Parent strategies for improving compliance with eyeglass wear in young children.

SIGNIFICANCE: Results of this study provide preliminary data on parent strategies for improving compliance with eyeglass treatment in young children, an age group for which previous data are limited. Parent responses provide important insights to support parents of young children who wear eyeglasses and provide preliminary data to guide additional research. PURPOSE: The goal of this exploratory study was to learn more about parents' strategies to improve compliance with eyeglass treatment of young children. METHODS: An online survey of parents of 1-year-old to less than 5-year-old children who wear eyeglasses was conducted. Parents indicated whether they used various strategies to encourage wear and were asked to provide advice for parents of young children recently prescribed eyeglasses. Use of various strategies by age was determined. Open-ended responses regarding advice for other parents were analyzed using qualitative content analysis. RESULTS: The final sample included 104 parents who were predominantly White (81%), non-Hispanic (76%), and college graduates (68%). During the 2 weeks prior to survey completion, 74% of parents reported their child wore their eyeglasses ≥8 hours/day. Use of strategies for improving eyeglass wear varied by child age. The most frequent recommendations that parents provided for other parents were to be consistent in encouraging wear, use social modeling, provide positive reinforcement when the eyeglasses are worn, and ensure that the eyeglasses fit well and were comfortable. CONCLUSIONS: Parents provided many useful insights into their experiences. However, results may not be broadly generalizable, because of the limited diversity and high rate of compliance in the study sample. Further research with more diverse populations and research on effectiveness of various strategies to increase compliance in this age group are recommended to support eyeglass treatment compliance in young children.

Mediastinal infantile hemangioma with spinal canal extension and extensive gastrointestinal involvement complicated by respiratory failure.

Infantile hemangioma is the most common soft tissue tumor of infancy. Extensive organ involvement is rare. This report describes an infant with biopsy confirmed infantile hemangioma with diffuse organ involvement causing anemia and failure to thrive. Treatment was initiated with propranolol and led to initial improvement; however, course was complicated by several episodes of respiratory failure secondary to pulmonary edema. Propranolol therapy was interrupted for several months while patient was maintained on a diuretic regimen and treated with vincristine and high-dose corticosteroids. Patient was transitioned back to propranolol and is clinically thriving with objective improvement on radiographic imaging.

Kaposiform hemangioendothelioma of the bone in children and adolescents.

Kaposiform hemangioendothelioma (KHE) is a rare, locally aggressive vascular tumor that mainly occurs during infancy or early childhood. Approximately 70% of cases are complicated by Kasabach-Merritt phenomenon. Although osseous extension of the primary lesion is relatively common, primary bone involvement by KHE is rare. Given the paucity of literature on primary KHE of the bone, we report a case series of primary KHE of the bone treated at our institution and describe the clinical presentation, radiologic and pathologic findings, management and outcomes.

Catastrophic congenital hemangioma with severe coagulopathy leading to fatal cardiac failure: Case report and review.

We present a complex case of a neonate, delivered urgently for hydrops fetalis, with a large vascular mass of the extremity, diagnosed postnatally as a congenital hemangioma. The patient suffered immediate cardiac compromise and severe coagulopathy atypical for the diagnosis and subsequently died from these complications. Treatment was imperative but challenging due to a lack of a standardized treatment approach and few historical reports of equally critically ill patients. In this report, we review potential medical and surgical interventions and discuss treatment considerations in similar, life-threatening cases of congenital hemangiomas.

Objective Assessment of Spectacle Wear in Infants and Toddlers Using a Wearable Sensor.

Purpose: To assess the feasibility of using a thermal microsensor to monitor spectacle wear in infants and toddlers, to determine the inter-method reliability of two methods of estimating spectacle wear from sensor data, and to validate sensor estimates of wear. Methods: Fourteen children, 3 to <48 months of age, and one adult were provided pediatric spectacles containing their spectacle prescription. A thermal microsensor attached to the spectacle headband recorded date, time, and ambient temperature every 15 minutes for 14 days. Parents were asked for daily spectacle wear reports, and the adult recorded wear using a smartphone app. Sensor data were dichotomized (wear/non-wear) using two methods: temperature threshold (TT) and human judgment (HJ). Kappa statistics assessed inter-method reliability (child data) and accuracy (adult data). Results: Data from two child participants were excluded (one because of corrupted sensor data and the other because of no parent log data). Sensor data were collected more reliably than parent wear reports. The TT and HJ analysis of child data yielded similar reliability. Adult sensor data scored using the HJ method provided more valid estimates of wear than the TT method (κ = 0.94 vs. 0.78). Conclusions: We have demonstrated that it is feasible to deduce periods of spectacle wear using a thermal data logger and that the sensor is tolerated by children. Translational Relevance: Results indicate that it is feasible to use a thermal microsensor to measure spectacle wear for use in clinical monitoring or for research on spectacle treatment in children under 4 years of age.

Health History Skills for Interprofessional Learners in Transgender and Nonbinary Populations.

INTRODUCTION: Transgender and nonbinary peoplehave been identified as vulnerable and clinically underserved and experience health disparities. Lack of health care provider knowledge about transgender and gender diverse populations is a barrier to care, impacting health outcomes. The aim of this project was to develop, implement, and evaluate a simulation learning activity for midwifery and women's health nurse practitioner students and obstetrics and gynecology residents to interact with transgender and nonbinary individuals, with the goal of enhancing health history taking comfort and skills. METHODS: A partnership was formed among University faculty and simulation educators, a community clinic providing gender-affirming care, and members of transgender and gender diverse populations who served as patient-teachers. Two cases frequently encountered in clinics providing care to transgender individuals were developed for the simulation. Learners were divided into interprofessional groups of 3 and completed one of 2 case scenarios with a patient-teacher. Learners and patient-teachers debriefed after the simulation to discuss and reflect on the experience. RESULTS: Thirty-three learners participated in the simulation, 12 midwifery students, 16 women's health nurse practitioner students and 5 obstetrics and gynecology residents. Significant differences were observed for all comfort and skills questions, showing increased perceived comfort and skills from pre- to postsimulation. There were no significant differences in attitude responses. DISCUSSION: We successfully created and implemented a new sexual and reproductive history taking skills simulation in partnership with community clinic staff and transgender and nonbinary persons. The session was well received by learners and patient-teachers. Learners demonstrated significant improvements in comfort and skills in history taking in this setting and provided favorable feedback about the experience. This simulation can serve as a guide to others providing education to future midwives, women's health nurse practitioners, and obstetrician-gynecologists.

A multidisciplinary approach to management of abdominal lymphatic malformations.

BACKGROUND/PURPOSE: Abdominal lymphatic malformations (LM) are a rare subset of vascular anomaly caused by abnormal development of the lymphatic system. They are classified as macrocystic, microcystic or combination macrocystic and microcystic. Surgical resection, percutaneous sclerotherapy, and medical therapy are all employed to treat these complex and often symptomatic lesions. No standardized treatment algorithm exists currently. The purpose of this study was to establish a multidisciplinary treatment approach to abdominal LMs. METHODS: A retrospective observational study was conducted from 2013 to 2019 on patients with abdominal LMs at a single tertiary children's hospital vascular anomalies center. Demographics, imaging, and treatment modality were recorded. Clinical and/or radiographic response to the primary treatment modality as well as complications was the outcomes measured. RESULTS: Nineteen patients (12 macrocystic, 5 microcystic and 2 combined) were identified, with a median age at diagnosis of 2.2 years (range 0.1-20.8 years). Sclerotherapy was the most common primary treatment, followed by surgical resection and sirolimus. No difference in clinical response (p = 0.58) or complications (p = 0.31) was observed based on primary treatment or subtypes. CONCLUSIONS: Based on our institutional experience, we propose an LM subtype-based treatment algorithm for abdominal LMs. It employs a multidisciplinary approach, and results in satisfactory patient outcomes with minimal complications. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Telemedicine distance and near visual acuity tests for adults and children.

We describe a set of distance and near, adult and child, visual acuity tests for home use. The five charts are packaged in a PDF document and are also available as JPEG images that can be printed on standard letter paper or displayed on a monitor or handheld device. Adult distance visual acuity is tested using a modified ETDRS Chart R; child distance vision is tested using a similarly formatted HOTV logMAR chart. Testing distance is 5 or 10 feet, appropriate for home use. Near visual acuity is displayed in the range of J16 to J1 using random words (for adults) or in HOTV matching format (for young children). An Amsler Grid and HOTV matching card are included. The charts include a calibration circle. For those without a printer, sending a JPEG image as an email attachment initiates onscreen testing with a single click. Devices with smaller screens require an assistant to scroll through the display. The test can performed without assistance from a printed page.

A preliminary study of astigmatism and early childhood development.

PURPOSE: To determine whether uncorrected astigmatism in toddlers is associated with poorer performance on the Bayley Scales of Infant and Toddler Development, 3rd edition (BSITD-III). METHODS: Subjects were 12- to 35-month-olds who failed an instrument-based vision screening at a well-child check. A cycloplegic eye examination was conducted. Full-term children with no known medical or developmental conditions were invited to participate in a BSITD-III assessment conducted by an examiner masked to the child's eye examination results. Independent samples t tests were used to compare Cognitive, Language (Receptive and Expressive), and Motor (Fine and Gross) scores for children with moderate/high astigmatism (>2.00 D) versus children with no/low refractive error (ie, children who had a false-positive vision screening). RESULTS: The sample included 13 children in each group. The groups did not differ on sex or mean age. Children with moderate/high astigmatism had significantly poorer mean scores on the Cognitive and Language scales and the Receptive Communication Language subscale compared to children with no/low refractive error. Children with moderate/high astigmatism had poorer mean scores on the Motor scale, Fine and Gross Motor subscales, and the Expressive Communication subscale, but these differences were not statistically significant. CONCLUSIONS: The results suggest that uncorrected astigmatism in toddlers may be associated with poorer performance on cognitive and language tasks. Further studies assessing the effects of uncorrected refractive error on developmental task performance and of spectacle correction of refractive error in toddlers on developmental outcomes are needed to support the development of evidence-based spectacle prescribing guidelines.

Spectacle Wear in Toddlers: Frequency of Wear and Impact of Treatment on the Child and Family.

PURPOSE: We assessed the frequency of spectacle wear and impact of spectacle treatment in toddlers. METHODS: Children 12 to <36 months old with significant refractive error were provided spectacles. After 12 (±6) weeks, parents reported the frequency of spectacle wear and completed the Amblyopia Treatment Index (ATI, modified for spectacle treatment). Factor analysis assessed usefulness of ATI for spectacle treatment. Spectacle wear and ATI results were compared across age (1- vs. 2-year-olds) and sex. RESULTS: Participants were 91 children (60% male; mean age, 22.98 [SD 6.24] months, 41 1- and 50 2-year-olds) prescribed spectacles for astigmatism (92%), hyperopia (9%), or myopia (1%). Reported frequency of wear was low (<2 hours/day) in 41%, moderate in 23% (2 to <6 hours/day), and high (≥6 hours/day) in 36% and did not differ across age or sex. ATI factor analysis identified three subscales: adverse effects, treatment compliance, and perceived benefit. One-year-olds had poorer scores on adverse effects (P = 0.026) and treatment compliance scales (P = 0.049). Low frequency of spectacle wear was associated with poorer scores on treatment compliance (P < 0.001) and perceived benefit scales (P = 0.004). CONCLUSIONS: Frequency of spectacle wear was not related to age or sex. Younger children may have more difficulty adjusting to treatment. Parents of children with low spectacle wear reported less perceived benefit of treatment. TRANSLATIONAL RELEVANCE: Data on factors associated with frequency of spectacle wear in toddlers is valuable for parents and clinicians and may lead to methods to improve compliance and reduce the negative impact of treatment.

Interrater and Test-Retest Reliability of the Beery Visual-Motor Integration in Schoolchildren.

PURPOSE: To assess interrater and test-retest reliability of the 6th Edition Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI) and test-retest reliability of the VMI Visual Perception Supplemental Test (VMIp) in school-age children. METHODS: Subjects were 163 Native American third- to eighth-grade students with no significant refractive error (astigmatism <1.00 D, myopia <0.75 D, hyperopia <2.50 D, anisometropia <1.50 D) or ocular abnormalities. The VMI and VMIp were administered twice, on separate days. All VMI tests were scored by two trained scorers, and a subset of 50 tests was also scored by an experienced scorer. Scorers strictly applied objective scoring criteria. Analyses included interrater and test-retest assessments of bias, 95% limits of agreement, and intraclass correlation analysis. RESULTS: Trained scorers had no significant scoring bias compared with the experienced scorer. One of the two trained scorers tended to provide higher scores than the other (mean difference in standardized scores = 1.54). Interrater correlations were strong (0.75 to 0.88). VMI and VMIp test-retest comparisons indicated no significant bias (subjects did not tend to score better on retest). Test-retest correlations were moderate (0.54 to 0.58). The 95% limits of agreement for the VMI were -24.14 to 24.67 (scorer 1) and -26.06 to 26.58 (scorer 2), and the 95% limits of agreement for the VMIp were -27.11 to 27.34. CONCLUSIONS: The 95% limit of agreement for test-retest differences will be useful for determining if the VMI and VMIp have sufficient sensitivity for detecting change with treatment in both clinical and research settings. Further research on test-retest reliability reporting 95% limits of agreement for children across different age ranges is recommended, particularly if the test is to be used to detect changes due to intervention or treatment.

Visual Motor and Perceptual Task Performance in Astigmatic Students.

Purpose. To determine if spectacle corrected and uncorrected astigmats show reduced performance on visual motor and perceptual tasks. Methods. Third through 8th grade students were assigned to the low refractive error control group (astigmatism < 1.00 D, myopia < 0.75 D, hyperopia < 2.50 D, and anisometropia < 1.50 D) or bilateral astigmatism group (right and left eye ≥ 1.00 D) based on cycloplegic refraction. Students completed the Beery-Buktenica Developmental Test of Visual Motor Integration (VMI) and Visual Perception (VMIp). Astigmats were randomly assigned to testing with/without correction and control group was tested uncorrected. Analyses compared VMI and VMIp scores for corrected and uncorrected astigmats to the control group. Results. The sample included 333 students (control group 170, astigmats tested with correction 75, and astigmats tested uncorrected 88). Mean VMI score in corrected astigmats did not differ from the control group (p = 0.829). Uncorrected astigmats had lower VMI scores than the control group (p = 0.038) and corrected astigmats (p = 0.007). Mean VMIp scores for uncorrected (p = 0.209) and corrected astigmats (p = 0.124) did not differ from the control group. Uncorrected astigmats had lower mean scores than the corrected astigmats (p = 0.003). Conclusions. Uncorrected astigmatism influences visual motor and perceptual task performance. Previously spectacle treated astigmats do not show developmental deficits on visual motor or perceptual tasks when tested with correction.

Treatment of Pseudomonas Keratitis by Continuous Infusion of Topical Antibiotics With the Morgan Lens.

PURPOSE: Despite following standard treatment, Pseudomonas keratitis can continue to progress and result in loss of vision or of the eye. Our cases demonstrate that the Morgan Lens can be an effective topical antibiotic delivery vehicle in advanced keratitis. METHODS: Two patients (3 eyes) with Pseudomonas keratitis were included in this report after failing to respond to intense inpatient topical treatment. Because loss of the eyes was imminent, the Morgan Lenses were used for continuous lavage with ceftazidime (50 mg/mL), in conjunction with other conventional treatment. RESULTS: Three days after lavage, corneal cultures became negative in all eyes. Infusion was continued for at least a week to ensure sterilization of the infection before switching to standard topical therapy. The infection in both cases was promptly eradicated and the eyes were rescued. CONCLUSIONS: The Morgan Lens can be a viable alternative in treating severe and aggressive infectious keratitis or sclerokeratitis. Application of the Morgan Lens is noninvasive and requires minimal training. Intravenous tubing connectors allow for easy swapping between medications, simultaneous administration of multiple medications, and titration of dosing. Additionally, it is cost-effective as the low demand for nursing care essentially eliminates the need for intensive care unit admission.

Convergence Insufficiency, Accommodative Insufficiency, Visual Symptoms, and Astigmatism in Tohono O'odham Students.

Purpose. To determine rate of convergence insufficiency (CI) and accommodative insufficiency (AI) and assess the relation between CI, AI, visual symptoms, and astigmatism in school-age children. Methods. 3rd-8th-grade students completed the Convergence Insufficiency Symptom Survey (CISS) and binocular vision testing with correction if prescribed. Students were categorized by astigmatism magnitude (no/low: <1.00 D, moderate: 1.00 D to <3.00 D, and high: ≥3.00 D), presence/absence of clinical signs of CI and AI, and presence of symptoms. Analyses determine rate of clinical CI and AI and symptomatic CI and AI and assessed the relation between CI, AI, visual symptoms, and astigmatism. Results. In the sample of 484 students (11.67 ± 1.81 years of age), rate of symptomatic CI was 6.2% and symptomatic AI 18.2%. AI was more common in students with CI than without CI. Students with AI only (p = 0.02) and with CI and AI (p = 0.001) had higher symptom scores than students with neither CI nor AI. Moderate and high astigmats were not at increased risk for CI or AI. Conclusions. With-the-rule astigmats are not at increased risk for CI or AI. High comorbidity rates of CI and AI and higher symptoms scores with AI suggest that research is needed to determine symptomatology specific to CI.

Assessment of Grating Acuity in Infants and Toddlers Using an Electronic Acuity Card: The Dobson Card.

PURPOSE: To determine if testing binocular visual acuity in infants and toddlers using the Acuity Card Procedure (ACP) with electronic grating stimuli yields clinically useful data. METHODS: Participants were infants and toddlers ages 5 to 36.7 months referred by pediatricians due to failed automated vision screening. The ACP was used to test binocular grating acuity. Stimuli were presented on the Dobson Card. The Dobson Card consists of a handheld matte-black plexiglass frame with two flush-mounted tablet computers and is similar in size and form to commercially available printed grating acuity testing stimuli (Teller Acuity Cards II [TACII]; Stereo Optical, Inc., Chicago, IL). On each trial, one tablet displayed a square-wave grating and the other displayed a luminance-matched uniform gray patch. Stimuli were roughly equivalent to the stimuli available in the printed TACII stimuli. After acuity testing, each child received a cycloplegic eye examination. Based on cycloplegic retinoscopy, patients were categorized as having high or low refractive error per American Association for Pediatric Ophthalmology and Strabismus vision screening referral criteria. Mean acuities for high and low refractive error groups were compared using analysis of covariance, controlling for age. RESULTS: Mean visual acuity was significantly poorer in children with high refractive error than in those with low refractive error (P = .015). CONCLUSIONS: Electronic stimuli presented using the ACP can yield clinically useful measurements of grating acuity in infants and toddlers. Further research is needed to determine the optimal conditions and procedures for obtaining accurate and clinically useful automated measurements of visual acuity in infants and toddlers.

Reading Fluency in School-Aged Children with Bilateral Astigmatism.

PURPOSE: To compare oral reading fluency (ORF) in students with no/low astigmatism and moderate/high astigmatism and to assess the impact of spectacle correction on ORF in moderate and high astigmats. METHODS: Subjects were third- to eighth-grade students from a highly astigmatic population. Refractive error was determined through subjectively refined cycloplegic autorefraction. Data from students with ocular abnormalities, anisometropia, symptomatic binocular vision disorders, or refractive error that did not meet study criteria (no/low [cylinder < 1.00 both eyes, no significant myopia/hyperopia], moderate [cylinder ≥ 1.00 D both eyes, mean ≥ 1.00 D and < 3.00 D], or high astigmatism group [cylinder ≥ 1.00 D both eyes, mean ≥ 3.00 D]) were excluded. Oral reading fluency was tested with a modified version of the Dynamic Indicators of Basic Early Literacy Skills (DIBELS) Next test of ORF. No/low astigmats were tested without spectacles; astigmats were tested with and without spectacles. Mean ORF was compared in no/low astigmats and astigmats (with and without correction). Improvement in ORF with spectacles was compared between moderate and high astigmats. RESULTS: The sample included 130 no/low, 67 moderate, and 76 high astigmats. ORF was lower in uncorrected astigmats than in no/low astigmats (p = 0.011). ORF did not significantly differ in no/low astigmats and corrected astigmats (p = 0.10). ORF significantly improved with spectacle correction in high astigmats (p = 0.001; mean improvement, 6.55 words per minute) but not in moderate astigmats (p = 0.193; mean improvement, 1.87 words per minute). Effects of spectacle wear were observed in students who read smaller text stimuli (older grades). CONCLUSIONS: ORF is significantly reduced in students with bilateral astigmatism (≥1.00D) when uncorrected but not when best-corrected compared with their nonastigmatic peers. Improvement in ORF with spectacle correction is seen in high astigmats but not in moderate astigmats. These data support the recommendation for full-time spectacle wear in astigmatic students, particularly those with high astigmatism.

Accuracy of the Spot and Plusoptix photoscreeners for detection of astigmatism.

PURPOSE: To evaluate the accuracy of the Spot (V2.0.16) and Plusoptix S12 (ROC4, V6.1.4.0) photoscreeners in detecting astigmatism meeting AAPOS referral criteria in students from a population with high prevalence of astigmatism. METHODS: Students attending grades 3-8 on the Tohono O'odham reservation were examined. Screening was attempted with both the Spot and Plusoptix photoscreeners. Results were compared to cycloplegic refraction. Screening attempts providing no estimate of refractive error were considered fail/refer. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for detection of refractive errors were determined using AAPOS referral criteria and receiver operating characteristic area under the curve (ROC AUC) analysis was conducted for measures of astigmatism. Agreement between screening and cycloplegic refraction measurements of astigmatism, spherical equivalent, and anisometropia were assessed using t tests and correlation analyses. RESULTS: A total of 209 students were included. Of the total, 116 (55%) met examination-positive criteria based on cycloplegic refraction, with 105 of those (90%) meeting the criterion for astigmatism. Measurements success rates were 97% for Spot and 54% for Plusoptix. Comparing the Spot and the Plusoptix, sensitivity was 96% versus 100%, specificity was 87% versus 61%, PPV was 90% versus 76%, and NPV was 94% versus 100% for detection of refractive error. Both screeners overestimated astigmatism by 1/3 D to 2/3 D. AUC for astigmatism was 0.97 for Spot and 0.83 for Plusoptix. CONCLUSIONS: In this highly astigmatic population, the Spot and the Plusoptix had similar sensitivity, but the Spot had better specificity and measurement success rates. Compared with results from study samples with lower rates of astigmatism, our results highlight the need to assess the ability of screening instruments to detect individual types of refractive errors.

Case 222: Pericardioesophageal Fistula after Cardiac Radiofrequency Ablation.

History A 56-year-old woman presented to the emergency department after a cross-country flight. While in flight, she experienced sudden onset of epigastric and midsternal chest pain with shortness of breath. Her symptoms improved markedly after she received oxygen on board, and she finished the flight without further incident. Once home later that night, the pain recurred, and she was taken to the hospital. Her history included chronic pain syndrome, hypertension, and refractory paroxysmal atrial fibrillation, for which she had undergone radiofrequency ablation on two occasions. Her most recent ablation was 1 month prior. Upon arrival in the emergency department, her vital signs were within normal limits, and an electrocardiogram was unchanged from baseline. A chest radiograph obtained at the time of physical examination was unchanged from baseline. Given her recent travel history, there was suspicion for a pulmonary embolism. Ventilation-perfusion imaging and lower extremity Doppler ultrasonography were performed (images not shown) and revealed no evidence of pulmonary embolism or lower extremity thrombus. Because of the patient's clinical stability and because her symptoms had improved, she declined admission for observation and returned home against medical advice. The patient returned to the emergency department 2 days later in severe distress, with unstable vital signs, a jaundiced appearance, and substantial pain in her chest and abdomen. Her creatinine level was 4.4 mg/dL (388.9 µmol/L) (increased from 0.9 mg/dL [79.6 µmol/L] 2 days prior). Frontal and lateral radiographs of the chest were obtained and indicated increasing pericardial effusion. Bedside echocardiography enabled confirmation of these radiographic findings, and pericardiocentesis was performed. The patient's condition immediately improved, and she was admitted to the cardiac intensive care unit. Her symptoms recurred 3 days later, and a pericardial drain was placed. Fluid cultures were preliminarily positive for enterococcus and gram-negative rods. After drain placement, she was scheduled for definitive treatment of recurrent symptomatic effusion. The preoperative work-up included a water-soluble contrast material-enhanced (iodixanol, 320 mg of iodine per milliliter) esophagram with computed tomography (CT) of the chest performed immediately thereafter.