Unilateral lateral rectus recession is an effective surgery for intermittent exotropia in young children.

BACKGROUND: Different surgical methods have been suggested for the correction of intermittent exotropia. Unilateral lateral rectus recession has been described as a surgical alternative for small and moderate-angle exotropia. In general, previous studies did not focus on the outcomes of unilateral lateral rectus recession in young children with intermittent exotropia. The purpose of this study is to evaluate the surgical outcomes of unilateral lateral rectus recession in the treatment of moderate-angle exotropia (≤ 25 PD (prism diopters)) in children. METHODS: The charts of all patients younger than 12 years of age with moderate-angle exotropia (up to 25 PD) who were operated during the years 2006-2018 were retrospectively reviewed. Fifty-eight patients underwent unilateral lateral rectus recession and had a minimum follow up of 6 months. The angle of exotropia (PD) before and after surgery and the success rate were documented. RESULTS: Mean age at surgery was 6.4 ± 1.9 (range 3.5-11.0) years. Exotropia improved from a preoperative angle of 21.4 ± 4.0 PD to 3.5 ± 5.9 PD postoperatively (p < 0.001). Success rate, defined as deviation of ≤ 10 PD, was achieved in 86.2%. There were 2 (3.4%) cases of overcorrection (consecutive esotropia). There were no intra- or postoperative complications. The mean follow-up duration after surgery was 2.3 ± 1.7 years. CONCLUSIONS: In children with moderate angle exotropia, good postoperative success rate was achieved by performing unilateral lateral rectus recession.

Retinopathy of prematurity in discordant twins: is the small twin at increased risk?

PURPOSE: To examine the effect of birth weight (BW) independent of gestational age (GA) on Retinopathy of prematurity (ROP) in preterm discordant twins. METHODS: A retrospective cohort study of 45 preterm twin pairs born at < 34 weeks of gestation with BW discordance of ≥ 20%. The twin pairs were divided into two groups based on BW - small or large. Rates of ROP, stage, treatment, and prognosis were compared between the two groups. Other neonatal outcomes related to prematurity were also compared between groups. RESULTS: The mean gestation age at delivery was 31.1 weeks of gestation. The rate of ROP was significantly higher among the smaller twins compared to the larger twins (8.9% vs 0% respectively, p = 0.04). All smaller twins with ROP had stage 2 disease, and all cases of ROP had resolved without treatment. Regarding neonatal morbidities, the smaller twins had longer hospitalization length (53.8 vs 39.4 days respectively, p < 0.01) and a higher rate of hypoglycemia (55.6% vs 24.4% respectively, p = 0.003), whereas the larger twins were more commonly affected by respiratory distress syndrome (59.1% vs 26.7% respectively, p = 0.002). CONCLUSION: The rate of ROP was higher among the small twins in preterm discordant twins. This may indicate that low BW rather than early GA is the main factor contributing to the development of ROP.

How crowding, masking, and contour interactions are related: A developmental approach.

Young children are characterized by poor visual performances. Visual crowding, lateral interactions, and contour detection are critical functions for visual perception, context effect, and recognition that develop over the years up to maturity. The age at which the maturation's onset of the functions can be observed and the functions' underlying neural basis remain unclear. Here we used a development approach to investigate the onset of the foveal visual functions in order to learn about their neuronal basis and their relationships. We measured lateral interactions, crowding, and contour integration in participants aged 3-15 years. The results show that very young children do not exhibit collinear facilitation; rather, their vision is dominated by suppression and a high degree of crowding. Our results show sequential changes in the visual functions in parallel with the development of facilitation-that is, a significant reduction in crowding and an improved contour detection threshold. Our data suggest that the correlation between the onset age of maturation of collinear facilitation with crowding reduction and improvement of contour integration has underlying mutual neuronal mechanisms.

Secondary membrane formation after cataract surgery with primary intraocular lens implantation in children.

To evaluate the risk factors for secondary membrane (SM) formation after congenital cataract surgery with intraocular lens (IOL) implantation. A retrospective non-interventional comparative study. Thirty-nine patients (63 eyes) aged 1-135 months. The study included patients who underwent cataract extraction and primary IOL implantation between 1994 and 2001 at the University Hospital. The postoperative follow-up was 6-24 months. Thirty-three eyes received a poly(methyl methacrylate) (PMMA) IOL without square edges, 29 eyes received a hydrophobic acrylic IOL with truncated square edges (AcrySof), and there was no data for IOL type in one eye. Thirty-nine eyes had primary posterior capsulotomy (PPC) and anterior vitrectomy (AV) and in 24 eyes the posterior capsule was left intact. Cox proportional hazard regression analysis was performed to identify significant risk factors for SM formation, and Wilcoxon test to evaluate the difference in time from surgery to SM formation. SM developed in 24 eyes (38 %)--58 % of eyes with an intact posterior capsule and 26 % of eyes having PPC and AV, 42 % of eyes with a PMMA IOL, and 34 % of eyes with an AcrySof lens. In multivariate Cox regression analysis intraoperative PPC and AV (P = 0.02) and AcrySof lens implantation (P = 0.097) were associated with decreased postoperative incidence of SM formation. Median time until SM development was 2.9 months with PMMA IOLs (range 1-17 months) and 6 months with AcrySof lenses (range 1-21.8 months) (P = 0.037). Posterior capsule management as well as IOL design and material influence the incidence and the timing of SM formation after primary IOL implantation in children.

Results of congenital cataract surgery with and without intraocular lens implantation in infants and children.

BACKGROUND: Operations for congenital cataract in children in the past had resulted in aphakia. Improvement in surgical tools and techniques as well as in intraocular lens (IOL) implantation has led to correction of the aphakia by IOL implantation. We report the outcome of cataract surgery with and without IOL on these children in our institution between 1991-2008. METHODS: In this retrospective cohort study, the medical records of all children who underwent surgery for congenital cataract were reviewed. The final study group included 144 children (218 eyes). Postoperative visual acuity (VA) was tested either by Teller Acuity Cards (in preverbal children) or by the Snellen chart. Data on VA status and postoperative complications were retrieved. RESULTS: Patients with bilateral cataract had better postoperative VA than patients with unilateral cataract (logMAR 0.559 ± 0.455 vs. 0.919 ± 0.685, respectively, P < 0.001). Children who underwent IOL implantation had better postoperative VA than those who did not, but the type of surgery had no significant effect after correction for the child's age at surgery (P = 0.346). Secondary cataract occurred more frequently in the extra-capsular cataract extraction (ECCE) + IOL implantation group than in the ECCE only group (20.6 % vs. 8.3 %, respectively, P = 0.018). CONCLUSIONS: Patients with bilateral cataract had better postoperative VA compared with those with unilateral cataract. The type of surgery had no effect on final VA, but there was a higher rate of secondary cataract in the ECCE + IOL patients compared to the ECCE only patients.

Comparison of hang-back and conventional bimedial rectus recession in infantile esotropia.

PURPOSE: To compare surgical outcome of hang-back and conventional bimedial rectus muscle recession in infantile esotropia. PATIENTS AND METHODS: The charts of 67 consecutive patients with infantile esotropia who underwent bilateral medial rectus muscle from 1990 through 2005 were retrospectively reviewed. Thirty patients were operated by hang-back technique (group 1) and 37 by conventional bimedial rectus recession in which the tendon was sutured directly to the globe (group 2). In each group, the angle of esotropia (PD - prism diopters) before and 6 months after surgery and the success rate (deviation of < or =10 PD) were documented. RESULTS: Esotropia improved an average of 39.7 (SD 14.9) PD in group 1 (from a preoperative 42.7 (SD 11.6) PD to 3.0 (SD 8.5) PD postoperatively) and 45.5 (SD 19.3) PD in group 2 (from a preoperative 54.3 (SD 16.8) PD to 8.7 (SD 12.1) PD postoperatively) (p = 0.18, independent sample t-test). Success rate (defined as deviation of < or =10 PD at 6 months postoperative examination) was 83.3% in group 1 and 70.2% in group 2 (p = 0.21, Chi-square). Multivariate logistic regression suggests that surgical outcomes are not significantly influenced by age and preoperative angle of esotropia. No complications occurred in both groups. CONCLUSION: Hang-back technique is as effective as the conventional bimedial rectus muscle recession in correcting infantile esotropia.

Moderate-angle exotropia: a comparison of unilateral and bilateral rectus muscle recession.

BACKGROUND AND OBJECTIVE: To compare the surgical outcome of unilateral lateral rectus recession and bilateral lateral rectus recession in moderate-angle exotropia (< or = 30 prism diopters [PD]). PATIENTS AND METHODS: The charts of all patients with moderate-angle exotropia (30 PD) who were operated on during the years 1993 to 2005 were retrospectively reviewed. Twenty-nine patients underwent unilateral lateral rectus recession (group 1) and 27 patients underwent bilateral lateral rectus recession (group 2). RESULTS: Exotropia improved an average of 9.4 +/- 7.1 PD in group 1 and 15.5 +/- 10.6 PD in group 2 (P < .05, independent samples Student's t test). The success rate, defined as deviation of 10 PD or less, was achieved in 69% of patients in group 1 and 74% of patients in group 2 (P = .67, chi-square). No postoperative complications occurred in either group. CONCLUSION: Similar postoperative success rates were achieved with unilateral lateral rectus recession and bilateral lateral rectus recession.

Retinopathy of prematurity in very low birth weight infants and the potential protective role of indomethacin.

BACKGROUND AND OBJECTIVE: To describe clinical features of very low birth weight (VLBW) infants and examine the effect of indomethacin on the incidence of retinopathy of prematurity (ROP). PATIENTS AND METHODS: Medical records of all VLBW infants over a 4-year period were reviewed. Data regarding systemic and ophthalmic examinations were analyzed. RESULTS: Forty-seven infants with ROP were evaluated. Most infants had bilateral stage 1 or 2 disease extending 5 clock hours. Infants with ROP had younger mean gestational age, had lower gestational weight, and demonstrated higher incidence of diseases of prematurity. These infants were exposed to increased doses of surfactant and higher oxygen concentration for a prolonged duration given their immature pulmonary status. Independent predictors of ROP susceptibility also included length of hospitalization and Apgar score at 5 minutes. Patent ductus arteriosus was more common among infants with ROP. Approximately half of the infants who received one or two doses of indomethacin had ROP, but the ROP rate was decreased in infants who received three doses. CONCLUSION: Premature infants with younger gestational age, lower gestational weight, and severe morbidities were found to have an increased prevalence of ROP. Indomethacin treatment for patent ductus arteriosus may have a protective role in the development of severe ROP.

The relationship between patient age and astigmatism magnitude after congenital cataract surgery.

PURPOSE: To evaluate the magnitude of refractive astigmatism after congenital cataract surgery and to define its correlation with patient age. METHODS: The authors retrospectively reviewed the charts of all pediatric patients who underwent congenital cataract extraction with intraocular lens (IOL) implantation through a 3.0-mm clear corneal incision from 1998 to 2003, and had no suture removal for 5 months afterward. Thirty-four children were included, aged 2 months to 15 years. Refractive astigmatism was assessed manually 1 week, 3 months, and 5 months after surgery by an experienced optometrist. The paired t test was used to compare the magnitude of postoperative astigmatism at different postoperative periods. Spearman correlation was used to determine the correlation between patient age and the postoperative refractive astigmatism. RESULTS: Mean refractive astigmatism in all patients was 1.8+/-1.5 diopters (D) at 1 week postoperatively. It significantly decreased to 1.0+/-0.7 D at 3 months postoperatively (p=0.001), and to 0.8+/-0.7 D at 5 months postoperatively (p=0.03). The change in astigmatism was significantly greater during the first 3 postoperative months than during the following 2 months (p=0.04). Patient age was significantly correlated with 1 week postoperative astigmatism (Spearman coefficient, r = -0.46; p=0.006) and with 3 months postoperative astigmatism (Spearman coefficient, r =-0.37; p=0.03). CONCLUSIONS: Congenital cataract surgery using a small, clear corneal incision for IOL implantation caused high early postoperative astigmatism, which spontaneously regressed thereafter. Younger patients had higher early postoperative astigmatism.

Challenging Management of Double Vision After Functional Endoscopic Sinus Surgery-A Series of 6 Cases.

PURPOSE: To present 6 cases of orbital trauma, diplopia and strabismus after functional endoscopic sinus surgery (FESS). DESIGN: Retrospective observational case series. METHODS: The medical charts of suitable patients were reviewed for information on medical examination, imaging studies, the type of corrective surgery, and surgical outcomes. STUDY POPULATION: All patients with diplopia and strabismus after undergoing FESS who were treated or consulted at our institution between 2008 and 2017 were included. MAIN OUTCOME MEASURES: The presence and extent of strabismus and double vision at the end of follow-up. RESULTS: Six patients complained of diplopia after FESS; all of them had proven orbital trauma. In Cases 1-5, patients suffered medial rectus (MR) muscle transection and subsequent exotropia. Their prognosis was guarded despite prompt surgical intervention, and ranged from large exotropia when direct recovery of the MR was attempted, to primary gaze orthotropia but with minimal adduction capacity, during which vertical recti transposition was attempted. Patient 6 sustained transient diplopia, although all of his extraocular muscles appeared intact on imaging. His eye position and movement were completely resolved with conservative measures only. CONCLUSIONS: Our experience was that immediate recovery procedures to reattach the muscle in cases with proven transection of the MR muscle are futile, and that definitive corrective strabismus surgery (ie, vertical muscle transposition) has a better chance to achieve favorable results.

Suture-related complications after congenital cataract surgery: Vicryl versus Mersilene sutures.

PURPOSE: To evaluate 10-0 polyester sutures (Mersilene) and 10-0 absorbable polyglactin sutures (Vicryl) for small-incision congenital cataract surgery. SETTING: Goldschleger Eye Institute, Sheba Medical Center, Tel-Aviv University, Tel-Aviv, Israel. METHODS: A retrospective review comprised 51 patients (70 eyes) who had small-incision congenital cataract extraction and intraocular lens implantation between 1999 and 2005. Surgery was done using Mersilene sutures or Vicryl sutures. Retinoscopy and a careful examination for suture-related complications were done 1 week after surgery and then every month for 6 months. The sutures were removed in cases of local tissue reaction but not for high postoperative astigmatism. The t test was used to evaluate postoperative astigmatism and the Fisher exact test, to evaluate the difference in the incidence of suture-related complications. RESULTS: The patients' age ranged from 2 months to 15 years. Ten cases (18%) of corneal vascularization occurred in the Mersilene group during the 6-month follow-up period. This necessitated suture removal, after which 1 incident of endophthalmitis occurred. In contrast, no suture-related complications were noted in the Vicryl group during that time. The difference in the incidence of complications between the 2 groups approached statistical significance (P = .07). Mean astigmatism 1 week postoperatively was 2.3 diopters (D) +/- 2.1 (SD) in the Mersilene group, which was significantly higher than in the Vicryl group (mean 1.4 +/- 1.1 D) (P = .038). However, the mean astigmatism decreased to less than 1.0 D in both groups during the 6-month follow-up period. CONCLUSION: Vicryl sutures are recommended for small-incision congenital cataract surgery.

Use of amniotic membrane graft and corneal transplantation in a patient with bilateral keratomalacia induced by uncontrolled phenylketonuria.

PURPOSE: To report a patient with a rare complication of bilateral keratomalacia induced by uncontrolled phenylketonuria (PKU) that was successfully treated with amniotic membrane transplantation in 1 eye and penetrating keratoplasty in the second eye. METHODS: Case report and literature review. RESULTS: A 9-month-old girl with uncontrolled PKU was referred to our clinic because of bilateral keratomalacia. Slit-lamp examination of the right eye revealed 2 large corneal erosions with stromal thinning on the nasal and inferior regions of the right cornea. Left eye examination revealed a large area of melting involving two thirds of the cornea with corneal perforation and iris bulging on the temporal side and no anterior chamber. She underwent amniotic membrane transplantation on her right cornea and penetrating keratoplasty on her left cornea. Treatment after surgery included antibiotic and steroid eye drops and a special diet regimen with partial phenylalanine intake. Examination under anesthesia 4 months after surgery revealed intact cornea in her right eye and a clear corneal graft with a deep anterior chamber on her left eye. Intraocular pressure was normal in both eyes. CONCLUSIONS: Bilateral keratomalacia, although a rare ophthalmic manifestation of PKU, can cause a severe corneal injury that may threaten the eyeball integrity. Surgical treatments with amniotic membrane graft and corneal transplantation, along with the appropriate diet treatment, were found to be effective procedures, yielding rapid healing of the corneal surface.

Bilateral medial rectus muscle recession: results in children with developmental delay compared with normally developed children.

PURPOSE: We sought to compare bimedial rectus muscle recession (BMR) results for esotropia in children with developmental delay with the results in normal children. METHODS: A retrospective analysis of all the children that underwent standard BMR surgery for esotropia during a 10 year period was undertaken. The surgical results of children with developmental delay were compared with those of normal children. RESULTS: In the developmentally delayed group, the mean angle of esotropia before surgery was 53+/-12 PD, the mean amount of medial rectus recession was 5.4+/-0.56 mm, 0.84 mm less than the standard amount of recession, and at the last follow-up visit only 56% achieved surgical success (within 10 PD of orthophoria). Among the failures, 86% were undercorrected, only one patient developed consecutive exotropia after surgery. In the developmentally intact group, the mean angle of esotropia before surgery was 37.4+/-8 PD, the mean amount of medial rectus recession was 5.2+/-0.65 mm, and 94% achieved surgical success. Among surgical failures, we observed only a single case of overcorrection. CONCLUSION: A higher rate of surgical failure was found in developmentally delayed children who received a smaller recession amount of the medial rectus muscles when compared with the developmentally normal children who received a standard amount of recession. The main reason for surgical failure in the developmentally delayed group, in a follow-up period of 2 years, was undercorrection of the angle of esotropia. It seems that decreasing the surgical table by a certain amount in children with developmental delay may lead to undercorrection. Therefore, we need to delineate the ideal amount of surgery in this unique group of individuals.

Unilateral and bilateral lateral rectus recession in exotropia.

BACKGROUND AND OBJECTIVE: To evaluate the surgical results obtained by unilateral and bilateral lateral rectus recession for the correction of exotropia. PATIENTS AND METHODS: The charts of all patients with exotropia who were operated on at the Goldschleger Eye Institute at Sheba Medical Center during an 11-year period were retrospectively reviewed. Study participants all underwent a complete orthoptic and ocular examination. Twenty-five patients with moderate-angle exotropia underwent unilateral lateral rectus recession (group 1) and 38 patients with large-angle exotropia underwent bilateral lateral rectus recession (group 2). The angle of exotropia was measured by the prism and cover test. Moderate exotropia was defined as 25 prism diopters (PD) and large-angle exotropia as greater than 25 PD. RESULTS: The mean age at the time of the surgery was 10.0+/-5.2 years in group 1 and 8.5+/-8.0 years in group 2. The mean preoperative exotropia was 16.1+/-5.7 PD in group 1 and 29.6+/-14.4 PD in group 2. A mean postoperative exodeviation of 4.2+/-5.4 PD was found in group 1 and 5.8+/-13.6 PD in group 2. The success rate (deviation of < 10 PD) was 84% in group 1 and 74% in group 2. There was no incomitance in group 1. CONCLUSION: Unilateral lateral rectus recession is an effective surgical method for correcting moderate-angle exotropia with results similar to bilateral lateral rectus recession for larger exotropia angles.

Strabismus in senile cataract patients.

PURPOSE: We sought to determine the prevalence of strabismus among patients with senile cataract. METHODS: Forty-seven consecutive patients who were scheduled for cataract surgery underwent complete eye examinations, including ocular alignment evaluation. Twenty-four normal adults of the same age range underwent also complete eye examinations and were used as a control group. All patients of the cataract group underwent unilateral cataract surgery. The angle of strabismus was measured by the prism and cover test or prism and corneal reflex test. RESULTS: Mean preoperative deviation of the study group was 17.8 +/- 9.7 prism diopters (PD) of exophoria/tropia. In this group, 70.2% had exophoria and 27.7% had exotropia. In the control group exophoria was found in 75% of the persons whereas none of them had any heterotropia. Mean deviation in the control group was 4.7 +/- 5.1 PD of exophoria. Postoperatively, the angle of exophoria/tropia improved to 12.8 +/- 8.5 PD, which was different from the preoperative measurements (P < 0.01). In this group 78.8% had exophoria and 19.1% had exotropia. CONCLUSIONS: Patients with cataract have greater tendency to develop exotropia or exophoria than noncataract persons of the same age. Cataract surgery improves the heterophoric status of these patients.

The effect of oral propranolol on intraocular pressure in infants with Sturge-Weber syndrome glaucoma.

PURPOSE: To report the effect of oral propranolol on intraocular pressure (IOP) in infants newly diagnosed with unilateral Sturge-Weber syndrome (SWS) glaucoma receiving no other treatment. METHODS: This was a prospective, nonrandomized interventional case series. Four infants presenting with unilateral SWS glaucoma with no prior treatment were treated with oral propranolol at a dose of 2 mg/kg and followed thereafter. RESULTS: Propranolol had a temporary IOP-lowering effect in 3 of 4 children after 1 week of treatment. This effect diminished thereafter and 3 of 4 children required additional medical or surgical treatment. CONCLUSIONS: Oral propranolol has a temporary effect on IOP in SWS glaucoma and is not effective as a single treatment in this syndrome, yet can serve to delay surgical treatment for a short period of time. In one case, the glaucoma was well-controlled on this medication.

Measurement of Axial Length in an Office Setting Versus Under General Anesthesia in Infants and Toddlers: A Comparative Study.

PURPOSE: To examine whether axial length measurement in awake infants and toddlers is feasible, and whether there is a difference in axial length measurement between an office setting and under general anesthesia. METHODS: This prospective comparative case study was conducted at the Goldschleger Eye Institute, Sheba Medical Center, Israel. Using the same instruments, axial length measurements were obtained using a standard applanation technique twice: once in an office setting when the infant/toddler was awake and once under general anesthesia in the operating room. A paired t test was used to test for differences between measurements. RESULTS: Thirty-three eyes of 19 participants younger than 28 months were examined; 24 (73%) eyes had cataracts and the remainder had clear lenses. One child was excluded from the study due to lack of cooperation during axial length measurement in the office setting and another due to the lengthy gap between measurements. Of the remaining 31 children, the average age was 9 months. Average axial length measurements were shorter by 0.12 mm in the office setting than under general anesthesia (P = .14). No adverse effects were observed after axial length measurements in the office setting. CONCLUSIONS: Axial length measurement in an office setting is generally reasonable to obtain. The results showed no significant difference in the axial length measured in the two settings.

Changes in astigmatism after congenital cataract surgery and intraocular lens implantation: a comparative study.

OBJECTIVE: To evaluate the postoperative changes in astigmatism in the pseudophakic eyes of children who underwent 1 of 3 different types of surgical incisions for congenital cataract extraction with intraocular lens implantation, and in whom astigmatism of at least 3 diopters (D) was recorded 1 week after the operation. METHODS: We retrospectively reviewed the medical records of all the children in our department who had undergone surgery for nontraumatic cataract between 1992 and 2001. Cataract surgery with intraocular lens implantation was performed using 1 of 3 types of surgical incisions: a limbal incision, a scleral tunnel, or a clear corneal incision allowing the use of a foldable intraocular lens. In 28 children (32 eyes) aged 2 months to 11 years (mean +/- SD, 4.7 +/- 3.4 years), astigmatism of 3 D or more was found when assessed 1 week after surgery. The refraction was measured and recorded again 3 months and 5 months after surgery. The paired t test was used to compare the outcome variables. MAIN OUTCOME MEASURES: Refractive error 1 week, 3 months, and 5 months after surgery. RESULTS: Mean +/- SD astigmatism 1 week postoperatively was 5.8 +/- 2.2 D, 5.1 +/- 2.1 D, and 4.0 +/- 1.3 D in groups 1, 2, and 3, respectively. Thereafter, the astigmatic component of the refractive error underwent a spontaneous decline, reaching mean +/- SD values of 0.9 +/- 1.0 D, 1.6 +/- 1.6 D, and 1.0 +/- 0.8 D, respectively, in the 3 groups 5 months after the operation. The difference between the mean values at 1 week and at 5 months in each group was statistically significant (P <.001 in group 1; P =.01 in group 2; and P<.001 in group 3). CONCLUSION: Children who underwent extraction of congenital cataract and intraocular lens implantation by different surgical techniques showed a significant spontaneous reduction in astigmatism postoperatively.

Spectacle use and reduced unaided vision in third grade students: a comparative study in different educational settings.

BACKGROUND: The development of myopia is influenced by hereditary factors, environmental factors and gene-environment interaction. Reading and near-work activity are associated with myopia and myopic progression. This study sought to determine and compare the prevalence of reduced unaided vision and spectacle use among third grade Israeli students from three different educational settings. METHOD: A sample of 917 students (mean age 8.5 years, range seven to 10 years) was drawn from the three Israeli educational streams: secular, Orthodox and ultra-Orthodox. Children in the ultra-Orthodox education pathway begin studying at the age of three years and their daily reading involves sustained near work with increased accommodative effort accompanied by head-rocking movements. Reduced distance vision was used to indicate the likely development of or an increase in the amount of myopia. Spectacle lenses were measured to determine the prevalence of myopia. RESULTS: Of the 917 students studied, 103 (11.2 per cent) wore spectacles (14.2 per cent of the males and eight per cent of the females); 82.5 per cent of those who wore spectacles were myopic. Males from ultra-Orthodox schools had the highest rate of reduced unaided vision (72.5 per cent) compared with males from secular schools (27.3 per cent), males from Orthodox schools (59.3 per cent) or with females from all three groups (average of 34.8 per cent, p < 0.0001, chi squared). Males had a higher rate of reduced unaided vision, especially in the Orthodox and ultra-Orthodox schools. CONCLUSIONS: Our study suggests that Jewish ultra-Orthodox males have a higher prevalence and degree of myopia. The study habits of young children, including exposure to prolonged near tasks, high accommodative demands and possibly optical defocus induced by body sway, may contribute to the development of myopia.

Refractive error in premature infants.

PURPOSE: To determine the incidence and the degree of refractive error between the ages of 2 weeks and 6 months in premature infants without retinopathy of prematurity and to seek a correlation between refractive error and age at examination, birth weight, or gestational age. SUBJECTS AND METHODS: In this observational cross-sectional study, eye refraction in 390 premature infants, with no ocular pathology, was measured by cycloplegic retinoscopy at the age of 2 weeks to 6 months. A correlation was sought between refractive error and perinatal variables. RESULTS: Of the 390 infants reviewed, 347 (89%) had a refractive error and 43 (11%) were emmetropic in both eyes. Most of the infants were hyperopic (76.8%). Myopia was observed in only 11.9%. Astigmatism was found in 24.4% of the infants. The mean age at examination was 2.1 +/- 1 months; the mean birth weight was 1639 +/- 444 g, and the mean gestational age at birth was 32.2 +/- 2.4 weeks. The mean spherical equivalent of refraction was +1.56 +/- 1.82 diopters (D) in the right eye and +1.55 +/- 1.78 D in the left eye. Refractive error was positively correlated with age at examination ( R = 0.16, P = 0.001). The mean refractive error was +1.24 D in infants aged 1 month or less and reached +2.50 D at the age of 4 to 6 months. Refractive error was not correlated with birth weight or gestational age. CONCLUSIONS: The incidence of refractive error in premature infants without retinopathy of prematurity in the first 6 months of life may be as high as 89%. Most of these infants are hyperopic. Eye refraction is correlated with age at examination, but not with birth weight or gestational age.