Overminus Lens Therapy for Children 3 to 10 Years of Age With Intermittent Exotropia: A Randomized Clinical Trial.

IMPORTANCE: This is the first large-scale randomized clinical trial evaluating the effectiveness and safety of overminus spectacle therapy for treatment of intermittent exotropia (IXT). OBJECTIVE: To evaluate the effectiveness of overminus spectacles to improve distance IXT control. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial conducted at 56 clinical sites between January 2017 and January 2019 associated with the Pediatric Eye Disease Investigator Group enrolled 386 children aged 3 to 10 years with IXT, a mean distance control score of 2 or worse, and a refractive error between 1.00 and -6.00 diopters (D). Data analysis was performed from February to December 2020. INTERVENTIONS: Participants were randomly assigned to overminus spectacle therapy (-2.50 D for 12 months, then -1.25 D for 3 months, followed by nonoverminus spectacles for 3 months) or to nonoverminus spectacle use. MAIN OUTCOMES AND MEASURES: Primary and secondary outcomes were the mean distance IXT control scores of participants examined after 12 months of treatment (primary outcome) and at 18 months (3 months after treatment ended) assessed by an examiner masked to treatment group. Change in refractive error from baseline to 12 months was compared between groups. Analyses were performed using the intention-to-treat population. RESULTS: The mean (SD) age of 196 participants randomized to overminus therapy and 190 participants randomized to nonoverminus treatment was 6.3 (2.1) years, and 226 (59%) were female. Mean distance control at 12 months was better in participants treated with overminus spectacles than with nonoverminus spectacles (1.8 vs 2.8 points; adjusted difference, -0.8; 95% CI, -1.0 to -0.5; P < .001). At 18 months, there was little or no difference in mean distance control between overminus and nonoverminus groups (2.4 vs 2.7 points; adjusted difference, -0.2; 95% CI, -0.5 to 0.04; P = .09). Myopic shift from baseline to 12 months was greater in the overminus than the nonoverminus group (-0.42 D vs -0.04 D; adjusted difference, -0.37 D; 95% CI, -0.49 to -0.26 D; P < .001), with 33 of 189 children (17%) in the overminus group vs 2 of 169 (1%) in the nonoverminus group having a shift higher than 1.00 D. CONCLUSIONS AND RELEVANCE: Children 3 to 10 years of age had improved distance exotropia control when assessed wearing overminus spectacles after 12 months of overminus treatment; however, this treatment was associated with increased myopic shift. The beneficial effect of overminus lens therapy on distance exotropia control was not maintained after treatment was tapered off for 3 months and children were examined 3 months later. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02807350.

Case Series: Pediatric Herpes Simplex Keratitis.

SIGNIFICANCE: Although the clinical appearance of pediatric ocular herpes simplex virus (HSV) is similar in children and adults, there is evidence that stromal disease and recurrences are more common in pediatric patients. Misdiagnosis of these patients is common, and patients can develop corneal scarring and amblyopia. PURPOSE: This case series will review important clinical concepts on pediatric ocular HSV including differences in presentation and current treatment recommendations. CASE REPORTS: Three pediatric patients with HSV keratitis are presented: a 6-year-old girl who was treated for unilateral disease over the course of 3 years, a 7-year-old boy who presented with bilateral disease, and a 3-year-old girl in whom the diagnosis was not apparent initially. All patients were successfully treated with oral acyclovir and topical steroids. One patient was also treated with topical antivirals. CONCLUSIONS: Pediatric HSV keratitis should be considered as a differential diagnosis in pediatric patients who present with keratitis. Accurate diagnosis of these patients is important so that amblyopia does not develop. Pediatric ocular HSV patients can be successfully treated with topical and/or oral medications, although their treatment duration may be 12 months or longer.

Pediatric acquired brain injury.

BACKGROUND: Although pediatric patients are sometimes included in studies about visual problems in patients with acquired brain injury (ABI), few studies deal solely with children. Unlike studies dealing with adult patients, in which mechanisms of brain injury are divided into cerebral vascular accident (CVA) and traumatic brain injury (TBI), studies on pediatric patients deal almost exclusively with traumatic brain injury, specifically caused by accidents. CASE REPORT: Here we report on the vision problems of 4 pediatric patients, ages 3 to 18 years, who were examined in the ophthalmology/optometry clinic at a children's hospital. All patients had an internally caused brain injury and after the initial insult manifested problems in at least one of the following areas: acuity, binocularity, motility (tracking or saccades), accommodation, visual fields, and visual perceptual skills. CONCLUSION: Pediatric patients can suffer from a variety of oculo-visual problems after the onset of head injury. These patients may or may not be symptomatic and can benefit from optometric intervention.

An analysis of vision screening data from New York City public schools.

OBJECTIVE: This study compares different vision screening batteries and documents the failure rates of different vision tests in children who receive periodic vision screenings. METHODS: Vision screenings were conducted on 1,992 preschool through fifth grade children attending schools in lower socioeconomic areas in New York City. The screening battery incorporated visual acuity, retinoscopy, cover test, stereopsis, near point of convergence, ocular motility, accommodation, color vision, and ocular health. RESULTS: Slightly less than one third (30%) of the children screened failed the State University of New York (SUNY) battery and were referred for a comprehensive examination, of which 249 (41%) children actually passed distance visual acuities. The referral rate for distance visual acuity alone was 19%. The referral rate for the Modified Clinical Technique (MCT) was 22%. A greater percentage (33%) of the children in grades kindergarten through fifth were referred compared with the preschoolers (20%). Only a small percentage (8%) of the children wore corrective lenses at the time of testing. There was a significant increase in the prevalence of binocular vision problems found in children from grades kindergarten through 5. CONCLUSIONS: Poor visual acuity and binocular vision problems exist in schoolchildren despite ongoing vision screenings. The results provide evidence for the necessity of periodic rescreening starting in kindergarten and the importance of screening for hyperopia and binocular vision problems in addition to distance visual acuities.

Ptosis and cranial nerve IV palsy reveal juvenile myasthenia gravis.

BACKGROUND: Ptosis and strabismus are 2 common presenting complaints of preschool-age patients. In both cases, these conditions can be benign and require no further workup. However, sudden onset of these findings can indicate a more serious neurologic problem. If a patient presents with multiple neurologic signs, a sudden onset eye turn, or ptosis, the patient must undergo a workup to rule out a pathologic etiology, specifically a brain tumor. The workup should include neuroimaging. If the results of the neuroimaging are normal, and the findings are variable, myasthenia gravis should be considered, and additional testing should be ordered to assist in the diagnosis. CASE REPORT: This case report presents a 3-year-old boy who presented with a sudden onset of ptosis and hypertropia. Diagnosis of myasthenia gravis was made based on clinical presentation and response to ice pack testing. The patient was treated with pyridostigmine (Mestinon; Valent Pharmaceuticals, Costa Mesa, California) and has shown improvement in his clinical signs. CONCLUSIONS: Although rare, myasthenia should be considered a diagnosis in children who present with variable ptosis or strabismus. Patients can be successfully treated with medication.

A warfarin-induced subconjunctival hemorrhage.

BACKGROUND: Patients who are on warfarin therapy may present with a variety of ocular side effects, particularly hemorrhages. These ocular events may be the only indication that the patient is at risk for serious sequelae, including hemorrhagic stoke. CASE REPORT: A 76-year-old patient, taking warfarin, presented with a subconjunctival hemorrhage. Four days later the hemorrhage worsened, and the patient developed a headache. Blood testing revealed an elevated International Normalization Ratio (INR) and prothrombin time (PT). The patient's primary care physician adjusted the patient's medication dosage, and the patient's signs and symptoms improved. CONCLUSIONS: Patients on warfarin therapy who present with ocular bleeding require immediate blood work and consultation with their primary care provider or cardiologist. The optometrist should be aware of the ocular and systemic sequelae of warfarin, its possible drug interactions, and potential controversies regarding cataract surgery in these patients.

Blurred vision during airline flight reveals prolactinoma.

BACKGROUND: Pituitary adenomas can manifest with a variety of endocrinologic signs and symptoms, including amenorrhea, galactorrhea, infertility, and acromegaly. Because of the anatomic location of the pituitary gland, and its proximity to the optic chiasm and cavernous sinuses, pituitary adenomas can also result in decreased visual acuity, diplopia, ophthalmoplegia, visual-field loss, and optic atrophy. In general, these tumors are slow-growing. However, there are reports in the medical literature of patients with previously undiagnosed brain tumors in whom neurological signs suddenly developed when in higher altitudes. CASE REPORT: A 47-year-old woman came in for an evaluation of a one-month history of blurry peripheral vision that occurred during-then persisted following--an international flight. Examination and automated visual-field testing revealed a decrease in her best-corrected visual acuity and a bi-temporal hemianopsia. Subsequent examinations by a neurologist and endocrinologist revealed a significant pituitary adenoma-specifically, a prolactinoma. The patient was treated with bromocriptine and has shown a rapid improvement in her visual field and a regression of the tumor, as evidenced by a repeat MRI. CONCLUSION: In this case, the sudden development of the patients symptoms during an airline flight, and the persistence of the symptoms after landing, resulted in the discovery of a prolactinoma.