Surgical Treatment of Epiblepharon Effectively Alleviates Keratopathy but Not Astigmatism: A Case-Control Study Utilizing Vector Analysis in East Asian Children.

PURPOSE: To identify an appropriate surgical indication of epiblepharon by comparing keratopathy and astigmatism outcomes after surgical and medical treatments for epiblepharon in Asian children. METHODS: Children diagnosed with epiblepharon (n = 82, age 5.93 ± 2.76 years) with >6 months of follow-up were enrolled. The clinical presentations and cycloplegic refractive status at the baseline and 3 and 6 months after treatment were compared between surgical (91 eyes from 47 children) and nonsurgical (67 eyes from 35 children) groups. The refractive and keratometric astigmatism at each time point were evaluated with vector analysis methods. For Thibos and Horner's method, the astigmatic power vector was decomposed into horizontal and oblique meridians (J 0 and J 45). However, the treatment-induced astigmatism (TIA) vectors were calculated by Alpins' method and depicted by the AstigMATIC software. RESULTS: In the surgical and nonsurgical groups, the baseline astigmatism magnitude was similar (2.22 ± 1.39 and 2.26 ± 1.46 D, p = 0.87). The rate of complete resolution of keratopathy at 6 months was 71.4% and 11.5%. The astigmatism magnitude in the surgical group differed among baseline and 3 months (2.25 ± 1.23 D) and 6 months postoperatively (1.97 ± 1.28 D) (p = 0.001). Power vector analyses confirmed a nuanced against-the-rule shift in the surgical group. This trend was especially observed in the subgroup of baseline astigmatism >2.0 D. However, the difference in the astigmatism magnitude between surgical and nonsurgical groups, even in highly astigmatic children, was not significant at 6 months. CONCLUSIONS: The improvement of keratopathy in the surgical group was greater than that in the nonsurgical group in consideration of the more advanced severity in the surgery group at baseline. Decreased with-the-rule astigmatism can be observed at 6 months postoperatively, particularly among those with greater baseline astigmatism. However, the amount of change is small, and the outcome does not differ significantly from the nonsurgical treatment. Therefore, surgical indications should majorly base on the severity of symptoms and keratopathy.

UVB promotes the initiation of uveitic inflammatory injury in vivo and is attenuated by UV-blocking protection.

PURPOSE: Uveitic inflammatory injury can cause irreversible visual loss; however, no single animal model recapitulates all the characteristics of human uveitis. Ultraviolet radiation (UVR) is one of the risk factors for uveitis, but the role of UVR in the pathogenesis of uveitic injury is unclear. The aim of this study was to elucidate whether UVB promotes the initiation of, and subsequently contributes to, uveitic inflammatory injury. METHODS: Mice were assigned to either a blank control group or one of three UVB treatment groups: no protection, protection with Nelfilcon A contact lens (Food and Drug Administration [FDA] class II, about 46.8% UVB transmittance), or protection with Etafilcon A contact lens (FDA class IV, about 0.55% UVB transmittance). The contact lenses acted as blocking barriers against UVR. After the application of UVR, pathologic injuries were determined with slit-lamp microscopy and histologic examination. RESULTS: Compared with the intact status of the controls, the anterior eyes of the UVB groups showed pathologic alterations in physiologic properties and tissue integrity. UVR promoted anterior uveitic inflammatory injury, with expansion of the hyperemic iris vessels, over-production of aqueous humor protein, disruption of the blood-aqueous barrier, and embedding of infiltrative leukocytes inside the iridocorneal angle. However, blockage of UVR in vivo retarded the progression of uveitic inflammatory injury. The highest level of UV protection in the Etafilcon A group resulted in greater inhibition of uveitic inflammatory injury than that in the Nelfilcon A group. CONCLUSIONS: This study demonstrates that UVB initiated and promoted uveitic inflammatory injury. UV protection is needed for the clinical management of anterior uveitis. The Etafilcon A lenses provide better protection of the anterior segment of the eye against UVB damage compared with the Nelfilcon A lenses.

Relative and absolute reliability of a vertical numerical pain rating scale supplemented with a faces pain scale after stroke.

BACKGROUND: Pain is a serious adverse complication after stroke. The combination of a vertical numerical pain rating scale (NPRS) and a faces pain scale (FPS) has been advocated to measure pain after stroke. OBJECTIVE: This study was conducted to investigate whether an NPRS supplemented with an FPS (NPRS-FPS) would show good test-retest reliability in people with stroke. The relative and absolute reliability of the NPRS-FPS were examined. DESIGN: A test-retest design was used for this study. METHODS: Fifty people (>3 months after stroke) participating in an outpatient occupational therapy program were recruited through medical centers to rate current pain intensity twice, at a 1-week interval, with the NPRS-FPS (on a scale from 0 to 10). The relative reliability of the NPRS-FPS was analyzed with the intraclass correlation coefficient for determining the degree of consistency and agreement between 2 measures. The standard error of measurement, the smallest real difference, and Bland-Altman limits of agreement were the absolute reliability indexes used to quantify measurement errors and determine systematic biases of repeated measurements. RESULTS: The relative reliability of the NPRS-FPS was substantial (intraclass correlation coefficient=.82). The standard error of measurement and the smallest real difference at the 90% confidence interval of the NPRS-FPS were 0.81 and 1.87, respectively. The Bland-Altman analyses revealed no significant systematic bias between repeated measurements for the NPRS-FPS. The range of the limits of agreement for the NPRS-FPS was narrow (-2.50 to 1.90), indicating a high level of stability and little variation over time. LIMITATIONS: The pain intensity of the participants ranged from no pain to a moderate level of pain. CONCLUSIONS: These findings suggest that the NPRS-FPS is a reliable measure of pain in people with stroke, with good relative and absolute reliability.

Rasch validation of a combined measure of basic and extended daily life functioning after stroke.

BACKGROUND: Tools used to measure poststroke functional status must include basic and instrumental activities of daily living and reflect the patient's and the clinician's perspective of the disease and its effect on daily living performance. OBJECTIVE: The authors combined the Functional Independence Measure (FIM) and the Nottingham Extended Activities of Daily Living (NEADL) to create a scale providing a comprehensive evaluation of ADLs functional status in patients with stroke. METHODS: The study participants were 188 patients completing the FIM and the NEADL. The psychometric properties of the combined measure were examined with Rasch analysis. RESULTS: A 3-point scale and a dichotomous scale were suggested for use in the FIM and the NEADL, respectively. The combined 40 items worked consistently to reflect a single construct, and "bladder management" and "bowel management" were highly related. After "bowel management" was removed from the combined scale, all but 3 items fit the model's expectations, and the 39-item scale showed reasonable item difficulty hierarchy, with high reliability. The 3 misfit items were removed, and no differences in unidimensionality, differential item functioning, and reliability were found between the 36-item and 39-item scales. CONCLUSIONS: The combined measure of the FIM and the NEADL provides a comprehensive picture of ADLs. It extends the utility of the FIM and the NEADL and is recommended for use to measure the independence of patients after discharge home.

Refractive outcome of premature infants with or without retinopathy of prematurity at 2 years of age: a prospective controlled cohort study.

This study evaluated the extent to which refractive morbidity is correlated to preterm birth or retinopathy of prematurity (ROP) itself, or both, and examined the risk factors associated with refractive errors in a cohort of preterm infants with and without ROP compared with full-term infants. This longitudinal, prospective, controlled cohort study enrolled 109 infants, including 74 preterm and 35 full-term infants. Infants were divided into the following groups: no ROP, regressed ROP, laser-treated threshold ROP, and full-term. Cycloplegic refraction was determined at 6 and 24 months' corrected age. Multiple regression models, analysis of variance (ANOVA) with post hoc comparisons, paired t test, and the χ(2) test were used for data analysis. ROP status was highly predictive of significant refractive errors in preterm infants. Eyes with laser-treated threshold ROP had significant myopia at both ages (mean spherical equivalent [MSE] in right eye at both refractions -0.72, -1.21 diopters [D]), astigmatism (MSE -1.62, -1.80 D), and anisometropia (MSE 0.82, 1.02 D; ANOVA p < 0.05), and increased refractive errors across ages (paired t test p < 0.05). Eyes with regressed ROP (MSE + 0.35 D) and eyes without ROP (MSE + 0.78 D) were less hyperopic than the controls (MSE + 1.60 D) before 1 year (post hoc comparisons p < 0.05). After 1 year, however, hyperopic status, astigmatism, and anisometropia were similar to eyes with regressed ROP (MSE + 0.38 D, astigmatism -0.94 D, anisometropia 0.32 D), eyes without ROP (MSE + 0.35 D, astigmatism -0.51 D, anisometropia 0.31 D) and the controls (MSE + 0.72 D, astigmatism -0.59 D, anisometropia 0.50 D) by post hoc comparisons (p > 0.05). Thus, the persistent hyperopic status across ages in patients with regressed ROP and in patients without ROP differed significantly (paired t test p > 0.05) from that in the full-term infants, with a reduction in hypermetropia noted for the first 2 years of life (paired t test p < 0.05). The incidence and magnitude of significant refractive errors increased with severe ROP and with age. Although the emmetropization process of preterm birth, including regressed ROP and no ROP, differed from full-term birth in early infancy, we found no differences in the refractive status after 1 year in patients with regressed ROP and in patients without ROP, who were at risk of developing ametropia similar to that of full-term patients. Therefore, apart from laser-treated ROP, children with regressed ROP and without ROP can likely be observed with a verbal vision screening at 3-4 years of age.

Psychometric comparison of the shortened Fugl-Meyer Assessment and the streamlined Wolf Motor Function Test in stroke rehabilitation.

OBJECTIVE: We aimed to compare the responsiveness, concurrent and predictive validity of the shortened Fugl-Meyer Assessment (S-FMA) and the streamlined Wolf Motor Function Test (S-WMFT) in persons with subacute stroke. DESIGN: Test-retest design. SETTING: Departments of physical medicine and rehabilitation at three hospitals. PARTICIPANTS: PARTICIPANTS with first-time stroke (N = 51; 38 men, 13 women; mean age ± SD, 55.1 ± 11.7 years) based on scores of Mini-Mental State Examination and Brunnstrom stage. INTERVENTIONS: PARTICIPANTS received one of three rehabilitation therapies for three weeks and were evaluated at baseline and end of treatment. MAIN OUTCOME MEASURES: Responsiveness was examined using the paired t-test and the standardized response mean (SRM). Criterion validity was investigated using the Pearson's correlation coefficient (r). RESULTS: Changes from baseline to end of treatment assessed by both tests were significant (P < 0.001). The value for responsiveness of the S-FMA was significantly higher than that of the S-WMFT (SRM difference, 0.48; 95% confidence interval, 0.23-0.63). There were stronger associations between the comparison scales and the S-FMA (r = 0.57-0.68) than with the S-WMFT (r = 0.39-0.58). CONCLUSIONS: The S-FMA had better concurrent and predictive validity than the S-WMFT and was more sensitive to changes caused by rehabilitation therapies. The S-FMA is recommended for expedited assessment of arm motor function outcome in stroke patients receiving rehabilitative therapy.

Assessing the stroke-specific quality of life for outcome measurement in stroke rehabilitation: minimal detectable change and clinically important difference.

BACKGROUND: This study was conducted to establish the minimal detectable change (MDC) and clinically important differences (CIDs) of the physical category of the Stroke-Specific Quality of Life Scale in patients with stroke. METHODS: MDC and CIDs scores were calculated from the data of 74 participants enrolled in randomized controlled trials investigating the effects of two rehabilitation programs in patients with stroke. These participants received treatments for 3 weeks and underwent clinical assessment before and after treatment. To obtain test-retest reliability for calculating MDC, another 25 patients with chronic stroke were recruited. The MDC was calculated from the standard error of measurement (SEM) to indicate a real change with 95% confidence for individual patients (MDC95). Distribution-based and anchor-based methods were adopted to triangulate the ranges of minimal CIDs. The percentage of scale width was calculated by dividing the MDC and CIDs by the total score range of each physical category. The percentage of patients exceeding MDC95 and minimal CIDs was also reported. RESULTS: The MDC95 of the mobility, self-care, and upper extremity (UE) function subscales were 5.9, 4.0, and 5.3 respectively. The minimal CID ranges for these 3 subscales were 1.5 to 2.4, 1.2 to 1.9, and 1.2 to 1.8. The percentage of patients exceeding MDC95 and minimal CIDs of the mobility, self-care, and UE function subscales were 9.5% to 28.4%, 6.8% to 28.4%, and 12.2% to 33.8%, respectively. CONCLUSIONS: The change score of an individual patient has to reach 5.9, 4.0, and 5.3 on the 3 subscales to indicate a true change. The mean change scores of a group of patients with stroke on these subscales should reach the lower bound of CID ranges of 1.5 (6.3% scale width), 1.2 (6.0% scale width), and 1.2 (6.0% scale width) to be regarded as clinically important change. This information may facilitate interpretations of patient-reported outcomes after stroke rehabilitation. Future research is warranted to validate these findings.

Assessing the streamlined Wolf motor function test as an outcome measure for stroke rehabilitation.

OBJECTIVE: This study investigates the clinimetric properties of the streamlined Wolf Motor Function Test (WMFT), a 6-item version of the performance time scale of the WMFT. METHODS: The streamlined WMFT, along with 2 criterion measures, the Fugl-Meyer Assessment (FMA) and the Stroke Impact Scale (SIS), were administered to 64 stroke patients before and after a 3-week intervention. Responsiveness was examined using the Wilcoxon signed rank test and standardized response mean (SRM). Criterion-related validity was investigated using the Spearman correlation coefficient (ρ). RESULTS: The mean score on the baseline FMA upper extremity of the patients was 44.84 (standard deviation = 12.77). The streamlined WMFT and the original performance time scale showed comparable responsiveness (SRM = 0.29 and 0.37, respectively). The concurrent validity of the streamlined WMFT was good (ρ = 0.57-0.69). For predictive validity, the streamlined WMFT showed slightly better association with the criterion measures (ρ = 0.60-0.68) than did the original scale (ρ = 0.56-0.64). CONCLUSIONS: Compared with the original scale, the streamlined WMFT showed improved clinical utility.

Neonatal Candidemia Exacerbated the Progression of Retinopathy of Prematurity in an Extremely-Low-Birth-Weight Infant with Persistent Tunica Vasculosa Lentis.

Eyes with threshold retinopathy of prematurity (ROP) often show dilation of the existing tunica vasculosa lentis (TVL), which is a prognostic factor in ROP screening and treatment, but can be frequently misdiagnosed as true iris neovascularization (NV). Besides, candidemia in preterm infants can aggravate the severity of ROP, possibly to the threshold stage requiring laser treatment. A case of prolonged candidemia without ophthalmic infection in an extremely-low-birth-weight (ELBW) (birth weight: 800 g), pre-term (gestation: 26 weeks) infant with persistent TVL and severe ROP are reported. The threshold ROP was successfully treated with argon laser therapy. Candidemia without eye infection in this case was associated with early use of a systemic antifungal drug. To our knowledge, no similar cases have been reported in the literature.

Minimal detectable change and clinically important difference of the Stroke Impact Scale in stroke patients.

OBJECTIVES: The purpose of this study was to establish the minimal detectable change (MDC) and clinically important differences (CIDs) of the physical domains of the Stroke Impact Scale (SIS) and to assess the proportions of patients' change scores exceeding the MDC and CIDs after stroke rehabilitation. METHODS: Seventy-four patients received 1 of 3 treatments for 3 weeks and underwent clinical assessment before and after treatment. The MDC was calculated from the standard error of measurement to indicate a real change with 95% confidence for individual patients (MDC(95)). Anchor-based and distribution-based approaches were adopted to triangulate the ranges of minimal CIDs. The percentage of patients exceeding MDC(95) and minimal CIDs were also calculated. RESULTS: The MDC(95) of the strength, activities of daily living/instrumental activities of daily living, mobility, and hand function subscales were 24.0, 17.3, 15.1, and 25.9, respectively. The respective minimal CIDs for these 4 subscales were 9.2, 5.9, 4.5, and 17.8 points, respectively, and the MDC(95) and CID proportions were 14% to 43%, 16% to 49%, 10% to 50%, and 23% to 64%, respectively. CONCLUSIONS: The change score of an individual patient has to reach 24.0, 17.3, 15.1, and 25.9 on the 4 subscales to indicate a true change. The mean change scores of a stroke group on the 4 subscales should reach 9.2, 5.9, 4.5, and 17.8 points to be regarded as clinically important changes. Future research with larger sample sizes is warranted to validate these estimates.