A Comparison of Chemodnervation to Incisional Surgery for Acute, Acquired, Comitant Esotropia: An International Study.

PURPOSE: To compare the efficacy of botulinum toxin injections to strabismus surgery in children with acute, acquired, comitant esotropia (ACE), and to investigate factors predicting success. DESIGN: International, multi-center nonrandomized comparative study METHODS: Setting: Cloud-based survey. STUDY POPULATION: Children aged 2 to 17 years who underwent a single surgical intervention for ACE. INTERVENTIONS: Botulinum toxin injection ("chemodenervation" group) or strabismus surgery ("surgery" group). MAIN OUTCOME MEASURES: Primary measure: success rate at 6 months in propensity-matched cohort, defined as total horizontal deviation of 10 prism diopters or less with evidence of binocular single vision. Secondary measure: Risk factors for poor outcomes in the full cohort. RESULTS: Surgeons from 19 centers contributed. There were 74 patients in the chemodenervation group and 97 patients in the surgery group. In the propensity-matched data (n = 98), success rate was not significantly different at 6 months (70.2% vs 79.6%; P = .2) and 12 months (62.9% vs 77.8%; P = .2), but was significantly lower in the chemodenervation group at 24 months (52% vs 86.4%; P = .015). Irrespective of treatment modality, treatment delay was associated with lower success rates at 6 months, with median time from onset to intervention 4.5 months (interquartile range (IQR): 2.1, 6.7) in the success group and 7.7 months (IQR: 5.6, 10.1) in the failure group (P < .001). CONCLUSIONS: In children with ACE, success rate after chemodenervation was similar to that of surgery for up to 12 months but lower at 24 months. Those with prompt intervention and no amblyopia had the most favorable outcomes, regardless of treatment modality.

Digital therapeutic improves visual acuity and encourages high adherence in amblyopic children in open-label pilot study.

BACKGROUND: The effectiveness of amblyopia therapy can be limited by poor adherence. Dichoptic therapies are a new approach, but recent trials have demonstrated difficulty maintaining high adherence over extended periods of at-home treatment. We evaluated the efficacy and adherence of Luminopia One-a dichoptic treatment that applies therapeutic modifications to streaming content chosen by the patient. METHODS: This single-arm, multicenter prospective pilot study enrolled children aged 4-12 with anisometropic, strabismic, or mixed amblyopia at 10 pediatric ophthalmic and optometric practices across the United States. The therapeutic was prescribed for 1 hour/day, 6 days/week for 12 weeks of at-home use. The primary endpoint was best-corrected visual acuity (BCVA) at the 12-week follow-up visit. RESULTS: In total, 90 participants (mean age, 6.7 ± 2.0 years) were enrolled, and 73/90 participants (81%) had prior treatment beyond refractive correction. For those who completed the 12-week visit, mean amblyopic eye BCVA improved from 0.50 logMAR to 0.35 logMAR (1.5 logMAR lines; 95% CI, 1.2-1.8 lines; P < 0.0001). Mean stereoacuity improved by 0.28 log arcsec (95% CI, 0.14-0.42 log arcsec; P < 0.0001). Median adherence was 86% (interquartile range, 70%-97%). CONCLUSIONS: In our study cohort, adherence over the 12-week study period was high, and participants demonstrated clinically and statistically significant improvements in visual acuity and stereoacuity.

The management of large-angle esotropia in Graves ophthalmopathy with combined medial rectus recession and lateral rectus resection.

PURPOSE: To describe surgical management and outcomes for large-angle esotropia of ≥50Δ secondary to Graves ophthalmopathy using combined initial nonadjustable medial rectus recessions and lateral rectus resections. METHODS: The medical records of consecutive patients undergoing strabismus surgery for large-angle esotropia secondary to Graves ophthalmopathy from 1995 to 2012 by a single surgeon at each of two institutions was performed. Patient characteristics, surgical technique, and pre- and postoperative measurements of ocular alignment were analyzed. A modified Gorman diplopia scale was used to assess outcome. RESULTS: Of 38 patients, 36 had bilateral nonadjustable medial rectus recessions and lateral rectus resections as initial treatment for esotropia, and 6 patients underwent simultaneous vertical muscle surgery. Mean preoperative horizontal deviation was 60Δ and mean preoperative vertical deviation was 10Δ. Of the 38 patients, 19 (50%) reached the primary outcome, including 5 of 6 (85%) who had no preoperative vertical strabismus. The indications for reoperation were vertical strabismus in 13 of 21 patients (62%), residual esotropia in 7 of 21 (33%), and consecutive exotropia in 1 of 21 (5%). With a median follow-up of 13.2 months after first surgery, 32 of 38 patients (84%) reached the secondary outcome. CONCLUSIONS: Combining nonadjustable medial rectus recessions with lateral rectus resections can be a beneficial primary treatment for large-angle esotropia in patients with Graves ophthalmopathy, especially in those patients with small or no associated vertical strabismus.

A novel method for computerized measurement of episcleral venous pressure in humans.

Episcleral venous pressure (EVP) is an important determinant of intraocular pressure (IOP) and can be estimated by the pressure required to compress an episcleral vein. However, the lack of objective measurement endpoints makes EVP measurements in humans uncertain. To address this issue, we developed a new method to measure EVP objectively and reproducibly, and demonstrated its utility on a group of normal subjects. Our system for pressure chamber based venomanometry included a computer-controlled motor drive to increase pressure automatically, a transducer to record pressure, and a high-definition video camera to record vein collapse. Pressure measurements were synchronized with the video stream to determine the pressure required to collapse the vein to a specific pre-determined degree. This system was used to measure EVP in 10 eyes from 5 young healthy volunteers. Episcleral veins were selected in each of 4 quadrants. EVP was calculated to be the pressure in the chamber that compressed the vein by 0% (by back-projection), 10% or 50% as determined by using image analysis of the video stream. For this group of subjects, mean EVP was 6.3 ± 2.8 mmHg (mean ± SD, n = 40 measurements), 7.0 ± 2.6 mmHg, and 9.6 ± 2.6 mmHg using the 0%, 10% and 50% reduction endpoints, respectively. Pressures and standard deviations determined from these endpoints were significantly different from each other (p < 0.001). Coefficients of variation between right and left eyes were 12.7%, 10.2%, and 6.8% using the 0%, 10% and 50% endpoints, respectively. Based on previous research and theoretical considerations, the 0% endpoint is assumed to provide the most accurate estimate of baseline EVP, and can only be estimated by analyzing the brightness profiles of the vessels in the video stream. Objective measurement of EVP is important for understanding normal aqueous humor dynamics and its changes in disease states and with therapies. EVP has typically been assumed to be constant because of the lack of a convenient means of its measurement. This new method provides a precise means to assess EVP based on specific endpoints of vessel collapse, and enables, for the first time, objective and non-invasive measurements of EVP changes.

Survey of intravitreal injection techniques among retinal specialists in the United States.

PURPOSE: To describe the intravitreal injection technique practice patterns of retinal specialists in the United States from April 8, 2010 to April 21, 2010. DESIGN: Questionnaire survey. METHODS: All members of the American Academy of Ophthalmology who self-categorized as "Retinal/Vitreous Surgery" were contacted by e-mail to complete an anonymous, 20-question, internet-based survey. RESULTS: A total of 765 retinal specialists (44%) responded to the survey. Most respondents wear gloves (58%) and use an eyelid speculum (92%) when performing an intravitreal injection. More than 99% use povidone-iodine preinjection. The majority measure the injection site from the limbus (56%) and inject straight into the vitreous cavity (96%). Most do not displace the conjunctiva (83%). Seventy-two percent routinely assess postinjection optic nerve perfusion, primarily by gross visual acuity measurement (32%). While nearly one third of participants use prophylactic topical antibiotics preinjection, more than two thirds use topical antibiotics postinjection. Forty-six percent perform bilateral simultaneous intravitreal injections. The majority of respondents use a 30-gauge needle for the injection of ranibizumab (78%) and bevacizumab (60%). However, respondents use both a 27- and 30-gauge needle for the injection of triamcinolone acetonide. CONCLUSIONS: Retinal specialists in the United States participate in a range of techniques for the care before, during, and after intravitreal injections. Further study is needed to elucidate best practice patterns.

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.

Intravitreal alemtuzumab penetrates full-thickness retina in rabbit eyes.

PURPOSE: The purpose of this study was to assess whether alemtuzamab, a large antibody of 150 kDa, would be able to penetrate through the full-thickness retina of Dutch-belted rabbits. METHODS: Four Dutch-belted rabbits had intravitreal injections of alemtuzumab (1.5 mg in 0.05 mL). One rabbit each was killed at Day 1, Day 8, Day 15, and Day 29. The eyes were examined under frozen section and graded by immunostaining techniques for the degree of penetration of alemtuzumab into the retina. The degree of retinal staining was graded from 0 (no stain) to 4+ (marked stain). RESULTS: All study eyes showed antibody staining of the full-thickness retina as follows: 4+ at Day 1, 4+ at Day 8, 3+ at Day 15, and 2+ at Day 29. CONCLUSION: A 1.5-mg intravitreal dose of alemtuzumab was able to penetrate full-thickness retina throughout the full 29-day course of the study. Retinal toxicity studies are required before clinical use.

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.

Intravitreal silicone oil droplets after intravitreal drug injections.

PURPOSE: To present the finding of tiny silicone oil droplets in 15 eyes of 15 patients after intravitreal injections of an anti-vascular endothelial growth factor agent or triamcinolone acetonide and to discuss the likely source of silicone oil. METHODS: In an observational case series, charts of patients who had undergone intravitreal injections by one surgeon were reviewed retrospectively. The finding of intravitreal silicone oil droplets was noted. The following information was also documented: number and type of injections before the appearance of silicone oil droplets, symptoms and evidence of ocular inflammation, visual acuity before and after silicone oil droplets, length of follow-up, and visual acuity at the last examination. RESULTS: Fifteen eyes of 15 patients were found to have silicone oil droplets documented after a various number of injections (range, 1-16). Patients were asymptomatic, and there were no adverse side effects associated with the presence of silicone oil droplets at examination. CONCLUSIONS: Silicone oil droplets may occur in the vitreous cavity after intravitreal drug injections. There were no adverse effects found associated with silicone oil in the vitreous after injections of anti-vascular endothelial growth factor agents or triamcinolone acetonide. The likely source of silicone oil is the needles and syringes used for the injections.