Long-term strabismus outcomes after unilateral infantile cataract surgery in the Infant Aphakia Treatment Study.

PURPOSE: To characterize long-term strabismus outcomes in children in the Infant Aphakia Treatment Study (IATS). METHODS: This study was a secondary data analysis of long-term ocular alignment characteristics of children aged 10.5 years who had previously been enrolled in a randomized clinical trial evaluating aphakic management after unilateral cataract surgery between 1 and 6 months of age. RESULTS: In the IATS study, 96 of 109 children (88%) developed strabismus through age 10.5 years. Half of the 20 children who were orthophoric at distance through age 5 years maintained orthophoria at distance fixation at 10.5 years. Esotropia was the most common type of strabismus prior to age 5 years (56/109 [51%]), whereas exotropia (49/109 [45%]) was the most common type of strabismus at 10.5 years (esotropia, 21%; isolated hypertropia, 17%). Strabismus surgery had been performed on 52 children (48%), with 18 of these (35%) achieving microtropia <10Δ. Strabismus was equally prevalent in children randomized to contact lens care compared with those randomized to primary intraocular lens implantation (45/54 [83%] vs 45/55 [82%]; P = 0.8). Median visual acuity in the study eye was 0.56 logMAR (20/72) for children with orthotropia or microtropia <10Δ versus 1.30 logMAR (20/400) for strabismus ≥10Δ (P = 0.0003). CONCLUSIONS: Strabismus-in particular, exotropia-is common irrespective of aphakia management 10 years following infant monocular cataract surgery. The delayed emergence of exotropia with longer follow-up indicates a need for caution in managing early esotropia in these children. Children with better visual acuity at 10 years of age are more likely to have better ocular alignment.

Nonsurgical treatment of teenagers with high AC/A ratio esotropia.

Nonsurgical treatment options commonly prescribed for teenagers with high AC/A ratios are progressive lens spectacles, single vision lens spectacles, bifocal contact lenses, and monovision. The gold standard treatment for high AC/A ratios in patients with esotropia is bifocal spectacles, but they are not cosmetically acceptable for most teenagers. However, excellent binocularity is often sacrificed with the alternative treatment options. Quality of life surveys acknowledge that poor cosmesis can have a negative psychosocial impact on individuals. Therefore, it is often necessary for practitioners to strike a balance between good psychosocial health and best visual potential with treatment options other than bifocal spectacles.

The efficacy of botulinum toxin treatment for children with a persistent esotropia following bilateral medial rectus recessions and lateral rectus resections.

BACKGROUND AND PURPOSE: To report on the outcomes of treating children with a persistent esotropia with an injection of botulinum toxin in a medial rectus muscle. PATIENTS AND METHODS: The medical records were reviewed of all children at one institution with a persistent esotropia after bilateral medial rectus recessions and bilateral lateral rectus resections then treated with a botulinum toxin injection. RESULTS: Five patients with a mean preoperative esotropia of 37Δ (range 25­50Δ) underwent bilateral medial rectus recessions and then bilateral lateral rectus resections. Their residual esotropia (mean of 25Δ; range 18­35Δ) was then treated with a single injection of 3­5 units of botulinum toxin into one medial rectus muscle. The patients were then followed for a mean of 34 months (range 14­79 months). At last follow-up, two patients had an esotropia <10Δ. The other three patients had no long-term improvement in their ocular alignment. Two of these patients then underwent additional strabismus surgery. In both cases, they then developed a consecutive exotropia. CONCLUSION: Treatment with a single injection of botulinum toxin was beneficial in 2 of 5 children. Botulinum toxin treatment alone did not result in a consecutive exotropia in any patients treated.

Development of a vision-related quality of life instrument for children ages 8-18 years for use in juvenile idiopathic arthritis-associated uveitis.

OBJECTIVE: To determine the validity and reliability of a novel questionnaire to measure vision-related quality of life (VRQOL) in children ages 8-18 years for use in juvenile idiopathic arthritis (JIA)-associated uveitis: the Effects of Youngsters' Eyesight on Quality of Life (EYE-Q). METHODS: Several steps validated the EYE-Q. We interviewed experts and children on how vision affects a child's activities. We developed new items and selected relevant items from existing instruments. We administered initial versions of the EYE-Q to normal-sighted children and those with JIA-associated uveitis. For this study, children with various (or no) ocular conditions were recruited from a clinical population. Visual acuity and contrast sensitivity were performed, and the EYE-Q and Pediatric Quality of Life Inventory (PedsQL) were administered. The EYE-Q was repeated 10 days later. Patients, parents, and physicians rated vision severity. RESULTS: Of 120 patients, 48% were female, 46.7% had no visual impairment, and 53.3% had bilateral eye involvement. The mean age was 11.3 years. There were significant differences in the measures based on visual acuity (P < 0.001). Children with more severe visual acuity and bilateral eye involvement had worse EYE-Q scores (P < 0.001). There were significant associations between the EYE-Q and PedsQL (r = 0.375), repeat EYE-Q (r = 0.864), and clinical measures of ocular disease (r = -0.620). CONCLUSIONS: Our study provides evidence of the validity and reliability of the EYE-Q in the measurement of VRQOL. The EYE-Q may complement clinical measures of visual impairment and overall QOL and become an important tool in the assessment of QOL in JIA-associated uveitis.

Vision therapy and orthoptics.

Vision therapy by orthoptists is a form of treatment to restore binocular single vision and to enhance the control of a deviation using prisms and convergence therapy. It is differentiated from optometric behavioral vision therapy (BVT) as a form of treatment to decrease rates ofjuvenile recidivism and to improve learning disabilities using colored overlays and tools such as trampolines. Evidence-based findings of randomized controlled clinical trials versus conclusions drawn from nonrandomized, poorly controlled studies of various forms of vision therapy are explored. Concrete evidence in the mainstream literature supports the positive effects of eye exercises in patients with convergence insufficiency and yoked prisms in patients with neurologic deficits. Vision therapy for juvenile delinquents and patients with dyslexia is unsubstantiated.

High AC/A ET: Bifocals? Surgery? Or Nothing at All?

INTRODUCTION: Bifocals have been the standard of care for pure high AC/A esotropia for over 100 years, though surgery for the near esotropia is being offered more and more frequently. There has been no long term study comparing the effects of bifocals and surgery with a control group prescribed single vision lenses for the distance hyperopia. PURPOSE: This study compares the effects of these three treatment strategies on magnitude and control of the near angle, distance-near disparity, gradient AC/A ratio, binocular vision, and refractive error over a minimum follow-up interval of five years. METHODS: Patients with "pure" accommodative esotropia with a high AC/A were given the option of surgery, bifocals, or single vision hyperopic lenses. All were followed a minimum of five years with sensorimotor exams and cycloplegic refraction. RESULTS: Patients managed with bifocals or single vision lenses experienced a 5(Δ) reduction in the near esotropia, with no corresponding decrease in gradient AC/A. Patients in the Bifocal Group were less likely to undergo emmetropization, and tended to an increase in the gradient AC/A with time. Surgery resulted in a significant reduction of the near angle and collapse of the distance-near disparity. The surgical reduction of the AC/A ratio was not permanent. More patients lost stereoacuity in the Surgery Group than in the other two Groups combined. Approximately one-third of patients in each of the three treatment groups achieved long-term success, though success was achieved at a significantly earlier age in the Surgery Group. CONCLUSION: Any of the three treatments can be effective if used under the right circumstances, though each has unique benefits and the potential for undesirable sequelae.