Shared decision making in the treatment of pediatric strabismus.

PURPOSE: To quantify the results of shared decision making in pediatric strabismus surgery from the parent perspective using the nine-item Shared Decision Making (SDM) Questionnaire and the associations of SDM score with parental education level; secondarily, to evaluate postoperative parental satisfaction as a function of child age, parental education level, SDM scores, and motor outcomes. METHODS: Consecutive parents of children 2-14 years of age with concomitant manifest strabismus that consented to strabismus surgery were surveyed using the SDM Questionnaire. A four-point Likert scale was used to gauge the level of postoperative satisfaction (POS). Potential predictors were estimated in multivariable regression analysis, with results adjusted for education level, children's age, and motor outcomes. RESULTS: A total of 100 parents (86 women) completed the survey and were included. Significant differences for SDM score were found between individuals with university-level versus the other three educational levels (P < 0.001 for primary and secondary levels; P = 0.017 for college or lyceum level). Categorical regression analysis showed that POS level was inversely correlated with education level and positively correlated with SDM score. Children's age at time of surgery and postoperative motor outcome were not significantly associated with POS. CONCLUSIONS: In our study cohort, SDM score was correlated with educational level. Satisfaction was greater among responders with higher SDM scores, indicating that SDM may help improve parent-reported satisfaction with treatment results.

Extraocular muscle resection, recession length and surgery outcome modelling in strabismus treatment: a pilot study.

BACKGROUND: Many surgical formulas have been developed and proposed based on the experience of surgeons to improve the predictability of strabismus surgery. However, the consent among strabismus surgeons regarding the dose effect of the extraocular muscle (EOM) recession or resection was not achieved yet and the disagreement about the appropriate amount of strabismus surgery still exists. OBJECTIVE: Our study aimed to propose an instrument for EOM resection (RsL) and recession length (RcL) estimation before the surgery and second to elaborate an postoperative angle of deviation (PAD) predictive model using simple potential predictors. METHODS AND ANALYSIS: The analytical prospective clinical study was conducted from April 2016 to July 2019, on a sample of 216 patients (aged between 2-58) with concomitant strabismus who underwent strabismus surgery in Clinical Republican Hospital 'Timofei Mosneaga'and Children Hospital 'Em Cotaga' from Republic of Moldova. The correlations of patients' age, strabismus type, amblyopia degree, RsL, RcL, preoperative angle of deviation (PreAD) with PAD were estimated using Pearson's correlation analysis. Multiple linear regression analysis, multicollinearity analysis and residual analysis were performed. RESULTS: The EOM RsL was predicted using strabismus type, patient's age, PreAD and EOM RcL. EOM RcL, in turn, was estimated by the similar covariates set, instead of RcL being RsL. PAD modelling showed the PreAD, EOM RsL and EOM RcL predictive ability for strabismus surgery outcome prediction. CONCLUSION: In our study, we propose four mathematical models as potential instruments for EOM RsL, EOM RcL and PAD modelling in esotropia and exotropia surgery.

Causes of concomitant strabismus surgery delay in teenagers and adults.

To reveal the reasons for strabismus surgery delay and motivations for seeking surgical treatment in adulthood. Prospective survey among 91 adult patients, suffering from concomitant strabismus acquired in the childhood that underwent delayed strabismus surgery. The mean age of participants was 24 years (from 16 to 58 years); 48 females (52.7%), and 43 males (47.3%). Strabismus surgery has been delayed for about 20 years in adult patients who could potentially benefit of it in childhood. The most common reasons for strabismus surgery delay, reported by patients, included the following: lack of awareness about surgery (37.4%); surgery was recommended but declined by patients' parents/guardians in their childhood (6.6%); fear of surgery (17.6%); eye specialists affirmation that surgery would not lead to strabismus improvement (27.5%); previous poor surgical experience (6.6%); and non-affordability (4.4%). The main motivations for seeking strabismus surgery in adulthood among our patients were the following: appearance improvement (38.5%), strengthening of self-confidence (30.8%), better social relationship (16.5%), better job opportunities (7.7%), and advice from family and friends (6.6%). About 80% of strabismus surgery delays in teenagers and adults were caused by lack of awareness regarding strabismus surgery and even the misconception among primary health-care practitioners and some eye doctors who considered that surgery would not lead to strabismus correction. The main reasons for seeking strabismus surgery in adulthood were: esthetical ones, self-confidence strengthening, and building better social relationship. All factors mentioned below confirmed the negative impact of oculomotor disorders on patient's psychological condition. The focus on patient's individual concerns and needs was especially important for recovery and well-being of adult patients with strabismus and formed a central feature of patient centered medical approach.

Shared decision making and patients satisfaction with strabismus care-a pilot study.

BACKGROUND: Strabismus is a complex disease that has various treatment approaches each with its own advantages and drawbacks. In this context, shared decisions making (SDM) is a communication process with the provider sharing all the relevant treatment alternatives, all the benefits, and risks of each procedure, while the patient shares all the preferences and values regarding his/her choices. In that way, SDM is a bidirectional process that goes beyond the typical informed consent. Therefore, it is known a little of the extent to which SDM influences the satisfaction with the treatment outcome along with strabismus patients. To study this correlation, an SDM-Q-9 questionnaire was provided within surgical consultations where treatment decisions were made; the SDM-Q-9 aims to assess the relationship between the post-operative patient's satisfaction and their SMD score. METHODS: The study is considered a prospective observational pilot study. Eligible patients were adult patients diagnosed with strabismus, who had multiple treatment options, were given at the right of choice without being driven into a physician's preference. Ninety-three strabismus patients were asked to fill out the SDM-Q-9 questionnaire related to their perception of SDM during the entire period of strabismus treatment. After the treatment, patients were asked to rate their satisfaction level with the surgical outcome as excellent, good, fair, and poor. Descriptive statistics and the linear regression statistical tests (Spearman, Mann Whitney U, and Kriskal-Wallis) were used as analysis tools. RESULTS: The average age of the participants was 24, where 50.6% were women. The mean SDM-Q-9 score among patients was 32 (IQR = 3). The postoperative patient satisfaction was rated as being excellent by 16 (17.2%) patients, good by 38 (40.9%), fair by 32 (34.4%), and poor by 7 patients (7.5%). Data analysis by linear regression statistical tests showed a positive correlation between the SDM-Q-9 score and the patient satisfaction related to the surgery outcome (B = 0.005, p < 0.001). Criteria in assessing patients' satisfaction were age, gender, and strabismus type. A positive correlation between SDM and real satisfaction (r = 0.834, p < 0.01) was found with age, and no significant relationship was found while taking into consideration the responder's gender and the strabismus type. CONCLUSIONS: Assessing patient satisfaction after choosing a treatment for strabismus method helped us evaluate the gaps in constructive dialogue that would lead to a positive outcome for both patient and clinician. The correlation between the SDM process and the patients' satisfaction with surgery outcome, adjusted by age, has been established. These findings can serve as a springboard to further communicative improvements related to the SDM process and between patients and physicians, thereby consequently leading to patients' satisfaction raise in strabismus care. The study underlines the importance of further analysis and validation of on-ground interactions among the adolescent and adult patients and the clinicians across the strabismus management trajectory. A multicentral study and its validation will follow.

Epidemiology of childhood manifest strabismus in the Republic of Moldova.

The purpose of this study was to determine the prevalence and the rate of newly detected pediatric manifest strabismus cases in the Republic of Moldova. A descriptive study was conducted in the Republic of Moldova. The data about the number of children that passed the prophylactic ophthalmological examination every year (children of 3 months- 17 years), the number of new strabismus cases found annually and the number of manifest strabismus cases under evidence were collected from the Health Family Centers in the Northern, Southern, and Central districts of the Republic of Moldova. The study period was performed in 2011- 2017. The prevalence rate of pediatric manifest strabismus in the study was 1.3%. The rate of newly diagnosed strabismus was 0.2%, with a higher ratio for esotropia versus exotropia (16.7/4.9 cases per 10000 children). The age of esotropia detection was mainly in the first 6 years of life (76.1%); beyond this age, exotropia predominates until the teenage years (75.6%). The study revealed a lower prevalence of pediatric manifest strabismus in comparison with the prevalence reported in other European countries. Esotropia was the most common type among patients with strabismus, this being detected mainly at first 6 years of life. The prevalence rate of exotropia was lower and the detection age was more frequent beyond the age of 6 years. The age at which most pediatric manifest strabismus cases were detected ranged between 3 and 6 years.

Neuroanatomical Structures in Human Extraocular Muscles and Their Potential Implication in the Development of Oculomotor Disorders.

The potential role of sensory feedback from human extraocular muscles has been subjected to considerable speculation in the ophthalmic literature. Extraocular muscles pull against a fairly even load and do not initiate a stretch reflex, even when the eyes are directed toward the boundaries of their respective field of action. These unique working conditions and physiological properties have led to the notion that the sensory signal arising from receptors in extraocular muscles differs from the conventional proprioceptive signal arising from their somatic counterparts. The interest in the receptors at the myotendinous junction of human extraocular muscles has been renewed due to their alleged role in the development of binocular vision and their potential implication in the etiology of binocular vision anomalies. The idea that extraocular muscles provide knowledge of eye position and whether this function can be affected by surgical intervention has initiated several clinical and neuroanatomical studies. Many of these studies support this concept and suggest that surgical procedures that impose only minimal interference with the proprioceptive signal will give a better postoperative result. However, other studies contradict this view because the afferent capacity of the receptors can be questioned and some uncertainties remain. The purpose of this study was to review the related literature and discuss the possible role of ocular proprioceptors in relation to binocular vision and the development of eye motility disorders. [J Pediatr Ophthalmol Strabismus. 2018;55(1):14-22.].

Effect of Direct Glare on Orbicularis Oculi and Trapezius During Computer Reading.

PURPOSE: Unfavorable visual conditions during computer work may affect development of both eyestrain and musculoskeletal pain in the neck and shoulder area. The aim of the study was to investigate how direct glare affects symptom development, muscle activity, and muscle blood flow in m. orbicularis oculi and m. trapezius during reading on a computer screen. METHODS: Fifteen healthy young adults with normal binocular vision read text on a computer screen at an optimized computer workplace, 30 minutes with glare exposure and 30 minutes with appropriate lighting. Postural angles were continuously registered. Development of eye symptoms and musculoskeletal pain in the neck and shoulder area were recorded using VAS scales. Muscle activity and muscle blood flow were measured continuously using electromyography and photoplethysmography, respectively. RESULTS: Glare exposure resulted in significantly more pronounced eye pain, increased orbicularis muscle activity, and increased trapezius blood flow compared to reading with appropriate lighting. There were no significant differences in posture between the two light conditions. There were also significant associations between orbicularis oculi activity and both trapezius blood flow and neck pain during both conditions. CONCLUSIONS: Results from the current study show that direct glare conditions cause increased eyestrain and orbicularis oculi contraction during reading on a computer screen. This study also indicates that exposure to direct glare affects the trapezius muscle, possibly by an interaction between the visual system, sympathetic nervous system, and head-stabilizing muscles. In addition, there were associations between the use of orbicularis oculi, trapezius blood flow, and development of neck pain independent of the lighting.

Musculoskeletal, visual and psychosocial stress in VDU operators after moving to an ergonomically designed office landscape.

This study investigated the effect of moving from single occupancy offices to a landscape environment. Thirty-four Visual Display Unit (VDU) operators reported significantly worsened condition of lighting and glare in addition to increased visual discomfort. For visual discomfort, the difference with 95% confidence interval was 10.7 (1.9-19.5) Visual Analog Scale (VAS) as group mean value. The most reasonable explanation for these results may be that the operators were glared from high luminance from the windows, when the Venetian blinds were not properly used. Glare was significantly correlated with visual discomfort, rs=0.35. Both illuminance and luminance in the work area, and contrast reduction on the VDU screen were in line with recommendations from CIE for VDU work. In a regression analysis, the visual discomfort explained 53% of the variance in the neck and shoulder pain. In the office landscape, the eye blink rate during habitual VDU work was recorded for 12 randomly selected operators from the 34 participants. A marked drop in eye blink rate during VDU work was found when this was compared to "easy conversation" (VDU work, mean=9.7 blinks per minute; "easy conversation," mean=21.4 blinks per minute). Participants reported many of the organizational and psychosocial conditions and work factors worse when landscape office was compared to single occupancy office. These factors may have influenced the musculoskeletal pain. However, the pain level was still low at 6 years and not significantly different when compared with the start of the study period, except for a small but significant increase in shoulder pain. In this study, visual discomfort is clearly associated with pain in the neck and shoulder area.

Variability of the accommodation response in early onset myopia.

PURPOSE: Hyperopic retinal defocus (blur) is thought to be a cause of myopia. If the retinal image of an object is not clearly focused, the resulting blur is thought to cause the continuing lengthening of the eyeball during development causing a permanent refractive error. Both lag of accommodation, especially for near targets, and greater variability in the accommodative response, have been suggested as causes of increased hyperopic retinal blur. Previous studies of lag of accommodation show variable findings. In comparison, greater variability in the accommodative response has been demonstrated in adults with late onset myopia but has not been tested in children. This study looked at the lag and variability of accommodation in children with early onset myopia. METHODS: Twenty-one myopic and 18 emmetropic children were tested. Dynamic measures of accommodation and pupil size were made using eccentric photorefraction (PowerRefractor) while children viewed targets set at three different accommodative demands (0.25, 2, and 4 D). RESULTS: We found no difference in accommodative lag between groups. However, the accommodative response was more variable in the myopes than emmetropes when viewing both the near (4 D) and far (0.25 D) targets. Since pupil size and variability also varied, we analyzed the data to determine whether this could account for the inter-group differences in accommodation variability. Variation in these factors was not found to be sufficient to explain these differences. Changes in the accommodative response variability with target distance were similar to patterns reported previously in adult emmetropes and late onset myopes. CONCLUSIONS: Children with early onset myopia demonstrate greater accommodative variability than emmetropic children, and have similar patterns of response to adult late onset myopes. This increased variability could result in an increase in retinal blur for both near and far targets. The role of accommodative variability in the etiology of myopia is discussed.

Double insertions of extraocular rectus muscles in humans and the pulley theory.

Recent studies have promoted the concept that rectus muscles pass through connective tissue pulleys located near the equator of the eye and act, in effect, as the muscle origins. Orbital muscle fibres (facing bone) terminate in pulleys, permitting adjustment of their position independent of the global fibres responsible for rotating the eye. The structure of pulleys (or muscle sleeves) and the passage taken by their muscle fibre insertions are unclear, and a detailed description is presented here together with a review of the active pulley hypothesis. Segments including the full width of single muscles were removed from the full orbital contents of dissection room cadavers and fresh perfusion-fixed rhesus and cynomolgus monkeys and prepared for light microscopy. Thin longitudinal sections were cut as facets from resin-embedded tissue blocks and montages assembled. Interrupted serial sections of selected regions of both species and ultrathin sections of monkey material were prepared for light and electron microscopy, respectively. Slender tendons leave the orbital surface of rectus muscles at intervals, aggregating and entering sleeves in humans and monkey; less frequently, tendons pass from the global surface to sleeves or insert directly in the posterior fascia bulbi. The orbital sides of sleeve rings are continuous with the fascial canopy of the globe and are 5-6 times as thick as the global sides; sleeve structure differs in the four recti. Medial rectus sleeves are the thickest, and contain smooth muscle, whereas little or none is present in the other rectus sleeves. Superior rectus sleeves are variable in structure and relatively insubstantial. A narrow interval separates muscles from the surrounding connective tissue equatorially in some preparations, consistent with a capacity to slide, but the tissues are contiguous in others, especially in monkey material. The structural organization of sleeves and their tendons, together with other presented factors, is inconsistent with a facility for the separate adjustment of sleeve position. The results favour the theory that sleeve tendons have just one role, to counter the viscoelastic resistance of global fascia - ocular and sleeve muscle fibres acting in unison. Whether the fragile sleeve structure can meet the physical demands of pulleys is questionable; but otherwise the veracity of the pulley hypothesis cannot be assessed from the structural relations of muscles and fascia bulbi reported.