The development of myopia among children with intermittent exotropia.

PURPOSE: To describe the long-term refractive error changes in children diagnosed with intermittent exotropia (IXT) in a defined population. DESIGN: Retrospective, population-based observational study. METHODS: Using the resources of the Rochester Epidemiology Project, the medical records of all children (<19 years) diagnosed with IXT as residents of Olmsted County, Minnesota, from January 1, 1975 through December 31, 1994 were retrospectively reviewed for any change in refractive error over time. RESULTS: One hundred eighty-four children were diagnosed with IXT during the 20-year study period; 135 (73.4%) had 2 or more refractions separated by a mean of 10 years (range, 1-27 years). The Kaplan-Meier rate of developing myopia in this population was 7.4% by 5 years of age, 46.5% by 10 years, and 91.1% by 20 years. There were 106 patients with 2 or more refractions separated by at least 1 year through 21 years of age, of which 43 underwent surgery and 63 were observed. The annual overall progression was -0.26 diopters (SD +/- 0.24) without a statistically significant difference between the observed and surgical groups (P = .59). CONCLUSION: In this population-based study of children with intermittent exotropia, myopia was calculated to occur in more than 90% of patients by 20 years of age. Observation versus surgical correction did not alter the refractive outcome.

Prevalence and sex differences of psychiatric disorders in young adults who had intermittent exotropia as children.

OBJECTIVE: To evaluate the prevalence and sex differences of mental disorders diagnosed among young adults who had intermittent exotropia (IXT) as children. METHODS: The medical records of all children (<19 years) diagnosed as having IXT as residents of Olmsted County, Minnesota, from January 1, 1975, through December 31, 1994, and their randomly selected nonstrabismic birth- and sex-matched controls (1:1) were retrospectively reviewed. RESULTS: A mental health disorder was diagnosed in 97 (53.0%) of the 183 patients with childhood IXT followed to a mean age of 22 years compared with 55 (30.1%) controls (P < .001). Patients with IXT were 2.7 (95% confidence interval, 1.7-4.1) times more likely to develop a psychiatric illness than controls. A mental health disorder was diagnosed in 63% (41 of 65) and 47% (56 of 118) of males and females with IXT, respectively, compared with 33% (22 of 66) and 28% (33 of 117) of male and female controls, respectively. Additionally, males with IXT had a greater use of psychotropic medication (P = .003), psychiatric emergency department visits (P < .001), psychiatric hospital admissions (P = .04), suicide attempts (P = .004), and suicidal ideation (P = .002) than controls, and females with IXT had more suicidal ideation (P = .02) than controls. CONCLUSIONS: Children diagnosed as having IXT, especially males, are more likely to develop mental illness by the third decade of life compared with children without strabismus.

Postoperative outcomes in children with intermittent exotropia from a population-based cohort.

PURPOSE: To describe the long-term surgical outcomes in a population-based cohort of children with intermittent exotropia. METHODS: The medical records of all children (<19 years) who were diagnosed with intermittent exotropia as residents of Olmsted County Minnesota, from January 1, 1975, through December 31, 1994, and managed with surgery were retrospectively reviewed. RESULTS: Of 184 patients with intermittent exotropia, 61 (33%) underwent surgery at a mean age of 7.6 years (range, 3.2 to 23 years). Twelve of the 61 children (19.7%) underwent a second surgery (10 for recurrent exotropia and 2 for consecutive esotropia), and no patient received 3 or more surgeries during a mean follow-up of 10 years from the first surgery. The final postoperative measurements were recorded in 56 of 61 patients (92%) at a mean of 7.4 years (range, 0 to 18 years) after the first surgery: 31 of the 56 (55%) were within 9(Delta) of orthotropia at distance and 25 of 55 (45%) had better than 60 seconds of stereopsis. The Kaplan-Meier rate of developing >/=10(Delta) of misalignment after the first surgery was 54% by 5 years, 76% by 10 years, and 86% by 15 years. CONCLUSIONS: In this population-based study of surgery in children with intermittent exotropia, although only 1 in 5 received a second surgery, after a mean follow-up of 8 years, approximately half were successfully aligned and 45% had high-grade stereopsis.

Mental illness in young adults who had strabismus as children.

OBJECTIVE: We investigated the prevalence and types of psychiatric disorders diagnosed by early adulthood among patients who had common forms of strabismus as children. METHODS: The medical records of children (<19 years) who were diagnosed as having esotropia (N = 266) or exotropia (N = 141) while residents of Olmsted County, Minnesota, between January 1, 1985, and December 31, 1994, were reviewed retrospectively for psychiatric disease diagnoses. Each case subject was compared with a randomly selected, individually birth- and gender-matched, control subject from the same population. RESULTS: A mental health disorder was diagnosed for 168 (41.3%) of the 407 patients with a history of childhood strabismus, who were monitored to a mean age of 17.4 years, compared with 125 control subjects (30.7%). Children with exotropia were 3.1 times more likely to develop a psychiatric disorder than were control subjects when monitored to a mean age of 20.3 years. Children with esotropia were no more likely to develop mental illness than were control subjects when monitored for similar periods. Patients with intermittent exotropia also were significantly more likely to have greater numbers of mental health disorders, mental health emergency department visits, and mental health hospitalizations and to have suicidal or homicidal ideation. CONCLUSIONS: Children diagnosed as having strabismus in this population, especially those with exotropia, were at increased risk for developing mental illness by early adulthood. Patients with intermittent exotropia seemed to be particularly prone to developing significant psychiatric diseases by the third decade of life.

The course of intermittent exotropia in a population-based cohort.

PURPOSE: To evaluate the change in the angle of deviation in an incidence cohort of pediatric patients diagnosed with intermittent exotropia during a 20-year period. DESIGN: Retrospective, population-based observational study. PARTICIPANTS: All pediatric (<19 years old) residents of Olmsted County, Minnesota diagnosed with intermittent exotropia (> or =10 prism diopters) from January 1, 1975 through December 31, 1994. METHODS: The medical records of all potential patients identified by the resources of the Rochester Epidemiology Project were reviewed. MAIN OUTCOME MEASURES: The change in the angle of deviation and its association with treatment were reviewed for each patient. RESULTS: A total of 184 pediatric patients were diagnosed during the study period, of which 138 patients (75.0%) had > or =2 examinations. The deviation resolved in 5 of the 138 patients (3.6%) during a median follow-up of 9.2 years, while the Kaplan-Meier rate of increasing by 10 or more prism diopters (PD) was 23.1% at 5 years and 52.8% at 20 years. The distance deviation increased by a median of 5 PD during the preoperative period in the 55 patients who underwent surgery during a mean follow-up of 3.2 years compared with a zero PD median change in the 83 patients who avoided surgery during a mean follow-up of 7.1 years. The Kaplan-Meier probability of undergoing surgery within 20 years after diagnosis was 74.0% in this population. We were unable to detect a significant association between nonsurgical treatments and a change in the angle of deviation. CONCLUSIONS: In this population-based cohort of pediatric patients with intermittent exotropia, the deviation resolved in 4%, and more than half of the patients were expected to have an increase of 10 or more PD within 20 years of their diagnosis. Children who received surgery in this population were significantly more likely to have demonstrated an increase in their deviation during the preoperative period.

Periorbital edema as the initial presentation of T-cell prolymphocytic leukemia.

A 57-year-old woman presented with a history of progressive bilateral upper and lower eyelid edema. Laboratory tests revealed T-cell prolymphocytic leukemia. Despite systemic treatment, she died 2 weeks after presentation. This life-threatening disorder should be added to the differential diagnosis of eyelid edema.

Female predominance in intermittent exotropia.

PURPOSE: To evaluate gender differences among children diagnosed with intermittent exotropia. DESIGN: Retrospective, population-based cohort study. METHODS: The medical records of all Olmsted County, Minnesota residents younger than 19 years diagnosed with intermittent exotropia from January 1, 1975, through December 31, 1994, were reviewed. RESULTS: One hundred eighteen (64.1%) of the 184 study patients were girls with an age-adjusted incidence rate of 38.3 (95% CI: 31.4-45.2) per 100,000 compared to 20.8 (95% CI: 15.7-25.8) per 100,000 for boys (P < .0001). There were no significant differences between girls and boys in their family history of strabismus, birth weight, prevalence of prematurity, age at diagnosis and surgery, refractive error, and initial angle of deviation. CONCLUSIONS: Intermittent exotropia was nearly twice as common in girls compared with boys in this defined population. There were, however, no significant historical or clinical differences between the genders.

Rapid, objective detection of cataract-induced blur using a bull's eye photodetector.

PURPOSE: To determine whether optical aberrations caused by cataract can be detected and quantified objectively using a newly described focus detection system (FDS). SETTING: The Wilmer Opthalmological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. METHODS: The FDS uses a bull's eye photodetector to measure the double-pass blur produced from a point source of light. To determine the range and level of focus, signals are measured with a series of trial lenses in the light path selected to span the point of best focus to generate focus curves. The best corrected visual acuity (BCVA), refractive error, lens photograph grades, and FDS signals were obtained in 18 patients scheduled to have cataract surgery. The tests were repeated 6 weeks after surgery. RESULTS: The mean FDS outcome measures improved after cataract surgery, with increased peak height (P=.001) and decreased peak width (P=.001). Improvement in signal strength (integral of signal within +/-1.5 diopters of the point of best focus) strongly correlated with improvement in peak height (R(2)=.88, P<.0001) and photographic cataract grade (R(2)=.72, P<.0001). The mean BCVA improved from 20/50 to 20/26 (P<.0001). The improvement in BCVA correlated more closely with FDS signal strength (R(2)=.44, P=.001) than with cataract grade (R(2)=.25, P=.06). CONCLUSIONS: Improvement in FDS outcome measures correlated with cataract severity and improvement in visual acuity. This objective approach may be useful in long-term studies of cataract progression.

Automated detection of ocular focus.

We characterize objectively the state of focus of the human eye, utilizing a bull's eye photodetector to detect the double-pass blur produced from a point source of light. A point fixation source of light illuminates the eye. Fundus-reflected light is focused by the optical system of the eye onto a bull's eye photodetector [consisting of an annulus (A) and a center (C) of approximately equal active area]. To generate focus curves, C/A is measured with a range of trial lenses in the light path. Three human eyes and a model eye are studied. In the model eye, the focus curve showed a sharp peak with a full width at half maximum (FWHM) of +/-0.25 D. In human eyes, the ratio C/A was >4 at best focus in all cases, with a FWHM of +/-1 D. The optical apparatus detects ocular focus (as opposed to refractive error) in real time. A device that can assess focus rapidly and objectively will make it possible to perform low-cost, mass screening for focusing problems such as may exist in children at risk for amblyopia.