Visual and auditory attention defects in children with intermittent exotropia.

BACKGROUND: Previous studies have shown that children with intermittent exotropia (IXT) have a higher rate of psychiatric abnormalities as they grow up, such as attention deficit. This study explored visual and hearing attention among children with IXT, and evaluated its association with clinical characteristics and cognitive development. METHODS: Forty-nine children with a diagnosis of IXT and 29 children with traditional development were recruited. The Integrated Visual and Auditory Continuous Performance Test (IVA-CPT) was used to measure the subjects' full-scale response control quotient (FSRCQ), full-scale attention quotient (FSAQ), auditory response control quotient (ARCQ), auditory attention quotient (AAQ), visual response control quotient (VRCQ), and visual attention quotient (VAQ). The Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) was used to assess their cognitive function. The differences between the scores of children with IXT and normal controls were analyzed. RESULTS: The results showed that the FSRCQ, FSAQ, ARCQ, AAQ, VRCQ, and VAQ of children with IXT were all lower than those of normal controls with the same age (P < 0.05). The level of attention was significantly correlated with the age of strabismus onset (P < 0.05), but not with the degree of strabismus, stereopsis, or fusion control score. In addition, audiovisual attention was correlated significantly with their cognitive development level. The random forest classifier prediction model showed that age of strabismus onset was an important predictor of attention. CONCLUSION: Children with IXT have lower visual and auditory attention and control than their peers, and the age of onset of strabismus may be a major factor.

Strabismus and Health Related Quality of Life in a pediatric Portuguese population.

Introduction: Strabismus is a common condition among children, and its psychosocial impact has been demonstrated in recent years. The interest in a more comprehensive approach was enhanced by the recognition of health as a four-dimensional concept, arising the term Health-related Quality of Life. Therefore, we aim to evaluate the influence of strabismus in Health-Related Quality of Life of a Portuguese pediatric population. Material and Methods: Case-control prospective transversal study enrolling children between 5 and 12 years old. All had a complete orthoptic and ophthalmological evaluation, followed by an interview with a legal representative to answer the Pediatric Quality-of-Life Inventory 4.0, proxy-version. Results: Seventy-one children were included, 35 in the control group (CG) and 36 in the strabismus group (SG). In the SG, 30 (83.3%) patients had esotropia, 20 (55.6%) had more than 10 prismatic diopters and 26 (72.2%) were already surgically treated. Overall, SG was not statistically different from the CG, showing only mild inferior performance (p > .05). Furthermore, children with exotropia, higher deviations, none or gross stereoacuity and treatment-naïve, scored worse, especially in emotional, social, educational and psychosocial scores although not statistically significant (p > .05). Conclusion: This is the first prospective study addressing HRQoL and strabismus in a pediatric Portuguese population. It would be relevant to further address this issue in order to delineate more effective and global treatment strategies, not only considering ophthalmological goals but also the well-being of both children and guardians.

Infantile esotropia in Malaysian children: The impact of surgery on health-related quality of life assessment in patients and their parents.

INTRODUCTION: Limited information is available on healthrelated quality of life (HRQoL) in children with strabismus in South East Asia. We aimed to evaluate the HRQoL and associated factors pre- and post-strabismus surgery in Malaysian children with infantile esotropia and their parents/guardians. METHODS: A prospective study was conducted on children with infantile esotropia aged 8-17 years old and their parents/guardians who attended two tertiary hospitals with a paediatric ophthalmology service from 2017 to 2018. The patients and parents answered the Intermittent Exotropia Questionnaire (IXTQ), translated into Malay, at the time of enrolment and three months after the surgery. RESULTS: Thirty-four children and one (each) of their parents/guardians were enrolled. Thirteen (38.2%) children had esotropia with angles of deviation of more than 50 prism dioptres. A total of 33 (97.1%) children achieved successful alignment correction three months after surgery. Surgery significantly improved the total mean scores of the children, which were 62.87 (17.05) preoperatively and 87.13 (13.26) postoperatively (p<0.001). There was statistically improvement in the total mean scores in the parent/guardian group, which was 37.07 (22.01) preoperatively and 75.39 (22.09) postoperatively (p<0.001). The parents/guardians functional, psychosocial and surgery subscales also had a significant increment in the score postoperatively (p<0.001). Older children and children with poorer visual acuity on presentation had a lower score preoperatively, while girls scored better postoperatively (p<0.05). Mothers scored significantly lower preoperatively and postoperatively (p<0.05). CONCLUSION: Surgery significantly improved the HRQoL score in Malaysian children with infantile esotropia and their parents/guardians. The score was significantly higher in female children after the surgery. Mothers exhibited poor scores before and after surgery.

Does successful surgical correction of childhood large angle exotropia in adults make any difference to binocularity and quality of life?

Background/Aim: Strabismus surgery could achieve motor alignment and improve health-related quality of life (HRQOL) in adults with large angle exotropia, but whether it could improve binocularity and whether the binocularity is associated with HRQOL are unknown. The aim of this study is to evaluate the binocularity and HRQOL following successful surgical correction of childhood large angle exotropia in adults. Methods: Consecutive adults with childhood large angle exotropia (≥90 prism diopters) who underwent strabismus surgery in the Department of Ophthalmology and Vision Science, Eye and ENT Hospital, Shanghai Medical School, Fudan University were enrolled. Static and dynamic stereopsis tests were performed before surgery and 1 month after surgery. At the same time, Adult Strabismus-20 (AS-20), and Amblyopia and Strabismus questionnaire (A&SQ) were investigated. Results: A total of 29 adults achieved successful alignment: 18 intermittent exotropes (IXT) and 11 constant exotropes (CXT). One month after surgery, stereopsis was demonstrated better in all types of tests (p < .05 for all comparisons). Twelve patients gained normal stereopsis. More patients in IXT group gained normal stereopsis than in CXT group (x2 = 7.62 p = .008). All HRQOL scores showed statistically significant improvement after surgery (p < .05 for all comparisons). IXT group had more changes of the composite score (t = 2.24, p = .03) and the functional score (t = 2.92, p = .007) of AS-20, and the functional score (t = 3.06, p= .005) of A&SQ than CXT group. Only the change of the functional score of A&SQ was demonstrated a statistically significant correlation with the normal stereopsis (t = 2.67, p = .02). Conclusions: The stereopsis and HRQOL in adults with childhood large angle exotropia can be improved after successful surgical correction. More patients in IXT group gained normal stereopsis correlated with better functional aspects of HRQOL.

Improvement in psychiatric symptoms after strabismus surgery in adolescent patients in long-term follow-up.

AIMS: To assess the psychological effects of preoperative primary eye position and surgical correction of strabismus in adolescent patients. METHODS: Eighty-three adolescent patients with exotropia were included in this observational and prospective study. Patients with preoperative manifest exotropia formed the manifest exotropia group. Patients with intermittent exotropia that had orthophoria with overcorrecting minus lenses and recently increased frequency of manifest phase were indicated for surgery and formed the latent deviation group. All patients were scored with the Turkish version of the Social Appearance Anxiety Scale (SAAS), depression subscale of Hospital Anxiety and Depression Scale (HAD-D) Brief Fear of Negative Evaluation Scale (BFNE), state anxiety subscale of State-Trait Anxiety Inventory (STAI-S) and trait anxiety subscale of State-Trait Anxiety Inventory (STAI-T) before and 1 year after strabismus surgery. RESULTS: The mean preoperative scores of the HAD-D, SAAS, BFNE, STAI-S and STAI-T before strabismus surgery were significantly higher in the manifest exotropia group than in the latent deviation group (p≤0.001 for all). Surgical correction significantly improved the outcomes of all scales in the manifest exotropia group (p≤0.001 for all). Outcomes of the STAI-S and STAI-T significantly improved in the latent deviation group after the surgery (p=0.008, p=0.006, respectively), whereas outcomes of the HAD-D, SAAS and BFNE did not improve (p=0.079, p=0.071, p=0.127, respectively). The mean postoperative scores of all scales did not differ between the two groups (p>0.05 for all). CONCLUSIONS: Strabismus has psychological consequences in adolescent patients, and the visible eye deviation caused by strabismus is a strong indicator of psychological distress.

Symptoms in Children with Intermittent Exotropia and Their Impact on Health-Related Quality of Life.

PURPOSE: In childhood intermittent XT, the frequency and type of symptoms have not been rigorously studied. We aimed to identify specific symptoms in children with intermittent XT, their frequency, and effects on health-related quality of life (HRQOL). METHODS: 35 children (5-13 years) with intermittent XT without previous surgery were enrolled in a prospective cohort study. Specific symptoms were identified from a previous study involving child and parent interviews and formulated as a 22-item symptom questionnaire. A frequency Likert-type rating scale was used and a response of "sometimes" or more was considered consistent with having the symptom. All 35 children, along with one parent for each child, also completed the patient-derived intermittent XT HRQOL questionnaire (IXTQ) with Child, Proxy, and Parent components. The frequency of symptoms was calculated, and the relationship between individual symptom question scores and Child, Proxy, and Parent HRQOL scores, was evaluated in multivariate linear regression analyses. RESULTS: The mean number of specific symptoms was 7 (range 2 to 19). The most frequently reported were: rubbing the eye (29 [83%] of 35), problems with eyes in the sun, and the eyes feeling tired (each 22, 63%). Lower (worse) Child IXTQ HRQOL scores were associated with symptoms of difficulty focusing eyes (P=0.0007), double vision (P=0.007), eyes hurting (P=0.006), and problems with eyes in the sun (P=0.06). There were weak associations between Proxy IXTQ and Parent IXTQ scores and child symptoms. Overall, 7 symptom questions were associated with reduced HRQOL in multivariate models. CONCLUSION: Children with intermittent XT frequently experience symptoms, some of which impact the child's HRQOL. Formal assessment of symptoms may aid understanding of the effects of intermittent XT on an individual child, and could use just the 7 symptom questions associated with reduced HRQOL.

[Utilization of Quality-of-life assessment Questionnaires for Intermittent Exotropia in China].

OBJECTIVE: To evaluate the reliability and validity of Chinese version of Quality-of-life assessment Questionnaires for Intermittent Exotropia (CIXTQ). METHODS: Cross-sectional study. The original English version of the IXTQ was translated into Chinese. The final Chinese version of the IXTQ (CIXTQ) consists of 3 parts: the 12-item child CIXTQ (for children ≥5 and<8 years old and ≥8 and<18 years old, respectively, to assess their health quality of life (HRQoL)), the 12-item proxy CIXTQ (for parents to assess children's HRQoL), and the 17-item parent CIXTQ (containing functional, psychosocial, and surgery subscales; for parents to assess their HRQoL). 175 IXT children and 151 control children along with one of their parents were recruited to answer the CIXTQ. Cronbach's α coefficient and split-half reliability were used to test the internal consistency reliability of the CIXTQ. Kappa coefficient was used to assess the test-retest reliability. Scale-level content validity index/average (S-CVI/Ave) was used to evaluate the content validity of the CIXTQ. Principal component analysis (PCA) was used to verify the construct validity of the parent CIXTQ. Comparison of different CIXTQ scores in IXT patients with controls was conducted by independent-samples t test to evaluate the discriminate validity of the CIXTQ. RESULTS: For all scales and subscales of the CIXTQ in different age groups, the Cronbach's α ranged from 0.804 to 0.963; the split-half reliability ranged from 0.658 to 0.963 and was higher than 0.7 except for the proxy CIXTQ for children aged ≥5 and<8 years old; the test-retest reliability ranged from 0.569 to 0.944. The S-CVI/Ave of the child, proxy and parent CIXTQ was 0.988, 0.988 and 0.966, respectively. Principal factors identified by PCA for the parent CIXTQ could be regrouped into the originally described 3 subscales which was functional, social psychology and surgery in different age groups. The mean scores of all the scales and subscales among IXT children and their parents (8.0±12.5-81.6 ±15.1) were significantly lower than these among control children and their parents (83.1±11.3-99.6±1.2) (t values range from -50.36 to -6.93, P<0.001). CONCLUSIONS: The CIXTQ are useful tools to evaluate the influence of IXT on HRQoL among Chinese children and their parents. (Chin J Ophthalmol, 2016, 52: 596-603).

Effectiveness of strabismus surgery on the health-related quality of life assessment of children with intermittent exotropia and their parents: a randomized clinical trial.

PURPOSE: To evaluate the ability of strabismus surgery to improve the health-related quality of life (HRQOL) assessment scores of children with intermittent exotropia and their parents. METHODS: For this prospective, randomized, parallel group study, 130 children (8-17 year of age) with intermittent exotropia were recruited and randomized to undergo either corrective strabismus surgery or active monitoring without surgery. Each child was accompanied by a parent. HRQOL was assessed with 3 intermittent exotropia questionnaires (IXTQ)--the child self-report, parental proxy report, and parental self-report--administered at enrollment and 3 months after intervention. The primary outcome was change in IXTQ score after 3 months for both groups. RESULTS: At enrollment the scores of the surgery group (n = 63) and monitoring group (n = 57) did not differ significantly (P > 0.05). The sex of the reporting parent had no significant influence on the proxy or parental scores at enrollment or at 3 months (P > 0.05, multivariate analysis). Strabismus surgery significantly improved all parts of the IXTQ scores (P < 0.0001, repeated measures analysis of variance). No significant changes were found for the child scores at 3 months in the monitoring group (P = 0.33). However, the parental and proxy scores were significantly decreased (P < 0.0001). CONCLUSIONS: Corrective strabismus surgery significantly improved the HRQOL scores of the children with intermittent exotropia and their parents.

Childhood intermittent exotropia from a different angle: does severity affect quality of life?

BACKGROUND: Few studies have explored the relationship between health-related quality of life (HRQOL) and clinical severity of childhood intermittent exotropia (IXT) measured by angle of deviation, control and stereoacuity. METHODS: Sixty-eight consecutive children aged 5-17 years with childhood IXT who attended the paediatric eye clinic were recruited. One accompanying parent was recruited concurrently. Child, parent and proxy (parent about the child) HRQOL was measured using the IXT questionnaire (IXTQ). Angle of deviation, control and stereoacuity of the children were measured and correlated with IXTQ scores using Spearman's correlation coefficient and paired t test for differences in child and proxy IXTQ mean scores. RESULTS: The mean age of the children was 9.0±2.6 years. Child HRQOL was not correlated to any strabismus measurements. Poorer parent HRQOL was correlated with poorer distance control (surgery subscale, r=-0.24 p=0.049), poorer near control (surgery subscale, r=-0.30, p=0.013), poorer office near control (mean, r=-0.24, p=0.047; psychological subscale, r=-0.27, p=0.025; surgery subscale, r=-0.28, p=0.020) and larger angle of deviation (psychological subscale, r=-0.30, p=0.013). Poorer proxy HRQOL was correlated with poorer home control (r=-0.28, p=0.022) and larger angle of deviation (r=0.33, p=0.0061). CONCLUSIONS: It is difficult to predict child HRQOL based on clinical measurements. However, parent HRQOL tends to be worse with poorer control and larger angle of deviation. Perhaps HRQOL should be routinely assessed in clinic alongside clinical measurements in order to tailor management appropriately.

Evaluation of the Intermittent Exotropia Questionnaire using Rasch analysis.

IMPORTANCE: The Intermittent Exotropia Questionnaire (IXTQ) is a patient, proxy, and parental report of quality of life specific to children with intermittent exotropia. We refine the IXTQ using Rasch analysis to improve reliability and validity. OBSERVATION: Rasch analysis was performed on responses of 575 patients with intermittent exotropia enrolled from May 15, 2008, through July 24, 2013, and their parents from each of the 4 IXTQ health-related quality-of-life questionnaires (child 5 through 7 years of age and child 8 through 17 years of age, proxy, and parent questionnaires). Questionnaire performance and structure were confirmed in a separate cohort of 379 patients with intermittent exotropia. One item was removed from the 12-item child and proxy questionnaires, and response options in the 8- to 17-year-old child IXTQ and proxy IXTQ were combined into 3 response options for both questionnaires. Targeting was relatively poor for the child and proxy questionnaires. For the parent questionnaire, 3 subscales (psychosocial, function, and surgery) were evident. One item was removed from the psychosocial subscale. Resulting subscales had appropriate targeting. CONCLUSIONS AND RELEVANCE: The Rasch-revised IXTQ may be a useful instrument for determining how intermittent exotropia affects health-related quality of life of children with intermittent exotropia and their parents, particularly for cohort studies.

Binocular inhibition in strabismic patients is associated with diminished quality of life.

PURPOSE: To characterize the relationship between binocular summation (BiS) and binocular inhibition (BI) on the quality of life of adults and children with strabismus. METHODS: Strabismus patients at a single center from 2010 to 2012 were prospectively enrolled. A BiS score was measured using ETDRS and Sloan low-contrast visual acuity (LCA) protocols at 2.5% and 1.25% contrast. Patients were categorized as having BiS (binocular better than better-eye visual acuity by ≥5 letters), BI (binocular worse than better-eye visual acuity by ≥5 letters), or otherwise indeterminate visual acuity (a difference between binocular visual acuity and monocular visual acuity of the better eye of <5 letters). Quality of life was evaluated by the National Eye Institute Visual Functioning Questionnaire 25 (VFQ-25), 20-item Adult Strabismus Questionnaire (AS-20), and the Amblyopia and Strabismus Questionnaire. RESULTS: A total of 108 patients were included. There was no significant BiS or BI for high-contrast ETDRS or 2.5% LCA tests; however, a mean BiS score of -2.14 ± 7.0 letters for 1.25% LCA demonstrated significant binocular inhibition (P = 0.004) for this contrast level. The mean composite VFQ-25 score was significantly lower in subjects with BI on ETDRS (80 ± 19 vs 57 ± 7 for subjects with BiS and BI, resp. [P = 0.03]), 2.5% LCA (81 ± 14 vs 66 ± 16 for subjects with BiS and BI, resp. [P = 0.01]), and 1.25% LCA tests (91 ± 9 vs 72 ± 14 for subjects with BiS and BI, resp. [P = 0.005]). After accounting for potential covariates, significant association persisted for BI, demonstrated by 1.25% LCA (P = 0.01). With BI demonstrable at 2.5%, AS-20 scores were also significantly lower (P = 0.04). CONCLUSIONS: Strabismic patients with BI had significantly lower quality-of -life scores than those who did not, even after accounting for potential covariates and the absence of diplopia.

Functional and psychosocial impact of strabismus on Singaporean children.

PURPOSE: To quantify the effects of strabismus in Singaporean children using the Intermittent Exotropia Questionnaire (IXTQ) and the Adult Strabismus 20 Questionnaire (AS20). METHODS: Consecutive strabismus patients 5-16 years of age were recruited along with an equal number of age-matched controls with eye conditions other than strabismus and amblyopia (group A) and controls with no known eye conditions (group B). All children completed the IXTQ; those 8-16 years of age also completed the AS20 questionnaire. Parents completed the parental proxy IXTQ (pp-IXTQ) and AS20 (pp-AS20) and a parental IXTQ (PIXT). RESULTS: A total of 60 patients and 60 age-matched controls in each group were included. Children with strabismus had lower IXTQ (70.1 ± 19.0) and AS20 (80.0 ± 13.8) scores than those in group B (IXTQ, 90.3 ± 11.8 [P < 0.001]; AS20, 90.0 ± 10.9 [P < 0.001]) and group A (IXTQ, 80.6 ± 14.9 [P = 0.001]; AS20, 81.6 ± 18.3 [P = 0.691]). Among children with strabismus, child IXTQ scores were significantly lower than parental proxy scores (70.1 ± 19.0 vs 76.4 ± 15.8 [P = 0.026]), but there was no difference in control group scores or with AS20 scores. Item-level analysis suggested that children's worry focused on what others thought about them and their ability to make friends, whereas parents were more concerned about eyesight and whether surgery was required. CONCLUSIONS: The IXTQ and AS20 were better at differentiating between children with strabismus and those with no eye condition than between children with strabismus and other eye conditions. Parental proxies were accurate in predicting child scores but parents were more likely to underestimate the psychosocial effects of their children's strabismus.

Associations between health-related quality of life and the decision to perform surgery for childhood intermittent exotropia.

OBJECTIVE: To assess associations between health-related quality of life (HRQOL) and the decision to perform strabismus surgery for children with intermittent exotropia. DESIGN: Retrospective chart review. PARTICIPANTS: Children with intermittent exotropia. METHODS: Included subjects, identified in a clinical practice, had assessment of HRQOL using the intermittent exotropia questionnaire (IXTQ), comprising child, proxy, and parent components (parent domains: function, psychosocial, and surgery). The IXTQ scores were evaluated for association with surgery, along with standard clinical measures: prism and alternate cover test (PACT), stereoacuity, and control score (mean of the 3 most recent scores). Included data were from preoperative examination (surgical cohort) or from most recent follow-up examination (nonsurgical cohort). Univariate and multivariate logistic regression analyses were performed, and relative risk (RR) ratios were calculated. Spearman rank correlations were calculated to identify highly correlated items. MAIN OUTCOME MEASURES: Association of individual factors with the decision to perform surgery, calculated using RR ratios. RESULTS: One hundred six children with intermittent exotropia (median age, 6 years; range, 2-16 years) were eligible for inclusion. Nineteen (18%) of 106 underwent surgery. Using all available data, the IXTQ proxy score, IXTQ parent function score, IXTQ parent psychosocial score, distance control score, near control score, near PACT, and Randot Preschool stereoacuity (Stereoptical Co, Inc, Chicago, IL) were associated with undergoing surgery (P<0.1). Sixty-nine of 106 patients had complete data on all factors identified in univariate analysis and were included in multivariate analyses. Fourteen (20%) of these 69 patients underwent surgery. In multivariate analyses, poor distance control score (RR, 1.83; 95% confidence interval [CI], 1.25-2.68) and reduced IXTQ parent function score (RR, 0.96; 95% CI, 0.92-0.99) were associated with surgical intervention. Repeat multivariate analyses retaining only 1 of the highly correlated items showed IXTQ proxy, IXTQ parent psychosocial, larger near PACT, and worse near control were also associated with surgery. CONCLUSIONS: After accounting for poorer exodeviation control at distance, reduced parent and proxy HRQOL were associated with undergoing strabismus surgery for childhood intermittent exotropia. Recognizing reduced parental HRQOL may be important, with a possible role for educational or counselling interventions.

Specific health-related quality of life concerns in children with intermittent exotropia.

PURPOSE: To assess the frequency of specific health-related quality of life (HRQOL) concerns in children with intermittent exotropia (XT) using the Intermittent Exotropia Questionnaire (IXTQ). METHODS: Eighty children with intermittent XT (aged 5 to <17 years), plus one parent for each child, completed the Child and Proxy IXTQ respectively. Each item was scored from 0 to 100 (worst to best HRQOL). Mean scores were calculated for each item and items were ranked from lowest to highest impact (worst HRQOL). Analysis was repeated for sub-groups of 5- to <8-year-olds (n = 46) and 8- to <17-year-olds (n = 34). RESULTS: Highest impact Child IXTQ items were: "It bothers me that I have to shut one eye when it is sunny," "I worry about my eyes," and "It bothers me because I have to wait for my eyes to clear up." Highest impact Proxy IXTQ items were: "It bothers my child because he/she has to shut one eye when it is sunny" and "My child worries about his/her eyes." Lowest impact Child and Proxy items were "My eyes make it hard to make friends" and "Kids tease me because of my eyes." Ranking of items was similar for younger and older children. CONCLUSIONS: The greatest HRQOL concerns for children with intermittent XT were shutting one eye when sunny, waiting for their eyes to clear up, and worrying about their eyes. Items related to teasing and making friends were of least concern. Evaluation of HRQOL concerns using the IXTQ may be helpful in the clinical care of individual patients.

Use of the PedsQL in childhood intermittent exotropia: estimates of feasibility, internal consistency reliability and parent-child agreement.

PURPOSE: To evaluate the PedsQLs performance in children with intermittent exotropia (X[T]) in terms of feasibility, internal consistency, floor-ceiling effects and levels of parent-child agreement. METHODS: Children with X(T) aged <12 years were recruited from 26 UK Hospital Eye Clinics/Orthoptic Departments. QOL was assessed using child (n = 166) and proxy (n = 392) versions of the PedsQLv4. Feasibility was assessed by percentage of missing responses; internal consistency by Cronbach's alpha and agreement by Bland-Altman plots and intraclass correlations. Analyses included age and gender comparisons. RESULTS: Missing response rates were no higher than 1.8%. Cronbach's alpha reached ≥ 0.70 on all but one parent-rated scale and on most child-rated Total, Psychosocial Summary and Social Functioning scales, but was <0.70 on most child-rated Physical, Emotional and School Functioning scales. On parent-rated scales, there were no floor effects; ceiling effects reached 27-56% in parents' Physical, Social and School Functioning. On child-rated scales, there were 0-1% floor effects and 0-28% ceiling effects. Parent-child agreement was fair to poor and varied by child's gender. CONCLUSIONS: Proxy-rated PedsQLs demonstrated good internal consistency/feasibility in parents of children with X(T); child-rated reports appeared acceptable, although caution is advised regarding Physical, Emotional and School Functioning scales in younger children. Low-fair agreement between proxy and self-ratings is common in paediatric QOL assessment, reiterating the importance of obtaining both perspectives. We encourage future studies to explore the influence of child's age and gender, and the relationship of the proxy respondent.

Negative social reaction to strabismus in school children ages 8-12 years.

PURPOSE: To investigate children's willingness to sit next to a child with noticeable exotropia as a measure of social alienation. METHODS: This was a cross-sectional, mixed-design study. Children in primary grades 3-6 (8-12 years old) were asked to view 8 digitally modified images of exotropic or orthotropic children in classroom settings and rate their willingness to sit next to the child in each image. RESULTS: A total of 157 children participated. A 4 × 2 × 2 mixed-design analysis of variance revealed a significant main effect for primary level (F [3, 151] = 4.06, P = .01, partial η(2) = .08) and for image type, exotropic versus orthotropic, (F [1, 151] = 108.45, P = .00, partial η(2) = .42). The results of the main effects were qualified by a significant primary level X image type interaction (F [3, 151] = 4.00, P = .01, partial η(2) = .08). Children were less willing to sit next to a person with noticeable exotropia. Although this phenomenon was consistent across all primary levels, the magnitude of the effect diminished in strength for children in higher primary levels. CONCLUSIONS: This study further strengthens existing evidence for strabismus-related prejudice that suggests that children with noticeable strabismus may be subjected to social alienation by other children.

Health-related quality of life in parents of children with intermittent exotropia.

PURPOSE: To assess the health-related quality of life (HRQOL) of parents of children with intermittent exotropia with use of the newly developed condition-specific Parent Intermittent Exotropia Questionnaire (Parent IXTQ) and the generic PedsQL Family Impact Module (PedsQL FIM) and to compare the performance of both instruments. METHODS: One parent was recruited for each of 59 children with intermittent exotropia (age range, 3-16; median, 7 years) and for each of 29 visually normal children (age range, 5-13; median, 8 years). The parent completed the Parent IXTQ and the PedsQL FIM. For each questionnaire, we compared median HRQOL scores between the intermittent exotropia group and visually normal group. We also calculated normal thresholds, which were defined as the 5th percentile score in the cohort of parents of visually normal children. The proportion of subnormal scores between questionnaires in parents of children with intermittent exotropia was compared. RESULTS: The Parent IXTQ score was worse in the intermittent exotropia group than in the visually normal group (70.6 vs 94.1, p < 0.0001), whereas the PedsQL FIM scores were similar (97.9 vs 95.8, p = 0.8). More parents scored below normal when the Parent IXTQ was used than when the PedsQL FIM was used (31% vs 12%; p = 0.008, McNemar's test). CONCLUSIONS: The Parent IXTQ detects subnormal HRQOL in parents of children with intermittent exotropia more often than the PedsQL FIM. It is possible that parental worry may influence management decisions in children with intermittent exotropia and therefore parental HRQOL is worthy of further study.

The perception of strabismus by children and adults.

BACKGROUND: Visible strabismus has been shown to have adverse psychosocial consequences. It remains controversial if esotropia or exotropia is perceived more negatively. The aim of this study was to determine if esotropia or exotropia and the eye (side) in which strabismus is present are perceived differently. We also asked our adult participants: (1) if they thought visible strabismus should be corrected by surgery, (2) if they thought that strabismus surgery should only be to improve the cosmesis, and (3) if they thought that the surgery should be paid for by health insurance. METHODS: One hundred adults and 61 children rated four photographs of a digitally altered picture of a boy and four of a girl, showing a large-angle esotropia or exotropia either in the left or on the right eye. The adults were additionally asked if a squint should be operated, if they considered strabismus surgery to be a cosmetic procedure, if in their opinion strabismus surgery should be covered by compulsory health insurance, and if children with strabismus are disadvantaged. Comparisons were performed using ANOVA and regression analysis. RESULTS: Adults perceived a squinting right eye as more disturbing than a squinting left eye p < 0.001). The direction of strabismus, the age, gender, and the number of persons with a squint among family and friends of the respondents did not influence the perception of strabismus by adults (p > 0.1 for each). Children also found that a squinting right eye is more disturbing (p < 0.001) than a left one. Additionally, children ranked esotropia worse than exotropia (p < 0.001). Neither age nor gender had an impact on the perception of strabismus by children. Of the adults, 94% would recommend surgery for all forms of strabismus, 18% thought that surgery is only cosmetic, and 94% found that health insurance should cover strabismus surgery for everybody. Problems of squinting children named by the adults included: being made fun of by other children (53%), problems with eyesight (39%), people looking strangely at them (21%), less acceptance by peers (17%), less self confidence (6%), problems judging distances (4%), and that they are perceived as less intelligent (3%). CONCLUSIONS: Adults and children rated a squinting right eye as worse compared to a left one. Children perceived esotropia as more disturbing than exotropia. Neither age, nor gender, nor the fact that the respondents have friends or family members with a squint, had an impact on this ranking. Almost all adults would correct all forms of strabismus, and think that surgery should be covered by compulsory health insurance.

Strabismus-related prejudice in 5-6-year-old children.

AIMS: There is a general consensus that individuals with conspicuous strabismus are perceived more negatively with respect to physical appearance, personality and capability. Such social biases can potentially lead to social alienation and negative psychosocial development, particularly when experienced at a young age. This study aims to explore young children's perception of peers with noticeable exotropia. METHODS: 128 children, 5-6 years old, took part in this cross-sectional within-group study. The sample viewed four paired images of peers with orthotropia and exotropia, and chose the image they LIKED and the image they would SHARE their favourite toy with. All images were created using digital morphing technique. RESULTS: Single proportion tests showed that a significantly greater proportion of the sample chose the orthotropic images as the ones they like (z=5.74, p<0.001) and the ones they would share their favourite toy with (z=4.90, p<0.001). Phi coefficient analysis further demonstrated an association between the choice to like and the choice to share ((504)=0.34, p<0.001). CONCLUSIONS: Children as young as 5 years old are found to have negative social reactions towards peers with noticeable exotropia. These findings imply that children with noticeable strabismus may be subjected to social alienation at an early age.

Comparison of quality-of-life instruments in childhood intermittent exotropia.

PURPOSE: To compare 2 health-related quality-of-life (HRQOL) instruments: the condition-specific Intermittent Exotropia Questionnaire (IXTQ) and the generic Pediatric Quality of Life Inventory (PedsQL) in children with intermittent exotropia. METHODS: Fifty-one children with intermittent exotropia (median, 7 years; range, 5-16 years) were recruited from outpatient clinics with one of their parents. All children completed age-appropriate Child IXTQ (12 items) and Child PedsQL (23 items). Parents completed parallel Proxy IXTQ and Proxy PedsQL (parent assessment of child's HRQOL). Possible scores ranged from 0 to 100 (worst to best HRQOL). Normal thresholds were defined using the 5th percentile in a control group of 47 normal nonstrabismic children. Proportions scoring below normal on each questionnaire were compared. Median scores in intermittent exotropia and control groups also were compared. RESULTS: More scores were subnormal using Proxy IXTQ than Proxy PedsQL (55% vs 18%, p = 0.0004). When Child questionnaires were used, we found that similar proportions scored below normal (IXTQ 8% vs PedsQL 14%, p = 0.3). Median scores were lower for intermittent exotropia children compared with control patients for Child IXTQ (83 vs 92; p = 0.04), Proxy IXTQ (81 vs 98; p < 0.0001), and Proxy PedsQL (p = 0.04) but not for Child PedsQL (p = 0.3). CONCLUSIONS: The Proxy IXTQ detects reduced HRQOL related to intermittent exotropia more often than the Proxy PedsQL. There were few subnormal scores on Child IXTQ and Child PedsQL. Children with intermittent exotropia scored, on average, lower than control patients on the IXTQ, but most individual scores fell within the normal range. The IXTQ may prove useful for clinical assessment of intermittent exotropia.