STRABISMUS UPDATE LIONEL KOWAL PERTH NOVEMBER 2007.

STRABISMUS UPDATE

LIONEL KOWAL

PERTH

NOVEMBER 2007

Weird diplopia22yo WCF with hyperopic astigmatism OU, L ET 20∆, L

amblyopia 20/100 part. Some latent nystagmus. With L fixation has R DVD. No previous strabismus surgery.Epilepsy as a child.

With recess / resect is improved to straight for distance, ET' 8∆.

Now complains of crossed diplopia for objects on

her L - they are seen to her far R.

Weird diplopia 2When the L is straightened, she has an

expanded field to the LShe is aware that the L visual field is expanded,

but that it is blurred. This new expanded field has ARC and is the source of her diplopia!.

Beware of weird sensory responses in pts with childhood strabismus who have late surgery

Good news: better after 4-5 mo

REFRACTIVE FINDINGS IN CHILDREN WITH ASTIGMATIC PARENTS: THE SYDNEY MYOPIA STUDY AMER J OPHTH 8/07

1741 6yo [231 astigmats] 2367 12 yo [237 astigmats] Cyclo autorefraction Parents: glasses scripts NO statistical relationship

Objectively monitored patching regimens for treatment of amblyopia: randomised trial

Fielder AR ….. ROTAS Cooperative. Department of Optometry and Visual Science, City University, London

Compare visual outcome to two prescribed rates of occlusion (6 & 12 h/d).

97 children with amblyopia due to strabismus &/or anisometropia

Rx: 18 w of wearing gls (refractive adaptation) then occlusion prescribed for 6 or 12 h/d


OUTCOMES: VA & objectively monitored rate of occlusion (h/d).

RESULTS: Change in VA of amblyopic eye not significantly different (P=0.64) between the two groups (0.26 log units in 6h group; 0.24 log units in 12h group).

h/d actually received not significantly different (4.2 in 6h group v 6.2 in 12h group; P=0.06).


Visual outcome similar for children who received >3h/d day [up to 12] & better than children who received <3h/d.

Children aged < 4 required significantly less occlusion than older children.

Visual outcome not influenced by type of amblyopia.

Apparently ≠ PEDIG

AAPOS 2007 Costenbader Lecture

"Natural History of Treated Childhood Intermittent XT”

Dr John [Jack] Baker 20y follow-up study of 30 pts with childhood XT 21 required 1 surgery, 7 required 2 surgeries, and 3 required > 2

surgeries. Patients who required >1 surgery: 6 had recurrent XT, 1 consecutive ET. The level of stereopsis decreased as the number of surgeries increased.

Patients requiring only 1 surgery had excellent stereopsis; those requiring 2 had some stereopsis; and those requiring > 2 surgeries had none.

In patients with recurrent strabismus, surgery was typically performed by the teen years; patients who were stable into their teens tended to stay that way.

Visual function and ocular features in children and adolescents with attention deficit hyperactivity disorder, with and without treatment with stimulants.

Eye. 2007 Apr;21(4):494-502. Grönlund MA, … Göteborg, Sweden.

42 children (37 boys) with AD/HD with /& -out stimulants, mean age 12y, c.f. reference group (n=50; mean age 11.9y; 44 boys).

RESULTS: VA: 83% had visual acuity of >0.8 (<0.1 logMAR)

without treatment, 90% with stimulants (ref 98%; P=0.032 and n.s., respectively).

Visual function and ocular features in children and adolescents with ADHD

Heterophoria in 29% without, and in 27% with, stimulants (ref 10%; P=0.038 and n.s., respectively)

Subnormal stereovision (>60 s of arc) in 26% (ref 6%; P=0.016) without stimulants, and in 27%, with (P=0.014).

Abnormal convergence (>6 cm or absent) in 24% (ref 6%; P=0.031) without treatment and in 17% with (n.s.).

Astigmatism (> or =1.0 D) in 24% (ref 6%; P=0.03) Signs of visuoperceptual problems in 21% (ref 2%;

P=0.007).

Visual function and ocular features in children and adolescents with ADHD…

Smaller optic discs (n=8/38) and neuroretinal rim areas (n=7/38) (P<0.0001) and decreased tortuosity of retinal arteries (n=6/34) (P=0.0002) than controls.

CONCLUSIONS: Children with AD/HD had a high frequency of ophthalmologic findings, which were not significantly improved with stimulants.

They presented subtle morphological changes of the optic nerve and retinal vasculature, indicating an early disturbance of the development of these structures.

Infant Hyperopia: Detection, Distribution, Changes and Correlates.

Outcomes From the Cambridge Infant Screening Programs ATKINSON, J; BRADDICK, O; et alii. London & OxfordAmerican Academy of Optometry Volume 84(2),February 2007,pp 84-96

2 screening programs to detect significant refractive errors in >8000 8-9 mo infants, examine sequelae of infant hyperopia, and test whether early partial spectacle correction improved visual outcome (strabismus and acuity).

2nd program: also examined whether infant hyperopia was associated with developmental differences across various domains such as language, cognition, attention, and visuomotor competencies up to age 7y.

Infant Hyperopia: Detection, Distribution, Changes and Correlates.

Outcomes From the Cambridge Infant Screening Programs

#1: orthoptic examination and isotropic photorefraction, with cycloplegia.

#2: no cycloplegia. Hyperopic infants (≥+4D) were followed up

alongside an emmetropic control group, with visual and developmental measures up to age 7y, and entered a controlled trial of partial spectacle correction.

Cambridge Infant Screening Programs RESULTS

#2 : accommodative lag with a target at 75 cm (focus ≥+1.5 D) was a marker for significant hyperopia.

In each program, prevalence of significant hyperopia at 9 to 11 mo was around 5%

Infant hyperopia : increased strabismus at 4y.Manifest strabismus was 0.3% at 9 mo and 2% by school age. Infant hyperopia : poor acuity at 4y. The hyperopic group showed poorer overall performance than

controls between 1 - 7 y on visuoperceptual, cognitive, motor, and attention tests …… no consistent differences in early language or phonological awareness.

Cambridge Infant Screening Programs RESULTS….continued

Spectacle wear by infant hyperopes : better visual outcome than uncorrected infants. Improvement in

strabismus with spectacle wear was found in the first program only. .. did not affect emmetropization to 3.5y. Both corrected and uncorrected groups remained more hyperopic

than controls in the preschool years.Conclusions. Visual outcomes may be improved by early

refractive correction. Infant hyperopia is associated with mild delays

across many aspects of visuocognitive and visuomotor development.

Eye advance online publication 2 February 2007

Ethnic differences in refraction and ocular biometry in a population-based sample of 11–15-year-old Australian childrenJ M Ip1, …. P Mitchell Sydney

2353 students (75% response) from a random cluster-sample of 21 secondary schools across Sydney.

Examinations included cycloplegic autorefraction, Ks, AC depth, and axial length.

Ethnic differences in refraction and ocular biometry in a population-based sample of 11–15-year-old Australian children

Participants mean age was 12.7 y (range 11-14); 49% female.

60% European Caucasian ethnicity, 15% East Asian, 7% Middle Eastern, and 5% South Asian.

The most frequent refractive error was mild hyperopia (59%), [SE +0.50 - +1.99D].

Myopia (≤-0.5D) was found in 12%, Moderate hyperopia (+2D) in 3.5%.

Ethnic differences in refraction and ocular biometry in a population-based sample of 11–15-year-old Australian children

Myopia prevalence was lower among European Caucasian children (5%) and Middle Eastern children (6%) than among East Asian (40%) and South Asian (32%) children.

European Caucasian children had the most hyperopic mean SE (+0.8D) and shortest mean axial length (23.2mm). East Asian children had the most myopic mean SE (-0.7D) and greatest mean axial length (23.9mm).

Conclusions The overall myopia prevalence in this sample was lower than in

recent similar-aged European Caucasian population samples. East Asian children in our sample had both a higher prevalence of

myopia and longer mean axial length.

Prevalence of Hyperopia and Associationswith Eye Findings in 6- and 12-Year-OldsJenny M. Ip, MBBS,1 … Paul Mitchell, MD, PhD1

Ophthalmology 2007;xx:xxx © 2007 by the American Academy of Ophthalmology.

Purpose: To describe the prevalence of hyperopia and associated factors in a representative sample of Australian schoolchildren 6 and 12 years old.

Participants: Schoolchildren ages 6 (n 1765) and 12 (n 2353) from 55 randomly selected schools across Sydney.

Methods: Detailed eye examinations included cycloplegic autorefraction, ocular biometry, cover testing, and dilated fundus examination. Information on birth and medical history were obtained from a parent questionnaire.

Main Outcome Measures: Moderate hyperopia defined as spherical equivalent refraction of 2D), and eye conditions including amblyopia, strabismus, astigmatism, and anisometropia.

Prevalence of Hyperopia and Associationswith Eye Findings in 6- and 12-Year-Olds…2

Results: Prevalences of moderate hyperopia among children ages 6 and 12 were 13.2% and 5.0% respectively

It was more frequent in children of Caucasian ethnicity (15.7% and 6.8%, respectively) than in children of other ethnic groups.

Compared with children without significant ametropia, the prevalence of eye conditions including amblyopia, strabismus, abnormal convergence, and reduced stereoacuity was significantly greater in children with moderate hyperopia (all Ps 0.01).

Maternal smoking was significantly associated with moderate hyperopia among 6-year-olds (P 0.03), but this association was borderline among 12-year-olds (P 0.055).

Smoking and hyperopiaPRELIMINARY ANALYSIS ON FIRST 70 Q'AIRES 8 pts with mild hyperopia have either

parent a smoker,23 didn't. 16 pts with mod hyperopia (>+2) have

either parent a smoker and 20 didn't. The odds of having either parent a

smoker is 2.3 times higher for kids with moderate hyperopia than those with mild hyperopia

Longitudinal changes in the spherical equivalent refractive error of children with accommodative esotropiaS R Lambert…. Atlanta, GA, USA

British Journal of Ophthalmology 2006;90:357-361

Longitudinal changes in spherical equivalent (SE) refractive errors of children with accommodative ET as a function of the age when glasses were prescribed.

126 children with AET followed longitudinally for 4.4 (SD 2.5) years.

Cycloplegic refractions were performed using autorefractor for older children and retinoscopy for younger children.

The refractive data were analysed for three groups of children based on their age at the time spectacles were prescribed.

Longitudinal changes in the spherical equivalent refractive error of children with accommodative esotropiaRESULTS…..

The initial SE refractive error was age dependent <2y +5.1 (1.9) D 2- <4y +4.2 (1.9) D 4-8y, +3.8 (1.7) D. All ages : initial increase in refractive error, followed by later

decrease. Greatest decrease in oldest age group. Refractive error peaked 1y after glasses prescribed for

children 4-8y vs...... 6y after glasses prescribed for children < 2y.

Conclusion: Longitudinal changes in refraction for children with accommodative ET vary as a function of age when glasses wear is initiated.

Interesting pt #2 .1

2007: 31.

2004: i-mitt dip, L ET. Wearing +4 DS EWSCLs. Childhood occlusion.

ET 30. UG 40, DG 25. E’ 25 [adapts to >35 without X]. SOOA / F intorsion.

Cyclo: some latent +

Interesting pt #2. 2

2007: wants Sx for ET & diplopia. Wants to look better sc.

cc ET 20+,ET’ 18. sc 45 ACA 45-20+/4= 5+ Cut + by +1.25: ET 30 Plan: largest surgery that will not give

diplopia while wearing 1.25 less than MR [& bilateral sup obl weakening]

Interesting pt #2.3 Day 2: little / no ET/ ET’ sc/ cc Day 5: sc ET 10, ET’ 12, A 8 Week 3 Peter McClurg : slight myopic

shift. sc ET/ ET’ 6-7. cc E/E’ 3. 100” Month 2 PMc: small E sc/cc. UG E4, E’8.

Diplopia on RG. cc 80”, sc 100”. Intermitt use of CLs.

Management of Childhood Hyperopia: A Pediatric Optometrist's Perspective

COTTER, SUSAN A. California American Academy of Optometry Volume 84(2),February 2007, pp 103-109

Variations in prescribing patterns for childhood + occur within & between optometry & ophthalmology.

Differences : due to a greater level of concern among optometrists about associated vision functions such as accommodation, vergence, & stereopsis, & potential impact of uncorrected + on reading & school performance.

Conclusions. If indications for prescribing spectacles for children with hyperopia are to be validated, randomized controlled trials need to be performed.


Survey 1: Prescribing for bilateral

asymptomatic + in young children

65% of pediatric optometrists use +3 D of bilateral hyperopia as their prescribing threshold for 2yo.

28% used a higher threshold with 25% using +5 D as their threshold.

Pediatric ophthalmologists: 66% use +5D as their threshold. 25% use a +3D threshold.

Survey 2: What magnitude of + in asymptomatic children should be referred in a vision screening because it is worrisome

College of Optometrists in Vision Development (COVD) & American Association of Pediatric Ophthalmology and Strabismus (AAPOS)

COVDAAPOS

Months

+3.5+50-6

+3+46-24

+2,5+424-30

+2+430-48


Hyperopic children who have strabismus and/or amblyopia Teachings of Donders (1864) and Worth (1903) used

similarly within both professions maximum + to produce alignment in ET, full amounts of correction for anisometropia and

astigmatism to provide equal retinal image clarity between the eyes,

symmetrically reduced + prescriptions when needed to ensure or promote acceptance of spectacles.

Greatest prescribing variability: children ≤12 y who have approximately equal + in the 2 eyes with neither strabismus nor amblyopia.

Ocular Dominance Diagnosis and Its Influence in Monovision Olga Seijasa … Pilar Gomez de Liano, Rosario Gomez de Liano, …American Journal of Ophthalmology Volume 144, Issue 2, August 2007, Pages 209-216

9 different tests were carried out in a group of 51 emmetropic subjects to determine both motor and sensory ocular dominance.

For analysis, patients were divided into 2 groups according to age.

Normal ophthalmologic examination results were the inclusion requirement, with normal binocular vision and good stereoacuity.

Ocular Dominance Diagnosis and Its

Influence in Monovision RESULTS

A significant % of uncertain or ambiguous results in all tests performed was found, except in the hole-in-card and kaleidoscope tests.

When the tests were compared, two by two, the correlation or equivalence found was low and was much lower if tests were compared three by three.

No clear ocular dominance was found in most studied subjects; instead, there must be a constant alternating balance between both eyes in most emmetropic persons, but not in those with pathologic features. This fact would explain the great variability both between and within different kinds of tests.

Ocular Dominance Diagnosis and Its

Influence in Monovision RESULTS

Also, it would explain why monovision technique is well tolerated in most patients, with unsuccessful results only in those patients with strong or clear dominance.

…. it seems appropriate to evaluate patient’s dominance before monovision surgery to exclude those individuals with clear dominance.

Association between fixation preference testing and strabismic pseudoamblyopia Hakim OM Saudi Arabia J Pediatr Ophthalmol Strabismus. 2007 May-Jun;44(3):174-7

.. to evaluate the strength of the association between fixation preference and strabismic amblyopia.

80 pts (3 to 8y) with manifest strabismus and ability to do a Snellen E test ….

Fixation preference was graded from 0 (free alternation) to 3 (strong uniocular fixation).

We compared acuity and the grade of fixation preference.

Association between fixation preference testing and strabismic pseudoamblyopia RESULTS

60 pts had strong uniocular fixation (grade 3). Of these patients, 50 had no amblyopia and only 10 had deep amblyopia.

10 pts had moderate fixation (grades 1 and 2). Of these patients, 5 had no amblyopia and 5 had moderate amblyopia.

10 patients had free alternation (grade 0). These patients had equal vision.

Treatment of strabismic amblyopia on the basis that the sound eye will show strong fixation preference can be hazardous. Fixation preference could be a severe form of eye dominance

Age at strabismus diagnosis in an incidence cohort of children.Mohney BG, …. Mayo Clinic, Minnesota Am J Ophthalmol. 2007 Sep;144(3):467-

9 Medical records of all Olmsted County,

Minnesota, residents < 19 y diagnosed with ET, XT or hypertropia from 1985-94 reviewed.

The median age at diagnosis of esotropia (n = 380) : 3.1y exotropia (n = 205): 7.2y hypertropia (n = 42) : 6.1y (P = .001).

Age at strabismus diagnosis in an incidence cohort of children.

First 6 y, ET had highest incidence

XT predominated age 7-12. Each form similarly likely to

occur 13 -18 y P = .001

Common forms of childhood strabismus in an incidence cohort.Mohney BG. Mayo Clinic

Am J Ophthalmol. 2007 Sep;144(3):465-7.

Medical records of all Olmsted County, Minnesota, residents < 19 y with ET, XT or hypertropia 1985 - 94. 627 new cases of childhood strabismus identified

ET 380 (60%)

accomm 28%, nonaccomm 10%, neurological 7%, XT 205 (33%)

I-mitt 17%, convergence insufficiency 6% Hypertropia 42 (7%).

Refractive effect of the horizontal rectus muscle recession

Int Ophthalmol. 2007 Jul 19 Rajavi Z, …. Tehran, Iran

49 eyes of 27 patients : (1) XT (24 eyes) - LR (s) Rc(2) ET (25 eyes) who underwent MR (s) Rc. Full ophthalmic examination including cycloplegic

automated refraction before, 1 & 3 mo after surgery.

Corneal topography preoperatively, repeated 3 mo postop.


MR Rc: statistically significant myopic shifts @ mo 1 (from + 2.09 +/- 1.82 to + 1.88 +/- 1.83 DS, P = 0.03)

,,, in astigmatic power @ both mo 1 (from -0.85 +/- 0.67 to -1.15 +/- 0.65 DC, P = 0.04) and mo 3 (from -0.85 +/- 0.67 to -1.16 +/- 0.65 DC, P = 0.01).

LR Rc: Myopic shifts not statistically meaningful.

…Significant astigmatic axis shift, which was toward with the rule astigmatism @ both mo 1 (P = 0.02) and mo 3 (P = 0.02).


Corneal power measured by topography : statistically significant reduction (less than 0.3 D) after recession of either MR(P < 0.001) or LR (P < 0.001). Amounts of refractive and corneal topographic changes were not clinically remarkable.

Therefore, it does not seem necessary to perform cycloplegic refraction early after horizontal rectus muscle recession; however, a precise refraction in all cases of strabismus should not be deferred later than 3 months.

STRABISMUS UPDATE LIONEL KOWAL PERTH NOVEMBER 2007.

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