Meeting the need for post-stroke vision care in Australia: a scoping narrative review of current practice.

PURPOSE: Determine current vision care pathways and practices for stroke survivors in Australia and internationally, focusing on identifying reoccurring gaps in these pathways and unmet care needs. METHOD: A scoping narrative review was conducted to identify literature related to post-stroke vision care practices and perspectives of patients and health professionals. RESULTS: A total of 16193 articles were retrieved and 28 deemed eligible for inclusion. Six were Australian, 14 from the UK, four from the USA, and four from within Europe. Post-stroke vision care is largely unstandardized, with substantial inconsistency in the use of vision care protocols, who executes them and at what point in post-stroke care they are utilised. Health professionals and stroke survivors expressed that unmet care needs were primarily a result of lack of education and awareness regarding post-stroke eye problems. Other gaps in care pathways related to the timing of vision assessment, provision of ongoing support, and the integration of eye-care specialists into the stroke team. CONCLUSION: Further research is needed into current Australian post-stroke vision care to accurately assess whether the needs of stroke survivors are being met. Available evidence indicates that in Australia, there is a requirement for well-defined protocols for vision screening, education, management, and referral of stroke survivors.Implications for RehabilitationPost-stroke vision care in Australia is unstandardised, which may cause inequities in vision care provision to Australian stroke survivors in different regions and/or care facilities.Education and training pertaining to stroke-related vision conditions for stroke healthcare professionals and the inclusion of eye-care professionals in stroke care teams is likely to improve gaps in care practice/pathways identified in the current evidence base.Management of stroke-related visual conditions should be inclusive of detailed information provision that is specific to the patients condition(s) and circumstances, as well as ongoing, long-term management strategies/support services to better aid stroke survivor"s reintegration into the community.

Time outdoors positively associates with academic performance: a school-based study with objective monitoring of outdoor time.

BACKGROUND: To explore the relationship between outdoor time and academic performance among school-aged children. METHODS: This study was designed as a cross-sectional study. Data were derived from a school-based prospective children myopia intervention study (STORM). Outdoor time was recorded by self-developed algorithm-validated wristwatches in real-time and calculated as the cumulative average of 10 months. The academic performance was recorded and provided by the participating schools and further standardized. Other information was collected using an online standardized questionnaire. Mixed-effects model and B-Spline method were used to investigate the association between time spent on different types of daily activity, including outdoor activity and academic performance. RESULTS: A total of 3291 children with mean age 9.25 years were included in the final analysis. Overall, outdoor time was associated with academic performance in a non-linear manner; specifically, not exceeding 2.3 h per day, outdoor time was positively associated with academic performance; exceeding 2.3 h per day, this association became non-significant. Likewise, daily sleep duration and out-of-school learning time were associated with academic performance in a non-linear manner, resulting in turning points of 11.3 and 1.4 h per day, respectively. Separate analysis showed that outdoor time and sleep duration but not out-of-school learning time were positively associated with academic performance in Chinese, mathematics and English. CONCLUSION: Outdoor time, sleep duration and out-of-school learning time were associated with academic performance in a non-linear manner. Promotion of outdoor time may not negatively impact on academic performance. TRIAL REGISTRATION: Our study was registered in ClinicalTrials.gov (Identifier: NCT02980445).

Effect of Myopic Undercorrection on Habitual Reading Distance in Schoolchildren: The Hong Kong Children Eye Study.

INTRODUCTION: This study aimed to evaluate the habitual reading distance among non-myopic children and also myopic children with undercorrection and with full correction. METHODS: This was a population-based cross-sectional study with a total of 2363 children aged 6-8 years who were recruited from the Hong Kong Children Eye Study. Cycloplegic autorefraction, subjective refraction, habitual visual acuity, and best corrected visual acuity were measured. The entire reading process (9 min) was recorded using a hidden video camera placed 5 m away from the reading desk. Reading distances were taken at 6, 7, 8, and 9 min after the child began reading and were measured using a customized computer program developed in MATLAB. The main outcome was the association of habitual reading distances with refraction status. Habitual reading distances of children were documented via video camera footage. RESULTS: The habitual reading distances of undercorrected myopic children (23.37 ± 4.31 cm) were the shortest when compared to non-myopic children (24.20 ± 4.73 cm, P = 0.002) and fully corrected myopic children (24.81 ± 5.21 cm, P < 0.001), while there was no significant difference between the last two children groups (P = 0.17). A shorter reading distance was associated with myopia (OR 1.67; 95% CI 1.11-2.51; P = 0.013) after adjusting for age, sex, height, near work time, outdoor time, and parental myopia. The association of reading distance with myopia did not hold after undercorrected myopic children were excluded (OR 0.97, 95% CI 0.55-1.73; P = 0.92). A shorter reading distance correlated with poorer vision under habitual correction (ß = - 0.003, P < 0.001). CONCLUSION: A shorter reading distance was present among undercorrected myopic children. Myopia undercorrection is not recommended as a strategy for slowing myopic progression.

Vision Screening in Children: The New South Wales Statewide Eyesight Preschooler Screening Program.

PURPOSE: The aim was to investigate universality of access, screening rate, and outcomes from the New South Wales (NSW) Statewide Eyesight Preschooler Screening (StEPS) over the period of 2009 to 2016. DESIGN: Cross-sectional, observational study. METHODS: The StEPS program provides vision screening to 4-year-old children residing in NSW and is administered within Local Health Districts (LHDs). Visual acuity (VA) was examined by trained lay and nurse screeners using HOTV logMAR. Children who had VA <6/9-2 were referred to local practitioners while those with VA <6/18 were referred to public hospital pediatric ophthalmic outpatient clinics where available. Activity data were collected by NSW Health and screening rates determined from population projections of 4-year-olds per LHD based on adjusted 2014 Census data. To determine factors impacting screening and referral rates, a random effects panel analysis was undertaken. RESULTS: A total of 719,686 (96.4%) NSW 4-year-old children were offered StEPS vision screening between 2009 and 2016, 84% accepted and 564,825 children (75.6%) were screened. The screening rate increased from 67.3% in 2009 to 74.5% in 2016, with an 80% target reached for 3 consecutive years from 2013 to 2015. Of those screened, 19.2% were referred to an eye health professional or advised to have a vision retest in 12 months. This referral rate remained steady over the period studied, with little variation between metropolitan, and rural and regional LHDs. CONCLUSIONS: StEPS is an ideal service model for preschool vision screening providing coverage that is comparable to school-based screening programs and at an age likely to facilitate optimal treatment outcomes.

Validation of a vision-screening tool for use by nurses and other non-eye care health practitioners on stroke survivors.

Purpose: To validate a vision-screening tool for use by nurses and other non-eye care health practitioners (NECHP) to aid identification of visual deficits and ocular conditions in stroke survivors.Material and Methods: Stroke survivors were recruited from two metropolitan Sydney public hospitals who had no access to on-site eye care professionals. Those admitted for 3 days and who were able to provide clear responses were randomly allocated into two groups. All were assessed by a NECHP using a purposely designed bedside vision-screening tool to assess their visual function. In Group 1, the orthoptist repeated the assessment with the same vision-screening tool, in Group 2 they performed a comprehensive orthoptic assessment. Levels of agreement and sensitivity and specificity for key outcomes were assessed.Findings: Levels of agreement for most items analyzed for Group 1 reached 80%. Comparison of the screening tool to a comprehensive orthoptist assessment (Group 2), demonstrated high (88.57-91.12%) sensitivity and specificity for detecting pre-existing and acquired visual problems.Conclusion: The vision-screening tool is a valid instrument for use by NECHP, for the detection of vision defects in stroke survivors. Improved detection of eye conditions may facilitate timely identification and management of visual conditions in stroke survivors, potentially improving patient care and rehabilitation outcomes.

Time Outdoors in Reducing Myopia: A School-Based Cluster Randomized Trial with Objective Monitoring of Outdoor Time and Light Intensity.

PURPOSE: To evaluate the efficacy of time outdoors per school day over 2 years on myopia onset and shift. DESIGN: A prospective, cluster-randomized, examiner-masked, 3-arm trial. PARTICIPANTS: A total of 6295 students aged 6 to 9 years from 24 primary schools in Shanghai, China, stratified and randomized by school in a 1:1:1 ratio to control (n = 2037), test I (n = 2329), or test II (n = 1929) group. METHODS: An additional 40 or 80 minutes of outdoor time was allocated to each school day for test I and II groups. Children in the control group continued their habitual outdoor time. Objective monitoring of outdoor and indoor time and light intensity each day was measured with a wrist-worn wearable during the second-year follow-up. MAIN OUTCOME MEASURES: The 2-year cumulative incidence of myopia (defined as cycloplegic spherical equivalent [SE] of ≤-0.5 diopters [D] in the right eye) among the students without myopia at baseline and changes in SE and axial length (AL) after 2 years. RESULTS: The unadjusted 2-year cumulative incidence of myopia was 24.9%, 20.6%, and 23.8% for control, test I, and II groups, respectively. The adjusted incidence decreased by 16% (incidence risk ratio [IRR], 0.84; 95% confidence interval [CI], 0.72-0.99; P = 0.035) in test I and 11% (IRR = 0.89; 95% CI, 0.79-0.99; P = 0.041) in test II when compared with the control group. The test groups showed less myopic shift and axial elongation compared with the control group (test I: -0.84 D and 0.55 mm, test II: -0.91 D and 0.57 mm, control: -1.04 D and 0.65 mm). There was no significant difference in the adjusted incidence of myopia and myopic shift between the 2 test groups. The test groups had similar outdoor time and light intensity (test I: 127 ± 30 minutes/day and 3557 ± 970 lux/minute; test II: 127 ± 26 minutes/day and 3662 ± 803 lux/minute) but significantly more outdoor time and higher light intensity compared with the control group (106 ± 27 minutes/day and 2984 ± 806 lux/minute). Daily outdoor time of 120 to 150 minutes at 5000 lux/minutes or cumulative outdoor light intensity of 600 000 to 750 000 lux significantly reduced the IRR by 15%～ 24%. CONCLUSIONS: Increasing outdoor time reduced the risk of myopia onset and myopic shifts, especially in nonmyopic children. The protective effect of outdoor time was related to the duration of exposure and light intensity. The dose-response effect between test I and test II was not observed probably because of insufficient outdoor time achieved in the test groups, which suggests that proper monitoring on the compliance on outdoor intervention is critical if one wants to see the protective effect.

IMI Risk Factors for Myopia.

Risk factor analysis provides an important basis for developing interventions for any condition. In the case of myopia, evidence for a large number of risk factors has been presented, but they have not been systematically tested for confounding. To be useful for designing preventive interventions, risk factor analysis ideally needs to be carried through to demonstration of a causal connection, with a defined mechanism. Statistical analysis is often complicated by covariation of variables, and demonstration of a causal relationship between a factor and myopia using Mendelian randomization or in a randomized clinical trial should be aimed for. When strict analysis of this kind is applied, associations between various measures of educational pressure and myopia are consistently observed. However, associations between more nearwork and more myopia are generally weak and inconsistent, but have been supported by meta-analysis. Associations between time outdoors and less myopia are stronger and more consistently observed, including by meta-analysis. Measurement of nearwork and time outdoors has traditionally been performed with questionnaires, but is increasingly being pursued with wearable objective devices. A causal link between increased years of education and more myopia has been confirmed by Mendelian randomization, whereas the protective effect of increased time outdoors from the development of myopia has been confirmed in randomized clinical trials. Other proposed risk factors need to be tested to see if they modulate these variables. The evidence linking increased screen time to myopia is weak and inconsistent, although limitations on screen time are increasingly under consideration as interventions to control the epidemic of myopia.

Time spent outdoors in childhood is associated with reduced risk of myopia as an adult.

Myopia (near-sightedness) is an important public health issue. Spending more time outdoors can prevent myopia but the long-term association between this exposure and myopia has not been well characterised. We investigated the relationship between time spent outdoors in childhood, adolescence and young adulthood and risk of myopia in young adulthood. The Kidskin Young Adult Myopia Study (KYAMS) was a follow-up of the Kidskin Study, a sun exposure-intervention study of 1776 children aged 6-12 years. Myopia status was assessed in 303 (17.6%) KYAMS participants (aged 25-30 years) and several subjective and objective measures of time spent outdoors were collected in childhood (8-12 years) and adulthood. Index measures of total, childhood and recent time spent outdoors were developed using confirmatory factor analysis. Logistic regression was used to assess the association between a 0.1-unit change in the time outdoor indices and risk of myopia after adjusting for sex, education, outdoor occupation, parental myopia, parental education, ancestry and Kidskin Study intervention group. Spending more time outdoors during childhood was associated with reduced risk of myopia in young adulthood (multivariable odds ratio [OR] 0.82, 95% confidence interval [CI] 0.69, 0.98). Spending more time outdoors in later adolescence and young adulthood was associated with reduced risk of late-onset myopia (≥ 15 years of age, multivariable OR 0.79, 95% CI 0.64, 0.98). Spending more time outdoors in both childhood and adolescence was associated with less myopia in young adulthood.

Objective Quantification of Spontaneous Retinal Venous Pulsations Using a Novel Tablet-Based Ophthalmoscope.

Purpose: Dynamic assessment of retinal vascular characteristics can aid in identifying glaucoma-specific biomarkers. More specifically, a loss of spontaneous retinal venous pulsations (SVPs) has been reported in glaucoma, but a lack of readily available tools has limited the ability to explore the full potential of SVP analysis in glaucoma assessment. Advancements in smart technology have paved the way for the development of portable, noninvasive, and inexpensive imaging modalities. By combining off-the-shelf optical elements and smart devices, the current study aims to determine whether SVPs can be detected and quantified using a novel tablet-based ophthalmoscope in glaucoma and glaucoma suspects. Methods: Thirty patients, including 21 with confirmed glaucoma (9 men; average age 75 ± 8 years) and 9 glaucoma suspects (5 men; average age 64 ± 9 years), were studied. All patients had intraocular pressure measurements, Humphrey visual field assessment, optical coherence tomography, and a 10-second videoscopy of the retinal circulation. The retinal vasculature recordings (46° field of view at 30 frames per second) were analyzed to extract SVP amplitudes. Results: SVPs were detected and quantified in 100% of patients with glaucoma and those with suspected glaucoma using the novel device. The average SVP amplitudes in glaucoma and glaucoma suspects were 42.6% ± 10.7% and 34% ± 6.7%, respectively. Conclusions: Our results suggest that a novel tablet-based ophthalmoscope can aid in documenting and objectively quantifying SVPs in all patients. Translational Relevance: Outcomes of this study provide an innovative, portable, noninvasive, and inexpensive solution for objective assessment of SVPs, which may have clinical relevance in glaucoma screening.

Independent Influence of Parental Myopia on Childhood Myopia in a Dose-Related Manner in 2,055 Trios: The Hong Kong Children Eye Study.

PURPOSE: To determine the effects on childhood myopia of parental myopia, parental education, children's outdoor time, and children's near work. DESIGN: Population-based cross-sectional study. METHODS: A total of 6,155 subjects in 2,055 family trios (1 child and both parents). Cycloplegic autorefraction was measured for children and noncycloplegic autorefraction for parents. Parental education, children's outdoor time, and near work were collected by questionnaires. Children were categorized into 10 groups based on parental myopia levels. Associations of the above factors with myopia were evaluated by regression analyses. The areas under the receiver operating characteristic curve (AUROCs) for myopia were evaluated. RESULTS: Mild parental myopia did not increase childhood myopia's risk, but the risk was 11.22-folds when both parents were highly myopic. Higher parental education (Father: OR 1.08, P = .046; Mother: OR 1.11, P = .001) and more reading time of children were risk factors (OR 1.21, P = .044). Reduced odds of myopia were associated with more time spent on outdoor activities (OR 0.78, P = .017). Notably, all these factors became insignificant after adjustment, except for parental myopia. Children with more severe parental myopia spent more time on reading, but less on electronic devices. Parental myopic status alone accounted for 11.82% of myopia variation in children. With age and parental myopia, the AUROC for myopia was 0.731. CONCLUSIONS: Among parental and environmental factors, parental myopia confers, in a dose-related manner, the strongest independent effect on childhood myopia. Therefore children with high risk of myopia can be identified for early prevention, based on parental myopia data.

Rationale and protocol for the 7- and 8-year longitudinal assessments of eye health in a cohort of young adults in the Raine Study.

INTRODUCTION: Eye diseases and visual impairment more commonly affect elderly adults, thus, the majority of ophthalmic cohort studies have focused on older adults. Cohort studies on the ocular health of younger adults, on the other hand, have been few. The Raine Study is a longitudinal study that has been following a cohort since their birth in 1989-1991. As part of the 20-year follow-up of the Raine Study, participants underwent a comprehensive eye examination. As part of the 27- and 28-year follow-ups, eye assessments are being conducted and the data collected will be compared with those of the 20-year follow-up. This will provide an estimate of population incidence and updated prevalence of ocular conditions such as myopia and keratoconus, as well as longitudinal change in ocular parameters in young Australian adults. Additionally, the data will allow exploration of the environmental, health and genetic factors underlying inter-subject differential long-term ocular changes. METHODS AND ANALYSIS: Participants are being contacted via telephone, email and/or social media and invited to participate in the eye examination. At the 27-year follow-up, participants completed a follow-up eye screening, which assessed visual acuity, autorefraction, ocular biometry and ocular sun exposure. Currently, at the 28-year follow-up, a comprehensive eye examination is being conducted which, in addition to all the eye tests performed at the 27-year follow-up visit, includes tonometry, optical coherence tomography, funduscopy and anterior segment topography, among others. Outcome measures include the incidence of refractive error and pterygium, an updated prevalence of these conditions, and the 8-year change in ocular parameters. ETHICS AND DISSEMINATION: The Raine Study is registered in the Australian New Zealand Clinical Trials Registry. The Gen2 20-year, 27-year and 28-year follow-ups are approved by the Human Research Ethics Committee of the University of Western Australia. Findings resulting from the study will be published in health or medical journals and presented at conferences. TRIAL REGISTRATION NUMBER: ACTRN12617001599369; Active, not recruiting.

Increased Time Outdoors Is Followed by Reversal of the Long-Term Trend to Reduced Visual Acuity in Taiwan Primary School Students.

PURPOSE: To investigate the change in the prevalence of reduced visual acuity (VA) in Taiwanese school children after a policy intervention promoting increased time outdoors. DESIGN: Prospective cohort study based on the Taiwan School Student Visual Acuity Screen (TSVAS) by the Ministry of Education in Taiwan. PARTICIPANTS: All school children from grades 1 through 6 were enrolled in the TSVAS from 2001 through 2015. METHODS: The TSVAS requires each school in Taiwan to perform measurements of uncorrected VA (UCVA) on all students in grades 1 through 6 every half year using a Tumbling E chart. Reduced VA was defined as UCVA of 20/25 or less. Data from 1.2 to 1.9 million primary school children each year were collected from 2001 through 2015. A policy program named Tian-Tian 120 encouraged schools to take students outdoors for 120 minutes every day for myopia prevention. It was instituted in September 2010. To investigate the impact of the intervention, a segmented regression analysis of interrupted time series was performed. MAIN OUTCOME MEASURES: Prevalence of reduced VA. RESULTS: From 2001 to 2011, the prevalence of reduced VA of school children from grades 1 through 6 increased from 34.8% (95% confidence interval [CI], 34.7%-34.9%) to 50.0% (95% CI, 49.9%-50.1%). After the implementation of the Tian-Tian 120 outdoor program, the prevalence decreased continuously from 49.4% (95% CI, 49.3%-49.5%) in 2012 to 46.1% (95% CI, 46.0%-46.2%) in 2015, reversing the previous long-term trend. For the segmented regression analysis controlling for gender and grade, a significant constant upward trend before the intervention in the mean annual change of prevalence was found (+1.58%; standard error [SE], 0.08; P < 0.001). After the intervention, the trend changed significantly, with a constant decrease by -2.34% annually (SE, 0.23; P < 0.001). CONCLUSIONS: Policy intervention to promote increased time outdoors in schools was followed by a reversal of the long-term trend toward increased low VA in school children in Taiwan. Because randomized trials have demonstrated outdoor exposure slowing myopia onset, interventions to promote increased time outdoors may be useful in other areas affected by an epidemic of myopia.

Association of Parental Myopia With Higher Risk of Myopia Among Multiethnic Children Before School Age.

Importance: Parental myopia is an important risk factor for preschool myopia in Asian children. Further investigation of the association between parental myopia and early-onset myopia risk in other racial/ethnic groups, such as African American and Hispanic white children, could improve understanding of the etiology and treatment of this condition. Objective: To investigate the association of parental myopia with refractive error and ocular biometry in multiethnic children aged 6 to 72 months. Design, Setting, and Participants: This cohort study pooled data from children in 3 population-based studies with comparable design from the US, Singapore, and Australia. Parental myopia was defined as the use of glasses or contact lenses for distance viewing by the child's biological parent(s). Multivariable regressions were conducted to assess the association of parental myopia. Data were collected from 2003 to 2011 and analyzed from 2017 to 2019. Main Outcomes and Measures: Cycloplegic refraction and prevalence of myopia (spherical equivalent refractive error of≤-0.5 diopters [D]) in the more myopic eye. Results: The analysis cohort included 9793 children, including 4003 Asian, 2201 African American, 1998 Hispanic white, and 1591 non-Hispanic white participants (5106 boys [52.1%]; mean [SD] age, 40.0 [18.9] months). Compared with children without parental myopia, the odds ratios for early-onset myopia were 1.42 (95% CI, 1.20-1.68) for children with 1 parent with myopia, 2.70 (95% CI, 2.19-3.33) for children with 2 parents with myopia, and 3.39 (95% CI, 1.99-5.78) for children with 2 parents with childhood-onset myopia. Even among children without myopia, parental myopia was associated with a greater ratio of axial length to corneal curvature radius (regression coefficient for myopia in both parents, 0.023; P < .001) and more myopic refractive error (regression coefficient for myopia in both parents, -0.20 D; P < .001). Effects of parental myopia were observed in all 4 racial/ethnic groups and across age groups except those younger than 1 year. However, parental myopia was not associated with the age-related trends of refractive error (regression coefficient for children without parental myopeia, 0.08; for children with 2 parents with myopia, 0.04; P = .31 for interaction) and ratio of axial length to corneal curvature radius (regression coefficient for children without parental myopeia, 0.031; for children with 2 parents with myopia, 0.032; P = .89 for interaction) beyond infancy. Conclusions and Relevance: Parental myopia, especially childhood-onset parental myopia, was associated with a greater risk of early-onset myopia in Asian, Hispanic, non-Hispanic white, and African American children. The observed associations of parental myopia in children as early as 1 year of age and in children without myopia suggests that genetic susceptibility may play a more important role in early-onset myopia and that parental myopia may contribute to myopia in children by setting up a more myopic baseline before school age.

Association of Ultraviolet Radiation Exposure With Dermatomyositis in a National Myositis Patient Registry.

OBJECTIVE: Dermatomyositis (DM) has been associated with geospatial differences in ultraviolet (UV) radiation, but the role of individual determinants of UV exposure prior to diagnosis is unknown. The objective was to examine the role of those individual determinants. METHODS: We analyzed questionnaire data from 1,350 adults in a US national myositis registry (638 with DM, 422 with polymyositis [PM], and 290 with inclusion body myositis [IBM] diagnosed at ages 18-65 years), examining the likelihood of DM compared with PM and IBM diagnosis, in relation to self-reported sunburn history and job- and hobby-related sun exposures in the year prior to diagnosis. We estimated odds ratios (ORs) and 95% confidence intervals (95% CIs) using logistic regression adjusted for age, skin tone, and sex, to determine the association of individual UV exposures with DM diagnosis. We also evaluated the proportion of DM by maximum daily ambient UV exposure, based on UVB erythemal irradiances for participant residence in the year prior to diagnosis. RESULTS: DM was associated with sunburn in the year before diagnosis (2 or more sunburns OR 1.77 [95% CI 1.28-2.43] versus PM/IBM; 1 sunburn OR 1.44 [95% CI 1.06-1.95]) and with having elevated job- or hobby-related sun exposure (high exposure OR 1.64 [95% CI 1.08-2.49] or moderate exposure OR 1.35 [95% CI 1.02-1.78] versus low or no exposure). Ambient UV intensity was associated with DM in females (ß = 3.97, P = 0.046), but not overall. CONCLUSION: Our findings suggest that high or moderate personal exposure to intense sunlight is associated with developing DM compared with other types of myositis. Prospective research on UV exposure as a modifiable risk factor for DM is warranted.

Persistent visual disturbances after concussion.

BACKGROUND: Ocular dysfunction, including eye movement defects, has been documented in up to 69% of patients with concussion. However, standard sports-related concussion assessment protocols do not typically include any clinical examination of the ocular system. OBJECTIVE: The aim of this article is to inform general practitioners (GPs) about ocular defects associated with concussion, identify test procedures and highlight the important role of GPs within the concussion paradigm. DISCUSSION: Ocular dysfunction that commonly occurs with concussion includes abnormalities of accommodation, convergence, saccades and smooth pursuits. This may cause blurred vision, double vision, ocular pain and difficulty with close work. Symptoms can severely affect daily work, school or play activities. Patients complaining of extended ocular symptoms following concussion should be referred to an ophthalmologist for a complete ocular assessment.

Prevalence, Characteristics, and Risk Factors of Moderate or High Hyperopia among Multiethnic Children 6 to 72 Months of Age: A Pooled Analysis of Individual Participant Data.

PURPOSE: To describe the prevalence, ocular characteristics, and associated risk factors of moderate to high hyperopia in early childhood. DESIGN: Pooled analysis of individual participant data from population-based studies. PARTICIPANTS: Six- to 72-month-old multiethnic children who participated in 4 population-based studies of pediatric eye diseases. METHODS: The pooled studies conducted comparable parental interviews and ocular examinations including cycloplegic autorefraction. Presence of hyperopia was defined based on cycloplegic refractive error in the worse eye. Multivariate analyses were performed to evaluate the association of potential risk factors with hyperopia risk. MAIN OUTCOME MEASURES: Prevalence and odds ratios of moderate to high hyperopia (≥4.0 diopters [D]). RESULTS: Cycloplegic refraction was completed in 15 051 children 6 to 72 months of age. Among these children, the overall prevalence of moderate to high hyperopia (≥4.0 D) in the worse eye was 3.2% (95% confidence interval, 2.9%-3.5%), accounting for 15.6% of all hyperopia (≥2.0 D). Among children with moderate to high hyperopia, both eyes were affected in 64.4%, 28.9% showed spherical anisometropia of 1.0 D or more, and 19.5% showed astigmatism of 1.5 D or more. Among 36- to 72-month-old children with moderate to high hyperopia, 17.6% wore glasses. Prevalence of moderate to high hyperopia was slightly less in 12- to 23-month-old children and was relatively stable in children 24 months of age and older. Non-Hispanic and Hispanic white race and ethnicity, family history of strabismus, maternal smoking during pregnancy, and being a participant in the United States studies were associated with a higher risk of moderate to high hyperopia (P < 0.05). CONCLUSIONS: By assembling similarly designed studies, our consortium provided robust estimates of the prevalence of moderate to high hyperopia in the general population and showed that in 6- to 72-month-old children, moderate to high hyperopia is not uncommon and its prevalence does not decrease with age. Risk factors for moderate to high hyperopia differ from those for low to moderate hyperopia (2.0-<4.0 D) in preschool children, with family history of strabismus and maternal smoking during pregnancy more strongly associated with moderate to high hyperopia than low to moderate hyperopia.

IMI - Clinical Management Guidelines Report.

Best practice clinical guidelines for myopia control involve an understanding of the epidemiology of myopia, risk factors, visual environment interventions, and optical and pharmacologic treatments, as well as skills to translate the risks and benefits of a given myopia control treatment into lay language for both the patient and their parent or caregiver. This report details evidence-based best practice management of the pre-, stable, and the progressing myope, including risk factor identification, examination, selection of treatment strategies, and guidelines for ongoing management. Practitioner considerations such as informed consent, prescribing off-label treatment, and guides for patient and parent communication are detailed. The future research directions of myopia interventions and treatments are discussed, along with the provision of clinical references, resources, and recommendations for continuing professional education in this growing area of clinical practice.

Myopia: is the nature-nurture debate finally over?

In the nineteenth century, the prevalence of myopia began to rise, and Cohn stressed the role of education. Later, based on twin studies, Sorsby argued that refraction was almost totally genetically determined. This became the dominant view. However, rapid increases in the prevalence of myopia were then reported, especially in East and Southeast Asia, where the prevalence of myopia in children completing secondary school is now 80-90 per cent, with around 20 per cent highly myopic, and at risk of ocular pathology. It is not possible to explain these rapid changes genetically, since gene pools cannot change that fast. Nevertheless, there are at least 200 genetic forms of myopia, but these account for myopia in only a low percentage of the population. Genome-wide association studies have identified over 150 single-nucleotide polymorphisms (SNPs) associated with myopia, but they account for < 10 per cent of the variation in refraction. In contrast, twin studies have given consistently high heritability estimates for myopia. The high twin study heritability may be explained by the limited environmental variation within twin pairs, combined with basic assumptions made in twin studies. The SNP-heritability approach suggests that 25-35 per cent of the variation may be accounted for by hundreds or even thousands of SNPs. The apparent conflicts in the literature can be explained by the aetiological heterogeneity of myopia, and the fact that estimates of heritability are population-specific. It has been proposed that environmental variation is more relevant to variations between populations; however, the current differences between populations are due to changes within populations, driven by educational pressures, and limited time spent outdoors. Ethnic differences in myopia and the effects of parental myopia now seem more likely to be explained by environmental influences. Genetic studies have not yet defined molecular pathways and preventive interventions, and the predictive power of current genetic data is limited.