Developmental Improvement in Children With Intellectual Disability After Photorefractive Keratectomy for Severe Isoametropia.

PURPOSE: To assess the impact of refractive error correction from photorefractive keratectomy on development in children with severe isoametropia, subnormal visual acuity, and intellectual disability unable to use refraction correction. DESIGN: Prospective noncomparative interventional case series. METHODS: Before and after photorefractive keratometry (PRK), subjects who had plateaued developmentally for 18 or more months were assessed using a battery of developmental tests. The primary outcome measure was the change in the developmental quotient (DQ) 6 months after PRK. Secondary outcomes were the change in the DQ, uncorrected visual acuity, cycloplegic refraction, and corneal status 12, 24, and 36 months after PRK. RESULTS: Sixteen subjects aged 2 to 8 years were included. Twelve were highly myopic (mean, -9.69 ± 3.82 diopters [D]), 3 highly hyperopic (mean, +5.75 ± 0.59 D) and 1 highly astigmatic (mean, +3.50 D). Six months after PRK, the DQ significantly improved for expressive communication (mean, 4.51 ± 2.27 months; P = .04), interpersonal relationships (mean, 9.45 ± 4.18 months; P = .02) and coping (mean, 6.44 ± 2.10 months; P = .05). Twelve months after PRK, the DQ significantly improved for receptive communication (8.04 ± 1.80 months; P < .001), expressive communication (6.99 ± 2.27 months; P < .05), written communication (9.28 ± 3.72 months; P < .04), domestic skills (6.50 ± 2.43 months; P < .03), interpersonal relationships (10.57 ± 4.17 months; P < .02), and coping (8.41 ± 3.25 months; P < .5). CONCLUSIONS: PRK significantly improves developmental abilities of children with intellectual disability, severe isoametropia, and previously plateaued development, in addition to improving visual acuity and refractive error.

Severe congenital chorioretinitis caused by congenital lymphocytic choriomeningitis virus infection.

PURPOSE: To describe a case of congenital lymphocytic choriomeningitis virus (LCMV), a potentially severe and under-diagnosed etiology of congenital chorioretinitis. OBSERVATIONS: A 5-month old boy presented with esotropia. Examination revealed light perception vision in the right eye and normal fixation and following behavior in the left eye, and a 50PD esotropia with full versions. The external, anterior segment, and pupil exams were normal. Fundus examination demonstrated slightly pale optic nerves, numerous geographic atrophic and hyperpigmented lesions along the vascular arcades in both eyes that extended into the fovea of the right eye. Head computed tomography (CT) imaging demonstrated bilateral cerebral volume loss with consequential ex vacuo dilation of the lateral ventricles and scattered intracranial calcifications. Serum IgG and IgM titers for toxoplasmosis, rubella, cytomegalovirus (CMV), herpes simplex virus (HSV), syphilis, and zika were all negative. Upon communication of negative TORCHS titers, the mother recalled a severe rat infestation of their home during the pregnancy. A LCMV antibody titer was then ordered and which resulted positive for IgG antibodies. CONCLUSIONS AND IMPORTANCE: Congenital LCMV infection is an under-recognized cause of congenital chorioretinitis.

Strabismus surgical time-out: an illustrated whiteboard modification.

BACKGROUND: Errors in strabismus surgery-including wrong eye, wrong muscle, and wrong procedure-can occur when there is confusion about the surgical plan among members of the surgical team, including surgeons, anesthesia staff, nurses, and technicians. The purpose of this study was to assess whether implementation of a strabismus-specific whiteboard combined with oral statement of the surgical plan using nonophthalmological terminology could improve communication among the team before commencement of surgery. METHODS: A strabismus-specific whiteboard with labeled diagram of the eyes and extraocular muscles was designed. Patient identifiers, diagnosis, deviation, and procedure name were included. This whiteboard was completed preoperatively and referenced during time-out. The surgeons and operating room staff were trained in its use, and surveys were completed before and 6 months after implementation of the whiteboard time-out. RESULTS: The pre-implementation survey was completed by 19 operating room staff members, of whom 15 completed the post-implementation survey. The strabismus specific whiteboard increased staff member understanding of procedure laterality (74% to 93%), muscle(s) to be operated (37% to 93%), and specific procedure(s) planned (37% to 87%). Surgeon surveys also showed increased confidence in staff member understanding of each parameter with whiteboard use. CONCLUSIONS: A standardized time-out combined with an illustrated strabismus surgery whiteboard improves communication between team members and has the potential to reduce surgical errors.

Novel finding of atrophic extraocular muscles in Loeys-Dietz syndrome: a case report and review of the literature.

A 19-year-old man with Loeys-Dietz syndrome and right exotropic Duane syndrome after bilateral lateral rectus recessions at age 22 months presented with recurrent progressive exotropia 17 years after his initial surgery. Surgical correction was aborted intraoperatively when extreme atrophy of the right medial rectus, lateral rectus, and superior rectus muscles was observed, later corroborated by orbital magnetic resonance imaging.

A survey of ophthalmology residents' attitudes toward pediatric ophthalmology.

PURPOSE: To assess the level of ophthalmology resident interest in pediatric ophthalmology. METHODS: An 18-item 5-point Likert scale was used to determine interest in pediatric ophthalmology among ophthalmology residents in the United States. RESULTS: The response rate was 23% (316 of 1,341). Of the respondents, 74% agreed they had a clinical role model in pediatric ophthalmology, 66% perceived a good job market for this field, and 67% cited liking strabismus surgery. The majority of residents (56%) found pediatric patients difficult to examine and 50% stated income levels for pediatric ophthalmologists are low. CONCLUSIONS: Although most residents have an overall positive view about pediatric ophthalmology, few indicate interest in pursuing a fellowship. Specifically, most residents reported having a clinical role model in pediatric ophthalmology, perceiving a good job market, and liking strabismus surgery, whereas few residents had interest in further pediatric training and many found pediatric patients difficult to examine and income levels low.

Cul-de-sac incision for strabismus surgery in older patients.

INTRODUCTION: A limbal surgical approach for strabismus surgery is often recommended for older patients, in the belief that the conjunctiva of older patients is too thin and prone to tear during surgery performed through a cul-de-sac incision. The purpose of this study was to evaluate the use of the cul-de-sac approach in patients more than 40 years of age. METHODS: This is a retrospective analysis of consecutive patients more than 40 years of age who underwent strabismus surgery using a modified cul-de-sac approach to reduce manipulation of the conjunctiva during surgery. RESULTS: A total of 32 cul-de-sac incisions were used to operate on 37 muscles in 19 consecutive patients more than 40 years old. The man age was 58 yeasr (41-77 years) with 8 patients (12 incisions) more than 60 years old. Absorbable sutures were used to close 28 of the incisions, with 19 incisions requiring 1 suture, 7 requiring 2 sutures, and 2 incisions in 2 patients requiring more than 2 sutures. Tears resulting in extension of the conjunctival incision occurred in several patients, but no other complications were encountered. One week following surgery, 28 (87.5%) of the incisions were well closed, while a small opening was noted with 4 (12.5%) of the incisions, but none required further intervention, and all healed well. CONCLUSION: Strabismus surgery can be performed through a cul-de-sac incision in older patients. Slight modifications of the surgical technique to prevent excessive manipulation of the incision and to reduce the risk of tearing the conjunctiva are helpful. The cul-de-sac approach offers some important potential advantages to older patients undergoing strabismus surgery.

Corneal indices following photorefractive keratectomy in children at least 5 years after surgery.

PURPOSE: To evaluate long-term corneal outcomes in pediatric patients who underwent photorefractive keratotomy (PRK) for the treatment of refractive amblyopia. METHODS: In this prospective interventional case series, children with refractive amblyopia underwent PRK between January 1, 2007, and December 31, 2011, at Texas Children's Hospital's Department of Ophthalmology, a single tertiary eye center, and were followed for at least 5 years after surgery. Main outcome measures were 5+ years postoperative indices of corneal thickness, keratometry, degree of corneal haze, and presence or absence of keratectasia. RESULTS: Twelve eyes of 8 subjects aged 3-9 years who underwent PRK and were followed for at least 5 years were included. The mean PRK treatment dose was 8.46 D for the myopic cohort and 4.49 D for the hyperopic cohort, which removed an average of 72 µm of corneal stromal tissue in addition to the 50 µm of corneal epithelium that was removed prior to laser ablation. The mean corneal thickness was 563 µm preoperatively, which decreased to 441 µm immediately following the PRK. The mean corneal thickness 5+ years after PRK was stable, at 498 µm, because of epithelial regrowth. None of the subjects developed visually significant corneal haze or topographic evidence of keratectasia. CONCLUSIONS: In this study cohort, there were no topographic signs of keratectasia or corneal haze in children treated with PRK for high refractive error 5 years or more after surgery.

Band keratopathy in children previously treated with diode laser for type 1 retinopathy of prematurity.

Band keratopathy is a corneal degeneration caused by chronic inflammation, systemic abnormalities, or, rarely, a primary biallelic SLC4A4 mutation leading to calcium hydroxyapatite deposition in Bowman's layer. We report a series of 16 eyes of 10 children with a remote history of diode laser treated retinopathy of prematurity who developed late-onset band keratopathy without evidence of other prior risk factors. The majority of patients developed band keratopathy bilaterally. Five eyes had visually significant central band keratopathy that required treatment with disodium ethylenediaminetetracetic acid (EDTA) chelation or phototherapeutic keratectomy. Band keratopathy may be an underreported late ophthalmic complication of diode-laser treated retinopathy of prematurity.

Cortical Visual Impairment in Congenital Cytomegalovirus Infection.

PURPOSE: To describe the presentation, evolution, and long-term outcome of cortical visual impairment (CVI) in patients with symptomatic congenital cytomegalovirus (CMV) infection, and to identify risk factors for the development of CVI in patients with symptomatic congenital CMV. METHODS: Retrospective subanalysis of a long-term prospective cohort study with data gathered from 1982 to 2013. RESULTS: Eleven of 77 (14.3%) patients with symptomatic CMV, 0 of 109 with asymptomatic CMV, and 51 control patients had CVI. Overall, patients with symptomatic CMV had worse vision than patients with asymptomatic CMV, who in turn had worse vision than control patients. Microcephaly, intracranial calcification, dilatation of ventricles, encephalomalacia, seizure at birth, optic atrophy, chorioretinitis/retinal scars, strabismus, and neonatal onset of sensorineural hearing loss were risk factors associated with CVI. CONCLUSIONS: CVI may result from symptomatic congenital CMV infection. The relationship of CVI and its risk factors in patients with CMV suggests the potential to predict the development of CVI through predictive modeling in future research. Early screening of CVI in children born with symptomatic congenital CMV can facilitate educational, social, and developmental interventions. [J Pediatr Ophthalmol Strabismus. 2019;56(3):194-202.].

Neural Plasticity Following Surgical Correction of Strabismus in Monkeys.

Purpose: Although widely practiced, surgical treatment of strabismus has varying levels of success and permanence. In this study we investigated adaptive responses within the brain and the extraocular muscles (EOM) that occur following surgery and therefore determine long-term success of the treatment. Methods: Single cell responses were collected from cells in the oculomotor and abducens nuclei before and after two monkeys (M1, M2) with exotropia (divergent strabismus) underwent a strabismus correction surgery that involved weakening of the lateral rectus (LR) and strengthening of the medial rectus (MR) muscle of one eye. Eye movement and neuronal data were collected for up to 10 months after surgery during a monocular viewing smooth-pursuit task. These data were fit with a first-order equation and resulting coefficients were used to estimate the population neuronal drive (ND) to each EOM of both eyes. Results: Surgery resulted in a ∼70% reduction in strabismus angle in both animals that reverted toward presurgical misalignment by approximately 6 months after treatment. In the first month after surgery, the ND to the treated MR reduced in one animal and ND to the LR increased in the other animal, both indicating active neural plasticity that reduced the effectiveness of the treatment. Adaptive changes in ND to the untreated eye were also identified. Conclusions: Active neural and muscle plasticity corresponding to both the treated and the untreated eye determines longitudinal success following surgical correction of strabismus. Outcome of surgical treatment could be improved by identifying ways to enhance "positive" adaptation and limit "negative" adaptation.

Heart rate variability changes and its association with the development of severe retinopathy of prematurity.

PURPOSE: To evaluate differences in autonomic nervous system (ANS) activity associated with the development of retinopathy of prematurity. METHODS: Heart rate variability (HRV) as an indicator of ANS activity was calculated in two groups of premature infants: (1) a treatment group of infants who developed type 1 ROP and underwent treatment and (2) a control group of infants who did not develop ROP more severe than stage 1 and who were matched to the treatment group in terms of age, weight, and similar risk factors, including similar frequency of intraventricular hemorrhage, bronchopulmonary dysplasia, and sepsis. HRV was analyzed during the first 5 days of life, within 5 days of initial ROP examination, and within 5 days of ROP treatment for the treatment group or, for controls, on the day of last electrocardiogram data prior to discharge. Calculations were performed for the high frequency, low frequency, and low frequency-high frequency values of the HRV components for all infants. RESULTS: Between the initial ophthalmologic evaluation and the final evaluation, there was a tendency for reduction in both the low- and high-frequency components of the HRV indices in the treatment group, whereas there was a tendency for an increase in both components of the HRV indices in the control group. The difference in the rate of change of the high frequency between groups was statistically significant (P = 0.021). CONCLUSIONS: Disruption in ANS activity may play an important role in the development and severity of ROP.

Ultrasound biomicroscopy (UBM) characteristics of scleral tunnels created with suture needles commonly used during strabismus surgery.

PURPOSE: To enhance the safety and efficacy of surgical treatment of strabismus, we sought to measure and determine the ultrasound biomicroscopy (UBM) profile of scleral tunnels created with needles commonly used during strabismus surgery, to determine which needles are less likely to create the complication of scleral perforation. METHODS: Adult cadaver eyes were secured in a styrofoam head. Intraocular pressure was maintained between 15 and 21 mm Hg. Then S14, S24, S28 and TG100 needles were used to create scleral tunnels simulating those created during routine strabismus surgery. Ten scleral tunnels were created with each needle type at 3 different sites on the globe, for a total of 120 passes. The thickness of the sclera and the maximum depth and length of each scleral tunnel were measured using UBM. RESULTS: The mean tunnel depth below the scleral surface (+/- SD) was 0.43 +/-0.11 mm, 0.37 +/-0.09, 0.40 +/-0.08 and 0.34 +/-0.07 mm, for the S14, S24, S28 and TG100 needles, respectively (P=0.002, One way ANOVA). For both the S14 and S28 needles, there was a "statistically significant" P 0.05) linear trend of an increase in the depth of the pass as the length of the pass increased (P=0.01 for the S14 and P=0.02 for the S28 {Pearson Correlation 2 tailed test}). A similar trend was found with the S24 needle but the trend was not "statistically significant" (P=0.35). No such trend was found with the TG100 needle. CONCLUSIONS: Needle design had a definite impact on the characteristics of scleral tunnels created to simulate those made during strabismus surgery and may influence needle selection by the surgeon for different or various surgical circumstances, but the differences were not such as to predicate for or against the general use of any of these four needles for strabismus surgery.

Long-term Visual and Ocular Sequelae in Patients With Congenital Cytomegalovirus Infection.

BACKGROUND: Cytomegalovirus (CMV) is the most common congenital viral infection in the United States. Visual and ocular sequelae in adolescents and adults who are congenitally infected with CMV have not been well studied. Better understanding of the long-term visual and ocular sequelae can help with early detection, intervention and appropriate educational accommodations. METHODS: This study evaluated 237 patients (77 symptomatic, 109 asymptomatic and 51 control) who underwent a series of age-appropriate ophthalmologic, audiologic and neurodevelopmental examinations from 1982 to 2013. The frequency and etiology of visual impairment and other nonophthalmologic findings were recorded for each patient. Ophthalmologic findings were tabulated, and risk factors for abnormalities were analyzed. RESULTS: Fourteen of the 77 (18.2%) symptomatic and none of the asymptomatic and control subjects had severe visual impairments (P ≤ 0.006). Moderate visual impairment did not differ between symptomatic and asymptomatic subjects. Three asymptomatic subjects had retinal scars. The most common visual or ocular sequelae in the symptomatic group were strabismus (23.4%), chorioretinal scars (19.5%), cortical visual impairment (14.3%), nystagmus (14.3%) and optic nerve atrophy (11.7%). Three symptomatic patients had delayed visual deterioration because of later occurring retinal disorders: peripheral retinal scar, rhegmatogenous retinal detachment and Coats' disease. CONCLUSION: Symptomatic CMV patients experienced more ophthalmologic sequelae and significantly worse visual outcomes than asymptomatic CMV and control patients. Later occurring retinal disorders were found in symptomatic patients, and there is no clear evidence that CMV can reactivate in the retinas of children who were congenitally infected. Major risk factors for severe visual impairment included symptomatic status, optic nerve atrophy, chorioretinitis, cortical visual impairment and sensorineural hearing loss.

Long-term outcomes of photorefractive keratectomy for anisometropic amblyopia in children.

PURPOSE: To evaluate the long-term visual acuity (VA) and refractive error responses to excimer laser photorefractive keratectomy (PRK) for treatment of anisometropic amblyopia in children. DESIGN: Prospective interventional case-control study. PARTICIPANTS: Eleven children, 2 to 11 years old, with anisometropic amblyopia who were noncompliant with conventional therapy with glasses or contact lenses and occlusion therapy were treated with PRK. A cohort derived retrospectively of 13 compliant and 10 noncompliant children with refractive errors similar to those of the PRK group who were treated with traditional anisometropic amblyopia therapy served as control groups. INTERVENTION: Photorefractive keratectomy for the eye with the higher refractive error. MAIN OUTCOME MEASURES: (1) Refractive error reduction and stability in the treated eye, (2) cycloplegic refraction, (3) VA, (4) stereoacuity, and (5) corneal haze up to 3 years after PRK. Compliant and noncompliant children with anisometropia amblyopia were analyzed as controls for refractive error and VA. RESULTS: Preoperative refractive errors were -13.70 diopters (D) (+/-3.77) for the myopic group and +4.75 D (+/-0.50) for the hyperopic group. Mean postoperative refractive errors at last follow-up (mean, 31 months) were -3.55 D (+/-2.2.5) and +1.41 D (+/-1.07) for the myopic and hyperopic groups, respectively. At last follow-up, cycloplegic refractions in 4 (50%) of 8 myopes and all hyperopes (100%) were within 3 D of that of the fellow eye. Five (63%) of 8 myopic children achieved a refraction within 2 D of the target refraction. Two (67%) of 3 hyperopic patients maintained their refractions within 2 D of the target. Refractive regressions (from 1 year after surgery to last follow-up) were 0.50+/-1.41 D (myopes) and 0.60+/-0.57 D (hyperopes). Seven children (77%) were able to perform psychophysical VA testing preoperatively and postoperatively. Five (71%) of the 7 children had uncorrected VA improvement of at least 2 lines, and 4 (57%) of 7 had best spectacle-corrected VA improvement of at least 2 lines, with 1 improving 7 lines. Five (55%) of 9 children had improvement of their stereoacuity at last follow-up. Subepithelial corneal haze remained negligible. The mean final VA of the PRK group was significantly better than that of the noncompliant control group (P = 0.003). The mean final refractive error for both myopic and hyperopic groups was also significantly better that that of the control groups (P = 0.007 and P<0.0001, respectively). CONCLUSIONS: Photorefractive keratectomy for severe anisometropic amblyopia in children resulted in long-term stable reduction in refractive error and improvement in VA and stereopsis, with negligible persistent corneal haze.

Visual outcomes after 3-port lens-sparing vitrectomy in stage 4 retinopathy of prematurity.

OBJECTIVE: To assess the visual acuity of eyes successfully treated with 3-port lens-sparing vitrectomy for stage 4 retinopathy of prematurity. METHODS: Of 102 consecutive eyes achieving at least posterior pole reattachment, 30 eyes of 26 patients were tested by Teller or Allen acuity measurements and were subsequently converted to logarithm of the minimum angle of resolution (logMAR). Visual outcomes were also examined as either favorable or unfavorable (Snellen equivalent >20/200). RESULTS: Seventy-two eyes were not tested because of either inability to perform testing (age or neurologic sequelae related to prematurity) or loss of follow-up. Of those tested, mean +/- SD logMAR visual acuity for the stage 4A and stage 4B groups was 0.51 +/- 0.09 (Snellen approximate 20/62) and 1.03 +/- 0.19 (Snellen approximate 20/200), respectively (odds ratio, 0.39; 95% confidence interval, 0.24-0.64; P = .001). Of those eyes assessed by Teller measurements, 10 of 10 stage 4A eyes and 3 (37.5%) of 8 stage 4B eyes had favorable outcomes; among eyes assessed with Allen measurements, 4 of 4 stage 4A eyes and 0 of 8 stage 4B eyes had favorable outcomes. CONCLUSIONS: The majority of eyes were not tested. Among eyes tested after successful 3-port lens-sparing vitrectomy, some eyes treated prior to macular detachment may be associated with a more favorable outcome and improved maintenance of functional visual acuity.

Prevalence and course of strabismus in the first year of life for infants with prethreshold retinopathy of prematurity: findings from the Early Treatment for Retinopathy of Prematurity study.

OBJECTIVE: To present strabismus data for premature infants with prethreshold retinopathy of prematurity (ROP) enrolled in the Early Treatment for Retinopathy of Prematurity study. DESIGN: The prevalence of strabismus was tabulated for all of the infants with high-risk prethreshold disease who participated in the randomized trial of the Early Treatment for Retinopathy of Prematurity study and were examined at 6 and/or 9 months' corrected age as well as for all of the infants with low-risk prethreshold disease who were examined at 6 months' corrected age. MAIN OUTCOME MEASURES: Presence or absence of strabismus at 6 and 9 months' corrected age. RESULTS: The prevalence of strabismus at 6 months was higher for infants with high-risk prethreshold ROP than for those with low-risk prethreshold ROP (20.3% vs 9.6%, respectively; P<.001). Risk factors associated with the development of strabismus at 9 months include abnormal fixation behavior, presence of amblyopia, and outborn birth status (ie, born outside of a study-affiliated hospital). At 9 months, 30% of infants with high-risk prethreshold ROP had strabismus, although only 42% showed strabismus at 6 months. Thirty percent of infants with strabismus at 6 months showed normal alignment at 9 months. CONCLUSIONS: Infants with high-risk prethreshold ROP show significant variability in the presence vs absence of strabismus in the first year of life; thus, conservative management is recommended. APPLICATION TO CLINICAL PRACTICE: Ophthalmologists managing strabismus in infants who have high-risk prethreshold ROP should be aware of the significant variability in ocular alignment during the first year of life.

Longitudinal Evaluation of Eye Misalignment and Eye Movements Following Surgical Correction of Strabismus in Monkeys.

PURPOSE: Strabismus correction surgery is well documented in both the literature and practice with varying levels of success and permanence. Our goal was to characterize longitudinal changes in eye alignment and eye movements following strabismus correction surgery in a monkey model for developmental strabismus. METHODS: We studied two juvenile rhesus monkeys with exotropia previously induced via an optical prism-rearing paradigm in infancy. Eye misalignment was corrected via a resection-recession surgery of the horizontal rectus muscles of one eye. Binocular search coils were used to collect eye movement data during smooth-pursuit, saccades, and fixation tasks before surgical treatment, immediately after surgery, and through 6 months after treatment. RESULTS: Both animals showed an immediate ∼70% reduction in misalignment as a consequence of surgery that regressed to a 20%-40% improvement by 6 months after treatment. Significant changes were observed in saccade and smooth-pursuit gain of the nonviewing eye after surgery, which also reverted to presurgical values by 6 months. A temporary improvement in fixation stability of the nonviewing eye was observed after surgery; naso-temporal (N/T) asymmetry of monocular smooth-pursuit remained unchanged. CONCLUSIONS: Surgical realignment is followed by plastic changes that often lead to reversal of surgery effects. Immediate improvement in misalignment and changes in eye movement gains are likely a result of contractility changes at the level of the extraocular muscle, whereas longer-term effects are likely a combination of neural and muscle adaptation.

Reasons for delay of surgical intervention in adult strabismus.

BACKGROUND: It has been our impression that adult patients with strabismus frequently delay surgical intervention. OBJECTIVES: To determine the length of time adult patients waited before undergoing strabismus surgery and to determine the reasons why these delays occurred. DESIGN, SETTING, AND PARTICIPANTS: Prospective survey of consecutive patients who delayed strabismus surgery for more than 1 year. INTERVENTION: Preoperative survey. MAIN OUTCOME MEASURES: The primary outcome measure was time between the onset of strabismus and surgery and the reason why surgery had not been previously sought. RESULTS: The mean age among 128 study participants was 45.7 years (age range, 18-86 years). The mean time between the onset of current strabismus and surgery was 19.9 years (range, 1-72 years). The major reasons for delay in seeking surgical treatment included the following: surgery was never offered by eye care specialist (35 patients [27%]), surgery was offered but declined by the patient (29 patients [23%]), the patient had received prior satisfactory nonsurgical care (17 patients [13%]), the patient had never sought care (14 patients [11%]), the patient had a previous poor surgical experience (8 patients [6%]), and the patient had been told by their eye specialist that nothing could be done or that surgery could make them worse (8 patients [6%]). CONCLUSIONS: Strabismus surgery is often delayed for many years in adult patients who could potentially benefit from it. Almost half of such delays could be avoided by better education of the lay public and the medical community.

Involution of retinopathy of prematurity after laser treatment: factors associated with development of retinal detachment.

PURPOSE: To identify specific features during the process of involution of retinopathy of prematurity after treatment at threshold that are associated with development of a retinal detachment. DESIGN: Retrospective case series. METHODS: The evolution of retinal detachments over time was analyzed retrospectively in 262 treated eyes of 138 infants. Specific features hypothesized to be associated with development of a retinal detachment were analyzed, including vitreous organization defined as clinically important, active stage 3 disease and active plus disease more than 21 days after treatment, and vitreous hemorrhage defined as clinically important. RESULTS: A retinal detachment developed in 36 (13.7%) of 262 eyes. Vitreous organization meeting our clinically important definition was associated with a 31-fold (confidence interval [CI] 5.37-183.63; P < .0001) and 13-fold (CI 2.97-58.59; P < .0001) increase in the odds for retinal detachment for right and left eyes, respectively. Vitreous hemorrhage defined as clinically important was associated with a 38-fold (CI 2.69-551.19; P = .007) and 15-fold (CI 1.65-144.12; P = .02) increase in the odds for retinal detachment for right and left eyes, respectively. The timing of retinal detachment relative to vitreous hemorrhage was not determined. Prolonged activity of Stage 3 disease or plus disease more than 21 days after treatment was not associated with development of a retinal detachment. CONCLUSIONS: Clinically important vitreous organization and vitreous hemorrhage were predictive for development of a retinal detachment. Evaluation of preemptive reintervention strategies for eyes at highest risk for developing a retinal detachment may be reasonable.

The management of strabismus in adults--III. The effects on disability.

INTRODUCTION: This is the third article in a series on the various facets of the management of strabismus in adults. Here, we give a broad overview of the types and severity of disability and provide initial validation of an instrument (questionnaire) to assess these disability aspects. METHODS: After undergoing strabismus surgery, 101 patients from 6 centers completed a 6-item questionnaire in which they rated both the before-surgery and after-surgery severity of problems associated with their strabismus, ranging from specific health, daily functioning, social interaction, concerns about the future, and self-image to job-related difficulties. RESULTS: The before-surgery outcomes showed significant variation across the 6 types of problems (P < 0.001), with "specific health" and "daily tasks" yielding the highest problem rating. Patients with diplopia reported more severe problems with "daily tasks" (P = 0.004) and "concerns about the future" (P = 0.026) than patients without diplopia. Overall, all problem ratings declined after surgery (P < 0.001), but patients who were not successfully aligned were left with higher problem ratings on "specific health" (P = 0.005), "daily tasks" (P = 0.003), and "social interaction" (P = 0.024). CONCLUSIONS: The results indicate a wide range of disability aspects in adult patients with strabismus, with moderate differences between patients with or without diplopia. Improvements in disability after surgery, as reflected by these ratings, should be taken into account when assessing the health value of adult strabismus management.