Accuracy and Reproducibility of Virtual Reality Perimetry in Children.

PURPOSE: To determine normal threshold values for the 24-2 program of the VisuALL-K (Olleyes, Inc), a portable static automated virtual reality perimeter that uses a video game-based testing modality on an updated version of the algorithm and to repeat the test to assess retest variability. METHODS: This prospective cohort study included 19 participants (aged 8 to 17 years) with healthy afferent systems. Participants performed two 24-2 automated perimetry tests on the virtual reality perimeter device. RESULTS: Mean age was 12.7 ± 2.5 years; 53% were boys and 47% were girls. Mean test location threshold was 30.5 ± 4.0 dB for test 1 and 31.3 ± 2.8 dB for test 2. Sensitivity decreased with eccentricity as expected (-0.17 dB per degree). Bland-Altman analysis showed a repeatability coefficient of ±5.1 dB for mean deviation, meaning that 95% of retest values were within ±5 dB of the threshold value for the first test. Higher thresholds for the first test regressed toward the mean values in the second test, indicating a learning effect. Intraclass correlation coefficient for mean deviation between test 1 and test 2 was 0.70 (0.55 to 0.80, P < .0001). Mean time to completion for the virtual reality perimeter was 5.1 ± 1.5 min/eye. CONCLUSIONS: The VisuALL-K virtual reality perimeter provided an assessment of the visual field in normal children aged 8 to 17 years. A shallow hill of vision was demonstrated. A notable learning effect was demonstrated, with repeatability difference wider than other published head-mounted display perimeters. [J Pediatr Ophthalmol Strabismus. 20XX:X(X):XX-XX.].

Outcomes of Strabismus Surgery Following Teprotumumab Therapy.

PURPOSE: To investigate the results of patients undergoing surgical treatment for strabismic diplopia in thyroid eye disease (TED) following teprotumumab. DESIGN: Multicenter, retrospective, case series. METHODS: We report 28 patients who underwent extraocular muscle surgery for strabismic diplopia after treatment with teprotumumab at 7 different academic centers. Elapsed time from last teprotumumab dose to the date of surgery, previous orbital decompression, primary preoperative horizontal and vertical deviation, surgical procedure, and 2-month postoperative results were collected from the patient records. RESULTS: Sixteen (57%) patients were diplopia-free after 1 surgery. Three (11%) chose prism spectacles to correct residual diplopia, 2 (7%) used compensatory head posture to resolve diplopia, and 1 (4%) had intermittent diplopia and was functionally improved (choosing no prisms or further surgery). These were considered treatment successes. Three (11%) patients required reoperation, and all were diplopia-free after their second procedure. CONCLUSIONS: Most patients requiring surgery for strabismic diplopia following teprotumumab achieve good outcomes with success rates comparable to series published before the availability of teprotumumab.

Eight-Year Outcomes of Bilateral Lateral Rectus Recessions versus Unilateral Recession-Resection in Childhood Basic-Type Intermittent Exotropia.

PURPOSE: To report 8-year outcomes from a randomized controlled trial (RCT) comparing bilateral lateral rectus muscle recession (BLRc) with unilateral recession-resection (R&R) for childhood intermittent exotropia (IXT). DESIGN: Eight-year follow-up of RCT cohort. PARTICIPANTS: Of 197 randomized participants, 123 agreed to continue follow-up after the 3-year outcome visit (baseline age, 3-< 11 years; basic-type IXT, 15-40 prism diopters [Δ] by prism and alternate cover test [PACT]; baseline stereoacuity, ≤ 400 arcsec; no prior surgery). METHODS: After the RCT primary outcome at 3 years, annual follow-up from 4 through 8 years with treatment at investigator discretion. MAIN OUTCOME MEASURES: Suboptimal surgical outcome by 8 years after randomization, defined as any of the following at any visit: exotropia of 10 Δ or more by simultaneous prism cover test (SPCT) at distance or near, constant esotropia (ET) of 6 Δ or more by SPCT at distance or near, loss of near stereoacuity by 0.6 log arcsec or more from baseline, or reoperation. Secondary outcomes included (1) reoperation by 8 years and (2) complete or near-complete resolution at 8 years, defined as exodeviation of less than 10 Δ by SPCT and PACT at distance and near and 10 Δ or more reduction from baseline by PACT at distance and near, ET of less than 6 Δ at distance and near, no decrease in stereoacuity by 0.6 log arcsec or more from baseline, and no reoperation or nonsurgical treatment for IXT. RESULTS: The Kaplan-Meier cumulative probability of suboptimal surgical outcome through 8 years was 68% (55 events among 101 at risk) for BLRc and 53% (42 events among 96 at risk) for R&R (difference, 15%; 95% confidence interval [CI], -2% to 32%; P = 0.08). Complete or near-complete resolution at 8 years occurred in 15% (7/46) for BLRc and 37% (16/43) for R&R (difference, -22%; 95% CI, -44% to -0.1%; P = 0.049). The cumulative probability of reoperation was 30% for BLRc and 11% for R&R (difference, 19%; 95% CI, 2%-36%; P = 0.049). CONCLUSIONS: Despite no significant difference for the primary outcome, the 95% CI did not exclude a moderate benefit of R&R, which together with secondary outcomes suggests that unilateral R&R followed by usual care may yield better long-term outcomes than BLRc followed by usual care for basic-type childhood IXT using these surgical doses. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Validation of a Published Model to Reduce Burden of Retinopathy of Prematurity Screening.

PURPOSE: The E-ROP study evaluated 1257 patients screened for retinopathy of prematurity (ROP), and found that no infant born at or after 27 weeks' gestational age and having a birthweight over 750 g developed treatable disease if they had no ROP at 37 weeks' gestational age. The study investigators suggested that there is little value in continued screening of infants meeting these criteria who have no ROP at 37 weeks. We attempted to replicate these published data in a larger multi-center cohort to validate or refute this hypothesis. DESIGN: Retrospective cohort study. METHODS: We conducted a chart review of every infant treated for ROP from February 2004 through April 2022 at 6 medical centers located in the mid-southern region of the United States. We evaluated gestational age, birthweight, and presence or absence of ROP at 37 weeks' gestational age to determine whether any treated infants would have been "missed" using these screening criteria. RESULTS: Of 6729 infants screened, 298 (4.43%) received treatment. Ten infants who required treatment developed first evidence of ROP after 37 weeks' gestational age. However, only 1 infant was >750 g birthweight and >27 weeks' gestational age. This patient developed zone 2, stage 3 with pre-plus disease and was treated because of limited access to care at a remote hospital; however, ROP was detected at the first examination after 37 weeks, so this infant would have been identified for continued follow-up. CONCLUSION: Our results, in a cohort 5 times that of the original study, replicated that infants >750 g birthweight and >27 weeks' gestational age did not develop treatable ROP if they had no ROP at 37 weeks, supporting the termination of examination at that time in patients meeting these criteria.

Surgical management of superior oblique palsy with coexisting exotropia.

PURPOSE: To analyze the surgical results of patients treated for superior oblique palsy with coexisting exotropia. METHODS: The medical records of patients with superior oblique palsy and exotropia who underwent inferior oblique weakening and simultaneous lateral rectus recession by a single surgeon from 1996 to 2022 were reviewed retrospectively. Demographics, pre- and postoperative vertical and horizontal deviation, and presence of diplopia were recorded. Surgical success was defined as horizontal deviation <10Δ and vertical deviation ≤4Δ without overcorrection or diplopia. The decision to operate for the horizontal deviation was made based on fusion in free space when the vertical deviation was offset with a prism. RESULTS: A total of 27 patients were included. Mean age was 26.1 ± 22 years (range, 26 months to 78 years). Preoperatively, mean vertical deviation was 15.2Δ ± 7.5Δ (range, 4Δ-30Δ); mean exodeviation, 17Δ ± 5.5Δ (range, 10Δ-35Δ). Of the 27 patients, 25 underwent unilateral and 2 underwent bilateral lateral rectus recession, according to the magnitude of the horizontal deviation. Mean follow-up was 3 ± 3.8 months (range, 2 weeks to 17 months). Postoperative mean vertical alignment was 3.0 ± 5.9, and horizontal alignment was 3.4Δ ± 5.2Δ (esotropia of 7Δ to exotropia of 12Δ; P < 0.0001). Nineteen patients (70%) had a successful result; 2 patients had residual exotropia of >10Δ, 2 had vertical overcorrection (range, 3Δ-4Δ), and 6 had residual vertical deviation ≥4Δ (range, 5Δ-20Δ). None had secondary esotropia >10Δ. Horizontal deviation was corrected successfully with no consecutive esotropia in 25 patients. CONCLUSIONS: In our study cohort, patients with superior oblique palsy and exotropia in whom fusion required both horizontal and vertical prism correction had a high likelihood of successful horizontal alignment after lateral rectus weakening in combination with inferior oblique surgery.

Prevalence of cerebrotendinous xanthomatosis among patients diagnosed with early-onset idiopathic bilateral cataracts: final analysis.

Cerebrotendinous xanthomatosis (CTX) is a rare, autosomal recessive bile acid synthesis disorder caused by pathologic variants in CYP27A1, a gene involved in bile acid synthesis. Impaired function in this gene leads to accumulation of plasma cholestanol (PC) in various tissues, often in early childhood, resulting in such clinical signs as infantile diarrhea, early-onset bilateral cataracts, and neurological deterioration. The current study aimed to identify cases of CTX in a population of patients with a greater CTX prevalence than the general population, to facilitate early diagnosis. Patients diagnosed with early-onset, apparently idiopathic, bilateral cataracts between the ages of 2 and 21 years were enrolled. Genetic testing of patients with elevated PC and urinary bile alcohol (UBA) levels was used to confirm CTX diagnosis and determine CTX prevalence. Of 426 patients who completed the study, 26 met genetic testing criteria (PC ≥ 0.4 mg/dL and positive UBA test), and 4 were confirmed to have CTX. Prevalence was found to be 0.9% in enrolled patients, and 15.4% in patients who met the criteria for genetic testing.

Evaluation of Virtual Reality Perimetry and Standard Automated Perimetry in Normal Children.

Purpose: The Olleyes VisuALL-K is a pediatric videogame-based static threshold perimeter using a virtual reality headset. We determined normal threshold sensitivities for the 24-2 test locations using the virtual reality perimetry (VRP) and also tested patients on the Humphrey Field Analyzer (HFA). Patient satisfaction for the two instruments was compared. Methods: This exploratory study tested 50 normal pediatric participants aged 8 to 17 years on the HFA and VRP. The main outcome measure was threshold sensitivity at the 24-2 test locations for the two instruments. Results: The mean participant age was 13.0 ± 2.6 years; 50% were female. The threshold values for VRP are reported as measured on the device and after conversion to an HFA-equivalent scale. Age-adjusted thresholds showed a mean sensitivity of 31.8 ± 1.1 dB (46.1 ± dB HFA equivalent) diminution from the maximum light intensity in the VRP and 31.0 ± 1.5 dB diminution from the maximum light intensity in the HFA; interparticipant variability in mean threshold sensitivity was 2.7 ± 0.4 dB for the VRP and 2.7 ± 0.6 dB for the HFA. The HFA demonstrated decreased threshold sensitivity with increasing eccentricity, whereas the VRP threshold did not seem to vary with eccentricity. Mild age effects on threshold sensitivity were seen in the VRP and the HFA (R2 = 0.11, P < 0.001 and R2 = 0.05, P < 0.05, respectively). The mean time to completion for VRP and HFA was 7.6 ± 1.5 and 5.3 ± 0.9 min/eye, respectively (P < 0.0001). Patient satisfaction scores favored VRP (P < 0.01) despite the longer test duration. Conclusions: The Olleyes game-based VRP and HFA can be used to map out the peripheral vision in normal children. The VRP has a higher patient satisfaction when used in children than the HFA. The portability of the test allows it to be performed in a myriad of environments, lending a flexibility that can benefit this population. Translational Relevance: This virtual reality perimetry device provides an alternative to the Humphrey Field Analyzer for children.

Randomized trial of bilateral gene therapy injection for m.11778G>A MT-ND4 Leber optic neuropathy.

Leber hereditary optic neuropathy (LHON) is an important example of mitochondrial blindness with the m.11778G>A mutation in the MT-ND4 gene being the most common disease-causing mtDNA variant worldwide. The REFLECT phase 3 pivotal study is a randomized, double-masked, placebo-controlled trial investigating the efficacy and safety of bilateral intravitreal injection of lenadogene nolparvovec in patients with a confirmed m.11778G>A mutation, using a recombinant adeno-associated virus vector 2, serotype 2 (rAAV2/2-ND4). The first-affected eye received gene therapy; the fellow (affected/not-yet-affected) eye was randomly injected with gene therapy or placebo. The primary end point was the difference in change from baseline of best-corrected visual acuity (BCVA) in second-affected/not-yet-affected eyes treated with lenadogene nolparvovec versus placebo at 1.5 years post-treatment, expressed in logarithm of the minimal angle of resolution (LogMAR). Forty-eight patients were treated bilaterally and 50 unilaterally. At 1.5 years, the change from baseline in BCVA was not statistically different between second-affected/not-yet-affected eyes receiving lenadogene nolparvovec and placebo (primary end point). A statistically significant improvement in BCVA was reported from baseline to 1.5 years in lenadogene nolparvovec-treated eyes: -0.23 LogMAR for the first-affected eyes of bilaterally treated patients (P < 0.01); and -0.15 LogMAR for second-affected/not-yet-affected eyes of bilaterally treated patients and the first-affected eyes of unilaterally treated patients (P < 0.05). The mean improvement in BCVA from nadir to 1.5 years was -0.38 (0.052) LogMAR and -0.33 (0.052) LogMAR in first-affected and second-affected/not-yet-affected eyes treated with lenadogene nolparvovec, respectively (bilateral treatment group). A mean improvement of -0.33 (0.051) LogMAR and -0.26 (0.051) LogMAR was observed in first-affected lenadogene nolparvovec-treated eyes and second-affected/not-yet-affected placebo-treated eyes, respectively (unilateral treatment group). The proportion of patients with one or both eyes on-chart at 1.5 years was 85.4% and 72.0% for bilaterally and unilaterally treated patients, respectively. The gene therapy was well tolerated, with no systemic issues. Intraocular inflammation, which was mostly mild and well controlled with topical corticosteroids, occurred in 70.7% of lenadogene nolparvovec-treated eyes versus 10.2% of placebo-treated eyes. Among eyes treated with lenadogene nolparvovec, there was no difference in the incidence of intraocular inflammation between bilaterally and unilaterally treated patients. Overall, the REFLECT trial demonstrated an improvement of BCVA in LHON eyes carrying the m.11778G>A mtDNA mutation treated with lenadogene nolparvovec or placebo to a degree not reported in natural history studies and supports an improved benefit/risk profile for bilateral injections of lenadogene nolparvovec relative to unilateral injections.

Safety of Lenadogene Nolparvovec Gene Therapy Over 5 Years in 189 Patients With Leber Hereditary Optic Neuropathy.

PURPOSE: To evaluate the safety profile of lenadogene nolparvovec (Lumevoq) in patients with Leber hereditary optic neuropathy. DESIGN: Pooled analysis of safety data from 5 clinical studies. METHODS: A total of 189 patients received single unilateral or bilateral intravitreal injections of a recombinant adeno-associated virus 2 (rAAV2/2) vector encoding the human wild-type ND4 gene. Adverse events (AEs) were collected throughout the studies, up to 5 years. Intraocular inflammation and increased intraocular pressure (IOP) were ocular AEs of special interest. Other assessments included ocular examinations, vector bio-dissemination, and systemic immune responses against rAAV2/2. RESULTS: Almost all patients (95.2%) received 9 × 1010 viral genomes and 87.8% had at least 2 years of follow-up. Most patients (75.1%) experienced at least one systemic AE, but systemic treatment-related AEs occurred in 3 patients; none were serious. Intraocular inflammation was reported in 75.6% of lenadogene nolparvovec-treated eyes. Almost all intraocular inflammations occurred in the anterior chamber (58.8%) or in the vitreous (40.3%), and were of mild (90.3%) or moderate (8.8%) intensity; most resolved with topical corticosteroids alone. All IOP increases were mild to moderate in intensity. No AE led to study discontinuation. Bio-dissemination of lenadogene nolparvovec and systemic immune response were limited. The safety profile was comparable for patients treated bilaterally and unilaterally. CONCLUSIONS: Lenadogene nolparvovec had a good overall safety profile with excellent systemic tolerability, consistent with limited bio-dissemination. The product was well tolerated, with mostly mild ocular side effects responsive to conventional ophthalmologic treatments.

Indirect Comparison of Lenadogene Nolparvovec Gene Therapy Versus Natural History in Patients with Leber Hereditary Optic Neuropathy Carrying the m.11778G>A MT-ND4 Mutation.

INTRODUCTION: Lenadogene nolparvovec is a promising novel gene therapy for patients with Leber hereditary optic neuropathy (LHON) carrying the m.11778G>A ND4 mutation (MT-ND4). A previous pooled analysis of phase 3 studies showed an improvement in visual acuity of patients injected with lenadogene nolparvovec compared to natural history. Here, we report updated results by incorporating data from the latest phase 3 trial REFLECT in the pool, increasing the number of treated patients from 76 to 174. METHODS: The visual acuity of 174 MT-ND4-carrying patients with LHON injected in one or both eyes with lenadogene nolparvovec from four pooled phase 3 studies (REVERSE, RESCUE and their long-term extension trial RESTORE; and REFLECT trial) was compared to the spontaneous evolution of an external control group of 208 matched patients from 11 natural history studies. RESULTS: Treated patients showed a clinically relevant and sustained improvement in their visual acuity when compared to natural history. Mean improvement versus natural history was - 0.30 logMAR (+ 15 ETDRS letters equivalent) at last observation (P < 0.01) with a maximal follow-up of 3.9 years after injection. Most treated eyes were on-chart as compared to less than half of natural history eyes at 48 months after vision loss (89.6% versus 48.1%; P < 0.01) and at last observation (76.1% versus 44.4%; P < 0.01). When we adjusted for covariates of interest (gender, age of onset, ethnicity, and duration of follow-up), the estimated mean gain was - 0.43 logMAR (+ 21.5 ETDRS letters equivalent) versus natural history at last observation (P < 0.0001). Treatment effect was consistent across all phase 3 clinical trials. Analyses from REFLECT suggest a larger treatment effect in patients receiving bilateral injection compared to unilateral injection. CONCLUSION: The efficacy of lenadogene nolparvovec in improving visual acuity in MT-ND4 LHON was confirmed in a large cohort of patients, compared to the spontaneous natural history decline. Bilateral injection of gene therapy may offer added benefits over unilateral injection. TRIAL REGISTRATION NUMBERS: NCT02652780 (REVERSE); NCT02652767 (RESCUE); NCT03406104 (RESTORE); NCT03293524 (REFLECT); NCT03295071 (REALITY).

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.

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.

Recession-Resection of the Vertical Rectus Muscles for Chin-up Vertical Abnormal Head Position Associated With Infantile Nystagmus Syndrome.

PURPOSE: To review the correction of chin-up abnormal head position (AHP) due to infantile nystagmus syndrome via surgery on the vertical rectus muscles, typically a combined recession-resection of these muscles. METHODS: This was a review of 6 patients who underwent surgical correction of chin-up vertical AHP in the context of infantile nystagmus syndrome at an academic institution. The correction of AHP, visual acuity, ductions, and ocular alignment were noted both preoperatively and postoperatively. The need for repeat surgery, induced strabismus, or correction of AHP were also noted. RESULTS: Six patients underwent surgery for chin-up AHP. A combined recession-resection of the vertical rectus muscles (bilateral inferior rectus muscle recession of 5 to 8 mm; bilateral superior rectus muscle resection of 7 to 8 mm) was performed in 4 of 6 patients, and isolated bilateral recession of the inferior rectus muscles was performed in the remaining 2 patients. Four of 6 patients (67%) achieved complete correction of their AHP at the last follow-up visit, with a mild residual chin-up AHP persisting in the other 2 patients. One patient developed large angle exotropia, one had restrictive hypertropia and horizontal plane null position, and another developed an incomitant horizontal strabismus with exotropia in right gaze. Reoperation was performed in the former 2 patients, with successful correction of the strabismus in each. CONCLUSIONS: Surgery on the vertical rectus muscles can reduce or eliminate a chin-up head position in patients with infantile nystagmus syndrome. Care should be taken to avoid producing a restriction of depression in abduction if the amount of resection is too large. [J Pediatr Ophthalmol Strabismus. 2022;59(6):410-415.].

MRSA Decolonization and the Eye: A Potential New Tool for Ophthalmologists.

PURPOSE: Methicillin-resistant Staphylococcus aureus (MRSA) is an opportunistic pathogen that can cause vision-threatening infections of the ocular surface, orbit, and periorbital structures. MRSA decolonization is a widespread technique employed outside of ophthalmology to reduce MRSA transmission and infection rates. Herein we explore whether decolonization protocols have a place in ophthalmology for combatting ocular MRSA infections. METHODS: We conducted a focused review of the MRSA decolonization literature using PubMed and Cochrane databases to identify key studies in ophthalmology and the broader medical literature. RESULTS: We summarize the relevance of the recent literature from an ophthalmic perspective, focusing on the clinical evidence supporting pre-operative MRSA decolonization. We also discuss current real-world decolonization practices, existing challenges, and propose recommendations for future opportunities to address these issues. CONCLUSION: Incorporating pre-operative MRSA decolonization approaches discussed herein may offer a new frontier for enhancing the ophthalmic care of patients colonized with MRSA.

AAPOS uniform guidelines for instrument-based pediatric vision screen validation 2021.

BACKGROUND: As instrument-based pediatric vision screening technology has evolved, the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) has developed uniform guidelines (2003, updated 2013) to inform the development of devices that can detect specified target levels of amblyopia risk factors (ARFs) and visually significant refractive error. Clinical experience with the established guidelines has revealed an apparent high level of over-referral for non-amblyopic, symmetric astigmatism, prompting the current revision. METHODS: The revised guidelines reflect the expert consensus of the AAPOS Vision Screening and Research Committees. RESULTS: For studies of automated screening devices, AAPOS in 2021 recommends that the gold-standard confirmatory comprehensive examination failure levels include anisometropia >1.25 D and hyperopia >4.0 D. Astigmatism >3.0 D in any meridian and myopia < -3 D should be detected in children <48 months, whereas astigmatism >1.75 D and myopia < -2 D should be detected after 48 months. Any media opacity >1 mm and manifest strabismus of >8Δ should also be identified. Along with performance in detecting ARFs and refractive error, validation studies should also report screening instrument performance with regard to presence or absence of amblyopia. Instrument receiver operating characteristic curves and Bland-Altman analysis are suggested to improve comparability of validation studies. CONCLUSIONS: Examination failure criteria have been simplified and the threshold for symmetric astigmatism raised compared to the 2013 guidelines, whereas the threshold for amblyogenic anisometropia has been decreased. After age 4 years, lower magnitudes of symmetric astigmatism and myopia are also targeted despite a low risk of amblyopia, because they can influence school performance and may warrant consideration of myopia prevention therapy.

Optimising telemedicine in ophthalmology during the COVID-19 pandemic.

Ophthalmology, an outpatient surgical specialty, depends on regular in-person encounters to manage complex eye disease. The coronavirus disease 2019 (COVID-19) pandemic has brought about unprecedented challenges in how we take care of our patients. At Vanderbilt University Medical Center, we have gone to great lengths to implement expeditiously a telemedicine platform for safely and securely evaluating our patients during the pandemic. Since implementing live videoconference appointments in late March, 840 patients received ophthalmic care during a 12-week period among all subspecialties at the Vanderbilt Eye Institute. Of these, the majority (79.6%) were either return or postoperative visits. Live telehealth visits were more amenable to certain ophthalmic subspecialties, with paediatrics, neuro-ophthalmology and oculoplastics encounters making up 80.5% of all telemedicine visits. As demonstrated through this care model and our initial experience, live video telemedicine is a sustainable and safe care delivery approach to extend ophthalmic care delivery during the COVID-19 pandemic and even post pandemic.

American Academy of Ophthalmology Recommendations on Screening for Endogenous Candida Endophthalmitis.

The American Academy of Ophthalmology evaluated the practice of routine screening for intraocular infection from Candida septicemia. In the United States, ophthalmologists are consulted in the hospital to screen for intraocular infection routinely for patients with Candida bloodstream infections. This practice was established in the era before the use of systemic antifungal medication and the establishment of definitions of ocular disease with candidemia. A recent systematic review found a rate of less than 1% of routinely screened patients with endophthalmitis from Candida septicemia. Other studies found higher rates of endophthalmitis but had limitations in terms of inaccuracies in ocular disease classification, lack of vitreous biopsies, selection biases, and lack of longer-term visual outcomes. Some studies attributed ocular findings to Candida infections, rather than other comorbidities. Studies also have not demonstrated differences in medical management that are modified for eye disease treatment; therefore, therapy should be dictated by the underlying Candida infection, rather than be tailored on the basis of ocular findings. In summary, the Academy does not recommend a routine ophthalmologic consultation after laboratory findings of systemic Candida septicemia, which appears to be a low-value practice. An ophthalmologic consultation is a reasonable practice for a patient with signs or symptoms suggestive of ocular infection regardless of Candida septicemia.