Objective assessment of control compared with clinical triple office control score in children with intermittent exotropia.

Poor control of intermittent exotropia may be used as an indication for surgery. However, control fluctuates during the day and from day to day. The standardized triple office control score (mean of three scores on a 6-point ordinal scale) is representative of repeated assessments throughout the day, but lacks validation against an objective measure of eye movements. We report the agreement between the triple office control score measured by the referring eyecare professional and lab-measured vergence instability using an EyeLink video eye tracker. Near and distance triple office control scores were moderately correlated with vergence instability. Near, but not distance, triple office control score was moderately correlated with the percentage of time intermittent exotropia was manifest during EyeLink recording. Larger triple office control scores for intermittent exotropia provide a meaningful description of larger vergence instability, supporting its use in clinical decisions and as a measure in clinical trials.

Binocular amblyopia treatment improves manual dexterity.

PURPOSE: To determine whether deficits in manual dexterity in children with amblyopia improve after binocular amblyopia treatment and whether improvements are related to age at treatment, baseline sensory status, or amount of improvement in sensory status with treatment. METHODS: Manual dexterity (Movement Assessment Battery for Children-2), visual acuity, fusion, suppression, and stereoacuity were measured at baseline and after 4-8 weeks of binocular amblyopia in 134 children with amblyopia, including 75 children in the "younger group" (aged 3 to <7 years) and 59 in the "older group" (aged 7-10 years), and in 40 age-similar control children. RESULTS: Baseline manual dexterity standard scores of amblyopic children were significantly below those of controls in both the younger (8.81 ± 0.33 vs 11.80 ± 0.60 [P < 0.0001]) and older groups (7.19 ± 0.34 vs 9.75 ± 0.57 [P = 0.00013]). After 4-8 weeks of binocular amblyopia treatment, the younger group standard score improved to 9.85 ± 0.35 and the older group improved to 8.08 ± 0.39, but both groups remained significantly lower than controls (P = 0.03 and P = 0.01, resp.). Improvement in manual dexterity standard score was not associated with any baseline factors but was weakly correlated with the amount of visual acuity improvement (rs = 0.26; 95% CI, 0.09-0.41) CONCLUSIONS: Manual dexterity impairments are common among children with amblyopia. In our study cohort, binocular amblyopia treatment improved visual acuity and manual dexterity.

Temporal Eye-Hand Coordination During Visually Guided Reaching in 7- to 12-Year-Old Children With Strabismus.

Purpose: We recently found slow visually guided reaching in strabismic children, especially in the final approach. Here, we expand on those data by reporting saccade kinematics and temporal eye-hand coordination during visually guided reaching in children treated for strabismus compared with controls. Methods: Thirty children diagnosed with esotropia, a form of strabismus, 7 to 12 years of age and 32 age-similar control children were enrolled. Eye movements and index finger movements were recorded. While viewing binocularly, children reached out and touched a small dot that appeared randomly in one of four locations along the horizontal meridian (±5° or ±10°). Saccade kinematic measures (latency, accuracy and precision, peak velocity, and frequency of corrective and reach-related saccades) and temporal eye-hand coordination measures (saccade-to-reach planning interval, saccade-to-reach peak velocity interval) were compared. Factors associated with impaired performance were also evaluated. Results: During visually guided reaching, strabismic children had longer primary saccade latency (strabismic, 195 ± 29 ms vs. control; 175 ± 23 ms; P = 0.004), a 25% decrease in primary saccade precision (0.15 ± 0.06 vs. 0.12 ± 0.03; P = 0.007), a 45% decrease in the final saccade precision (0.16 ± 0.06 vs. 0.11 ± 0.03; P < 0.001), and more reach-related saccades (16 ± 13% of trials vs. 8 ± 6% of trials; P = 0.001) compared with a control group. No measurable stereoacuity was related to poor saccade kinematics. Conclusions: Strabismus impacts saccade kinematics during visually guided reaching in children, with poor binocularity playing a role in performance. Coupled with previous data showing slow reaching in the final approach, the current saccade data suggest that children treated for strabismus have not yet adapted or formed an efficient compensatory strategy during visually guided reaching.

Web-based visual acuity testing for children.

PURPOSE: To evaluate a newly developed, web-based system for at-home pediatric visual acuity testing and to compare results with standard in-office visual acuity test results. METHODS: Children aged 3-12 years with and without visual deficits were enrolled (N = 65; 130 eyes). Monocular visual acuity was tested in-office using the ATS-HOTV (ages 3-6) or E-ETDRS (ages 7-12) protocol. Each child's family was emailed a link to a web-based version of the same visual acuity test for at-home testing. Equivalence was evaluated by using a linear mixed model to estimate the mean difference between in-office and at-home visual acuity test results and the corresponding two-sided 95% confidence interval. RESULTS: For children tested with the ATS-HOTV protocol, the mean difference between in-office and at-home visual acuity test results was 0.01 log MAR (95% CI, -0.06 to 0.09). For children tested with the E-ETDRS protocol, the mean difference was 0.04 log MAR (95% CI, -0.06 to 0.14). CONCLUSIONS: At-home, web-based ATS-HOTV and E-ETDRS visual acuity test results had excellent concordance with in-office visual acuity testing. If the burden of travel is significant, at-home testing of children's visual acuity may provide the information needed to continue care when it might otherwise be discontinued or delayed.

Reach Kinematics During Binocular Viewing in 7- to 12-Year-Old Children With Strabismus.

Purpose: Eye-hand coordination is essential for normal development and learning. Discordant binocular experience from childhood strabismus results in sensory and ocular motor impairments that can affect eye-hand coordination. We assessed reach kinematics during visually guided reaching in children treated for strabismus compared with controls. Methods: Thirty-six children aged 7 to 12 years diagnosed with esotropia, a form of strabismus, and a group of 35 age-similar control children were enrolled. Reach movements during visually guided reaching were recorded using the LEAP Motion Controller. While viewing binocularly, children reached out and touched a small dot that appeared randomly in one of four locations (±5° or ±10°). Kinematic measures were reach reaction time, total reach duration, peak velocity, acceleration duration, and deceleration duration. Touch accuracy and factors associated with impaired reach kinematics were evaluated. Results: Strabismic children had longer total reach duration (545 ± 60 ms vs. 504 ± 43 ms; P = 0.002), had longer deceleration duration (343 ± 54 ms vs. 312 ± 45 ms; P = 0.010), and were less accurate (93% ± 6% vs. 96% ± 5%, P = 0.007) than controls. No differences were found for reach reaction time, peak velocity, or acceleration duration (all Ps ≥ 0.197). Binocular dysfunction was more related to slow reaching than amblyopic eye visual acuity. Conclusions: Strabismus affects visually guided reaching in children, with slower reaching in the final approach and reduced endpoint accuracy. Binocular dysfunction was predictive of slow reaching. Unlike strabismic adults who show longer acceleration duration, longer deceleration in the final approach in strabismic children indicates a difference in control that could be due to reduced ability to use visual feedback.

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.

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.

Quality of life and functional vision across pediatric eye conditions assessed using the PedEyeQ.

PURPOSE: To evaluate eye-related quality of life (ER-QOL) and functional vision across a wide range of pediatric eye conditions, using the Pediatric Eye Questionnaires (PedEyeQ). METHODS: A total of 1,037 children with an eye condition and 254 visually normal controls, across 0-4, 5-11, and 12-17 years age groups, completed the following questionnaires: Child PedEyeQ (Functional Vision, Bothered by Eyes/Vision, Social, Frustration/Worry domains), Proxy PedEyeQ (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). The primary eye condition was classified as amblyopia (n = 171), cataract (n = 99), cerebral visual impairment (CVI; n = 50), cornea (n = 20), eyelid (n = 35), glaucoma (n = 24), nystagmus (n = 57), orbital (n = 19), pupil/iris (n = 7), refractive error (n = 119), retina (n = 82), strabismus (n = 332), and uveitis (n = 22). RESULTS: PedEyeQ domain scores (scaled 0-100) were significantly worse across eye conditions, compared with controls. Child PedEyeQ greatest differences were on the Bothered by Eyes/Vision domain (nystagmus 5-11 years, -26 points [95% CI, -39 to -12]; nystagmus 12-17 years, -45 [95% CI, -61 to -28]). Proxy PedEyeQ differences were greatest on Functional Vision (CVI 0-4 years, -45 [95% CI, -56 to -34]; CVI 5-11 years, -58 [95% CI, -72 to -43]; nystagmus 12-17 years, -50 [95% CI, -69 to -31]). Parent PedEyeQ differences were greatest on Worry about Child's Functional Vision (CVI 0-4 years, -64; 95% CI -77 to -50). CONCLUSIONS: The PedEyeQ detects reduced ER-QOL and functional vision across pediatric eye conditions, and across age groups, indicating its utility for clinical practice and clinical trials.

Association of Visual Acuity with Eye-Related Quality of Life and Functional Vision Across Childhood Eye Conditions.

PURPOSE: We evaluated relationships between visual acuity (VA) and eye-related quality of life and functional vision in children, across a spectrum of pediatric eye conditions, using the Pediatric Eye Questionnaire (PedEyeQ). DESIGN: Cross-sectional study. METHODS: Three hundred ninety-seven children (5-11 years of age) with an eye condition and 104 visually normal control subjects completed the Child PedEyeQ (functional vision, bothered by eyes/vision, social, and frustration/worry domains). One parent for each child completed the Proxy PedEyeQ (same domains as child 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). Each domain was Rasch-scored and Spearman rank correlations were calculated to evaluate relationships between better-seeing-eye and worse-seeing-eye VA and PedEyeQ domain score. RESULTS: There was a significant relationship between poorer better-seeing-eye VA and lower (worse) PedEyeQ score on 2 of 4 child domains (e.g., functional vision, r = -0.1474; P = .005), on 2 of 5 proxy PedEyeQ domains (e.g., functional vision, r = -0.2183; P < .001), and on 2 of 4 parent PedEyeQ domains (e.g., impact on parent and family, r = -0.1607; P = .001). Worse-seeing-eye VA was associated with lower PedEyeQ scores across all child, proxy and parent domains (P < .01 for each) with the exception of the child social domain (P = .15). CONCLUSIONS: Both better-seeing-eye and worse-seeing-eye VA were associated with functional vision and eye-related quality of life in children, assessed using the PedEyeQ, although other factors may also influence relationships. These data further validate using the PedEyeQ across pediatric eye conditions.

Self-perception in Preschool Children With Deprivation Amblyopia and Its Association With Deficits in Vision and Fine Motor Skills.

Importance: Although the development of self-perception and self-esteem has been investigated in children with strabismic and anisometropic amblyopia, we know little about how self-perception is affected in deprivation amblyopia. Deprivation amblyopia from a dense, unilateral cataract is the least common and typically most severe form of amblyopia. After cataract extraction, optical correction, and patching treatment for amblyopia, visual acuity almost always remains abnormal, and except in rare cases, stereoacuity is nearly always nil. Objective: To determine whether deprivation amblyopia is associated with altered self-perception in preschool children and to determine whether any differences in self-perception are associated with vision or motor skill deficits. Design, Setting, and Participants: Cross-sectional study conducted from 2016 to 2019 at a pediatric vision research laboratory. Children aged 3 to 6 years were enrolled, including 15 children with deprivation amblyopia and 20 control children. Main Outcomes and Measures: Self-perception was assessed using the Pictorial Scale of Competence and Acceptance for Young Children, which includes 4 specific domains: cognitive competence, peer acceptance, physical competence, and maternal acceptance. Fine motor skills were evaluated with the Manual Dexterity and Aiming & Catching Scales of the Movement ABC-2 test. Visual acuity and stereoacuity also were assessed. Results: Of the 35 children included, 13 of 35 were girls (37%) and 28 of 35 were non-Hispanic White (80%). Children with deprivation amblyopia had significantly lower peer acceptance and physical competence scores compared with control children (mean [SD], 2.80 [0.44] vs 3.25 [0.33]; mean difference, 0.45; 95% CI for difference, 0.19-0.71; P = .002 and 2.94 [0.45] vs 3.41 [0.37]; mean difference, 0.47; 95% CI for difference, 0.19-0.75; P = .002, respectively). Among children with amblyopia, moderate associations were found between self-perception domain scores and motor skills, including peer acceptance and manual dexterity (r = 0.68; 95% CI, 0.26-0.89; P = .005), peer acceptance and aiming (r = 0.54; 95% CI, 0.03-0.82; P = .03), and physical competence and aiming (r = 0.55; 95% CI, 0.06-0.83; P = .03). Conclusions and Relevance: Lower self-perception of peer acceptance and physical competence were associated with early visual deprivation in children in their everyday life.

Associations of Eye-Related Quality of Life With Vision, Visuomotor Function, and Self-Perception in Children With Strabismus and Anisometropia.

Purpose: To evaluate associations between eye-related quality of life (ER-QOL) assessed by the Child Pediatric Eye Questionnaire (Child PedEyeQ) and functional measures (vision, visuomotor function, self-perception) in children with strabismus, anisometropia, or both. Our hypothesis was that children with functional deficits would have lower ER-QOL, and if so, these associations would support the convergent construct validity of the Child PedEyeQ. Methods: We evaluated 114 children (ages 5-11 years) with strabismus, anisometropia, or both. Each child completed the Child PedEyeQ to assess four Rasch-scored domains of ER-QOL: Functional Vision, Bothered by Eyes/Vision, Social, and Frustration/Worry. In addition, children completed one or more functional tests: visual acuity (n = 114), Randot Preschool Stereoacuity (n = 92), contrast balance index (suppression; n = 91), Readalyzer reading (n = 44), vergence instability (n = 50), Movement Assessment Battery for Children-2 manual dexterity (n = 57), and Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (n = 44). Results: Child PedEyeQ Functional Vision domain scores were correlated with self-perception of physical competence (rs = 0.65; 95% confidence interval [CI], 0.35-0.96) and reading speed (rs = 0.47; 95% CI, 0.16-0.77). Bothered by Eyes/Vision domain scores were correlated with self-perception of physical competence (rs = 0.52; 95% CI, 0.21-0.83). Moderate correlations were observed between Social domain scores and vergence instability (rs = -0.46; 95% CI, -0.76 to -0.15) and self-perception of physical competence (rs = 0.43; 95% CI, 0.12-0.73) and peer acceptance (rs = 0.49; 95% CI, 0.18-0.80). Frustration/Worry domain scores were moderately correlated with self-perception of physical competence (rs = 0.41; 95% CI, 0.10-0.71) and peer acceptance (rs = 0.47; 95% CI, 0.16-0.77). Conclusions: Strong and moderate correlations were observed between functional measures and Child PedEyeQ domain scores. These associations provide supporting evidence that the Child PedEyeQ has convergent construct validity.

Understanding the Impact of Residual Amblyopia on Functional Vision and Eye-related Quality of Life Using the PedEyeQ.

PURPOSE: To evaluate the effect of residual amblyopia on functional vision and eye-related quality of life (ER-QOL) in children and their families using the Pediatric Eye Questionnaire (PedEyeQ). DESIGN: Prospective cross-sectional study. METHODS: Seventeen children with residual amblyopia (no current treatment except glasses), 48 visually normal controls without glasses, and 19 controls wearing glasses (aged 8-11 years) completed the Child 5-11 year PedEyeQ. One parent for each child completed the Proxy 5-11 PedEyeQ, Parent PedEyeQ. Rasch-calibrated domain scores were calculated for each questionnaire domain and compared between amblyopic children and controls. RESULTS: PedEyeQ scores were significantly lower (worse) for children with residual amblyopia than for controls without glasses across all domains: Child PedEyeQ greatest mean difference 18 points worse on Functional vision domain (95% confidence interval [CI] -29 to -7; P < .001); Proxy PedEyeQ greatest mean difference 31 points worse on Functional vision domain (95% CI -39 to -24; P < .001); Parent PedEyeQ greatest mean difference 34 points worse on the Worry about child's eye condition domain (95% CI -46 to -22; P < .001). Compared with controls wearing glasses, PedEyeQ scores were lower for residual amblyopia on the Child Frustration/worry domain (P = .03), on 4 of 5 Proxy domains (P ≤ .05), and on 3 of 4 Parent domains (P ≤ .05). CONCLUSIONS: Residual amblyopia affects functional vision and ER-QOL in children. Parents of amblyopic children also experience lower quality of life. These data help broaden our understanding of the everyday-life impact of childhood residual amblyopia.

Eye-related quality of life and functional vision in children wearing glasses.

PURPOSE: To evaluate eye-related quality of life (ER-QOL) and functional vision in children wearing glasses using the Pediatric Eye Questionnaire (PedEyeQ). METHODS: Children 5-17 years of age with normal visual acuity who wore glasses for correction of refractive error and with no other eye condition or treatment and control subjects who did not wear glasses, along with 1 parent for each child, were prospectively enrolled. Children completed the Child 5-11 or 12-17 PedEyeQ (four domains); parents completed the Proxy 5-11 or 12-17 questionnaires (perceived effect on child; five domains) and also the Parent questionnaire (effect on parent themselves; four domains). Each domain was Rasch-scored (converted to 0-100), and scores between groups were compared. RESULTS: A total of 40 subjects and 99 non-glasses-wearing controls, along with 1 parent for each child, were included. Children 5-11 and 12-17 years of age who wore glasses had lower PedEyeQ scores across all domains compared with controls (mean differences, -6 to -15; P ≤ 0.04 for each domain). Proxy scores were also lower for glasses wearers across age groups and domains (mean differences, -4 to -18; P ≤ 0.02), and Parent scores were lower for parents of children wearing glasses (mean differences, -6 to -18; P < 0.001 for each domain). CONCLUSIONS: In this study, glasses wearers had reduced ER-QOL and functional vision compared with control subjects. Parents of children wearing glasses also experience reduced quality of life.

Association of Strabismus With Functional Vision and Eye-Related Quality of Life in Children.

Importance: Strabismus is common, affecting 2% to 4% of children, but how children and their families are affected in everyday life is poorly understood. Objective: To evaluate the association of strabismus with functional vision and eye-related quality of life in children and their families using the Pediatric Eye Questionnaire (PedEyeQ). Design, Setting, and Participants: This cross-sectional study was conducted between December 2017 and October 2019 and included 91 children with strabismus and 166 visually normal controls across 3 age groups (0-4, 5-11, and 12-17 years) who were enrolled at Mayo Clinic, Rochester, Minnesota, and Retina Foundation of the Southwest, Dallas, Texas. Exposures: Children completed the child PedEyeQ (5 to 11- and 12 to 17-year versions: functional vision, bothered by eyes/vision, social, and frustration/worry domains); parents completed the proxy (0 to 4-, 5 to 11-, and 12 to 17-year versions: functional vision, bothered by eyes/vision, social, frustration/worry, and eye care domains) and the parent PedEyeQ (impact on parent and family, worry about child's eye condition, worry about child's self-perception and interactions, and worry about child's functional vision domains). Rasch-calibrated PedEyeQ scores were calculated for each domain and converted to 0 (worst) to 100. Main Outcomes and Measures: PedEyeQ domain scores. Results: Of 91 participants with strabismus, 41 (45.1%) were girls, 74 (81.3%) were white, 4 (4.4%) were Asian, 5 (5.5%) were more than 1 race, 5 (5.5%) were African American, and 2 (2.2%) were American Indian/Alaska Native. Child PedEyeQ domain scores were lower with strabismus vs visually normal controls among children ages 5 to 11 years and the greatest mean (SD) difference was in functional vision (12 [14] points; 95% CI, 6-18; P = .001), and among children ages 12 to 17 years, the greatest mean (SD) difference was in frustration/worry (27 [13] points; 95% CI, 18-36; P < .001). Proxy PedEyeQ domain scores were also lower with strabismus. The greatest difference among children ages 0 to 4 years was in functional vision (13 [9] points; 95% CI, 9-16; P < .001), among children ages 5 to 11 years was in functional vision (26 [10] points; 95% CI, 22-30; P < .001); and among children ages 12 to 17 years was in functional vision (21 [12] points; 95% CI, 12-30; P < .001), social (21 [13] points; 95% CI, 12-30; P < .001), and frustration/worry (21 [13] points; 95% CI, 12-30; P < .001). Parent PedEyeQ domain scores were lower with strabismus; the greatest difference was in worry about child's eye condition (38 [14] points; 95% CI, 34-42; P < .001). Conclusions and Relevance: Strabismus is associated with reduced functional vision and eye-related quality of life in children. Parents of children with strabismus also experience a reduced quality of life. These findings advance our understanding of how strabismus affects children and their families and should be considered when defining patient management goals.

Validation of the Pediatric Eye Questionnaire in Children with Visual Impairment.

PURPOSE: To evaluate the recently developed Pediatric Eye Questionnaire (PedEyeQ) in visually impaired and visually normal children, as an initial validation of the PedEyeQ. DESIGN: Questionnaire validation study. METHODS: A total of 48 children with visual impairment (retinal, cortical, and corneal conditions) and 59 visually normal controls were enrolled at 2 centers. Five- to 17-year-old children completed the Child PedEyeQ (5-11- and 12-17-year-old versions), and parents completed the Proxy PedEyeQ (0-4-, 5-11-, and 12-17-year-old versions) and the Parent PedEyeQ. Rasch scores were calculated by age group for each distinct domain within each age-specific PedEyeQ (converted to 0-100 for interpretation). Domains for the Child PedEyeQ are functional vision, bothered by eyes/vision, social, and frustration/worry. Proxy PedEyeQ domains are functional vision, bothered by eyes/vision, social, frustration/worry, and eye care. Parent PedEyeQ domains are impact on parent and family, worry about child's eye condition, worry about child's self-perception/interactions, and worry about child's functional vision. For each domain, median PedEyeQ scores were compared between visually impaired and visually normal cohorts. RESULTS: Child 5-11 and 12-17 PedEyeQ scores were significantly lower (worse) for visually impaired children than for controls for each domain (P < .007), except for the social domain in 5-11-year-old children (P = .13). In addition, Proxy 0-4-, 5-11-, and 12-17-year-old PedEyeQ scores, and Parent PedEyeQ scores, were lower for visually impaired children across all domains (P < .001). CONCLUSIONS: Visually impaired children and their parents had significantly lower (worse) PedEyeQ scores than visually normal controls, across functional vision and eye-related quality of life domains, demonstrating known-group validity of the PedEyeQ in children with visual impairment.

Self-perception in Children Aged 3 to 7 Years With Amblyopia and Its Association With Deficits in Vision and Fine Motor Skills.

Importance: Deficits in fine motor skills and slow reading speed have been reported in school-aged children and adults with amblyopia. These deficits were correlated with lower self-perception of athletic and cognitive competence. Although perceived competence and social acceptance are key determinants of developing self-perception in young children, the association of amblyopia with self-perception and the association of altered self-perception with fine motor skills to date have not been reported for young children aged 3 to 7 years. Objectives: To investigate whether amblyopia is associated with altered self-perception in young children and to assess whether any differences in self-perception are associated with deficits in vision and fine motor skills. Design, Setting, and Participants: In this cross-sectional study, conducted at a pediatric vision laboratory from January 10, 2016, to May 4, 2018, healthy children aged 3 to 7 years (preschool to second grade) were enrolled, including 60 children with amblyopia; 30 children who never had amblyopia but had been treated for strabismus, anisometropia, or both; and 20 control children. Main Outcomes and Measures: Self-perception was assessed using the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children, which includes the following 4 specific domains: cognitive competence, peer acceptance, physical competence, and maternal acceptance (total score range, 1-4; higher scores indicate higher perceived competence or acceptance). Fine motor skills were evaluated with the Manual Dexterity and Aiming and Catching scales of the Movement Assessment Battery for Children, second edition (score range, 1-19; higher scores indicate better skill performance). Visual acuity and stereoacuity also were assessed. Results: Children with amblyopia (28 girls and 32 boys; mean [SD] age, 6.3 [1.3] years) had significantly lower mean (SD) peer acceptance and physical competence scores compared with the control children (peer acceptance, 2.74 [0.66] vs 3.11 [0.36]; mean difference, 0.37; 95% CI for difference, 0.06-0.68; P = .04; and physical competence, 2.86 [0.60] vs 3.43 [0.52]; mean difference, 0.57; 95% CI for difference, 0.27-0.87; P = .009). Among the children with amblyopia, self-perception of physical competence was significantly correlated with aiming and catching skills (r = 0.43; 95% CI, 0.10-0.67; P = .001) and stereoacuity (r = -0.39; 95% CI, -0.05 to -0.65; P = .02). Children treated for strabismus or anisometropia, but who never had amblyopia, also had significantly lower mean (SD) physical competence scores compared with control children (2.89 [0.54] vs 3.43 [0.52]; 95% CI for difference, 0.23-0.85; P = .03). Conclusions and Relevance: These findings suggest that lower self-perception of peer acceptance and physical competence identify the broad effects of altered visual development in the everyday life of children with amblyopia.

Development of Pediatric Eye Questionnaires for Children With Eye Conditions.

PURPOSE: To develop patient-derived Pediatric Eye Questionnaires (PedEyeQ) to separately assess eye-related quality of life (ER-QOL) and functional vision in children with eye conditions. DESIGN: Questionnaire development study. METHODS: A total of 444 children (0 to <18 years old), across 10 diagnostic categories, were enrolled at 2 sites. All parents (n = 444) and 277 children (5 to <18 years old) completed master questionnaires, developed from patient-derived concerns. Factor analysis was performed to identify unidimensional domains (eigenvalue >1.0) and Rasch analyses (differential item functioning, targeting, fit) to reduce items (separate analyses for subjects aged 0-4, 5-11, and 12-17 years and for each factor). RESULTS: The Child 5- to 11-year-old PedEyeQ consisted of 4 unidimensional domains/questionnaires: functional vision, bothered by eyes/vision, social, frustration/worry (10 items each). The Child 12- to 17-year-old PedEyeQ consisted of the same 4 domains (total 39 items). The Proxy 0- to 4-year-old PedEyeQ consisted of 3 questionnaires/domains: functional vision, bothered by eyes/vision, social (total 29 items). The Proxy 5- to 11-year-old PedEyeQ consisted of 5 questionnaires/domains: functional vision, bothered by eyes/vision, social, frustration/worry, eye care (total 39 items), as did the Proxy 12- to 17-year-old PedEyeQ (total 42 items). The Parent PedEyeQ consisted of 4 questionnaires/domains: impact on parent/family, worry regarding child's eye condition, worry regarding child's self-perception and interactions, worry regarding child's visual function (total 35 items). Rasch look-up tables were created for scoring. CONCLUSIONS: By following a rigorous approach, we have developed Pediatric Eye Questionnaires for separately assessing functional vision and ER-QOL domains in children of any age and with any eye condition.

Fixation instability during binocular viewing in anisometropic and strabismic children.

PURPOSE: Strabismus or anisometropia disrupts binocularity and results in fixation instability, which is increased with amblyopia. Fixation instability has typically been assessed for each eye individually. Recently, vergence instability was reported in exotropic adults and monkeys during binocular viewing. We evaluated fixation instability during binocular viewing in children treated for anisometropia and/or strabismus. METHODS: 160 children age 4-12 years with treated esotropia and/or anisometropia (98 amblyopic, 62 nonamblyopic) were compared to 46 age-similar controls. Fixation instability was recorded during binocular fixation of a 0.3 deg diameter dot for 20 s using a 500 Hz remote video binocular eye tracker (EyeLink 1000; SR Research). The bivariate contour ellipse area (BCEA; log deg2) for fixation instability was calculated for each eye (nonpreferred, preferred) and for vergence instability (left eye position - right eye position). Best-corrected visual acuity, Randot Preschool stereoacuity, and extent of suppression scotoma (Worth 4-Dot) were also obtained. RESULTS: When binocularly viewing, both amblyopic and nonamblyopic children treated for anisometropia and/or strabismus had larger fixation instability and vergence instability than controls. Amblyopia primarily added to the instability of the nonpreferred eye. Anisometropic children had less nonpreferred eye instability and vergence instability than those with strabismus or combined mechanism. Nonpreferred eye instability and vergence instability were related to poorer stereoacuity and a larger suppression scotoma. Preferred eye instability was not related to any visual outcome measure. No relationships were found with visual acuity. CONCLUSIONS: Fixation instability and vergence instability during binocular viewing suggests that discordant binocular visual experience during childhood, especially strabismus, interferes with ocular motor development. Amblyopia adds to instability of the nonpreferred eye. Vergence instability may limit potential for recovery of binocular vision in these children.

Self-perception of School-aged Children With Amblyopia and Its Association With Reading Speed and Motor Skills.

Importance: Reading and eye-hand coordination deficits in children with amblyopia may impede their ability to demonstrate their knowledge and skills, compete in sports and physical activities, and interact with peers. Because perceived scholastic, social, and athletic competence are key determinants of self-esteem in school-aged children, these deficits may influence a child's self-perception. Objective: To determine whether amblyopia is associated with lowered self-perception of competence, appearance, conduct, and global self-worth and whether the self-perception of children with amblyopia is associated with their performance of reading and eye-hand tasks. Design, Setting, and Participants: This cross-sectional study was conducted from January 2016 to June 2017 at the Pediatric Vision Laboratory of the Retina Foundation of the Southwest and included healthy children in grades 3 to 8, including 50 children with amblyopia; 13 children without amblyopia with strabismus, anisometropia, or both; and 18 control children. Main Outcomes and Measures: Self-perception was assessed using the Self-perception Profile for Children, which includes 5 domains: scholastic, social, and athletic competence; physical appearance; behavioral conduct; and a separate scale for global self-worth. Reading speed and eye-hand task performance were evaluated with the Readalyzer (Bernell) and Movement Assessment Battery for Children, 2nd Edition. Visual acuity and stereoacuity also were assessed. Results: Of 50 participants, 31 (62%) were girls, 31 (62%) were non-Hispanic white, 6 (12%) were Hispanic white, 3 (6%) were African American, 4 (8%) were Asian/Pacific Islander, and 3 (6%) were more than 1 race/ethnicity, and the mean [SD] age was 10.6 [1.3] years. Children with amblyopia had significantly lower scores than control children for scholastic (mean [SD], 2.93 [0.74] vs 3.58 [0.24]; mean [SD] difference, 0.65 [0.36]; 95% CI, 0.29-1.01; P = .004), social (mean [SD], 2.95 [0.64] vs 3.62 [0.35]; mean [SD] difference, 0.67 [0.32]; 95% CI, 0.35-0.99] P < .001), and athletic (mean [SD], 2.61 [0.65] vs 3.43 [0.52]; mean [SD] difference, 0.82 [0.34]; 95% CI, 0.48-1.16; P = .001) competence domains. Among children with amblyopia, a lower self-perception of scholastic competence was associated with a slower reading speed (r = 0.49, 95% CI, 0.17-0.72; P = .002) and a lower self-perception of scholastic, social, and athletic competence was associated with worse performance of aiming and catching (scholastic r = 0.48; 95% CI, 0.16-0.71; P = .007; social r = 0.63; 95% CI, 0.35-0.81; P < .001; athletic r = 0.53; 95% CI, 0.21-0.75; P = .003). No differences in the self-perception of physical appearance (mean [SD], 3.32 [0.63] vs 3.64 [0.40]), conduct (mean [SD], 3.09 [0.56] vs 3.34 [0.66]), or global self-worth (mean [SD], 3.42 [0.42] vs 3.69 [0.36]) were found between the amblyopic and control groups. Conclusions and Relevance: These findings suggest that lower self-perception is associated with slower reading speed and worse motor skills and may highlight the wide-ranging effects of altered visual development for children with amblyopia in their everyday lives.

Patient-derived questionnaire items for patient-reported outcome measures in pediatric eye conditions.

PURPOSE: To identify specific health-related quality of life (HRQOL) and functional vision concerns of children with eye conditions, and create comprehensive lists of potential questionnaire items as a first step in developing patient-reported outcome measures. METHODS: Children experiencing a range of pediatric eye conditions, along with one of their parents, were interviewed to identify specific concerns. Transcribed interviews were reviewed, and specific HRQOL and functional vision concerns were coded independently by two reviewers. Coded concerns were reviewed to formulate questions to address specific child concerns (derived from child and parent interviews) and specific parent concerns. Questions were grouped into bins of like questions. Two comprehensive lists of questions were formulated, one addressing child-related concerns and one addressing parent-related concerns. RESULTS: This study included 180 children and 328 parents. A total of 614 individual child questions were grouped into 36 bins (eg, appearance, coordination, glasses, learning), and 589 parent questions were formulated and grouped into 61 bins (eg, having to assist the child, worry about deterioration, time off work, safety). CONCLUSIONS: Using rigorous methods based on individual interviews, we identified a comprehensive list of patient- and parent-derived questionnaire items that address functional vision and HRQOL concerns of children with eye conditions and of their parents. We plan to use this large pool of potential questionnaire items to develop a formal set of pediatric outcome measures, and this pool of questions may also be a resource for future research.