Publication rates of registered strabismus trials from ClinicalTrials.gov.

Presently, little is known regarding the characteristics and publication rates of registered strabismus trials from ClinicalTrials.gov. We queried registered strabismus trials that were completed prior to January 1, 2021, from ClinicalTrials.gov. Publication of trials in peer-reviewed journals was confirmed using PubMed.gov, ClinicalTrials.gov, and Google Scholar. Of the 117 trials found, only 69 (59%) were published with a publication delay of nearly 2.5 years. Interventional trials were associated with publication status compared with observational trials. The low publication rates and significant publication delay indicate potential bias in information dissemination of completed strabismus trials.

Teprotumumab for Thyroid Eye Disease-related Strabismus.

PURPOSE: To assess and quantify teprotumumab's effect on thyroid eye disease-related strabismus by change in measured horizontal and vertical deviations and change in extraocular motility. METHODS: We reviewed a series of patients with thyroid eye disease-related strabismus treated with teprotumumab. Exclusion criteria included age under 18 years, strabismus of alternate etiology, or thyroid eye disease-related reconstructive surgery during the treatment course. Primary outcomes were absolute (prism diopters) and relative (%) differences in horizontal and vertical deviations in primary position at distance, as well as change in ductions of the more affected eye. Secondary outcomes included incidence and timing of strabismus surgery postteprotumumab. RESULTS: Thirty-one patients were included, with mean age 63 years and thyroid eye disease duration 10 months. After teprotumumab, there was 6 prism diopters (39%) mean reduction in vertical deviation (p < 0.001), without significant change in mean horizontal deviation (p = 0.75). Supraduction, abduction, adduction, and infraduction significantly improved in the more restricted eye (p < 0.01, p < 0.01, p = 0.04, and p = 0.01, respectively). Thirty-five percent of patients underwent strabismus surgery posttreatment, at an average 10 months after last infusion. CONCLUSIONS: Teprotumumab produced a statistically significant reduction in vertical but not horizontal strabismus angles in primary position at distance. Extraocular motility in all 4 ductions also improved. A substantial minority of patients still required strabismus surgery following teprotumumab.

Prescribing patterns for paediatric hyperopia among paediatric eye care providers.

PURPOSE: To survey paediatric eye care providers to identify current patterns of prescribing for hyperopia. METHODS: Paediatric eye care providers were invited, via email, to participate in a survey to evaluate current age-based refractive error prescribing practices. Questions were designed to determine which factors may influence the survey participant's prescribing pattern (e.g., patient's age, magnitude of hyperopia, patient's symptoms, heterophoria and stereopsis) and if the providers were to prescribe, how much hyperopic correction would they prescribe (e.g., full or partial prescription). The response distributions by profession (optometry and ophthalmology) were compared using the Kolmogorov-Smirnov cumulative distribution function test. RESULTS: Responses were submitted by 738 participants regarding how they prescribe for their hyperopic patients. Most providers within each profession considered similar clinical factors when prescribing. The percentages of optometrists and ophthalmologists who reported considering the factor often differed significantly. Factors considered similarly by both optometrists and ophthalmologists were the presence of symptoms (98.0%, p = 0.14), presence of astigmatism and/or anisometropia (97.5%, p = 0.06) and the possibility of teasing (8.3%, p = 0.49). A wide range of prescribing was observed within each profession, with some providers reporting that they would prescribe for low levels of hyperopia while others reported that they would never prescribe. When prescribing for bilateral hyperopia in children with age-normal visual acuity and no manifest deviation or symptoms, the threshold for prescribing decreased with age for both professions, with ophthalmologists typically prescribing 1.5-2 D less than optometrists. The threshold for prescribing also decreased for both optometrists and ophthalmologists when children had associated clinical factors (e.g., esophoria or reduced near visual function). Optometrists and ophthalmologists most commonly prescribed based on cycloplegic refraction, although optometrists most commonly prescribed based on both the manifest and cycloplegic refraction for children ≥7 years. CONCLUSION: Prescribing patterns for paediatric hyperopia vary significantly among eye care providers.

Global Ophthalmology Practice Patterns during COVID-19 Pandemic and Lockdown.

AIM: To assess the impact of practice patterns amongst global ophthalmologists during severe acute respiratory syndrome Coronavirus 2 (SARS Cov2) causing Corona virus disease (COVID-19) and understand the various modifications made to address emergency surgeries and practice needs. METHODS: An online survey was sent to practicing ophthalmologists around the world through email, Whatsapp™ ListServ17.0™ (for pediatric ophthalmologists), WeChat™ (China) and ophthalmology associations (Indonesia, Philippines, Ireland). All queries were collected and categorized. Responses to the queries were given according to the recommendations by the Ophthalmology association. Practices ability to deal with the COVID were also classified according to country and type of access to PPE. Statistical analyses of the association between these data and queries, where appropriate were carried out. RESULTS: One thousand nine hundred sixteen ophthalmologists were invited to participate in a survey between April 10th and April 30th, 2020 of which 1207 responded, which is a response rate of approximately 63%. The majority of respondents were from India, Indonesia, China, Singapore and the USA. Our study indicates a precipitous drop in surgical procedures with 46% (n = 538) ophthalmologists ceased to operate on their patients and almost 40% (n = 486) were doing less than 25% of their original number of surgeries. The intent to resume elective surgeries was a consideration in 41% (n = 495) after an evaluation of the situation and in consultation with professional bodies. More than 2/3 of the respondents (n = 703) made it a priority to use and mandate their patients to practice physical distancing, wearing masks, and hand dis-infection for protection to limit the spread of infection. CONCLUSION: This global survey provides a real-world assessment of diverse practices that were in various forms of "shut down mode" and circumstances with varying capabilities to deal with COVID. It is unprecedented that the collective wisdom for a curtailment of practice has had an enormous immediate and far reaching implications on the livelihoods of ophthalmologists, their staff, and their families. Nevertheless, ophthalmologists and their staff remain resilient and have adapted to these changes pragmatically.

A 2020 Update on 20/20 X 2: Diplopia after Inadvertent Strabismus Surgery Complications.

The goals of successful strabismus surgery include the optimization of binocular potential through the establishment, reestablishment, or improvement of ocular alignment leading to a reduction or resolution of diplopia, as well as an improvement of compensatory head position or cosmesis. Fortunately, the incidence of new postoperative diplopia in patients without diplopia prior to strabismus surgery is extremely uncommon (less than 2%). Alternatively in a patient with preoperative diplopia that persists postoperatively, it is important to establish whether the diplopia is unchanged, increased, or of the same magnitude but shifted to a more disruptive position of gaze. During preoperative planning, the surgeon tries to anticipate and thus avoid postoperative diplopia. If the postoperative diplopia is unexpected, then a dispassionate evaluation of the outcome to identify planning, mechanical, or other factors is necessitated. These factors will be explored below systematically in the preoperative, intraoperative, and postoperative phases.

Socioeconomics of retinopathy of prematurity screening and treatment in the United States.

BACKGROUND: Retinopathy of prematurity (ROP) screening, an integral part of pediatric ophthalmology, can be time consuming and resource intensive. The purpose of this study was to evaluate the economic landscape of ROP screening and treatment among pediatric ophthalmologists in the United States. METHODS: An online survey was distributed to US pediatric ophthalmologists through a pediatric ophthalmology email listserv. Survey results were compiled, and responses were deidentified and analyzed, with particular focus on factors affecting financial compensation. RESULTS: A total of 97 responses were collected. Almost half of respondents worked in private practice settings. Over 80% of respondents had a formal contract to perform ROP care, but only 26% enlisted the assistance of an attorney to negotiate their contract. Just over half of respondents believed themselves adequately compensated for their services. Respondents that had retained an attorney for contractual negotiations were more likely to have a higher mean annual compensation rate ($126,545 ± $145,133 vs $70,214 ± $50,671; P = 0.05). Physicians who believed themselves adequately compensated were more likely to be in academic practice settings (78% academic vs 55% combo/other vs 24% private; P < 0.001) and were more likely to have contracts to perform ROP care (68% with contracts vs 15% without; P = 0.001). Average annual compensation was $82,968 ± $84,132, approximately $24,000 higher than reported in 2013. CONCLUSIONS: More pediatric ophthalmologists among our respondents obtained contracts for their services, and compensation rates have increased since 2013. Nevertheless, concerns regarding under-compensation and time commitment persist, raising concerns about the long-term sustainability of current models for providing ROP services.

The relationship between education levels, lifestyle, and religion regarding the prevalence of myopia in Israel.

BACKGROUND: The ultra-Orthodox Jewish community has a unique lifestyle including minimal outdoor activity and intense, prolonged nearby work, beginning at a very young age. Their prevalence of myopia is extremely high. This paper provides a unique insight into the attitudes of this community towards myopia. METHODS: Ultra-Orthodox Jewish parents of children who came to the pediatric ophthalmology clinic in one tertiary care and two community centers in ultra-Orthodox-oriented cities were given a questionnaire. Demographic information, along with myopia prevalence in the family, was gathered. In addition, their attitudes and common knowledge regarding myopia were investigated. RESULTS: 161 questioners were collected, mostly completed by mothers (n = 110, 68%). The average number of children per family was 6 (range 1-16). In 148 families (92%) at least one of the parents has myopia. The average parent refraction was - 4.5 diopters (range - 0.5 to 15 diopters). Out of 935 children, 410 (44%) wore glasses. Twelve parents (7%) believe that myopia is a disease and 94 (58%) reported that they are concerned because their child wears glasses. Twenty-four (15%) believe that glasses are a sign of a high education level. Regarding treating myopia progression, 144 (89%) think that myopia progression should be treated, but only 36 (22%) are aware of the available treatments for it. CONCLUSION: This study examines an insular community with a very high incidence of myopia. In this community most parents think that myopia progression should be treated but most of them are unaware of the currently available treatments.

Definition of successful outcomes after surgery for each type of strabismus: a Delphi study.

BACKGROUND: The Delphi process has been widely used to delineate guidelines for the treatment of disorders for which there is little or no evidence in the published literature. The purpose of this study was to use the Delphi process to identify areas of consensus and disagreement on the definition of success after surgery for each type of strabismus. METHODS: Two rounds of electronic questionnaires were sent to 28 members of the Strabismus Success Definition Delphi Study Group. For the first round, responses to 70 questions were captured as agree (= 1) and disagree (= 2). For round 2, a total of 89 questions were captured on a Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Consensus was determined a priori at 85%. RESULTS: In both the first and second rounds, inter-rater agreement of 85% consensus was reached for only 20% of questions. Intra-rater agreement per question was low, with κ values ranging from -0.11 to 0.62. Intra-rater agreement was also low among themes, ranging from poor to fair agreement: κ = 0.25 for motor, κ = 0.28 for sensory, and κ = 0.35 for follow-up. CONCLUSIONS: This study highlights consensus areas that could be considered by researchers in designing studies and identifies areas where lack of consensus indicates that further research is needed.

Inferior rectus displacement in heavy eye syndrome and sagging eye syndrome.

PURPOSE: To evaluate if there is a nasal displacement of the vertical rectus muscles in heavy eye syndrome (HES) and/or sagging eye syndrome (SES) compared with age-matched controls. METHODS: We reviewed the charts of all patients with the diagnosis of HES or SES who were seen at the University of California San Diego (UCSD) between the years 2008-2016 who underwent magnetic resonance imaging (MRI) of the brain and orbits. The control group included patients who had brain and orbital MRIs at UCSD in the absence of known pathology in the orbits or globes. Measurements were taken by 3 separate examiners for all groups. RESULTS: Twenty-four patients (16 with SES and 8 with HES) and 24 age-matched controls were retrospectively reviewed. The superior rectus (SR) of patients with HES and SES was more nasally displaced from the midline compared with that of age-matched controls (p = 0.04, p = 0.03, respectively). The inferior rectus (IR) of patients with HES but not with SES was more nasally displaced from the midline compared with that of age-matched controls (p = 0.04, p = 0.62, respectively). In all groups, the IR nasal displacement from the midline was approximately double compared with the SR. CONCLUSIONS: There is a significant nasal displacement of the SR in HES and SES and IR in HES. The observed IR nasal displacement in HES is a new finding and may explain the residual hypotropia and/or esotropia following surgical interventions for HES not involving the IR.

Use of the Delphi process for defining successful outcomes for strabismus surgery.

The purpose of this review was to identify areas of consensus and disagreement among experts for the definition of success following strabismus surgery using the Delphi process. Three rounds of electronic questionnaires were sent to a panel of 28 strabismus experts. Throughout the process, members of the panel were masked to one another's identities to minimize the possibility of influence among members. Prior to data collection, we defined consensus as an 85% agreement on the answer to each question. Questions for which there was no consensus were reworded, and the resultant new questions were used in each subsequent round of questioning. We arrived at consensus for 23 of the 36 questions (64%). Consensus was obtained for recommending unique criteria for the definition of success for certain specific strabismus conditions. In addition, it was considered important that stereopsis and the range of single binocular vision be included in the definition of success for certain types of strabismus.

Identification and Correction of Restrictive Strabismus After Pterygium Excision Surgery.

PURPOSE: To report the characteristics of patients with restrictive diplopia following pterygium excision and a successful treatment approach for the strabismus. DESIGN: Retrospective interventional case series. METHODS: This study was set in a single academic institution and included 15 patients with restrictive diplopia after pterygium excision. Patients with any other reason for strabismus were excluded. Patients were evaluated for deficits with special attention to diplopic measures. The intervention was a combined procedure by a strabismologist and oculoplastic surgeon to correct the diplopia. The primary outcome measurements were subjective and objective improvement of diplopia. RESULTS: Fifteen patients (mean age = 49 years) who developed diplopia after pterygium excision were included. Mean time to diplopia was 6 months. All patients had limited abduction in the previously operated eye causing esotropia in the abductive field (mean deviation = 18 prism diopters). After intervention, all patients were no longer diplopic in primary gaze. In the abductive field, 11 (73%) patients had residual small angle esotropia (mean = 7 prism diopters) in ipsilateral extreme end-gaze only. Only 2 patients required additional surgical intervention for scar tissue removal. No patients underwent medial rectus recession. CONCLUSIONS: Restrictive diplopia is a potential complication after pterygium excision, particularly for patients with a history of recurrent pterygia requiring multiple excisions and previous amniotic membrane graft placement with fibrin glue. However, diplopia after pterygium excision in primary position is surgically correctable with scar tissue removal and ocular surface reconstruction, without needing medial rectus recession. Given the high volume of pterygium excision, awareness of postoperative restrictive strabismus and the potential for correction is critical.

Complication rates of resident-performed cataract surgery: Impact of early introduction of cataract surgery training.

PURPOSE: To determine the effect of the early introduction of cataract surgery training on the complication rates of resident-performed cataract surgery. SETTING: University of California San Diego, San Diego, California, USA. DESIGN: Retrospective case series. METHODS: Two classes of ophthalmology residents were examined, one class with a late introduction of cataract surgery and one with an early introduction of cataract surgery. All cataract cases in which residents acted as primary surgeon were included. Patient charts were reviewed to collect data on patient characteristics, surgical details, and intraoperative and postoperative complications. RESULTS: The late-introduction cohort comprised 3 residents who performed 540 cataract cases, all during their final year of residency. The early-introduction cohort comprised 4 residents who performed 780 cataract cases beginning in the first year of residency. The late-introduction cohort had higher rates of major intraoperative complications than the early-introduction cohort (8.5% versus 3.1%) and of anterior vitrectomy (7.6% versus 2.1%) (both P < .001). Examination of the anterior vitrectomy rate as a function of experience showed the early-introduction cohort had a stable anterior vitrectomy rate of 1% to 2% throughout training, while the late-introduction cohort had a peak anterior vitrectomy rate of 12% at approximately case 20. Multivariable regression analysis showed the early-introduction cohort was independently associated with a lower rate of anterior vitrectomy (hazard ratio, 0.49; 95% confidence interval, 0.36-0.66) after adjusting for differences in patient characteristics and surgical complexity. CONCLUSIONS: Early introduction of cataract surgery training significantly decreased the rate of major intraoperative complications, specifically anterior vitrectomy, in resident-performed cataract surgeries.

Transcriptome Analysis of Orbital Adipose Tissue in Active Thyroid Eye Disease Using Next Generation RNA Sequencing Technology.

OBJECTIVE: This study utilized Next Generation Sequencing (NGS) to identify differentially expressed transcripts in orbital adipose tissue from patients with active Thyroid Eye Disease (TED) versus healthy controls. METHOD: This prospective, case-control study enrolled three patients with severe, active thyroid eye disease undergoing orbital decompression, and three healthy controls undergoing routine eyelid surgery with removal of orbital fat. RNA Sequencing (RNA-Seq) was performed on freshly obtained orbital adipose tissue from study patients to analyze the transcriptome. Bioinformatics analysis was performed to determine pathways and processes enriched for the differential expression profile. Quantitative Reverse Transcriptase-Polymerase Chain Reaction (qRT-PCR) was performed to validate the differential expression of selected genes identified by RNA-Seq. RESULTS: RNA-Seq identified 328 differentially expressed genes associated with active thyroid eye disease, many of which were responsible for mediating inflammation, cytokine signaling, adipogenesis, IGF-1 signaling, and glycosaminoglycan binding. The IL-5 and chemokine signaling pathways were highly enriched, and very-low-density-lipoprotein receptor activity and statin medications were implicated as having a potential role in TED. CONCLUSION: This study is the first to use RNA-Seq technology to elucidate differential gene expression associated with active, severe TED. This study suggests a transcriptional basis for the role of statins in modulating differentially expressed genes that mediate the pathogenesis of thyroid eye disease. Furthermore, the identification of genes with altered levels of expression in active, severe TED may inform the molecular pathways central to this clinical phenotype and guide the development of novel therapeutic agents.

The PlusoptiX Photoscreener and the Retinomax Autorefractor as Community-based Screening Devices for Preschool Children.

PURPOSE: To compare the performance of the PlusoptiX S12 mobile photoscreener and the Retinomax K+3 Autorefractor as screening devices in preschool children. METHODS: Children ranging from 3 to 5 years of age from 11 San Diego County preschools underwent vision screening in their schools where ambient light could not always be controlled using both the Retinomax and the PlusoptiX. Cycloplegic refraction on the consented children was subsequently performed on the UCSD EyeMobile for children on-site at the school locations. RESULTS: A total of 321 children were screened with the PlusoptiX and Retinomax. The PlusoptiX referred 22% of children, of whom 70% of the referrals were read as "unable". The Retinomax referred 13% and there were no "unables". Similar results occurred in the cycloplegic-refracted 182 consented children-64% of the PlusoptiX referrals were read as "unable" . Only one third of these "unables" required glasses. Both devices referred the four children with amblyopia and one case of strabismus. However, PlusoptiX's 3 false negatives had amblyopia risk factors (ARFs) while the one Retinomax's false negative did not have ARFs. The Retinomax screening had 95% sensitivity and 94% specificity. The PlusoptiX screening had 86% sensitivity and 84% specificity. CONCLUSION: In this preschool population and environment, the PlusoptiX referred 63% more than the Retinomax in addition to a lower specificity and sensitivity. Adjusting PlusoptiX referral criteria might not substantially improve the specificity of the PlusoptiX due to the high numbers of "unables".

ELECTRONEGATIVE ELECTRORETINOGRAM IN ACHROMATOPSIA.

PURPOSE: To report novel electroretinographic findings in a genetically confirmed case of achromatopsia. METHODS: A patient with a history of childhood nystagmus, photoaversion, and absent color vision was examined. Electroretinography and fundus examination were performed under anesthesia at the time of corrective surgery for nystagmus. Genomic DNA isolated from peripheral blood was directly sequenced for variations in the CNGA3 and CNGB3 genes. RESULTS: Ophthalmoscopic examination revealed no distinct abnormalities. Electroretinography obtained under anesthesia at age three years revealed absent photopic responses. The dark-adapted combined responses had reduced b-wave amplitudes resulting in an electronegative configuration. Genetic testing revealed two heterozygous sequence variations present in the coding sequence of the CNGA3 gene (Arg223Trp and Pro372Ser), which have been previously described in the setting of achromatopsia. Sequencing of the patient's parents confirmed that these two variations lie on separate alleles. CONCLUSION: Novel electroretinography findings in a patient with genetically confirmed achromatopsia are reported. The electronegative configuration in this clinical setting is of unclear etiology; however, it may suggest some component of inner retinal dysfunction.

Diagnosis and management of allergic conjunctivitis in pediatric patients.

BACKGROUND: Allergic conjunctivitis (AC), although one of the most common ocular disorders in pediatric patients, is frequently overlooked, misdiagnosed, and undertreated in children. OBJECTIVE: To guide pediatric health care professionals in the optimal diagnosis and management of AC in pediatric patients. METHODS: To identify any existing best practice guidelines for the diagnosis and treatment of AC in pediatric patients, a review of the literature published between 2004 and January 2015 was conducted. Diagnosis and treatment algorithms and guidelines for pediatric patient referrals were then developed. RESULTS: A literature search to identify best practice guidelines for the treatment of AC in pediatric patients failed to return any relevant articles, which highlighted the need for best practice recommendations. Based on publications on adult AC and clinical experience, this review provides step-by-step guidance for pediatric health care professionals, including recognizing clinical features of AC, establishing a comprehensive medical history, and performing a thorough physical examination to ensure a correct diagnosis and the optimal treatment or referral to an eye care specialist or allergist when required. In addition to established drug treatments, the role of subcutaneous and sublingual immunotherapy is discussed to inform pediatric health care professionals about alternative treatment options for patients who do not tolerate pharmacotherapy or who do not respond sufficiently. CONCLUSION: The diagnostic and treatment algorithms and guidelines provided in this review help address the current literature and educational gap and may lead to improvements in diagnosis and management of pediatric AC.