Durable recovery from amblyopia with donepezil.

An elevated threshold for neuroplasticity limits visual gains with treatment of residual amblyopia in older children and adults. Acetylcholinesterase inhibitors (AChEI) can enable visual neuroplasticity and promote recovery from amblyopia in adult mice. Motivated by these promising findings, we sought to determine whether donepezil, a commercially available AChEI, can enable recovery in older children and adults with residual amblyopia. In this open-label pilot efficacy study, 16 participants (mean age 16 years; range 9-37 years) with residual anisometropic and/or strabismic amblyopia were treated with daily oral donepezil for 12 weeks. Donepezil dosage was started at 2.5 or 5.0 mg based on age and increased by 2.5 mg if the amblyopic eye visual acuity did not improve by 1 line from the visit 4 weeks prior for a maximum dosage of 7.5 or 10 mg. Participants < 18 years of age further patched the dominant eye. The primary outcome was visual acuity in the amblyopic eye at 22 weeks, 10 weeks after treatment was discontinued. Mean amblyopic eye visual acuity improved 1.2 lines (range 0.0-3.0), and 4/16 (25%) improved by ≥ 2 lines after 12 weeks of treatment. Gains were maintained 10 weeks after cessation of donepezil and were similar for children and adults. Adverse events were mild and self-limited. Residual amblyopia improves in older children and adults treated with donepezil, supporting the concept that the critical window of visual cortical plasticity can be pharmacologically manipulated to treat amblyopia. Placebo-controlled studies are needed.

Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment.

Visual symptoms are common after concussion in children and adolescents, making it essential for clinicians to understand how to screen, identify, and initiate clinical management of visual symptoms in pediatric patients after this common childhood injury. Although most children and adolescents with visual symptoms after concussion will recover on their own by 4 weeks, for a subset who do not have spontaneous recovery, referral to a specialist with experience in comprehensive concussion management (eg, sports medicine, neurology, neuropsychology, physiatry, ophthalmology, otorhinolaryngology) for additional assessment and treatment may be necessary. A vision-specific history and a thorough visual system examination are warranted, including an assessment of visual acuity, ocular alignment in all positions of gaze, smooth pursuit (visual tracking of a moving object), saccades (visual fixation shifting between stationary targets), vestibulo-ocular reflex (maintaining image focus during movement), near point of convergence (focusing with both eyes at near and accommodation (focusing with one eye at near because any of these functions may be disturbed after concussion. These deficits may contribute to difficulty with returning to both play and the learning setting at school, making the identification of these problems early after injury important for the clinician to provide relevant learning accommodations, such as larger font, preprinted notes, and temporary use of audio books. Early identification and appropriate management of visual symptoms, such as convergence insufficiency or accommodative insufficiency, may mitigate the negative effects of concussion on children and adolescents and their quality of life.

Evaluation of the Visual System by the Primary Care Provider Following Concussion.

Concussion is a common injury in childhood and has the potential for substantial impact on quality of life. Visual issues have been increasingly recognized as a common problem after concussion. Many children initially seek care for concussion with their pediatrician, making it even more important for pediatricians to recognize, evaluate, and refer children with visual issues after concussion. This clinical report is intended to support the recommendations in the companion policy statement on vision and concussion and provides definitions of some of the physiologic aspects of the visual system as they relate to concussion. A description of clinically feasible testing methodologies is provided in more detail to aid the clinician in assessing the visual system in a focused fashion after concussion. This guidance helps direct clinical management, including support for return to school, sports, and other activities, as well as potential referral for subspecialty care for the subset of those with persistent symptoms.

First Visit Characteristics Associated with Future Surgery in Intermittent Exotropia.

PURPOSE: Identify demographic and clinical characteristics at the first presentation associated with later having surgery for intermittent exotropia (IXT). METHODS: Retrospective cohort study of 228 children with IXT and 5+ years of follow-up. Demographic and clinical data were extracted from medical records. A total 97 participants who underwent surgery during follow-up were compared to 131 participants who did not. Best subset regression was used to identify first visit variables associated with later having strabismus surgery. Surgery was then regressed on the selected variables using logistic models. RESULTS: Age and control were the only first visit variables significantly associated with having surgery for IXT. Notably, neither angle of deviation nor stereopsis were associated with later surgery. In an adjusted logistic model, each one-month increase in age at presentation was associated with a 1% decrease in the odds of having surgery (OR = 0.991, 95% CI: 0.982-0.999, P = .04). Children with poor control at initial visit had almost five times greater odds of having surgery than those with good control (OR = 4.95, 95% CI: 2.31-10.98, P < .0001). CONCLUSIONS: Age and control of IXT are important factors at presentation associated with future surgical intervention for IXT. The magnitude of deviation and stereopsis was not significantly associated with future surgical treatment for IXT.

Magnetic Resonance Imaging Features and Clinical Findings in Pediatric Idiopathic Intracranial Hypertension: A Case-Control Study.

The purpose of this study is to identify salient magnetic resonance imaging (MRI) findings of pediatric IIH, to determine the relevance of these findings with regard to disease pathogenesis, and to relate these findings to the clinical presentation towards identification of risk factors of disease. A retrospective, a case-control study of 38 pediatric patients with and 24 pediatric patients without IIH from the ophthalmology department at a tertiary care center was performed. Clinical data, including ophthalmic findings and lumbar puncture results, were recorded. Neuroimaging, including both MRI and magnetic resonance venography (MRV), was evaluated for perioptic subarachnoid space diameter enlargement, posterior globe flattening, optic nerve head protrusion, empty or partially empty sella turcica, dural venous sinus abnormalities, skull base crowding, and prominent arachnoid granulations. Compared with controls, IIH patients had larger perioptic subarachnoid space diameters, higher incidences of posterior globe flattening, protrusion of the optic nerve heads, an empty sella turcica, and dural venous sinus abnormalities. A perioptic subarachnoid space diameter of ≥5.2 mm was identified as an independent predictor of IIH (p < 0.001) with sensitivity of 87% and specificity of 67%. Several significant MRI findings in pediatric IIH were identified. Using a model that uniquely incorporated clinical and MRI findings at presentation, we provide a framework for risk stratification for the diagnosis of pediatric IIH which may be utilized to facilitate diagnosis. Future prospective work is needed to further validate the model developed in this study.

Traumatic Brain Injury in Children: The Psychological Effects of Mild Traumatic Brain Injury.

Concussion, or mild traumatic brain injury (mTBI), results from a force to the head and can cause acute physical, cognitive, and psychological symptoms. The majority of concussion symptoms will resolve within a month, but upward of a third of patients will have persistent, chronic symptoms. When these symptoms become chronic and persist beyond 1-3 months, this is termed post-concussion syndrome (PCS). Psychological changes associated with PCS may in part be due to a traumatic event and the injury itself and therefore post-traumatic stress reactions may contribute. In addition, alterations to daily life and alteration of lifestyle as a result of the injury can cause feelings of disconnection which in turn can feed anxiety and depression symptoms. A preinjury diagnosis or history of psychiatric or mood disorder, migraine, or family history of psychiatric illness is one the greatest risk factors for the development of PCS. It is recommended that evaluation of concussion and those with PCS take a multidisciplinary approach including evaluation by psychology, psychiatry, and/or neuropsychology. While most concussions do not require treatment, those with PCS will not likely see the resolution of their physical and psychological symptoms without intervention. Treatment is limited, but cognitive behavioral treatment has shown promise in the management of PCS symptoms. It is important to recognize the role psychology plays in the development and persistence of PCS and to recognize and seek collaborative care when treating these patients.

Vision therapy: are you kidding me? Problems with current studies.

BACKGROUND AND PURPOSE: Orthoptic exercises are routinely prescribed to treat symptoms of convergence insufficiency (CI). The type and duration of treatment tends to vary among providers as until recently, few strong randomized control studies have addressed the efficacy of convergence insufficiency management. The aim of this paper is to address these studies and discuss their limitations. METHODS: A review of the literature pertaining to convergence insufficiency was conducted. Articles relevant to the treatment of this disorder were analyzed, and those with adequate studies pertaining to CI treatment methods were included. RESULTS: There are limited randomized control trials evaluating the effectiveness of vision therapy, and those that do exist have limitations: small patient populations, differing outcome measures, treatment length and intensity, and placebo effects, which are all confounding factors when assessing the validity of the current studies. CONCLUSION: Despite the prevalence of convergence insufficiency, the known efficacy of vision therapy remains somewhat questionable. There is evidence to suggest that some form of therapy is effective in reducing symptoms and clinical findings of convergence insufficiency, but there is a lack of equal comparison in order to conclude which forms of treatment are best.

Improving ophthalmic outcomes in children with unilateral coronal synostosis by treatment with endoscopic strip craniectomy and helmet therapy rather than fronto-orbital advancement.

PURPOSE: To compare long-term ophthalmic outcomes in infants treated for unilateral coronal synostosis (UCS) by endoscopic strip craniectomy (ESC) and helmet therapy with those treated by fronto-orbital advancement (FOA). METHODS: Consecutive patients with UCS, uncomplicated by other suture synostosis, were identified by a retrospective review of medical records. Assessment of presence of amblyopia, cycloplegic refraction, strabismus, and strabismus surgical intervention at all visits was recorded. RESULTS: Between 2004 and 2010, 22 patients were treated by FOA (mean follow-up, 21.5 months) and 21 patients with ESC and helmet therapy (mean follow-up, 23.5 months). The mean aniso-astigmatism was equal; however, the SD was greater for those treated by FOA (P < 0.05). A more severe pattern of strabismus developed in those treated by FOA (P < 0.0001). Those treated by FOA were more likely to have amblyopia (P = 0.0015) and to undergo surgical correction of their strabismus (odds ratio, 6.3:1). CONCLUSIONS: Children with UCS treated with ESC and helmeting had less severe overelevation in adduction, amblyopia, extremes of astigmatism, and less need for strabismus surgery than those treated by FOA. Although the reason for these more favorable outcomes remains uncertain, we speculate that the earlier timing of ESC or differences in the anatomical changes resulting from the two procedures may play a role.