A Pilot Randomized Clinical Trial of Base-in Relieving Prism Spectacle Treatment of Intermittent Exotropia.

SIGNIFICANCE: This pilot randomized trial, the first to evaluate a specific base-in relieving prism treatment strategy for childhood intermittent exotropia, did not support proceeding to a full-scale clinical trial. Defining and measuring prism adaptation in children with intermittent exotropia are challenging and need further study. PURPOSE: This study aimed to determine whether to proceed to a full-scale trial of relieving base-in prism spectacles versus refractive correction alone for children with intermittent exotropia. METHODS: Children 3 years old to those younger than 13 years with distance intermittent exotropia control score of ≥2 points on the Intermittent Exotropia Office Control Scale (Strabismus 2006;14:147-150; 0 [phoria] to 5 [constant]), ≥1 episode of spontaneous exotropia, and 16 to 35∆ by prism-and-alternate-cover test, who did not fully prism adapt on a 30-minute in-office prism-adaptation test were randomized to base-in relieving prism (40% of the larger of distance and near exodeviations) or nonprism spectacles for 8 weeks. A priori criteria to conduct a full-scale trial were defined for the adjusted treatment group difference in mean distance control: "proceed" (≥0.75 points favoring prism), "uncertain" (>0 to <0.75 points favoring prism), or "do not proceed" (≥0 points favoring nonprism). RESULTS: Fifty-seven children (mean age, 6.6 ± 2.2 years; mean baseline distance control, 3.5 points) received prism (n = 28) or nonprism (n = 29) spectacles. At 8 weeks, mean control values were 3.6 and 3.3 points in prism (n = 25) and nonprism (n = 25) groups, respectively, with an adjusted difference of 0.3 points (95% confidence interval, -0.5 to 1.1 points) favoring nonprism (meeting our a priori "do not proceed" criterion). CONCLUSIONS: Base-in prism spectacles, equal to 40% of the larger of the exodeviations at distance or near, worn for 8 weeks by 3- to 12-year-old children with intermittent exotropia did not yield better distance control than refractive correction alone, with the confidence interval indicating that a favorable effect of 0.75 points or larger is unlikely. There was insufficient evidence to warrant a full-scale randomized trial.

Rasch-calibrated Intermittent Exotropia Symptom Questionnaire for Children.

SIGNIFICANCE: A rigorously designed and calibrated symptom questionnaire for childhood intermittent exotropia would be useful for clinical care and for research. PURPOSE: The aim of this study was to Rasch-calibrate and evaluate the previously developed Child Intermittent Exotropia Symptom Questionnaire using data gathered as part of a randomized clinical trial. METHODS: The questionnaire was administered to 386 children aged 3 to 10 years with intermittent exotropia who were enrolled in a randomized clinical trial comparing overminus with nonoverminus spectacles. Participants were followed at 6 and 12 months while on treatment and at 18 months off treatment. Factor analysis determined dimensionality, and Rasch analysis evaluated questionnaire performance. Logit values were converted to 0 (best) to 100 (worst). We evaluated differences in questionnaire scores between treatment groups and time points, and correlations with control scores. RESULTS: The Child Intermittent Exotropia Symptom Questionnaire was unidimensional. Rasch analysis indicated that there was no notable local dependence and no significant differential item functioning for sex or age. There was suboptimal targeting (mean logit, -1.62), and person separation was somewhat poor (0.95). There were no significant differences in the Child Intermittent Exotropia Symptom score between overminus spectacles and nonoverminus spectacles at 6, 12, and 18 months. Combining data from both treatment groups, there was significant improvement from baseline at all follow-up visits (e.g., mean change from baseline to 12 months, -6.6 points; 95% confidence interval, -8.6 to -4.6). Child Intermittent Exotropia Symptom scores were not correlated with distance or near control scores at 12 months. CONCLUSIONS: The seven-item Rasch-scored Child Intermittent Exotropia Symptom Questionnaire is limited by suboptimal performance. Future study is needed to determine whether it may be useful for clinical practice and for research.

Relationships among Clinical Factors and Patient-reported Outcome Measures in Adults with Convergence Insufficiency.

SIGNIFICANCE: When exploring relationships among clinical measures and patient-reported outcome measures in adults with convergence insufficiency, worse symptoms (Convergence Insufficiency Symptom Survey [CISS] score) seemed to be correlated with worse reading function domain score (Adult Strabismus-20 quality-of-life questionnaire). After treatment, improved symptoms were associated with improved reading function quality of life. PURPOSE: This study aimed to explore relationships between clinical measures and patient-reported outcome measures in adults undergoing treatment for symptomatic convergence insufficiency. METHODS: In a prospective multicenter observational study, we evaluated adults with symptomatic convergence insufficiency (i.e., clinical measures of near exodeviation, receded near point of convergence, reduced near positive fusional vergence; CISS score ≥21). Fifty-seven participants treated with vision therapy/exercises (n = 35) or base-in prism (n = 22) were analyzed. Spearman correlation coefficients ( R ) were used to assess associations among the three clinical measures and patient-reported outcome measures (CISS, Diplopia Questionnaire, four Adult Strabismus-20 quality-of-life domains) before treatment (baseline) and after 10 weeks and 1 year. Associations were interpreted to be present when the lower limit of the 95% confidence interval (CI) was moderate to strong ( R ≥ 0.4). RESULTS: Among multiple exploratory analyses, the only moderate to strong baseline correlation was between worse CISS and worse Adult Strabismus-20 reading function scores ( R = 0.62; 95% CI, 0.43 to 0.76). Regarding change in measures with treatment, the only moderate to strong correlations were between improved CISS and improved Adult Strabismus-20 reading function scores for prism at 10 weeks ( R = 0.78; 95% CI, 0.52 to 0.91) and 1 year ( R = 0.85; 95% CI, 0.65 to 0.94) and for vision therapy/exercises at 1 year ( R = 0.78; 95% CI, 0.57 to 0.89). CONCLUSIONS: In exploratory analyses, we found positive correlations between CISS symptom scores and reading function quality-of-life scores. The absence of correlations between symptoms and individual clinical measures is consistent with clinical experience that, in convergence insufficiency, symptoms and clinical findings can be discordant.

Conversion Factor for B-Scan Ultrasound Measurement of Intraocular Tumors With and Without the Sclera.

OBJECTIVES: To investigate the relationship between choroidal nevus and melanoma thickness measured with or without the sclera included by B-scan ultrasound and to present a simple conversion formula. METHODS: Medical records were retrospectively reviewed for choroidal nevus or melanoma evaluated at the Mayo Clinic in Rochester, Minnesota, with B-scan ultrasound between February 4, 2004, and April 23, 2020. Charts were retrospectively reviewed for high-quality B-scan images in which the ultrasound transducer was perpendicular to the lesion, measuring the tumor thickness without the sclera included. Measurements were repeated with the sclera included for each patient. Univariate and multiple linear regression analyses were performed to identify factors correlated with scleral thickness. RESULTS: There were 201 tumors included in the study, with a mean patient age ± SD of 61 ± 14 years, largest tumor basal diameter of 11.8 ± 4.8 mm, tumor thickness without the sclera included of 3.72 ± 2.7 mm, and thickness with the sclera included of 4.54 ± SD 2.8 mm. On the univariate analysis, factors associated with perceived scleral thickness by B-scan ultrasound included age (P < .001), tumor thickness (P < .001), and basal diameter (P = .06). On the multivariate analysis, factors associated with perceived scleral thickness included age and tumor thickness (P < .001) for all tumors and for the subset of 141 tumors with a thickness of 2 mm or greater (P < .001). For tumors of 2 mm or greater in thickness, perceived scleral thickness by ultrasound can be estimated by the formula 0.00495(patient age) + 0.02451(tumor thickness without the sclera) + 0.42549. CONCLUSIONS: We present a simple formula for converting between B-scan ultrasound measurements of choroidal nevus and melanoma measuring 2 mm or greater in thickness with and without the sclera included.

A Randomized Clinical Trial of Immediate versus Delayed Glasses for Moderate Hyperopia in 1- and 2-Year-Olds.

PURPOSE: Two strategies were compared for managing moderate hyperopia without manifest strabismus among 1- and 2-year-old children: (1) immediate prescription of glasses versus (2) observation without glasses unless reduced distance visual acuity (VA), reduced stereoacuity, or manifest strabismus. DESIGN: Prospective randomized clinical trial. PARTICIPANTS: A total of 130 children aged 1 to 2 years with hyperopia between +3.00 diopters (D) and +6.00 D spherical equivalent (SE) in at least 1 eye, anisometropia ≤1.50 D SE, and astigmatism ≤1.50 D based on cycloplegic refraction and no manifest strabismus. METHODS: Participants were randomly assigned to glasses (1.00 D less than full cycloplegic hyperopia) versus observation and followed every 6 months for 3 years. Glasses were prescribed to those assigned to observation if they met prespecified deterioration criteria of distance VA or near stereoacuity below age norms, or development of manifest strabismus. MAIN OUTCOME MEASURES: At the 3-year primary outcome examination, participants were classified as failing the randomized management regimen if distance VA or stereoacuity was below age norms or manifest strabismus was observed (each with and without correction in trial frames, confirmed by masked retest, irrespective of whether deterioration had occurred previously), or if strabismus surgery had been performed. RESULTS: Of the 106 participants (82%) completing the 3-year primary outcome examination, failure occurred in 11 (21%) of 53 in the glasses group and 18 (34%) of 53 in the observation group (difference = -13%; 95% confidence interval [CI], -31 to 4; P = 0.14). Sixty-two percent (95% CI, 49-74) in the observation group and 34% (95% CI, 23-48) in the glasses group met deterioration criteria (requiring glasses if not wearing). CONCLUSIONS: For 1- and 2-year-olds with uncorrected moderate hyperopia (+3.00 D to +6.00 D SE), our estimates of failure, after 3 years of 6-month follow-ups, are inconclusive and consistent with a small to moderate benefit or no benefit of immediate prescription of glasses compared with careful observation (with glasses only if deteriorated).

Intraoperative Findings in Consecutive Exotropia with and without Adduction Deficit.

PURPOSE: Consecutive exotropia may be associated with limited adduction, which has been reported to be caused by 1 or more anatomic abnormalities of rectus muscles or their insertions. We studied the relative frequency of grades of adduction deficit and the relative frequency of abnormal anatomic findings. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients undergoing surgery for consecutive exotropia. METHODS: Preoperative duction deficits were graded on a -5 (severe limitation) to 0 (normal) scale. Operative reports were reviewed to classify intraoperative factors: (1) medial rectus muscle attachment type (normal, abnormal [slipped or stretched scar], attached to pulley, behind pulley, or mixed [a tenuous normal attachment, but with muscle fibers also attached to the pulley or behind the pulley]), (2) medial rectus muscle distal fiber location (millimeters from original insertion), and (3) lateral rectus muscle tightness (normal, mild restriction, moderate restriction). MAIN OUTCOME MEASURES: Relationship of grade of adduction deficit to each intraoperative factor. RESULTS: Of 143 eyes, 124 (87%) had an adduction deficit. Eyes with abnormal (n = 23), pulley (n = 9), behind pulley (n = 8), or mixed (n = 7) attachments had worse adduction deficits than normal attachments (n = 96; P < 0.02). There was a significant correlation between distal medial rectus muscle fiber location (0-19.5 mm recessed) and grade of adduction deficit (P < 0.0001). Eyes with mild or moderate lateral rectus muscle tightness on forced duction testing (n = 48/143 eyes) had worse adduction deficits than eyes without tightness (P < 0.001). Nevertheless, despite overall correlation, there was considerable individual variability. For example, for -1 and -2 adduction deficits, medial rectus muscle attachment could be at the pulley, behind the pulley, or include the pulley (19/87 eyes [22%]), and the lateral rectus muscle was tight in 36 of 87 eyes (41%). CONCLUSIONS: Adduction deficits are common in patients with consecutive exotropia. Overall, more severe preoperative adduction deficits are associated with medial rectus muscle insertion abnormalities and abnormal forced ductions, but frequently there are exceptions. Severe medial rectus muscle insertion abnormalities, including lost muscles, may be found despite mild preoperative adduction deficits.

Diplopia in Medically and Surgically Treated Patients with Glaucoma.

PURPOSE: To report the prevalence, type, and cause of diplopia in medically and surgically treated patients with glaucoma. DESIGN: Cohort study. PARTICIPANTS: A total of 195 adult patients with glaucoma treated in a glaucoma referral practice. METHODS: A total of 195 adult patients with glaucoma who had undergone surgical or medical management were prospectively enrolled. Forty-seven patients had undergone glaucoma drainage device (GDD) surgery (Baerveldt 350, Baerveldt 250 [Abbott Medical Optics, Abbott Park, IL], or Ahmed FP7 [New World Medical Inc, Rancho Cucamonga, CA]), 61 patients had undergone trabeculectomy, and 87 patients were medically treated. All patients completed the Diplopia Questionnaire to assess diplopia. We defined the presence of diplopia as "sometimes," "often," or "always" in distance straight ahead or reading positions on the Diplopia Questionnaire. A chart review was performed jointly by a strabismus specialist and a glaucoma subspecialist to characterize the type and cause of the diplopia. MAIN OUTCOME MEASURES: Frequency, type, and cause of diplopia. RESULTS: Diplopia was reported in 41 of 195 medically and surgically treated patients (21%) with glaucoma. Binocular diplopia due to the glaucoma procedure was present in 11 of 47 patients (23%) after GDD (95% confidence interval, 12-38), which was significantly greater than in patients after trabeculectomy (2/61 [3%]; 95% confidence interval, 0.4-11; P = 0.002). The most common type of strabismus associated with binocular diplopia due to glaucoma surgery was hypertropia (10/11 GDD cases, 2/2 trabeculectomy cases). Monocular diplopia was found in a similar proportion of medically treated, post-trabeculectomy, and post-GDD cases (4/87 [5%], 4/61 [7%], and 2/47 [4%], respectively). Binocular diplopia not due to surgery was found in similar proportions of GDD, trabeculectomy, and medically treated cases (3/47 [6%], 5/61 [8%], and 10/87 [11%], respectively). CONCLUSIONS: Diplopia may be under-recognized in medically and surgically treated patients with glaucoma, and standardization of ascertaining patient symptoms using the Diplopia Questionnaire may be useful in these patients. Diplopia was more commonly seen after GDD than trabeculectomy, typically a noncomitant restrictive hypertropia. The prevalence of monocular diplopia and binocular diplopia unrelated to glaucoma surgery was similar among medical and surgical groups. It is important to counsel patients on the higher occurrence of diplopia associated with GDD surgery.

Associations between health-related quality of life and the decision to perform surgery for childhood intermittent exotropia.

OBJECTIVE: To assess associations between health-related quality of life (HRQOL) and the decision to perform strabismus surgery for children with intermittent exotropia. DESIGN: Retrospective chart review. PARTICIPANTS: Children with intermittent exotropia. METHODS: Included subjects, identified in a clinical practice, had assessment of HRQOL using the intermittent exotropia questionnaire (IXTQ), comprising child, proxy, and parent components (parent domains: function, psychosocial, and surgery). The IXTQ scores were evaluated for association with surgery, along with standard clinical measures: prism and alternate cover test (PACT), stereoacuity, and control score (mean of the 3 most recent scores). Included data were from preoperative examination (surgical cohort) or from most recent follow-up examination (nonsurgical cohort). Univariate and multivariate logistic regression analyses were performed, and relative risk (RR) ratios were calculated. Spearman rank correlations were calculated to identify highly correlated items. MAIN OUTCOME MEASURES: Association of individual factors with the decision to perform surgery, calculated using RR ratios. RESULTS: One hundred six children with intermittent exotropia (median age, 6 years; range, 2-16 years) were eligible for inclusion. Nineteen (18%) of 106 underwent surgery. Using all available data, the IXTQ proxy score, IXTQ parent function score, IXTQ parent psychosocial score, distance control score, near control score, near PACT, and Randot Preschool stereoacuity (Stereoptical Co, Inc, Chicago, IL) were associated with undergoing surgery (P<0.1). Sixty-nine of 106 patients had complete data on all factors identified in univariate analysis and were included in multivariate analyses. Fourteen (20%) of these 69 patients underwent surgery. In multivariate analyses, poor distance control score (RR, 1.83; 95% confidence interval [CI], 1.25-2.68) and reduced IXTQ parent function score (RR, 0.96; 95% CI, 0.92-0.99) were associated with surgical intervention. Repeat multivariate analyses retaining only 1 of the highly correlated items showed IXTQ proxy, IXTQ parent psychosocial, larger near PACT, and worse near control were also associated with surgery. CONCLUSIONS: After accounting for poorer exodeviation control at distance, reduced parent and proxy HRQOL were associated with undergoing strabismus surgery for childhood intermittent exotropia. Recognizing reduced parental HRQOL may be important, with a possible role for educational or counselling interventions.

Quantifying diplopia with a questionnaire.

PURPOSE: To report a diplopia questionnaire (DQ) with a data-driven scoring algorithm. DESIGN: Cross-sectional study. PARTICIPANTS: To optimize questionnaire scoring, 147 adults with diplopic strabismus completed both the DQ and the Adult Strabismus-20 (AS-20) health-related quality-of-life (HRQOL) questionnaire. To assess test-retest reliability, 117 adults with diplopic strabismus. To assess responsiveness to surgery, 42 adults (46 surgeries). METHODS: The 10-item AS-20 function subscale score (scored 0-100) was defined as the gold standard for severity. A range of weights was assigned to the responses and the gaze positions (from equal weighting to greater weighting of primary and reading). Combining all response option weights with all gaze position weights yielded 382848 scoring algorithms. We then calculated 382848 Spearman rank correlation coefficients comparing each algorithm with the AS-20 function subscale score. MAIN OUTCOME MEASURES: To optimize scoring, Spearman rank correlation coefficients (measuring agreement) between DQ scores and AS-20 function subscale scores. For test-retest reliability, 95% limits of agreement and intraclass correlation coefficient (ICC). For responsiveness, change in DQ score. RESULTS: For the 382 848 possible scoring algorithms, correlations with AS-20 function subscale score ranged from -0.64 (best correlated) to -0.55. The best-correlated algorithm had response option weights of 5 for rarely, 50 for sometimes, and 75 for often, and gaze position weights of 40 for straight ahead in the distance, 40 for reading, 1 for up, 8 for down, 4 for right, 4 for left, and 3 for other, totaling 100. There was excellent test-retest reliability with an ICC of 0.89 (95% confidence interval, 0.84-0.92), and 95% limits of agreement were 30.9 points. The DQ score was responsive to surgery with a mean change of 51 ± 34 (P<0.001). CONCLUSIONS: We have developed a data-driven scoring algorithm for the DQ, rating diplopia symptoms from 0 to 100. On the basis of correlations with HRQOL, straight-ahead and reading positions should be highly weighted. The DQ has excellent test-retest reliability and responsiveness, and may be useful in both clinical and research settings.

Association of preoperative sensory monofixation with surgical failure in adult-onset divergence insufficiency-type esotropia.

We investigated the frequency of sensory monofixation in patients with adult-onset divergence insufficiency esotropia and whether preoperative sensory monofixation was associated with surgical failure. Twenty-five patients with esotropia greater at distance than near who underwent bilateral medial rectus recessions were included. Near stereoacuity was measured preoperatively and 8 weeks postoperatively using the Randot Preschool test. Patients with best-corrected visual acuity worse than 0.3 logMAR in either eye or preoperative diplopia "rarely" or "never" in straight-ahead gaze at distance were excluded to minimize the inclusion of decompensated childhood strabismus. Sensory monofixation was defined as stereoacuity of 200 arcsec or worse and bifixation as 40 or 60 arcsec. Surgical failure was defined as esodeviation of >4Δ or exodeviation of >10Δ at distance or near, assessed 8 weeks (range, 6-17 weeks) postoperatively. We calculated the frequency of monofixation and surgical failure rates among patients with preoperative monofixation and those with preoperative bifixation. Preoperatively, sensory monofixation was common in divergence insufficiency-type esotropia (16 of 25 [64%]; 95% CI, 45%-83%). None of those with preoperative sensory monofixation had surgical failure, which does not support an association of surgical failure with preoperative monofixation.

Incidence of Glaucoma-Related Adverse Events in the First 5 Years After Pediatric Lensectomy.

Importance: Glaucoma can develop following cataract removal in children. Objective: To assess the cumulative incidence of glaucoma-related adverse events (defined as glaucoma or glaucoma suspect) and factors associated with risk of these adverse events in the first 5 years after lensectomy prior to 13 years of age. Design, Setting, and Participants: This cohort study used longitudinal registry data collected at enrollment and annually for 5 years from 45 institutional and 16 community sites. Participants were children aged 12 years or younger with at least 1 office visit after lensectomy from June 2012 to July 2015. Data were analyzed from February through December 2022. Exposures: Usual clinical care after lensectomy. Main Outcomes and Measures: The main outcomes were cumulative incidence of glaucoma-related adverse events and baseline factors associated with risk of these adverse events. Results: The study included 810 children (1049 eyes); 443 eyes of 321 children (55% female; mean [SD] age, 0.89 [1.97] years) were aphakic after lensectomy, and 606 eyes of 489 children (53% male; mean [SD] age, 5.65 [3.32] years) were pseudophakic. The 5-year cumulative incidence of glaucoma-related adverse events was 29% (95% CI, 25%-34%) in 443 eyes with aphakia and 7% (95% CI, 5%-9%) in 606 eyes with pseudophakia; 7% (95% CI, 5%-10%) of aphakic eyes and 3% (95% CI, 2%-5%) of pseudophakic eyes were diagnosed as glaucoma suspect. Among aphakic eyes, a higher risk for glaucoma-related adverse events was associated with 4 of 8 factors, including age less than 3 months (vs ≥3 months: adjusted hazard ratio [aHR], 2.88; 99% CI, 1.57-5.23), abnormal anterior segment (vs normal: aHR, 2.88; 99% CI, 1.56-5.30), intraoperative complications at time of lensectomy (vs none; aHR, 2.25; 99% CI, 1.04-4.87), and bilaterality (vs unilaterality: aHR, 1.88; 99% CI, 1.02-3.48). Neither of the 2 factors evaluated for pseudophakic eyes, laterality and anterior vitrectomy, were associated with risk of glaucoma-related adverse events. Conclusions and Relevance: In this cohort study, glaucoma-related adverse events were common after cataract surgery in children; age less than 3 months at surgery was associated with elevated risk of the adverse events in aphakic eyes. Children with pseudophakia, who were older at surgery, less frequently developed a glaucoma-related adverse event within 5 years of lensectomy. The findings suggest that ongoing monitoring for the development of glaucoma is needed after lensectomy at any age.

Improved control of intermittent exotropia with part-time patching.

We evaluated the effect of part-time patching versus observation on distance exodeviation control in post hoc analyses of 3- to <11-year-olds with intermittent exotropia who were assigned to either patching 3 hours/day or observation in a previously reported randomized clinical trial. The present analysis was limited to a subgroup of 306 participants who at distance fixation spontaneously manifested either a constant or intermittent exotropia or had prolonged recovery after monocular occlusion (a distance control score of 2 or worse using the 0-5 Office Control Score scale) at baseline. We assessed change in control at distance and near fixation, from baseline to 3 months and baseline to 6 months (1 month after discontinuing patching). We found greater improvement in the distance control score with patching than with observation at 3 months (mean difference, 0.4 points; 95% CI, 0.1-0.7) and 6 months (mean difference, 0.3 points; 95% CI, 0.02-0.6). These analyses suggest that part-time patching may improve distance control in children with intermittent exotropia and a control score ≥ 2; however, because this conclusion is based on post hoc subgroup analyses, further studies are needed.

Comparing outcome criteria performance in adult strabismus surgery.

PURPOSE: To evaluate the performance of motor, diplopia, and health-related quality of life (HRQOL) criteria when analyzing outcomes of adult strabismus surgery. DESIGN: Cohort study. PARTICIPANTS: We studied 159 adults undergoing 171 strabismus surgeries. METHODS: All patients underwent clinical assessment preoperatively and 6 weeks postoperatively, including completion of Adult Strabismus-20 HRQOL questionnaires. Preoperatively, strabismus was classified as either diplopic (n = 117), nondiplopic (n = 38), or atypical diplopic (n = 16). To assess performance of motor, diplopia, and HRQOL criteria, success was defined a priori and applied separately and in combinations. For success: (1) motor criteria, <10 prism diopters by simultaneous prism cover test; (2) diplopia criteria, none or only rare in primary distance and for reading; (3) HRQOL criteria, exceeding previously reported 95% limits of agreement (LOA). MAIN OUTCOME MEASURES: Surgical success rate when applying motor, diplopia, and HRQOL criteria alone and in combinations. RESULTS: Overall, success rates were 90% for motor criteria, 74% for diplopia criteria, and 60% for HRQOL criteria. Combining criteria, the highest success rate was for motor plus diplopia criteria (67%) and the lowest success rate was when combining motor, diplopia, and HRQOL criteria (50%). CONCLUSIONS: Applying motor criteria alone yields the highest success rates when evaluating outcomes in adult strabismus surgery, but motor criteria do not fully represent the patient's postoperative status. Combining diplopia criteria with motor criteria provides a more clinically relevant standard for judging the success of adult strabismus surgery. For HRQOL criteria, exceeding 95% LOA at 6 weeks postoperatively seems to be a difficult hurdle to clear for some individual patients, and evaluating change in HRQOL score may be more useful in cohort studies.

Stereoacuity thresholds before and after visual acuity testing.

PURPOSE: To compare stereoacuity thresholds before and after visual acuity testing in patients with intermittent strabismus and in controls. DESIGN: Prospective cohort study. PARTICIPANTS AND CONTROLS: Eighty-eight patients (41 with intermittent strabismus and 47 controls) with measurable stereoacuity on their initial stereoacuity test were enrolled prospectively. METHODS: Stereoacuity was measured before and immediately after visual acuity testing using the near Preschool Randot and Distance Randot stereotests. Stereoacuity was transformed to log units for analysis. MAIN OUTCOME MEASURES: Change in stereoacuity thresholds (log seconds of arc [arcsec]). RESULTS: There was no overall deterioration in distance stereoacuity or near stereoacuity thresholds in either the intermittent strabismus or control groups. The mean change for patients with intermittent strabismus was 0.02 log arcsec (95% confidence interval [CI], -0.02 to 0.06) for near stereoacuity and 0.04 log arcsec (95% CI, -0.01 to 0.09) for distance stereoacuity. Control patients demonstrated a mean change of 0.03 log arcsec (95% CI, -0.01 to 0.06) for near stereoacuity and 0.01 log arcsec (95% CI, -0.06 to 0.08) for distance stereoacuity. These mean changes correspond to less than approximately one eighth of an octave. For individual patients, deterioration in stereoacuity beyond previously reported test-retest variability (0.6 log arcsec or more) was not observed in patients with intermittent strabismus or controls using either test. CONCLUSIONS: Stereoacuity thresholds do not deteriorate after visual acuity testing, and therefore measurements of stereoacuity do not need to precede visual acuity measurement or other tests that involve short periods of dissociation. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Applying Normal PedEyeQ Thresholds to Assess Eye-related Quality of Life among Children with Strabismus.

PURPOSE: To determine proportions of children with strabismus with below-normal Pediatric Eye Questionnaire (PedEyeQ) scores. METHODS: Ninety-eight children with strabismus (70 aged 5-11 years; 28 aged 12-17 years) were evaluated. Children completed the Child 5-11 or 12-17 PedEyeQ (Functional Vision, Bothered by Eyes/vision, Social, and Frustration/worry domains). Parents completed the Proxy (same domains plus Eye Care) and Parent PedEyeQ (Impact on Parent and Family, Worry about Child's Eye Condition, Worry about Child's Self-perception and Interactions, and Worry about Functional Vision domains). Previously published normal (5th percentile) thresholds were applied to calculate proportions with below-normal scores for each domain. RESULTS: For the Child PedEyeQ more than 20% of 5- to 11-year-olds scored below normal, on all but the Social domain, whereas more than 50% of 12- to 17-year-olds scored below normal on all domains. On the Proxy PedEyeQ, more than 50% scored below normal on all domains when parents reported on 5- to 11-year-olds and 12- to 17-year-olds. For the Parent PedEyeQ, more than 50% of the parents of both 5- to 11-year-olds and 12- to 17-year-olds scored below normal on all domains. CONCLUSIONS: The majority of children with strabismus have below-normal PedEyeQ scores, particularly children aged 12-17 years.

Testing depth of suppression in childhood intermittent exotropia.

A test of suppression was developed to provide a standardized approach to detecting and grading density of suppression in children with intermittent exotropia when manifestly exotropic. This new Office Suppression Test is a three-step procedure to grade suppression on a 4-point scale (from 0 for "negligible suppression" to 3 for "dense suppression"). The test was performed in 57 children 3-13 years of age with intermittent exotropia (distance angle of 16Δ-35Δ, with spontaneous tropia) during enrollment in a randomized trial. Of the 57 children, 51 could complete testing: 28 (55%) had dense suppression, 12 (24%) had moderate suppression, 5 (10%) had mild suppression, and 6 (12%) had negligible suppression. In a subgroup of 20 untreated children, suppression was evaluated again at 8 weeks. There was moderate agreement between suppression scores at baseline and at 8 weeks (weighted κ = 0.65 [95% CI, 0.45-0.84]).

Diplopic versus nondiplopic strabismus: effects on functional vision and eye-related quality of life in adolescents.

Twenty adolescents (12-17 years old) with diplopic strabismus and 20 with nondiplopic strabismus (matched to diplopic subjects for direction and magnitude of ocular deviation) completed the Pediatric Eye Questionnaire (PedEyeQ). Children completed the Child PedEyeQ, and one parent for each child completed the Proxy PedEyeQ and Parent PedEyeQ. PedEyeQ Rasch domain scores were calculated and converted to a scale of 0 (worst) to 100 (best). Distributions of domain scores were compared between diplopic and nondiplopic cohorts using Wilcoxon tests. Diplopic adolescents had significantly lower Child PedEyeQ scores on Functional Vision (72 vs 90; P = 0.008), Bothered by Eyes/Vision (65 vs 90; P = 0.009), and Frustration/Worry (53 vs 75; P < 0.001) domains. There was no difference on the Child Social domain (85 vs 90; P = 0.22). Proxy and Parent PedEyeQ scores were similar between diplopic and nondiplopic cohorts (P > 0.06 for each comparison). These findings highlight the importance of addressing diplopia when managing childhood strabismus.

Normative pediatric visual acuity using electronic early treatment for diabetic retinopathy protocol.

There is a lack of normative data for children tested with the electronic Early Treatment for Diabetic Retinopathy Study (E-ETDRS) protocol. In the current cross-sectional study, the mean best-corrected normal and 95% lower tolerance limit for E-ETDRS visual acuity by year in children 7-12 years of age was measured. Our objective was to provide a large normative data set for E-ETDRS visual acuity in children for use in clinical management and clinical trials.

Comparison of Methods for Measuring Cyclodeviation.

PURPOSE: To compare the double-Maddox rod test with other methods of measuring cyclodeviation DESIGN: Retrospective cohort study. METHODS: We retrospectively identified 153 adults in a clinical practice with cyclodeviation assessed using double-Maddox rods, of whom 105 were also assessed using fusible synoptophore targets, 73 using nonfusible synoptophore targets, 118 using single-Maddox rod, and 43 using fundus photography. Relationships between double-Maddox rod and other tests were evaluated by calculating mean differences with 95% confidence intervals (CI), intraclass correlation coefficients (ICC), and Bland-Altman plots with linear regression. RESULTS: Synoptophore cross-in-circle targets and the largest (of right or left) single-Maddox rod values were similar to double-Maddox values (mean differences: -1.2° and 0.1°, respectively; ICC: 0.79 and 0.82, respectively). Synoptophore house targets measured less excyclodeviation (mean difference: -2.7°; ICC: 0.71). Mean summed single-Maddox rod values were somewhat similar to double-Maddox values (mean difference: 1.5°; ICC: 0.85), but differences increased with greater cyclodeviation (r2 = 0.2678; P < .001). Fundus photographs showed large, uncorrelated differences compared with double-Maddox rod test, when summing right and left eyes and when using the largest of right or left (mean differences: 12.2° and 6.2°; ICC: -0.02 and 0.21, respectively), and differences increased with greater cyclodeviation (r2 = 0.4094; P < .001 and r2 = .1143; P= .03, respectively). CONCLUSIONS: There was good agreement between double-Maddox and the largest single- Maddox test values and synoptophore cross-in-circle targets but poorer agreement with other tests. Further study is needed to understand which measurements best reflect true cyclodeviation and relationships with symptoms.

Applying normal PedEyeQ thresholds to define reduced quality of life.

Patient-reported outcome measures such as the Pediatric Eye Questionnaire (PedEyeQ) are increasingly recognized as important in healthcare assessment. Defining normal PedEyeQ thresholds would allow classification of individual children as having reduced versus normal domain scores. We prospectively enrolled visually normal children (aged 0-17 years; n = 310) to calculate normal PedEyeQ domain thresholds. In addition, 48 children with bilateral visual impairment (VI; best-eye acuity worse than 20/70 or 20/70 or better with limited visual fields) were enrolled for validation. The Child PedEyeQ (four domains) was completed by 5- to 17-year-olds. Parents completed Proxy (five domains) and Parent PedEyeQ (four domains). Each domain was Rasch scored (converted to 0-100); normal thresholds were defined as the 5th percentile of scores in visually normal controls. For Child 5-11 PedEyeQ, 39%-78% of VI children had reduced domain scores, and 88%-100% for 12- to 17-year-olds. For Proxy PedEyeQ, proportions ranged from 55% to 100% and for Parent PedEyeQ ≥83% had reduced scores. High prevalence of reduced PedEyeQ domain scores in the VI cohort, validates the use of normal thresholds. Nevertheless, variability in child self-reporting creates challenges for identifying individual 5- to 11-year-olds with reduced scores.