Comparing Visual Acuity Measured by Lea Symbols and Patti Pics.

INTRODUCTION: There is little data validating most illiterate eye charts. Lea Symbols®, however, have been well validated in numerous studies. In this study, we compare the assessment of visual acuity employing both the Lea Symbol hanging wall Early Treatment Diabetic Retinopathy Study (ETDRS)-style chart and a similar Patti Pics® ETDRS-style chart in order to determine whether the two charts provide clinically similar data. METHODS: We tested the vision of the right eyes of fifty-two consecutive patients. Patients were cooperative children or adults between the ages of 3 and 88 years (mean 58 years). We alternated the order of the chart used first. Patients were also categorized by age and by visual acuity. RESULTS: The visual acuities measured by the two charts were equal for 83% of the measurements (forty-three eyes). In 8% of eyes (four eyes), the visual acuity measured with the Lea Symbols was one line better than that measured by the Patti Pics; in 9% of eyes (five eyes), the acuity from the Patti Pics chart measured one line better than the Lea Symbols. There was no difference in measurements for either adults or children or among patients with different visual acuities. CONCLUSION: We believe this study will serve to provide useful information when choosing an eye chart to assess visual acuity in a clinic setting. Patti Pics performed similarly to Lea Symbols in adults and children tested in a multi-specialty ophthalmology practice. We suspect that it would also perform similarly in the primary care and school settings.

Convergence insufficiency associated with migraine: a case series.

BACKGROUND AND PURPOSE: The appearance of convergence insufficiency in migraineurs suggests a possible link between migraine and convergence insufficiency. PATIENTS AND METHOD: Relevant patients reporting to our neuro-ophthalmology clinic complained of symptoms consistent with convergence insufficiency and had a history of migraine. Patients underwent thorough neuro-ophthalmic evaluations including history, physical exam, and cranial imaging. Four illustrative cases are presented in this report. RESULTS: Convergence insufficiency may develop after migraine. In some cases, it may be a persistent cause of reduced visual functioning. In patients with persistent asthenopia, orthoptic therapy has proven successful. CONCLUSIONS: A history of migraine should be sought in patients complaining of reading difficulties secondary to new onset convergence insufficiency. Furthermore, migraineurs should be asked about whether they suffer asthenopia. Finally, a larger scale, prospective study should be considered to further explore a possible link between migraine and convergence insufficiency.

Silent sinus syndrome presenting after a roller coaster ride: a case report.

This is a case presentation of a 39-year-old male who presents with silent sinus syndrome. He was initially diagnosed by a neuroophthalmologist, and at first, the patient's otolaryngologist disagreed. The patient had a significant reduction in his symptoms with surgical and orthoptic intervention.

Performance of the Spot vision screener for the detection of amblyopia risk factors in children.

PURPOSE: To compare the accuracy of the Spot photoscreener (Pediavision Holdings LLC Lake Mary, FL) in detecting amblyopia risk factors in children to the 2003 and 2013 referral criteria of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). METHODS: The medical records of children 1-6 years of age who underwent vision screening at a single clinic from February 2012 through May 2012 were retrospectively reviewed. Participants were screened with the Spot photoscreener on the same day as a pediatric ophthalmology examination. Visual acuity examination, ocular alignment testing, and cycloplegic refraction were performed that day or within the preceding 6 months for all included subjects by one pediatric ophthalmologist. Sensitivity and specificity of the Spot photoscreening results were compared to the 2003 and to the recently revised 2013 AAPOS referral criteria. RESULTS: A total of 151 children were included. The Spot had a sensitivity of 80% and specificity of 74%. With the revised 2013 AAPOS referral criteria, the sensitivity was 87% and specificity was 74%. CONCLUSIONS: The Spot is a fully portable, automated tool for the detection of amblyopia risk factors in children. In this study cohort it was found to reliably detect amblyopia risk in children when compared to the 2003 and 2013 AAPOS referral criteria.

Comparison of SureSight autorefractor and plusoptiX A09 photoscreener for vision screening in rural Honduras.

PURPOSE: To evaluate the SureSight autorefractor and compare it to the plusoptiX A09 photoscreener in the detection of amblyopia risk factors in a cohort of Honduran children examined during medical mission work and to assess the utility of both devices in the rural setting. METHODS: The medical records of patients who had undergone SureSight autorefractor screening, plusoptiX photoscreening, and a gold standard pediatric ophthalmology examination, including cycloplegic refraction, during a recent medical mission trip to Honduras were retrospectively reviewed. RESULTS: A total of 216 children were examined. Of these, 9 (4%) were found to have amblyopia risk factors based on the current referral criteria of the American Association for Pediatric Ophthalmology and Strabismus on ophthalmological examination. The plusoptiX was found to have 89% sensitivity and 80% specificity; the SureSight, using manufacturer's referral criteria, was found to have sensitivity of 89% and specificity of 71%. CONCLUSIONS: Both devices were found to be reliable vision screening devices when used on the general population of remote villages in Honduras, although the specificity of the plusoptiX A09 was higher.

Flip chart Visual Acuity Screening for Amblyopia Risk Factors Compared to the PlusoptiX A09 Photoscreener,Tests Performed by a Lay Screener.

IMPORTANCE: The gold standard of vision screening is considered acuity testing, this article will compare the gold standard against new technology to provide more choices for pediatric vision screening programs. OBJECTIVE: To determine the reliability of recognition visual acuity screening performed by a lay screener compared to the plusoptiX A09 photoscreener for the detection of amblyopia risk factors. DESIGN: One lay screener received basic training in how to test monocular visual acuity using the 10 foot Patti Pics single crowded chart and the plusoptiX A09 photoscreener. All children underwent a complete pediatric ophthalmology examination and cycloplegic refraction after screening and this examination was the standard against which the screening method was compared. Each patient received a pass or refer grade after either screening. For the Patti Pics screening, children were referred if they failed to reach threshold visual acuity of twenty forty in either eye; the plusoptiX determines if the child is a pass or refer based on pre-set referral criteria. SETTING: Pediatric ophthalmology clinic. PARTICIPANTS: Screening was performed on children ages 3 to 10 years. RESULTS: Seventy-one children were screened. Flip chart-screening was found to have a sensitivity of 83%, specificity of 44%, false positive rate of 56% and false negative rate of 17%. Those same metrics for the plusoptiX A09 were 94%, 89%, 11% and 6%, respectively. CONCLUSION: The plusoptiX photoscreener was more sensitive and specific in making appropriate referrals for further care than flip chart-screening in this cohort of children age 3-10. The plusoptiX A09 photoscreener operated by a lay screener is a reliable method to screen for amblyopia risk factors. These finding have important implications for community based vision screening, and screening in the medical home.

Part-time vs. full-time occlusion for amblyopia: evidence for part-time patching.

Amblyopia is characterized by a decreased uncorrectable visual acuity in a structurally normal eye. Occlusion therapy has been used for years to improve acuity, and, traditionally, practitioners have utilized full-time patching. This article will explore more recent research looking at using part-time patching in the treatment of amblyopia.

Incidence of amblyopia risk factors in children with nasolacrimal duct obstruction.

Previously published research suggested that children with nasolacrimal duct obstruction and amblyopia risk factors on initial examination often develop clinical amblyopia. The present study reports the incidence of clinical amblyopia in children presenting with nasolacrimal duct obstruction but no amblyopia risk factors.

Nonsurgical treatment of neurologic diplopia.

The ocular motor pathways are complex and disorders of these pathways can be devastating for patients, in some cases leading to loss of employment and independence. Surgical intervention for these cases is not always warranted, possible, or even safe for some patients, and nonsurgical and orthoptic treatments can provide significant relief. This paper will discuss various treatment options, including eye exercises, prisms, optical manipulation, occlusion, and lifestyle changes.

Incidence of strabismus and amblyopia in preverbal children previously diagnosed with pseudoesotropia.

BACKGROUND AND PURPOSE: We previously reported that 12% of children under age 3 diagnosed with pseudoesotropia without significant refractive error later developed strabismus or mild refractive amblyopia. Mohan and Sharma recently reported on fifty-one patients with pseudoesotropia and hyperopia and noted that esotropia developed in 53.9% of the children with >1.50 D of hypermetropia compared to 2.6% of those who had ≤1.50 D hypermetropia, implying a low risk of esotropia unless hyperopia was greater than 1.50 D on initial exam. We reviewed our data to see if we had similar findings in our patients. METHOD: Medical records between January 1, 2001, and February 26, 2010, were reviewed retrospectively. Three hundred ninety-four patients diagnosed with pseudoesotropia with an otherwise normal examination were reviewed, and 253 with follow-up were analyzed. RESULTS: Forty-six children were 36 months or older at initial presentation; none developed strabismus; 207 children were <36 months at initial presentation; twenty-two children (11%) were later found to have strabismus. Seventy-eight of these children had hyperopia > 1.50 D; eight children (10%) later developed strabismus. One hundred twenty-nine children had hyperopia ≤ 1.50 D, and fourteen (11%) developed strabismus. Our analysis showed an equal risk of strabismus developing in pseudoesotropia patients under age 3 with greater or less than 1.50 D of hyperopia. CONCLUSION: There is a significant risk of esotropia developing in children under three diagnosed with pseudoesotropia. Hyperopia less than 1.50 D, does not obviate the need for careful follow-up.

Comparison of the INNOVA Visual Acuity System Stereotest with the Frisby-Davis 2 Stereotest for the Evaluation of Distance Stereoacuity.

PURPOSE: Distance stereo acuity has been shown to be useful in monitoring conditions such as control of intermittent strabismus. The Frisby Davis distance (FD2) stereotest has been shown to be reliable and is felt to be the gold standard in England. The device however is not widely available in the United States or Canada and is not automated. This study compares the Innova distance stereoacuity test with the Frisby Davis distance (FD2) stereotest. METHODS: Twenty-seven patients with normal acuity and a normal ophthalmology exam were evaluated. Prior to dilation all patients had an Innova distance stereoacuity test and FD2 test. Both the Innova distance stereoacuity test and the FD2 test were performed at ten feet. The results of the tests were compared using Bland-Altman plot analysis. RESULTS: The INNOVA system tended to underestimate distance stereoacuity by approximately 30 arc seconds compared to the FD2 test. If the INNOVA results were corrected by this amount, then there was a good correlation between the INNOVA results and the FD2. CONCLUSION: The Innova distance stereoacuity test underestimates stereopsis by approximately 30 arc seconds but does so with sufficient consistency that it may serve as an acceptable method of measuring distance stereoacuity. This study is the first that has correlated the Innova stereoacuity test with the FD2.

Intraobserver reliability of contact pachymetry in children.

BACKGROUND: Central corneal thickness (CCT) is an important measurement in the treatment and management of pediatric glaucoma and potentially of refractive error, but data regarding reliability of CCT measurement in children are limited. The purpose of this study was to evaluate the reliability of CCT measurement with the use of handheld contact pachymetry in children. METHODS: We conducted a multicenter intraobserver test-retest reliability study of more than 3,400 healthy eyes in children aged from newborn to 17 years by using a handheld contact pachymeter (Pachmate DGH55; DGH Technology Inc, Exton, PA) in 2 clinical settings--with the use of topical anesthesia in the office and with the patient under general anesthesia in a surgical facility. RESULTS: The overall standard error of measurement, including only measurements with standard deviation ≤5 µm, was 8 µm; the corresponding coefficient of repeatability, or limits within which 95% of test-retest differences fell, was ±22.3 µm. However, standard error of measurement increased as CCT increased, from 6.8 µm for CCT less than 525 µm, to 12.9 µm for CCT 625 µm and greater. The standard error of measurement including measurements with standard deviation >5 µm was 10.5 µm. Age, sex, race/ethnicity group, and examination setting did not influence the magnitude of test-retest differences. CONCLUSIONS: CCT measurement reliability in children via the Pachmate DGH55 handheld contact pachymeter is similar to that reported for adults. Because thicker CCT measurements are less reliable than thinner measurements, a second measure may be helpful when the first exceeds 575 µm. Reliability is also improved by disregarding measurements with instrument-reported standard deviations >5 µm.

Plusoptix photoscreening may replace cycloplegic examination in select pediatric ophthalmology patients.

PURPOSE: To determine whether children presenting to a pediatric ophthalmologist and found to have a normal Plusoptix photoscreener (PlusoptiX GmbH, Nuremberg, Germany) result, normal visual acuity (children age 3+), and normal alignment/motility receive additional benefit from a dilated fundus examination. METHODS: The medical records of all children seen at one pediatric ophthalmology practice between 2007 and 2010 who were coded as having had a photoscreening were retrospectively reviewed. Of the total number of records identified, one-half were selected randomly for review. Patients who underwent plusoptiX screening on the first visit were included. Patients with abnormal alignment and/or abnormal vision as well as those referred for examination as determined by a medical or ophthalmic condition that required a dilated fundus examination were excluded. RESULTS: Of 1,377 patients identified, 697 were selected randomly for record review. Of these, 451 had had an initial plusoptiX screening. A total of 222 had a normal result. Of the 190 patients analyzed, cycloplegic examination provided additional diagnostic information for only 4 children: 1 with nonvisually significant congenital cataract, 1 with refractive amblyopia from moderate astigmatism, 1 with moderate hyperopia who later was found to have accommodative esotropia, and 1 with increased cupping but normal IOP. CONCLUSIONS: A normal plusoptiX result, combined with normal alignment/motility evaluation and visual acuity was found to have a 98% negative predictive value for ophthalmic pathology, including significant refractive error. The plusoptiX and an abbreviated eye examination may obviate the need for dilation in select children.

Comparison of the iScreen and the MTI photoscreeners for the detection of amblyopia risk factors in children.

BACKGROUND: The iScreen and Medical Technology and Innovations, Inc, (MTI) photoscreeners objectively screen for amblyopia risk factors in children. The MTI photoscreener has been extensively validated as a device that objectively screens for amblyopia risk factors in children, but limited availability of the instant film it uses may soon render it obsolete. More recently the iScreen photoscreener has been introduced. This device captures images digitally and transmits them electronically to be interpreted. We compared the newer iScreen's ability to detect amblyopia risk factors in children with the established MTI photoscreener. METHODS: The medical records of consecutive subjects screened by both the iScreen and MTI photoscreeners on the same day were retrospectively reviewed. The iScreen images were analyzed by the device's central interpretation center; MTI images were analyzed by an expert masked examiner using the delta crescent method. Referrals by both instruments were compared to the results of cycloplegic examination as per the American Association for Pediatric Ophthalmology and Strabismus 2003 referral criteria. RESULTS: A total of 169 children were included in the study. Of these, 107 (63%) were found to have amblyopia risk factors. The iScreen was found to have an accuracy rate of 81%, sensitivity of 87%, and specificity of 76%. The MTI was found to have an accuracy rate of 81%, sensitivity of 81%, and specificity of 81%. CONCLUSIONS: The iScreen and MTI performed similarly in detecting amblyopia risk factors when compared to a comprehensive pediatric ophthalmology examination.

Diplopia secondary to orbital surgery.

Diplopia may occur following any type of ocular or pericocular surgery. The surgeries most frequently associated with postoperative diplopia include: repair of orbital fracture, endoscopic sinus surgery (from inadvertent orbital penetration), and orbital decompression for thyroid-related immune orbitopathy (TRIO). Postoperative diplopia after orbital tumor resection has been reported--e.g., after excision of fibrous dysplasia and osteoma. However, a recent case series suggests diplopia after orbital tumor resection is uncommon and transient. Surgical intervention for orbital trauma carries the highest risk of postoperative diplopia and will be the focus of this review. We will also present a case report of worsening diplopia following repair of orbital floor fracture to highlight potential motility issues that can arise when implants are employed to treat orbital floor fractures.

Vision screening across the world.

INTRODUCTION: Pediatric vision screening is a global need. The International Orthoptic Association (IOA), comprised of fifteen full member countries and five associate member countries, is an excellent source of information to determine the current state of international vision screening efforts globally. METHODS: An e-mail survey was sent to representatives of member countries of the IOA. RESULTS: Of the eighteen surveys returned, 89% of countries have pediatric vision screening programs, 44% have a national program, 56% are government funded, and 28% are obligatory. CONCLUSION: This survey sheds light on the state of international pediatric vision screening. Countries may use this information to help develop new methods and improve existing ones in order to enhance vision screening globally.

Clinical accuracy of the AAPOS pediatric vision screening referral criteria.

BACKGROUND: The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) referral criteria for amblyogenic risk factors are consensus criteria that were determined by the best-available data as well as survey results of pediatric ophthalmologists. In 2003 the AAPOS Vision Screening Committee published guidelines to standardize reporting the ability of vision screening devices to detect these factors. We attempted to assess the accuracy of the AAPOS referral criteria. METHODS: Billing records of one pediatric ophthalmologist were reviewed to identify all children who were seen in 2002. Records were excluded if photoscreening had not been performed at the initial visit or if photoscreening results were not available in the record. Of the remaining records, one-half were randomly selected for analysis. Cycloplegic refraction and binocular alignment were evaluated to determine whether the child would have been considered to be at risk for amblyopia on the basis of AAPOS referral critera. The sensitivity and specificity of these factors for detecting amblyopia was then determined. RESULTS: A total of 1,575 records were identified, of which 529 were randomly selected; 7 were excluded for incomplete data. AAPOS referral criteria would have referred 266 patients, of whom 255 had amblyopia and 11 did not; of the 256 patients who would not have been referred, 46 had amblyopia and 210 did not. In this population, the AAPOS referral criteria would have had an 85% sensitivity, 95% specificity, a 5% false-positive rate and a 15% false-negative rate for detecting amblyopia. CONCLUSIONS: Application of the AAPOS referral criteria resulted in underreporting of amblyopia in this study. We propose modifications that may result in increased sensitivity and a lower false-negative rate.

Incidence of strabismus and amblyopia in preverbal children previously diagnosed with pseudoesotropia.

PURPOSE: To determine how frequently children diagnosed with pseudoesotropia before 3 years of age are later found to have true strabismus or amblyopia. METHODS: Records of all patients presenting to one pediatric ophthalmologist between January 1, 2001, and February 26, 2010, were reviewed retrospectively. Patients diagnosed with pseudoesotropia who had an otherwise normal examination were included. RESULTS: A total of 306 patients were diagnosed with pseudoesotropia with no significant refractive error on initial examination. Of these, 201 had the follow-up examination recommended for all 306 patients. The average age at the time of the initial examination was 13 months (range, 2-33). The average age at follow-up was 33 months (range, 4-120). Of the 201 patients, 20 were later found to have strabismus (10%) and 5 were later found to have significant refractive error and mild refractive amblyopia (2%). Of the 20 children found to have strabismus, 15 had esodeviation, 3 had exodeviation, 1 had Duane syndrome, and 1 had Prader-Willi syndrome with esotropia. CONCLUSIONS: Of children initially diagnosed with pseudoesotropia under age 3 who returned for follow-up, 12% were later found to have strabismus or mild refractive amblyopia. The ultimate prevalence of strabismus or amblyopia was higher in children diagnosed with pseudoesotropia than would be expected in the general population.

Comparison of Tono-Pen and Goldmann applanation tonometers for measurement of intraocular pressure in healthy children.

PURPOSE: To assess the agreement of intraocular pressure (IOP) measured with the Tono-Pen and the Goldmann applanation tonometer (GAT) in normal children and adolescents. METHODS: A total of 439 subjects from birth to <18 years of age without anterior segment anomalies or glaucoma had their IOP measured with the two instruments by separate, masked examiners in the office or under general anesthesia. RESULTS: On average, the Tono-Pen measured values slightly lower than the GAT for IOP <11 mm Hg and slightly higher than the GAT for IOP >11 mm Hg in the office setting. Using the average of GAT and Tono-Pen IOPs to estimate the true IOP, the average difference (GAT - Tono-Pen) was 0.4 mm Hg at IOP of 10 mm Hg and -3.0 mm Hg at IOP of 20 mm Hg. The 95% limits of agreement on the average difference between instruments were ± 6.4 mm Hg in the office setting and ± 6.8 mm Hg under general anesthesia. Larger differences between instruments were found with younger age. Standard error of measurement with the Tono-Pen was 1.44 mm Hg and 1.82 mm Hg for the office and anesthesia settings, respectively. Thicker corneas were associated with higher IOP with both the GAT and the Tono-Pen. CONCLUSIONS: In normal children, average differences between IOP measured by Tono-Pen and GAT were small, although there was substantial test-retest variability. Younger age was associated with larger average differences, as was higher IOP in the office setting.