Parent and Teacher Perspectives on Factors Decreasing Participation in School-Based Vision Programs.

Purpose: To examine factors decreasing participation in school-based vision programs from parent and teacher perspectives.Methods: We conducted 41 semi-structured focus groups (20 parent groups, 21 teacher/staff groups), at 10 Baltimore and 11 Chicago public elementary and middle schools offering school-based vision programs. School-based vision programs provided vision screening, eye exams, and eyeglasses if needed. Focus groups ranged in size from 2-9 participants (median = 5). Sessions were recorded, transcribed, and coded through an iterative process to develop themes using inductive analysis.Results: Ninety parents and 117 teachers/staff participated. Participants identified five major factors decreasing participation in school-based vision programs: (1) challenges with the consent form, including distribution, collection, and literacy and language barriers; (2) having existing eye care; (3) misunderstandings about the program, especially related to cost and insurance; (4) difficulty raising parental awareness of the program; and (5) certain attitudes towards vision, eye care, and school-based programs, including low prioritization of eye care, mistrust of the program, fear of sharing private information, not believing their child needs glasses, and reluctance accepting 'subsidized' services.Conclusion: Parents and teachers identified important structural barriers to participation (i.e., consent form challenges and low parental awareness) and specific reasons for non-participation (i.e., attitudes, misunderstanding of the program, existing eye care) in school-based vision programs. Effective strategies are needed to facilitate return of consent forms and promote awareness of school-based vision programs among parents. Programs should also target services towards those currently without access to eye care and increase awareness about paediatric vision needs.

Computerized method of visual acuity testing: adaptation of the amblyopia treatment study visual acuity testing protocol.

PURPOSE: To report a computerized method for determining visual acuity in children using the Amblyopia Treatment Study visual acuity testing protocol. METHODS: A computerized visual acuity tester was developed that uses a programmed handheld device that uses the Palm operating system (Palm, Inc, Santa Clara, California). The handheld device communicates with a personal computer running a Linux operating system and 17-inch monitor. At a test distance of 3 m, single letters can be displayed from 20/800 to 20/12. A C program on the handheld device runs the Amblyopia Treatment Study visual acuity testing protocol. Using this method, visual acuity was tested in both the right and left eyes, and then the testing was repeated in 156 children age 3 to 7 years at four clinical sites. RESULTS: Test-retest reliability was high (r =.92 and 0.95 for and right and left eyes, respectively), with 88% of right eye retests and 94% of left eye retests within 0.1 logarithm of minimal angle of resolution (logMAR) units of the initial test. The 95% confidence interval for an acuity score was calculated to be the score +/- 0.13 logMAR units. For a change between two acuity scores, the 95% confidence interval was the difference +/- 0.19 logMAR units. CONCLUSIONS: We have developed a computerized method for measurement of visual acuity. Automation of the Amblyopia Treatment Study visual acuity testing protocol is an effective method of testing visual acuity in children 3 to 7 years of age.

Amblyopia. Current clinical studies.

Over the next two years, results from several multi-center amblyopia treatment studies will become available. These data may have a profound influence on our approach to treating this condition. This is indeed an exciting time to be taking care of children with amblyopia, as we anticipate the results of these studies.

The amblyopia treatment study visual acuity testing protocol.

OBJECTIVE: To evaluate the reliability of a new visual acuity testing protocol for children using isolated surrounded HOTV optotypes. METHODS: After initial pilot testing and modification, the protocol was evaluated using the Baylor-Video Acuity Tester (BVAT) to present isolated surrounded HOTV optotypes. At 6 sites, the protocol was evaluated for testability in 178 children aged 2 to 7 years and for reliability in a subset of 88 children. Twenty-eight percent of the 178 children were classified as having amblyopia. RESULTS: Using the modified protocol, testability ranged from 24% in 2-year-olds to 96% in 5- to 7-year-olds. Test-retest reliability was high (r = 0.82), with 93% of retest scores within 0.1 logMAR unit of the initial test score. The 95% confidence interval for an acuity score was calculated to be the score +/-0.125 logMAR unit. For a change between 2 acuity scores, the 95% confidence interval was the difference +/-0.18 logMAR unit. CONCLUSIONS: The visual acuity protocol had a high level of testability in 3- to 7-year-olds and excellent test-retest reliability. The protocol has been incorporated into the multicenter Amblyopia Treatment Study and has wide potential application for standardizing visual acuity testing in children.

Treatment of childhood myopia with atropine eyedrops and bifocal spectacles.

BACKGROUND: Animal and human studies have suggested that muscarinic antagonists and bifocal spectacles may decrease the progression of myopia in children. The purpose of this study is to report the largest known series of patients treated simultaneously with bifocals and topical atropine. DESIGN: Retrospective, interventional, non-comparative case series. METHODS: 706 myopic children (296 boys and 410 girls, ages 6 to 16 years) were prescribed full cycloplegic spectacle corrections, with photochromic lenses and +2.25 diopter (D) reading adds in each eye. Both eyes were treated with atropine 1% drops once daily. OUTCOME MEASURES: Annual change in cycloplegic refractions of right eyes. Compliance with therapy was monitored by patient and parental report. RESULTS: 496 (70%) of the 706 patients reported full compliance with the treatment regimen, whereas the remaining 210 (30%) patients were partially compliant. The median interval of treatment was 3.62 years (range, 21 days-10.1 years). The mean rate of myopic progression was significantly less (P<0.001) in patients who were fully compliant with atropine therapy and bifocals (0.08 D/year) than in patients who were partially compliant with the treatment regimen (0.23 D/per year). No serious adverse effects were associated with atropine therapy. CONCLUSIONS: Full compliance with topical atropine therapy and bifocal spectacles was associated with decreased progression of myopia compared to partial compliance with treatment. For each of the treated groups, the mean rate of myopic progression was significantly less (P<0.05) than the mean annual rates of myopic progression published for the pediatric population.

The Amblyopia Treatment Index.

OBJECTIVE: To develop a questionnaire to assess the acceptability of amblyopia treatment and its effect on the child and family. METHODS: A 20-item parental survey was developed and pilot tested on 64 subjects, aged 3 to 6 years, participating in the Amblyopia Treatment Study, a randomized trial comparing patching and atropine as treatments for moderate amblyopia. The survey was administered after 4 weeks of treatment. A descriptive item analysis and an internal consistency reliability analysis were performed. RESULTS: Nineteen of the 20 items demonstrated adequate variability as evidenced by the frequency distributions for item responses. Only 4 (<1%) of 1280 possible item responses were missing, one each by 4 different respondents. Factor analysis identified 3 treatment-related factors--"adverse effects," "compliance," and "social stigma"--among 11 of the 20 items. The internal-consistency reliability alpha for the 5-item adverse effects subscale was 0.82, the 4-item compliance subscale alpha was 0.81, and the 2-item social stigma subscale alpha was 0.84. CONCLUSIONS: The Amblyopia Treatment Index appears to be a useful instrument for assessing the impact of amblyopia treatment in 3- to 6-year-old children.

Randomized comparison of diode laser photocoagulation versus cryotherapy for threshold retinopathy of prematurity: seven-year outcome.

PURPOSE: To report the structural and functional outcomes at a minimum of 7 years postmenstrual age after randomized treatment of threshold retinopathy of prematurity with laser ablation or cryotherapy. METHODS: Nineteen patients were entered into a prospective, randomized protocol, in which one eye received cryotherapy, while the other eye received diode laser photocoagulation. Asymmetric eyes were randomly assigned. Two patients have died, and seven were no longer available for 7-year outcome examinations, leaving 10 children for analysis. RESULTS: Six males and four females with a mean birthweight of 631 g and a mean gestational age of 24.8 weeks were examined. Eight were symmetrical cases and treated in both eyes. Of these, there were six concordant and two discordant structural outcomes. The laser-treated eyes had the favorable outcome in each instance. The geometric mean visual acuity of the paired eyes after laser photocoagulation was 20/33, and after cryotherapy it was 20/133 (P =.03). The mean refractive error was -6.50 diopters after laser photocoagulation and -8.25 diopters after cryotherapy (P =.27), although one of the cryotherapy eyes could not be refracted because of phthisis. CONCLUSIONS: Laser photocoagulation appears to be associated with a structural and functional outcome at least as good as cryotherapy 7 years after therapy. Visual acuity and refractive error data suggest that laser photocoagulation may have an advantage over cryotherapy.

Spontaneous regression of optic gliomas: thirteen cases documented by serial neuroimaging.

OBJECTIVE: To demonstrate spontaneous regression of large, clinically symptomatic optic pathway gliomas in patients with and without neurofibromatosis type 1 (NF-1). METHODS: Patient cases were collected through surveys at 2 consecutive annual meetings of the North American Neuro-Ophthalmology Society (NANOS) and through requests on the NANOSNET Internet listserv. Serial documentation of tumor signal and size, using magnetic resonance imaging in 11 patients and computed tomography in 2 patients, was used to evaluate clinically symptomatic optic pathway gliomas. All tumors met radiologic criteria for the diagnosis of glioma and 4 patients had biopsy confirmation of their tumors. In 3 patients, some attempt at therapy had been made many years before regression occurred. In one of these, radiation treatment had been given 19 years before tumor regression, while in another, chemotherapy had been administered 5 years before signal changes in the tumor. In the third patient, minimal surgical debulking was performed 1 year before the tumor began to shrink. RESULTS: Spontaneous tumor shrinkage was noted in 12 patients. Eight patients did not have NF-1. In an additional patient without NF-1, a signal change within the tumor without associated shrinkage was detected. Tumor regression was associated with improvement in visual function in 10 of 13 patients, stability of function in 1, and deterioration in 2. CONCLUSIONS: Large, clinically symptomatic optic gliomas may undergo spontaneous regression. Regression was seen in patients with and without NF-1. Regression may manifest either as an overall shrinkage in tumor size, or as a signal change on magnetic resonance imaging. A variable degree of improvement in visual function may accompany regression. The possibility of spontaneous regression of an optic glioma should be considered in the planning of treatment of patients with these tumors.

Does cryotherapy affect refractive error? Results from treated versus control eyes in the cryotherapy for retinopathy of prematurity trial.

PURPOSE: To evaluate the effect of cryotherapy on refractive error status between ages 3 months and 10 years in children with birth weights of less than 1251 g in whom severe retinopathy of prematurity (ROP) developed in one or both eyes during the neonatal period. DESIGN: Randomized clinical trial. PARTICIPANTS: Two hundred ninety-one children in whom severe ROP developed during the neonatal period. INTERVENTION: Cryotherapy for ROP. MAIN OUTCOME MEASURES: Cycloplegic Refraction METHODS: The children underwent repeated follow-up eye examinations, including cycloplegic retinoscopy, between 3 months and 10 years after term due date. Refractive error data from all eyes that were randomized to cryotherapy were compared with data from all eyes that were randomized to serve as controls. Refractive error data were also compared for a subset of children who had both a treated and a control eye that could be refracted. RESULTS: At all ages, the proportion of treated eyes that were unable to be refracted because of retinal detachment, media opacity, or pupillary miosis was approximately half the proportion of the control eyes that were unable to be refracted. When data from all eyes that could be refracted were considered, the distribution of refractive errors between fewer than 8 diopters (D) of myopia and more than 8 D of hyperopia was similar for treated and control eyes at all ages. The proportion of eyes with 8 D or more of myopia was much higher in treated than in control eyes at all ages after 3 months. In the subset of children who had a treated eye and a control eye that could be refracted, distributions of refractive errors in treated versus control eyes were similar at most ages. CONCLUSIONS: In both treated and control eyes, there was an increase in the prevalence of high myopia between 3 and 12 months of age. Between 12 months and 10 years of age, there was little change in distribution of refractive error in treated or control eyes. The higher prevalence of myopia of 8 D or more in treated eyes, as compared with control eyes, may be the result of cryotherapy's preservation of retinal structure in eyes that, in the absence of cryotherapy, would have progressed to retinal detachment.

Bilateral recession-resection surgery for convergent strabismus fixus associated with high myopia.

The authors report two patients with more than 20 diopters of myopia, severely restricted abduction, and more than 90Delta of acquired esotropia. Marked axial elongation of the globes was present. Each underwent large bilateral medial rectus recessions and bilateral lateral rectus resections. The deviations were significantly reduced and abduction improved with combined horizontal recession-resection surgery on both eyes.

Restoration of fusion in children with intracranial tumors and incomitant strabismus.

PURPOSE: Intracranial tumors may cause eye misalignment and interruption of sensory fusion. The ocular misalignment may be permanent or may be corrected after tumor treatment with or without specific strabismus treatment. This report analyzes the binocular vision outcome of children with misaligned eyes from brain tumors who regain orthotropia. DESIGN: A retrospective noncomparative case series. PARTICIPANTS: Twenty-three surviving children less than 18 years of age with a new heterotropia and absence of fusion associated with the development of a brain tumor. INTERVENTIONS: Tumor resection/radiation/chemotherapy and necessary strabismus management. MAIN OUTCOME MEASURE: Stereopsis (>/= 4 of 10 circles) measured with the Randot II stereo test at near fixation. RESULTS: Fourteen children regained orthotropia either after tumor therapy, strabismus treatment, or both. Ten of these 14 children with realigned vision regained high-grade stereovision. Nine patients did not regain orthotropia and were excluded. The mean age at tumor diagnosis of the fusing group was 9.9 years (range, 3-17 years) compared with 8.5 years (range, 6-12 years) in the four realigned nonfusing patients. The mean duration of misalignment was 12 months (range, 2-51 months) for the fusing group, and 45 months (range, 14-120 months) for the nonfusing group. CONCLUSIONS: Children and adolescents with brain tumor-associated eye misalignment may regain the ability to fuse if their misalignment can be corrected. An improved prognosis was noted for those patients when the misalignment had been present for a shorter duration. These data suggest that the outcome may be better for incomitant strabismus than that reported for acute comitant esotropia.

Involution of retinopathy of prematurity. Cryotherapy for Retinopathy of Prematurity Cooperative Group.

OBJECTIVE: To report the timing of involution of acute retinopathy of prematurity (ROP). DESIGN: An analysis of prospective retinal observational data recorded at infants' eye examinations. PARTICIPANTS: Infants from the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) had birth weights less than 1251 g and served as subjects. The study population included 766 children who were examined in 5 of the 23 study centers and who developed at least 1 clock hour of acute ROP, stages 1 through 3. One eye from each patient was randomly chosen for analysis. MAIN OUTCOME MEASURES: Investigators documented the location, extent, and severity of ROP during serial retinal examinations. The onset of the ROP's involution was determined from a review of these data, applying a set of predetermined criteria. RESULTS: Acute-phase ROP began to involute at a mean of 38.6 weeks postmenstrual age. In 90% of patients, the ROP began to involute before 44 weeks of postmenstrual age. Acute ROP that demonstrated involution by moving from zone II to zone III was associated with an unfavorable outcome in 2 (1%) of 200 cases. Retinopathy of prematurity that was present only in zone III during a child's serial retinal examinations was never associated with the development of a partial or total retinal detachment. CONCLUSIONS: The onset of involution of acute retinopathy of prematurity correlates better with postmenstrual rather than with chronological age. This is reminiscent of the reported similar correlation of postmenstrual age to the time of onset of prethreshold and threshold ROP. Zone III ROP was nearly always associated with a favorable outcome.

Childhood optic atrophy.

PURPOSE: To determine the causes, and relative incidence of the common causes, of optic nerve atrophy in children under 10 years old and to compare prevalent aetiologies with those given in previous studies. METHODS: The Wilmer Information System database was searched to identify all children, diagnosed between 1987 and 1997 with optic atrophy, who were under 10 years old at diagnosis. The medical records of these children were reviewed retrospectively RESULTS: A total of 272 children were identified, Complications from premature birth were the most frequent aetiology of optic atrophy (n = 44, 16%); 68% of these premature infants having a history of intraventricular haemorrhage. Tumour was the second most common aetiology (n = 40, 15%). The most frequent tumour was pilocytic astrocytoma (50%), followed by craniopharyngioma (17%). Hydrocephalus, unrelated to tumour, was the third most common aetiology (n = 26, 10%). In 114 cases (42%), the cause of optic atrophy became manifest in the perinatal period and/or could be attributed to adverse events in utero. A cause was not determined in 4% of cases. CONCLUSIONS: In the last decade, prematurity and hydrocephalus appear to have become important causes of optic atrophy in childhood. This trend is probably the result of improved survival of infants with extremely low birth weight.

Congenital cystic eye: report of two cases and review of the literature.

A 13-month-old boy and a 2-week-old girl, who were considered to be anophthalmic and who later each developed a cystic lesion in the left orbit with protrusion of the lower eyelid, were studied. The fellow eye in case 1 was subsequently found to be microphthalmic with cyst and was normal in case 2. Histopathologic study of each case revealed a cyst lined externally by dense fibrous connective tissue to which skeletal muscle and adipose tissue were attached. The inner aspect of the cyst was lined by neuroglial tissue, possible immature retinal tissue, and cuboidal epithelium. No fully developed ocular structures or microphthalmos were identified. Fourteen cases of congenital cystic eye, including our cases, have been published in the English-language literature since 1964. We discuss and illustrate the findings in our cases and 10 others in which histopathologic findings were reported. Congenital cystic eye, microphthalmos with cyst, and microphthalmos with cystic teratoma should be suspected in patients with a small or unrecognizable eye and an orbital cystic mass that is detected by palpation or visualization.

A randomized comparison study of drop versus spray topical cycloplegic application.

PURPOSE: To evaluate the acceptance of ocular spray administration. METHODS: A randomized, single-masked comparison in a cohort of children from 3 to 13 years. Assessment of patient pain was recorded on a visual analog scale. Cycloplegia was assessed by an ophthalmologist masked to the assignment. A questionnaire was used to assess patient acceptance. 126 patients participated. The average age was 7.7 years for spray, 7.1 for drops. RESULTS: Pain (higher number = more painful): means: 41/100 for spray; 35/100 for drops (P=0.28). No difference in cycloplegia noted (i.e., satisfactory in all subjects). Subjective acceptance: high in both patient groups, but a preference for spray was noted (P=0.06). No untoward drug reactions occurred with either method. CONCLUSIONS: Cycloplegic spray was as acceptable, or more acceptable than drops. Cycloplegia was comparable for the two methods. Spray application of cycloplegic drugs is a satisfactory route of topical administration for children.

Ophthalmologic outcome after third cranial nerve palsy or paresis in childhood.

PURPOSE: The purpose of this study was to evaluate the causes and ophthalmologic outcome of oculomotor nerve palsy or paresis in children younger than 8 years of age. METHODS: Patients evaluated between 1985 and 1997 were retrospectively reviewed. Data analyzed included vision, residual strabismus after surgery, aberrant reinnervation, binocular function, and anisometropia. Long-term outcome was assessed in patients followed-up longer than 6 months. RESULTS: Forty-one patients were identified. The most frequent causes were congenital (39%), traumatic (37%), and neoplastic (17%). Visual acuities were reduced in 71% of patients at the time of the initial visit. Long-term outcome could be assessed in 20 of the 41 patients (49%), with a mean follow-up of 3.6 years (range, 0.5 to 13 years). Visual acuities were reduced because of amblyopia in 35% and nonamblyopic factors in 25% of patients in the long-term outcome group at last follow-up. The best response to amblyopia therapy was in the congenital group, in which all patients improved to normal visual acuity. Strabismus surgery was performed on 8 of 20 children (40%) followed-up, none of whom demonstrated measurable stereopsis after operation despite improved alignment. Aberrant reinnervation was present in 9 of 20 patients (45%). Only 3 patients fully recovered from their oculomotor nerve injuries, and these were the only patients to regain measurable stereopsis. The causes in those 3 patients were congenital, traumatic, and neoplastic. CONCLUSIONS: Oculomotor nerve palsy/paresis is associated with poor visual and sensorimotor outcome in children younger than 8 years of age. The best ophthalmologic outcome was in the resolved cases (3 of 20; 15%). Amblyopia therapy was most effective with congenital causes, but treatment results were poor with other causes. Young children with posttraumatic and postneoplastic oculomotor nerve injuries demonstrated the worst ophthalmologic outcomes.

Fourth cranial nerve palsy in pediatric patients with pseudotumor cerebri.

PURPOSE: To describe three children with acute fourth cranial nerve palsy secondary to pseudotumor cerebri. METHODS: We reviewed the medical records of children younger than 18 years who were diagnosed with pseudotumor cerebri between 1977 and 1997. Pseudotumor cerebri was defined by normal neuro-imaging, elevated intracranial pressure measured by lumbar puncture, and normal cerebrospinal fluid composition. RESULTS: Three children with pseudotumor cerebri presented with vertical diplopia and clinical signs of fourth cranial nerve palsy including a hypertropia of the affected eye, which increased with adduction and ipsilateral head tilt. The fourth cranial nerve palsy resolved after reduction of the intracranial pressure in all three children. CONCLUSIONS: Fourth cranial nerve palsy may occur in children with pseudotumor cerebri and may be a nonspecific sign of elevated intracranial pressure.