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Am J Ophthalmol ; 233: 48-56, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34303687


PURPOSE: Many clinicians treat unilateral amblyopia with glasses alone and initiate patching when needed; others start glasses and patching simultaneously. In this study, we reviewed the outcomes of the two approaches at our institution. DESIGN: Retrospective nonrandomized clinical trial. METHODS: Setting: Institutional practice. PATIENT POPULATION: All patients diagnosed with amblyopia at Boston Children's Hospital between 2010 and 2014. INCLUSION CRITERIA: Unilateral amblyopia (visual acuity (VA) 20/40 to 20/200 with interocular difference ≥3 lines,) age 3 to 12 years, with a 6-month follow-up visit. EXCLUSION CRITERIA: Deprivation amblyopia, prior amblyopia treatment, treatment other than patching, surgery. Patients were categorized as "simultaneous treatment" (concurrent glasses and patching therapy at their first visit) or "sequential treatment" (glasses alone at first visit, followed by patching therapy at second visit.) Observation procedures: Patient demographics, VA, and stereopsis were compared. OUTCOME MEASURES: VA and stereopsis at the last visit on treatment. RESULTS: We identified 98 patients who met inclusion criteria: 36 received simultaneous treatment and 62 sequential treatment. Median amblyopic eye VA improved similarly between the simultaneous (∆0.40; interquartile range [IQR], 0.56-0.30 logMAR) and sequential (∆0.40; IQR, 0.52-0.27 logMAR) groups. Patients without stereopsis at first visit had better stereopsis outcomes with sequential treatment (5.12 [IQR, 4.00-7.51] log stereopsis) compared with simultaneous treatment (8.01 [IQR, 5.65-9.21]) log stereopsis, P = 0.046). CONCLUSIONS: VA improved approximately 4 lines regardless of treatment type. For children without stereopsis at first presentation, sequential patching yielded better stereopsis outcomes. These findings require further validation and highlight the importance of evaluating stereopsis in future studies.

Ambliopia , Ambliopia/terapia , Criança , Pré-Escolar , Seguimentos , Humanos , Estudos Retrospectivos , Privação Sensorial , Resultado do Tratamento , Visão Binocular
Am J Ophthalmol ; 230: 200-206, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33992614


PURPOSE: To identify demographic and disease-related characteristics predictive of Lost-to-Follow-Up (LTFU) status in amblyopia treatment and create a risk model for predicting LTFU status. DESIGN: Retrospective cohort study METHODS: Setting: Single-center, ophthalmology department at Boston Children's Hospital (BCH). PATIENTS: 2037 patients treated for amblyopia at BCH between 2010 and 2014. OBSERVATION PROCEDURE: LTFU was defined as patients who did not return after initial visit, excluding those who came for second opinion. Multiple variables were tested for association with LTFU status. OUTCOME MEASURE: Odds ratio of LTFU risk associated with each variable. Multivariate logistic regression was used to create a risk score for predicting LTFU status. RESULTS: A large proportion of patients (23%) were LTFU after first visit. Older age, nonwhite race, lack of insurance, previous glasses or atropine treatment, and longer requested follow-up intervals were independent predictors of LTFU status. A multivariable risk score was created to predict probability of LTFU (area under the curve 0.68). CONCLUSIONS: Our comprehensive amblyopia database allows us to predict which patients are more likely to be LTFU after baseline visit and develop strategies to mitigate these effects. These findings may help with practice efficiency and improve patient outcomes in the future by transitioning these analyses to an electronic medical record that could be programmed to provide continually updated decision support for individual patients based on large data sets.

Ambliopia , Idoso , Ambliopia/diagnóstico , Ambliopia/terapia , Criança , Seguimentos , Humanos , Modelos Logísticos , Perda de Seguimento , Estudos Retrospectivos
Am J Ophthalmol ; 211: 87-93, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31712066


PURPOSE: Many bilateral amblyopia patients have asymmetric visual acuity (VA). There is no standard treatment for these patients, and outcomes have not been well described. Our goal is to compare VA outcomes in this group based on timing of occlusion therapy. DESIGN: Retrospective interventional comparative case series. METHODS: Setting: Institutional practice. PatientPopulation: Patients diagnosed with amblyopia at Boston Children's Hospital between 2010 and 2014. InclusionCriteria: VA ≥ 0.3 logMAR bilaterally by objective optotype-based measures, interocular difference (IOD) ≥ 0.18 logMAR, age 2-12 years. ExclusionCriteria: Loss to follow-up, managed surgically, deprivation amblyopia. Patients had either primary or secondary occlusion (primary = initiated when VA ≥ 0.3 logMAR bilaterally; secondary = initiated to correct residual IOD once VA improved to ≤0.18 logMAR in the stronger eye). ObservationProcedure: Patient demographics, VA, IOD, and stereopsis were compared between groups. OutcomeMeasures: VA improvement at 12-18 months and at last visits. RESULTS: Of 2,200 patients reviewed, 167 (7.6%) had asymmetric, bilateral amblyopia; 98 met inclusion and exclusion criteria. Patients were equally divided between primary (n = 50) and secondary (n = 48) occlusion groups. There were no differences in demographics, baseline VA, or IOD between groups (P ≥ .22), although the primary occlusion group had a higher proportion of strabismic amblyopia (P = .007). VA in both eyes, IOD, and stereopsis improved similarly between groups, even after stratifying by amblyopia subtype (P ≥ .48). The secondary occlusion group was more likely to achieve 20/30 bilaterally and IOD ≤ 1 line at 12-18 months (P ≤ .4), although this equalized by the last visit. CONCLUSION: In patients with asymmetric, bilateral amblyopia, VA improved by 4 lines in the weaker eye and 2 lines in the stronger eye, while IOD improved by 2 lines, irrespective of occlusion status. Primary occlusion thus provided no further benefit over spectacle correction alone.

Ambliopia/terapia , Privação Sensorial , Oclusão Terapêutica , Acuidade Visual/fisiologia , Ambliopia/fisiopatologia , Criança , Pré-Escolar , Percepção de Profundidade/fisiologia , Óculos , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos , Visão Binocular/fisiologia
J AAPOS ; 23(6): 325.e1-325.e6, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31689500


PURPOSE: To evaluate the finding of anomalous superior oblique muscles in congenital fibrosis of the extraocular muscles (CFEOM), a feature not previously emphasized in this condition. METHODS: The medical records of all patients clinically or genetically diagnosed with CFEOM at Boston Children's Hospital between 2010 and 2018 were reviewed retrospectively. Those who underwent strabismus surgery during the study period were included in the analysis. Baseline patient characteristics, type of CFEOM, results of genetic testing, and intraoperative features of the superior oblique muscle or tendon were recorded. RESULTS: Of 24 patients identified (age range, 1 month to 62 years), 10 (42%) had genetically confirmed CFEOM, and 22 underwent strabismus surgery, 14 (64%) involving the superior oblique muscle. Of these, 7 (50%) had anomalously inserted tendons (most commonly attached nasal to the superior rectus muscle), whereas 7 (50%) had increased superior oblique muscle tension. CONCLUSIONS: Half of CFEOM patients who underwent superior oblique surgery had abnormally inserted superior oblique tendons, and 50% had tight muscles or abnormally thin tendons, findings that have not been well-characterized in this condition. The findings suggest that abnormal insertion of the superior oblique muscles and tendons are additional features of the disease process in CFEOM that have not been described previously. These features may contribute to the severe upgaze limitation in CFEOM and highlight the importance of superior oblique tenotomy in surgical management.

Movimentos Oculares/fisiologia , Fibrose/diagnóstico , Músculos Oculomotores/fisiopatologia , Procedimentos Cirúrgicos Oftalmológicos/métodos , Oftalmoplegia/diagnóstico , Tendões/cirurgia , Tenotomia/métodos , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Fibrose/fisiopatologia , Fibrose/cirurgia , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Músculos Oculomotores/cirurgia , Oftalmoplegia/fisiopatologia , Oftalmoplegia/cirurgia , Estudos Retrospectivos , Adulto Jovem
Otolaryngol Head Neck Surg ; 159(2): 365-370, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29685082


Objective To review peripheral vestibular disorders in pediatric patients with dizziness following concussion. Study Design Case series with chart review. Setting Pediatric vestibular clinic and pediatric multidisciplinary concussion clinic at a tertiary level pediatric hospital. Subjects and Methods We retrospectively reviewed 109 patients seen for dizziness following a concussion between September 2012 and July 2015. Patients were ≤20 years of age at the time of concussion. Incidences of specific peripheral vestibular disorders were assessed along with timing of diagnosis relative to the date of injury, diagnostic test findings, and treatment interventions associated with those diagnoses. Results Twenty-eight patients (25.7%) were diagnosed with peripheral vestibular disorders. None of these disorders were diagnosed prior to evaluation in our pediatric vestibular clinic or our multidisciplinary concussion clinic, which occurred a mean of 133 days (95% confidence interval, 89.2-177.3) after injury. Benign paroxysmal positioning vertigo was diagnosed in 19 patients, all of whom underwent successful canalith repositioning maneuvers. Other diagnoses included temporal bone fracture (n = 3), labyrinthine concussion (n = 2), perilymphatic fistula (n = 2), and superior semicircular canal dehiscence (n = 2). Both patients with perilymphatic fistula and 1 patient with superior semicircular canal dehiscence underwent successful surgical management, while 1 patient with superior semicircular canal dehiscence was managed nonsurgically. Conclusion Peripheral vestibular disorders may occur in pediatric patients with dizziness following concussion, but these disorders may not be recognized until symptoms have persisted for several weeks. An algorithm is proposed to guide the diagnosis and management of peripheral vestibular disorders in pediatric patients with concussion.

Concussão Encefálica/complicações , Doenças Vestibulares/etiologia , Adolescente , Traumatismos em Atletas/complicações , Tontura/diagnóstico , Tontura/etiologia , Feminino , Humanos , Masculino , Estudos Retrospectivos , Doenças Vestibulares/diagnóstico , Testes de Função Vestibular