Diagnosis, Management, and Treatment of Vernal Keratoconjunctivitis in Asia: Recommendations From the Management of Vernal Keratoconjunctivitis in Asia Expert Working Group.

Vernal keratoconjunctivitis (VKC) is an underdiagnosed and underrecognized ocular surface disease with limited epidemiological data in Asia. It is more prevalent in warm, dry, and windy climates, and often has a substantial impact on a patient's quality of life. In rare cases, VKC can be associated with vision loss, either through corticosteroid overuse or inadequate treatment of persistent inflammation. As a potentially severe and complex disease, there is variability with how VKC is managed across Asia and among the various allergic eye diseases. Diagnosis and treatment of patients with VKC is a challenge for many ophthalmologists, since no precise diagnostic criteria have been established, the pathogenesis of the disease is unclear, and anti-allergic treatments are often ineffective in patients with moderate or severe disease. In addition, the choice of treatment and management strategies used for patients varies greatly from country to country and physician to physician. This may be because of a lack of well-defined, standardized guidelines. In response, the Management of Vernal Keratoconjunctivitis in Asia (MOVIA) Expert Working Group (13 experts) completed a consensus program to evaluate, review, and develop best-practice recommendations for the assessment, diagnosis, and management of VKC in Asia. The expert-led recommendations are summarized in this article and based on the currently available evidence alongside the clinical expertise of ophthalmologists from across Asia with specialism and interest in the ocular surface, VKC, and pediatric ophthalmology.

Global Ophthalmology Practice Patterns during COVID-19 Pandemic and Lockdown.

AIM: To assess the impact of practice patterns amongst global ophthalmologists during severe acute respiratory syndrome Coronavirus 2 (SARS Cov2) causing Corona virus disease (COVID-19) and understand the various modifications made to address emergency surgeries and practice needs. METHODS: An online survey was sent to practicing ophthalmologists around the world through email, Whatsapp™ ListServ17.0™ (for pediatric ophthalmologists), WeChat™ (China) and ophthalmology associations (Indonesia, Philippines, Ireland). All queries were collected and categorized. Responses to the queries were given according to the recommendations by the Ophthalmology association. Practices ability to deal with the COVID were also classified according to country and type of access to PPE. Statistical analyses of the association between these data and queries, where appropriate were carried out. RESULTS: One thousand nine hundred sixteen ophthalmologists were invited to participate in a survey between April 10th and April 30th, 2020 of which 1207 responded, which is a response rate of approximately 63%. The majority of respondents were from India, Indonesia, China, Singapore and the USA. Our study indicates a precipitous drop in surgical procedures with 46% (n = 538) ophthalmologists ceased to operate on their patients and almost 40% (n = 486) were doing less than 25% of their original number of surgeries. The intent to resume elective surgeries was a consideration in 41% (n = 495) after an evaluation of the situation and in consultation with professional bodies. More than 2/3 of the respondents (n = 703) made it a priority to use and mandate their patients to practice physical distancing, wearing masks, and hand dis-infection for protection to limit the spread of infection. CONCLUSION: This global survey provides a real-world assessment of diverse practices that were in various forms of "shut down mode" and circumstances with varying capabilities to deal with COVID. It is unprecedented that the collective wisdom for a curtailment of practice has had an enormous immediate and far reaching implications on the livelihoods of ophthalmologists, their staff, and their families. Nevertheless, ophthalmologists and their staff remain resilient and have adapted to these changes pragmatically.

Current approaches to myopia control.

PURPOSE OF REVIEW: Myopia is a global problem, being particularly prevalent in the urban areas of east and southeast Asia. In addition to the direct economic and social burdens, associated ocular complications may lead to substantial vision loss. With prevalence of myopia above 80% and high myopia over 20%, it is crucial to control myopia. The aim of this review to is provide an update on the interventions to slow the onset of myopia and retard its progression. RECENT FINDINGS: The epidemic of myopia is characterized by increasingly early onset, combined with high myopia progression rates. There are two pathways for myopia control: firstly to slow the onset of myopia and secondly to reduce or prevent progression. Increased time outdoors can reduce the onset of myopia. Atropine 0.01% dose offers an appropriate risk-benefit ratio, with no clinically significant visual side effects balanced against a significant 50% reduction in myopia progression. Orthokeratology contact lenses can slow axial length elongation, but infective keratitis is a risk. Peripheral defocussing lenses may both have a role in slowing myopic progression in a subset of children and further help our understanding of the physiologic control of ocular growth. SUMMARY: Myopia control can be achieved by slowing the onset of myopia, which now appears to be possible through increasing time outdoors and slowing the progression of myopia with interventions like atropine and orthokeratology.

Evidence of Microvascular Changes in the Retina following Kawasaki Disease.

It is unclear whether all children with Kawasaki disease (KD) have increased later cardiovascular risk. The retinal microvasculature reflects changes in the microcirculation and is associated with traditional cardiovascular risk factors and events. The aim of this study was to investigate retinal microvascular parameters in two populations of patients with previous KD and control participants. We performed case-control studies of 116 (57 patients and 59 control participants) Australian and 156 (78 patients and 78 control participants) Singaporean individuals, at least two years since their acute illness. Standardised retinal photographs were graded by trained technicians using a semi-automated software, which quantifies the retinal microvasculature (calibre, branching angle, fractal dimensions, and tortuosity). Retinal venules of Singaporean KD patients were 9.67 µm (95% CI 4.87 to 14.51, p < 0.001) larger than control participants following correction for traditional cardiovascular risk factors. An incremental increase in the size of retinal venules in those with coronary artery abnormalities was observed. There was limited evidence that retinal venules were larger in Australian KD patients with coronary artery abnormalities compared to control participants (7.34 µm, 95% CI 1.30 to 15.99, p = 0.10). Differences in retinal microvasculature were particularly evident in Singaporean KD patients. Larger retinal venules may reflect chronic inflammation and endothelial dysfunction, and are associated with coronary artery disease in adults.

Risk factors for strabismus and amblyopia in young Singapore Chinese children.

PURPOSE: To determine the risk factors for strabismus and amblyopia in young Singapore Chinese children. METHODS: A total of 3009 children were recruited for the population-based cross-sectional Strabismus, Amblyopia and Refractive Error in Singaporean Preschoolers Study (STARS). Strabismus was defined as any tropia identified on cover test. Visual acuity was measured in children aged 30-72 months with a logMAR chart where possible and the Sheridan-Gardiner test if not. Amblyopia was defined based on visual acuity and refractive error or presence of strabismus or past/present visual axis obstruction. Parents completed questionnaires on family, prenatal and birth histories. RESULTS: Our study showed that 24 children aged 6-72 months (1.2%) had strabismus (20 with exotropia), and 20 children aged 30-72 months (0.8%) were amblyopic. After multivariate analysis, strabismus was associated with astigmatism ≥1.00 diopter (D; p = 0.03), amblyopia (p = 0.003), a sibling with strabismus (p < 0.001), and families with lower parental education (p = 0.04). In addition to strabismus, amblyopia was associated with anisometropia ≥1.00 D (p < 0.001) and astigmatism ≥1.00 D (p < 0.001). No association was noted between either strabismus or amblyopia and prematurity, maternal age or smoking. CONCLUSION: This study highlights the importance of family history in strabismus, and the close associations between refractive error and strabismus with amblyopia. These factors play a more important role in young Singapore Chinese children.

Topical brinzolamide for foveal schisis in juvenile retinoschisis.

We describe a case series of 4 consecutive patients diagnosed with X-linked retinoschisis seen at a pediatric ophthalmology clinic during a 3-year period. All patients were treated with topical brinzolamide; 3 patients experienced significantly decreased severity of macular cysts on OCT in at least one eye.

Extensive facial and orbital infantile hemangiomas associated with high intraocular pressure.

High intraocular pressure is a rare ophthalmic condition associated with infantile hemangiomas that involves the orbit, eyelid, or both. Here, we describe a patient with extensive facial and orbital infantile hemangiomas associated with high intraocular pressure in the affected eye. The prompt management of this challenging condition is essential.

Visual acuity and visual skills in Malaysian children with learning disabilities.

BACKGROUND: There is limited data in the literature concerning the visual status and skills in children with learning disabilities, particularly within the Asian population. This study is aimed to determine visual acuity and visual skills in children with learning disabilities in primary schools within the suburban Kota Bharu district in Malaysia. METHODS: We examined 1010 children with learning disabilities aged between 8-12 years from 40 primary schools in the Kota Bharu district, Malaysia from January 2009 to March 2010. These children were identified based on their performance in a screening test known as the Early Intervention Class for Reading and Writing Screening Test conducted by the Ministry of Education, Malaysia. Complete ocular examinations and visual skills assessment included near point of convergence, amplitude of accommodation, accommodative facility, convergence break and recovery, divergence break and recovery, and developmental eye movement tests for all subjects. RESULTS: A total of 4.8% of students had visual acuity worse than 6/12 (20/40), 14.0% had convergence insufficiency, 28.3% displayed poor accommodative amplitude, and 26.0% showed signs of accommodative infacility. A total of 12.1% of the students had poor convergence break, 45.7% displayed poor convergence recovery, 37.4% showed poor divergence break, and 66.3% were noted to have poor divergence recovery. The mean horizontal developmental eye movement was significantly prolonged. CONCLUSION: Although their visual acuity was satisfactory, nearly 30% of the children displayed accommodation problems including convergence insufficiency, poor accommodation, and accommodative infacility. Convergence and divergence recovery are the most affected visual skills in children with learning disabilities in Malaysia.

An evidence-based update on myopia and interventions to retard its progression.

Myopia is the most common human eye disorder. With its increasing prevalence and earlier age-of-onset in recent birth cohorts, myopia now affects almost 33% of adults in the United States, and epidemic proportions of 85% to 90% adults in Asian cities. Unlike children in Western populations, where the prevalence of myopia is very low (less than 5%), Asian children have prevalences as high as 29% in 7-year-olds. In addition to the direct economic and social burdens of myopia, associated ocular complications may lead to substantial vision loss. This workshop summarizes the current literature regarding myopia epidemiology, genetics, animal model studies, risk factors, and clinical treatments. Published treatment strategies to retard the progression of myopia in children, such as pharmacologic agents, progressive addition lenses, and neural adaptation programs, are outlined.

Prevalence of refractive error in Singaporean Chinese children: the strabismus, amblyopia, and refractive error in young Singaporean Children (STARS) study.

PURPOSE: To determine the prevalence of refractive error types in Singaporean Chinese children aged 6 to 72 months. METHODS: The Strabismus, Amblyopia and Refractive Error in Singaporean Children (STARS) is a population-based study in southwest Singapore. Door-to-door recruitment of participants was used, with disproportionate random sampling in 6-month increments. Parental questionnaires were administered. Participant eye examinations included logMAR visual acuity, cycloplegic autorefraction, and ocular biometry. Overall and age-specific prevalences of myopia (spherical equivalence [SE] or= +3.00 D), astigmatism (cylinder >or= +1.50 D), and anisometropia (SE difference between each eye >or=2.00 D) were calculated. RESULTS: A total of 3009 children were examined (participation rate, 72.3%). Right eye (OD) cycloplegia data were available for 1375 boys and 1264 girls (mean age, 41 months). Mean OD SE was +0.69 D (SD 1.15). Overall myopia prevalence was 11.0% with no variance between the sexes (P = 0.91). The prevalence of high myopia (at least -6.00 D) was 0.2%. The prevalences of hyperopia, astigmatism, and anisometropia were 1.4%, 8.6%, and 0.6%, respectively. Most astigmatism (>95%) was with-the-rule (cylinder axes between 1 degrees and 15 degrees or 165 degrees and 180 degrees ). Myopia was present in 15.8%, 14.9%, 20.2%, 8.6%, 7.6%, and 6.4% of children aged 6 to 11, 12 to 23, 24 to 35, 36 to 47, 48 to 59, and 60 to 72 months, respectively. Prevalence increased with age for astigmatism (P < 0.001), but not for hyperopia or anisometropia (P = 0.55 and P = 0.37), respectively. CONCLUSIONS: The prevalences of myopia and astigmatism in young Singaporean Chinese children are high, but that of hyperopia is low. Age effects were observed for each refractive error category, but differences between the sexes were not significant. Age-related variation in myopia prevalence may be influenced by ocular development, environment, and/or testability.

Visual experience during phacoemulsification under topical anaesthesia: a nationwide survey of Singapore ophthalmologists.

BACKGROUND: All patients undergoing phacoemulsification under topical anaesthesia experience a variety of visual sensations that may be frightening in a small proportion of patients. This study evaluates Singapore ophthalmologists' knowledge and practices regarding patients' visual experience during phacoemulsification under topical anaesthesia. METHODS: A nationwide survey of all ophthalmologists in Singapore who had performed at least one cataract surgery within the last year was carried out. Questions regarding patients' experience were asked. Surgeons were also asked about patients' fear during surgery, usefulness of preoperative counselling and feedback from patients postoperatively. RESULTS: Of 105 ophthalmologists 89 responded, of which 44 performed phacoemulsification under topical anaesthesia. The percentage of respondents who thought that the patients experienced the various visual sensations were: no light perception (4.6%), light perception (97.7%), one or more colours (95.5%), flashes of light (77.3%), movements (90.9%), instruments (61.4%), surgeon's hands/fingers (56.8%), surgeon (47.7%) and change in brightness of light (90.9%). Although 52.3% of surgeons believed that patients may be frightened by their visual experience and 50.0% felt that preoperative counselling would be useful in reducing such fear, only 11.4% routinely offered preoperative counselling and 18.2% counselled their patients occasionally. In total, 50.0% ophthalmologists had patients who reported to them that they could see during surgery, whereas 20.5% had been told by patients that they were frightened by the visual experience. CONCLUSION: Despite the awareness of patients' visual experience and the belief that preoperative counselling may be useful, most ophthalmologists do not counsel their patients preoperatively.

Loop myopexy for treatment of myopic strabismus fixus.

In myopic strabismus fixus, there is acquired esotropia and hypotropia associated with restricted elevation and abduction. One possible etiology is an enlarged globe herniating superotemporally through the muscle cone. High-resolution magnetic resonance imaging (MRI) has demonstrated the inferolateral displacement of the lateral rectus (LR) muscle in this restrictive motility disorder. Surgical treatment is difficult. We report two cases of myopic strabismus fixus that were treated with a loop myopexy of the LR and superior rectus (SR) muscles.

Modulation transfer functions in children: pupil size dependence and meridional anisotropy.

PURPOSE: This study quantified preschool children's optical quality in terms of their aberrations and modulation transfer function (MTF), and examined the dependence of MTF on pupil size and grating orientation. METHODS: Aberrometry was used to measure Zernike coefficients in 34 Chinese preschool children (18 males, 16 females; aged 4.95-6.89 years; mean, 5.91 +/- 0.56). For each subject, after mathematical correction for refractive error, these wavefront errors were used to calculate MTF (lambda = 550 nm) for pupil sizes from 1 to 5 mm and for gratings at orientations in 15 degrees intervals. RESULTS: Aberrations were correlated between right and left eyes, for wavefront RMS and some Zernike coefficients. Average aberrometry results showed that third-order terms predominated, in addition to some positive spherical aberration with an average higher order root mean square (RMS) of 0.20 micro m over a 5-mm pupil. Average MTFs were optimal for 3-mm pupil sizes at lower spatial frequencies (<69 cyc/deg) and slightly better than those found by similar techniques in young adults. Heights of MTFs were significantly related to higher order RMS (Spearman rho = -0.926). MTFs showed a small meridional anisotropy for 3-mm pupils, with average MTF for vertical gratings (horizontal modulation) being slightly, but significantly better than for horizontal gratings (vertical modulation). There was no evidence of an oblique effect in the optics of these children. CONCLUSIONS: In these children, ocular optical quality is pupil dependent, shows slight meridional anisotropy and is slightly better than that for young adults.