Interventions for infantile esotropia.

BACKGROUND: Infantile esotropia (IE) is the inward deviation of the eye. Various aspects of the clinical management of IE are unclear; mainly, the most effective type of intervention and the age at intervention. OBJECTIVES: To examine the effectiveness and optimal timing of surgical and non-surgical treatment options for IE to improve ocular alignment and achieve or allow the development of binocular single vision. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, one other database, and three trials registers (November 2021). We did not use any date or language restrictions in the electronic searches for trials.  SELECTION CRITERIA: We included randomized trials and quasi-randomized trials comparing any surgical or non-surgical intervention for IE. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology and graded the certainty of the body of evidence for six outcomes using the GRADE classification. MAIN RESULTS: We included two studies with 234 children with IE. The first study enrolled 110 children (mean age 26.9 ± 14.5 months) with an onset of esotropia before six months of age, and large-angle IE defined as esotropia of ≥ 40 prism diopters. It was conducted between 2015 and 2018 in a tertiary care hospital in South Africa. It compared a maximum of three botulinum toxin injections with surgical intervention of bimedial rectus muscle recession, and children were followed for six months. There were limitations in study design and implementation; the risk of bias was high, or we had some concerns for most domains.  Surgery may increase the incidence of treatment success, defined as orthophoria or residual esotropia of ≤ 10 prism diopters, compared with botulinum toxin injections, but the evidence was very uncertain (risk ratio (RR) of treatment success 1.88, 95% confidence interval (CI) 1.27 to 2.77; 1 study, 101 participants; very low-certainty evidence). The results should be read with caution because 23 children with > 60 prism diopters at baseline in the surgery arm also received botulinum toxin at the time of surgery to augment the recessions. There was no evidence of an important difference between surgery and botulinum toxin injections for over-correction (> 10 prism diopters) of deviation (RR 0.29, 95% CI 0.06 to 1.37; 1 study, 101 participants; very low-certainty evidence), or additional interventions required (RR 0.66, 95% CI 0.36 to 1.19; 1 study, 101 participants; very low-certainty evidence). No major complications of surgery were observed in the surgery arm, while children experienced various complications in the botulinum toxin arm, including partial transient ptosis in 9 (16.7%) children, transient vertical deviation in 3 (5.6%) children, and consecutive exotropia in 13 (24.1%) children. No other outcome data for our prespecified outcomes were reported.  The second study enrolled 124 children with onset of esotropia before one year of age in 12 university hospitals in Germany and the Netherlands. It compared bilateral recession with unilateral recession surgeries, and followed children for three months postoperatively. Very low-certainty evidence suggested that there was no evidence of an important difference between bilateral and unilateral surgeries in the presence of binocular vision (numbers with event unclear, P = 0.35), and over-correction (RR of having exotropia 1.09, 95% CI 0.45 to 2.63; 1 study, 118 participants). Dissociated vertical deviation, latent nystagmus, or both were observed in 8% to 21% of participants. AUTHORS' CONCLUSIONS: Medial rectus recessions may increase the incidence of treatment success compared with botulinum toxin injections alone, but the evidence was very uncertain. No evidence of important difference was found between bilateral surgery and unilateral surgery.  Due to insufficient evidence, it was not possible to resolve the controversies regarding type of surgery, non-surgical intervention, or age of intervention in this review. There is clearly a need to conduct good quality trials in these areas to improve the evidence base for the management of IE.

Characteristics of babies with unstable clinical course screened for retinopathy of prematurity.

The medical records of 2,457 infants screened and staged for retinopathy of prematurity (ROP) at the University of Colorado Hospital and Children's Hospital Colorado between 2006 and 2021 were reviewed to identify those with "unstable clinical course," that is, babies who did not meet the published birthweight (BW) or gestational age (GA) screening criteria but for whom an ROP examination was requested by the treating neonatologist. A total of 146 infants (5.9%) with unstable clinical course were identified and found to be similar to infants meeting the BW/GA criteria for ROP screening in terms of sex, race/ethnicity, and singleton/multiple birth. Four of the unstable clinical course babies (2.7%) developed mild ROP; none developed type 1 or type 2 ROP. Rates of ROP were higher among babies meeting the BW/GA criteria, in which 6.9% developed type 1, 6.2% type 2, and 22.2% mild ROP (P < 0.0001). Overall, infants with unstable clinical course and screened for ROP did not develop treatment-requiring ROP.

Ocular Disorders in the Newborn.

Visual development begins at birth and continues throughout childhood. Ocular pathology can lead to permanent visual impairment and subsequent problems in overall development and school performance as well as signify serious systemic disease or even life-threatening malignancies. Prompt identification of congenital or early acquired ocular pathology via regular bedside ocular examinations and assessments of visual behaviors by neonatal clinicians is a critical component of newborn care. The goal of this article is to review the components of the newborn eye examination, describe key ocular findings and diagnoses that are common or critical to identify in the newborn period, and offer guidance on necessity and timing of ophthalmology referral.

A cumulative risk index for use in the medical home.

BACKGROUND AND OBJECTIVE: Previous studies have described the effect of sociodemographic factors on early development. We describe development of a simple cumulative risk index (CRI) based on four sociodemographic factors and explore the concurrent and predictive relationship of this index to a measure of the cognitive home environment in early childhood and to later school functioning. METHODS: This was a secondary data analysis of children from an urban pediatrics clinic. Baseline data were collected at 10-23 months (n = 324) with primary follow-up 6 months later at 18-35 months (n = 179) and secondary follow-up at 8-10 years (n = 68). A CRI score was derived at baseline using maternal education, marital status, race/ethnicity and child insurance. Baseline and primary follow-up included three subscales of the STIMQ, a measure of the cognitive home environment. Effectiveness of CRI was examined using analysis of variance (ANOVA) with linear contrasts. Chi-square examined differences in school function between children from CRI high-risk (CRI 3-4) and low-risk (CRI 0-2) families. RESULTS: CRI had a negative impact in early childhood on STIMQ subscale scores (p < 0.007-0.05) that increased as the number of risk factors increased (p < 0.05). Significantly more children from high-risk families (CRI 3-4) were rated as having poor school performance than children from low-risk families (CRI 0-2) (p < 0.05). CONCLUSIONS: We showed that a practice-friendly CRI, based on characteristics typically available in the medical record, could help identify families less likely to support development concurrently at 1 year of age and predictively at 2-3 years. School functioning at 8 to 10 years was also significantly better in children with a low CRI at 1 year. The CRI could be a useful tool for both clinicians and researchers needing a simple tool for risk assessment.

Trends in Retinopathy of Prematurity over 12 Years in a Colorado Cohort.

PURPOSE: To determine trends in retinopathy of prematurity (ROP) in a Colorado cohort between 2006 and 2017 and compare trends in risk factors between our cohort and statewide data. METHODS: A retrospective cohort study was conducted by the use of records from two registry databases: 1) an academic center's ROP registry, and 2) vital statistics birth data from the Colorado Department of Public Health and Environment (CDPHE). ROP was categorized as severe (type 1 or type 2), low grade (not type 1 or type 2), or no ROP. Other variables included in the analyses were gestational age and birth weight at delivery, and infant mortality. Trends over time were evaluated for both registry databases using generalized linear models. RESULTS: In our ROP registry cohort of 1,267 eligible infants, 134 (10.6%) developed severe ROP and 279 (22%) developed low-grade ROP. We found no overall trend in severe ROP rates (p = .23), and a decreasing trend in rates of low-grade ROP (p < .01) over the study period. Trends in gestational age, birth weight, and mortality rates remained stable during the study period in both the ROP registry and the CDPHE cohorts. CONCLUSION: The rate of severe ROP in our ROP registry cohort did not change over time. There was evidence of a decreasing trend in low grade ROP during the 12-year study period that was not explained by a change in the primary ROP risk factors in either the ROP registry cohort or the Colorado statewide data.

Ocular Findings in Pontine Tegmental Cap Dysplasia.

PURPOSE: To describe the ocular complications experienced by patients with pontine tegmental cap dysplasia (PTCD) and the management strategies used to care for these children. METHODS: Subjects with PTCD were recruited through social media advertisement and completed a survey gathering information on potential ocular problems related to the patient's PTCD disease and any current or previous treatments. RESULTS: Twenty-two patients or guardians completed the survey. Neurotrophic cornea was the most common ocular diagnosis (82%), followed by facial palsy (59%), dry eye syndrome (59%), and blepharitis (55%). Other diagnoses included cortical visual impairment (27%), strabismus (27%), amblyopia (18%), and nystagmus (18%). Common treatment modalities included lubricating eye drops (59%) or ointment (50%), contact lenses (14%), punctal plugs (27%), glasses (45%), and patching (18%). The most common surgical interventions were temporary or permanent tarsorrhaphy (64%) and amniotic membrane grafts (23%). In total, 68% of families reported self-injury to eyes and 91% reported the child to be primarily a visual learner. CONCLUSIONS: PTCD is a newly described, very rare disorder with a variety of vision-threatening ocular manifestations. It is essential that the ophthalmologist be aware of the potential for neurotrophic cornea because timely treatment could prevent corneal scarring, perforation, and blindness.

The ONE step initiative: quality improvement in a pediatric clinic for secondhand smoke reduction.

BACKGROUND AND OBJECTIVE: Although comprehensive smoking counseling to limit secondhand smoke (SHS) is widely endorsed, it is often not done. Published evaluations of brief and practical systems that improve screening and counseling to reduce SHS are limited. Our objective was to determine if a quality improvement activity around smoking counseling leads to changes in (1) medical assistant and pediatric provider assessment of smoking history and (2) smoking or other behaviors affecting children's SHS exposure. METHODS: In a large urban teaching clinic we assessed the ONE Step intervention, which included the following: (1) "Ask" (medical assistant asking whether caregivers smoke); (2) "Advise" (providers advising smoking outside and quitting if ready); (3) "Refer" (providers referring to the Colorado telephone QuitLine); and (4) electronic medical record prompts and required documentation regarding smoking. Medical assistant and provider assessments of smoking were evaluated with a chart review by using a pre-/posttest design. Caregiver behavior change was evaluated with a time-series survey that included assessment at baseline and follow-up via telephone at 6 and 12 months from study entry. RESULTS: ONE Step was associated with a statistically significant increase in Ask, Advise, and Refer documentation. Caregiver surveys showed that 97% found discussions of SHS with providers acceptable. Six- and 12-month follow-ups, respectively, showed that 14% and 13% of smokers reported quitting and that 63% and 70% of current smokers reported reduced SHS exposure. CONCLUSIONS: ONE Step was feasible to deliver in a busy outpatient setting, acceptable to families, and appears to have resulted in decreased exposure to SHS in our pediatric population.