a 95% confidence interval was used to determine the validity and internal consistency of the Filipino version of the CVFQ3plus questionnaire.@*Results@#A total of 122 participants were included in the study. Chronbach’s Alpha score (α=0.86, CI=95%) for the translated Filipino version of the CVFQ3plus suggests high reliability and internal consistency, comparable to the original English version of the questionnaire.@*Conclusion@#This study was able to produce a highly reliable and internally consistent Filipino version of the CVFQ3plus.

2014 updated recommendations for preschool vision screening: Guidelines for Filipino children entering the Philippine public school system

@#In 2004, the University of the Philippines Manila published the Philippine Guidelines on Periodic Health Examination (PHEX): Effective Screening for Diseases among Apparently Healthy Filipinos. 1 The document was envisioned to “contribute… to the quality and efficiency of health care and health maintenance for all Filipinos… It was an appeal for rational medical decision-making, and an important step toward “equitable distribution of health and health resources.” The guidelines were prepared by designated task forces, with vision disorders, specifically vision impairment, and glaucoma identified as areas of interest. PHEX recommendations were drafted using standardized principles and a common protocol, with each statement undergoing four phases of development: (1) preparation of the evidence- based draft; (2) en banc meeting that gave panelists a chance to assess and revise the draft, where issues of feasibility, resource limitations, value judgment, and experts’ opinions were taken into account. A consensus was declared when at least 75% agreed on a recommendation; (3) for unresolved issues, modified Delphi technique was employed by correspondence until a consensus was reached or a maximum of three circulations were accomplished. If still unresolved, the issue was labeled as such and included in the final draft; (4) lastly, a public forum was conducted before the final draft was written. In this manner, the recommendations for Screening for Visual Impairment were written by the Task Force for Vision Disorders.

A study protocol on the situational analysis on the current practice of screening and treatment of Retinopathy of Prematurity (ROP)

Objective@#The study protocolaims to provide an overview of the current practice of screening and treatment of ROP in the selected, to estimate the proportion of childhood blindness due to ROP and assess the number of premature babies at risk for ROP.@*Methods@#The study protocol is a descriptive, cross sectional study design using survey questionnaire to be sent out to pediatric ophthalmologists, vitreo-retina specialists and division heads of the neonatal intensive care units of different hospitals in a selected area. Student records and medical abstracts from local schools for the blind will be obtained and will be reviewed. All qualitative data will be reported by frequency distribution and percentages. Extrapolation on the proportion of ROP in the area will be done. @*Conclusion@#Results from the study can show an overview of the current situation of ROP in a selected area and provide the framework for recommendations for programs aimed providing criteria for timely screening and treatment of ROP to prevent complications such as childhood visual impairment and blindness in the country.

Mobius sequence with prenatal exposure to misoprostol

Objective@#To present 3 cases of Möbius sequence exposed in utero to misoprostol and discuss their clinical presentations, etiopathogenesis, and management. @*Methods@#Medical records of 3 patients with Möbius sequence and prenatal exposure to misoprostol were reviewed. Clinical findings were compared with those reported in the literature.@*Results@#Lack of facial-muscle movement, lagophthalmos with secondary exposure keratitis, decreased ability to crease forehead, and shallow nasolabial fold imply facial-nerve dysfunction. Small- and large-angle esotropia and apparent orthotropia with abduction limitation showed varying degrees of abducens nerve involvement. Two patients had early prenatal exposure to misoprostol during the first 3 months of gestation.@*Conclusion@#A history of misoprostol exposure should be routinely elicited from parents of children with Möbius sequence. Associated deficiencies in Möbius sequence and its variants require a multidisciplinary approach.