Aaron M. Miller

Optical treatment of strabismic and combined strabismic-anisometropic amblyopia.

OBJECTIVE To determine visual acuity improvement in children with strabismic and combined strabismic-anisometropic (combined-mechanism) amblyopia treated with optical correction alone and to explore factors associated with improvement. DESIGN Prospective, multicenter, cohort study. PARTICIPANTS We included 146 children 3 to <7 years old with previously untreated strabismic amblyopia (n = 52) or combined-mechanism amblyopia (n = 94). METHODS Optical treatment was provided as spectacles (prescription based on a cycloplegic refraction) that were worn for the first time at the baseline visit. Visual acuity with spectacles was measured using the Amblyopia Treatment Study HOTV visual acuity protocol at baseline and every 9 weeks thereafter until no further improvement in visual acuity. Ocular alignment was assessed at each visit. MAIN OUTCOME MEASURES Visual acuity 18 weeks after baseline. RESULTS Overall, amblyopic eye visual acuity improved a mean of 2.6 lines (95% confidence interval [CI], 2.3-3.0), with 75% of children improving ≥ 2 lines and 54% improving ≥ 3 lines. Resolution of amblyopia occurred in 32% (95% CI, 24%-41%) of the children. The treatment effect was greater for strabismic amblyopia than for combined-mechanism amblyopia (3.2 vs 2.3 lines; adjusted P = 0.003). Visual acuity improved regardless of whether eye alignment improved. CONCLUSIONS Optical treatment alone of strabismic and combined-mechanism amblyopia results in clinically meaningful improvement in amblyopic eye visual acuity for most 3- to <7-year-old children, resolving in at least one quarter without the need for additional treatment. Consideration should be given to prescribing refractive correction as the sole initial treatment for children with strabismic or combined-mechanism amblyopia before initiating other therapies. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

A randomized trial comparing part-time patching with observation for children 3 to 10 years of age with intermittent exotropia

OBJECTIVE To determine the effectiveness of prescribed part-time patching for treatment of intermittent exotropia (IXT) in children. DESIGN Multicenter, randomized clinical trial. PARTICIPANTS Three hundred fifty-eight children 3 to <11 years of age with previously untreated (except for refractive correction) IXT and near stereoacuity of 400 seconds of arc or better were enrolled. Intermittent exotropia met the following criteria: (1) IXT at distance OR constant exotropia at distance and either IXT or exophoria at near; (2) exodeviation (tropia or phoria) of at least 15 prism diopters (PD) at distance or near by prism and alternate cover test (PACT); and (3) exodeviation of at least 10 PD at distance by PACT. METHODS Participants were assigned randomly either to observation (no treatment for 6 months) or to patching for 3 hours daily for 5 months, with a 1-month washout period of no patching before the 6-month primary outcome examination. MAIN OUTCOME MEASURES The primary outcome was deterioration at either the 3-month or the 6-month follow-up visit, defined as: (1) constant exotropia measuring at least 10 PD at distance and near by simultaneous prism and cover test, and/or (2) near stereoacuity decreased by at least 2 octaves from baseline, both assessed by a masked examiner and confirmed by a retest. Participants who were prescribed any nonrandomized treatment without first meeting either deterioration criteria also were counted as having deteriorated. RESULTS Of the 324 participants (91%) completing the 6-month primary outcome examination, deterioration occurred in 10 of the 165 participants (6.1%) in the observation group (3 of these 10 started treatment without meeting deterioration criteria) and in 1 of the 159 participants (0.6%) in the part-time patching group (difference, 5.4%; lower limit of 1-sided exact 95% confidence interval, 2.0%; P = 0.004, 1-sided hypothesis test). CONCLUSIONS Deterioration of previously untreated childhood IXT over a 6-month period is uncommon with or without patching treatment. Although there is a slightly lower deterioration rate with patching, both management approaches are reasonable for treating children 3 to 10 years of age with IXT.

Acquired cataracts after diode laser photocoagulation for threshold retinopathy of prematurity

PURPOSE To report the incidence of acquired cataract after diode laser photocoagulation for threshold retinopathy of prematurity at our institution. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS One hundred fifty-three infants (293 eyes) with threshold retinopathy of prematurity. INTERVENTION Transpupillary diode laser photocoagulation. MAIN OUTCOME MEASURE Acquired cataract formation. RESULTS One cataract (0.003%) in 293 eyes occurred after transpupillary diode laser photocoagulation. This cataract consisted of peripheral cortical punctate lenticular opacities that were not progressive or visually significant. CONCLUSIONS The risk of acquired cataract after transpupillary diode laser photocoagulation for threshold retinopathy of prematurity is low. Transpupillary diode laser photocoagulation may be safer than argon laser photocoagulation for treatment of threshold retinopathy of prematurity.

A Randomized Trial of Levodopa as Treatment for Residual Amblyopia in Older Children

OBJECTIVE To assess the efficacy and short-term safety of levodopa as adjunctive treatment to patching for amblyopia. DESIGN Randomized, placebo-controlled trial. PARTICIPANTS One hundred thirty-nine children 7 to 12 years of age with residual amblyopia resulting from strabismus, anisometropia, or both combined (visual acuity [VA], 20/50-20/400) after patching. METHODS Sixteen weeks of oral levodopa or placebo administered 3 times daily while patching the fellow eye 2 hours daily. MAIN OUTCOME MEASURES Mean change in best-corrected amblyopic-eye VA at 18 weeks. RESULTS At 18 weeks, amblyopic-eye VA improved from randomization by an average of 5.2 letters in the levodopa group and by 3.8 letters in the placebo group (difference adjusted for baseline VA, +1.4 letters; 1-sided P=0.06; 2-sided 95% confidence interval, -0.4 to 3.3 letters). No serious adverse effects from levodopa were reported during treatment. CONCLUSIONS For children 7 to 12 years of age with residual amblyopia after patching therapy, oral levodopa while continuing to patch 2 hours daily does not produce a clinically or statistically meaningful improvement in VA compared with placebo and patching.

Office probing for treatment of nasolacrimal duct obstruction in infants

PURPOSE To determine whether demographic or clinical factors are associated with the outcome of office-based nasolacrimal duct probing for the treatment of congenital nasolacrimal duct obstruction (NLDO). METHODS In two multicenter prospective studies, 384 eyes of 304 children aged 6 to <15 months with NLDO underwent a nasolacrimal duct probing performed in the office using topical anesthesia. Treatment success, defined as no clinical signs of NLDO (epiphora, increased tear lake, or mucous discharge) and no reoperation, was assessed 1 month after probing in one study and 6 months after probing in the other study. Data from both studies were pooled to evaluate associations between baseline characteristics and treatment success. RESULTS Office probing was successful in 75% of eyes overall (95% CI, 70%-80%). The procedure was less successful in eyes of children with bilateral NLDO compared with unilateral NLDO (63% vs 80%; relative risk = 0.78 [95% CI, 0.66-0.92]) and in eyes that had 2 or 3 clinical signs of NLDO compared with one (71% vs 83%; relative risk = 0.88 [95% CI, 0.81-0.96]). Treatment success did not appear to be related to age, specific clinical signs of NLDO, prior treatment, or research study. CONCLUSIONS Performing nasolacrimal duct probing in the office successfully treats NLDO in the majority of cases in children aged 6 to <15 months. The success rate is lower with bilateral disease or when more than one clinical sign of NLDO is present.

Infantile Orbital Cellulitis

Dear Editor: Although orbital cellulitis can affect all age groups, it is more common in children than in adults. Children are particularly susceptible to serious complications such as optic neuropathy, endophthalmitis, meningitis, and brain abscess, due to their weakened immune system, and these complications can lead to vision loss and death. Before the introduction of the HiB vaccine in 1985, Haemophilus influenzae was the most common pathogen isolated in patients with orbital cellulitis. Recent studies, however, have demonstrated that the organisms currently responsible for pediatric orbital cellulitis are more frequently Staphylococcus aureus and Streptococcus pyogenes. The present study was designed to report on the presentation, etiology, computed tomography findings, and treatment outcome of infants admitted to a tertiary-care children’s hospital with a presenting diagnosis of orbital cellulitis. The inpatient records of all patients younger than 1 year treated for orbital cellulitis between December 2001 and September 2005 at Texas Children’s Hospital in Houston were reviewed. A total of 9 cases of infantile orbital cellulitis were identified that met study criteria. Average age at presentation was 3.8 months (range, 1.0–8.9). Presenting signs and symptoms of fever, periorbital edema, and periorbital erythema were noted in all 9 cases. Reduced appetite was noted in 6 patients, and lethargy was reported in 1 case. Just over half of the patients in our series (5/9 [55.6%]) responded to the intravenous antibiotics and did not require surgical management. A total of 4 patients required surgical drainage of a subperiosteal abscess with or without drainage of the sinuses. Ethmoid sinusitis was the source of infection in all of our cases. All but one of our patients had either a phlegmon or subperiosteal abscess adjacent to the medial rectus muscle on radiographic evaluation. This is consistent with previous studies that have demonstrated that ethmoid sinusitis accounts for more than 90% of all reported cases. Other causes of orbital cellulitis besides sinusitis include trauma and dental infections. We found Staphylococcus species to be the most common pathogen in our infantile orbital cellulitis patients, with methicillin-resistant S. aureus (MRSA) being identified in the cultures of 4 of 9 (44.4%) cases. Additional studies have found similar trends in the incidence of culture-positive MRSA in the general population within recent years. Specifically, a recent epidemiological analysis of data obtained from the National Health and Nutrition Examination Survey found that 31.6% of the United States population is colonized with Staphylococcus and that 0.84% carry MRSA. Moreover, a study of pediatric patients in the Houston area found that MRSA accounted for 67% of community-associated S. aureus infections among hospitalized patients. A study by Garcia and Harris of 9-year-olds with orbital cellulitis concluded that, in the absence of the symptoms frontal sinusitis, nonmedial location of subperiosteal abscess, large subperiosteal abscess, suspicion of anaerobic subperiosteal infenction, recurrence of superiosteal abscess after previous drainage, evidence of chronic sinusitis, acute optic nerve or retinal compromise, or infection of dental origin, surgical management of orbital cellulitis was needed in only 2 of 29 (7%) patients. Our population, however, is younger than that in the Garcia and Harris study. Furthermore, our facility is a major referral center. Due to the small number of patients in our study, it is difficult to draw definitive conclusions from these numbers. In conclusion, our study shows a high frequency of infection with MRSA among infants with orbital cellulitis. Ethmoid sinusitis was the most common etiology for the orbital cellulitis in our series. Aggressive broad-spectrum antibiotics covering MRSA should be promptly initiated when orbital cellulitis is suspected in the infantile patient population while awaiting results of culture specimens. Outcome is usually favorable, but serious complications can occur.

A Randomized Trial Comparing Bilateral Lateral Rectus Recession versus Unilateral Recess and Resect for Basic-Type Intermittent Exotropia

PURPOSE To compare long-term outcomes after bilateral lateral rectus recession (BLRc) or unilateral lateral rectus recession combined with medial rectus resection in the same eye (R&R) for primary treatment of childhood intermittent exotropia (IXT). DESIGN Multicenter, randomized clinical trial. PARTICIPANTS One hundred ninety-seven children 3 to younger than 11 years of age with basic-type IXT, a largest deviation by prism and alternate cover test at any distance of 15 to 40 prism diopters (PD), and near stereoacuity of at least 400 seconds of arc. METHODS Random assignment to BLRc or R&R and masked examinations conducted every 6 months after surgery for 3 years. MAIN OUTCOME MEASURES Proportion of participants meeting suboptimal surgical outcome by 3 years, defined as: (1) exotropia of 10 PD or more at distance or near using simultaneous prism and cover test (SPCT); or (2) constant esotropia of 6 PD or more at distance or near using SPCT; (3) loss of 2 octaves or more of stereoacuity from baseline, at any masked examination; or (4) reoperation without meeting any of these criteria. RESULTS Cumulative probability of suboptimal surgical outcome by 3 years was 46% (43/101) in the BLRc group versus 37% (33/96) in the R&R group (treatment group difference of BLRc minus R&R, 9%; 95% confidence interval [CI], -6% to 23%). Reoperation by 3 years occurred in 9 participants (10%) in the BLRc group (8 of 9 met suboptimal surgical outcome criteria) and in 4 participants (5%) in the R&R group (3 of 4 met suboptimal surgical outcome criteria; treatment group difference of BLRc minus R&R, 5%; 95% CI, -2% to 13%). Among participants completing the 3-year visit, 29% (25 of 86) in the BLRc group and 17% (13 of 77) in the R&R group underwent reoperation or met suboptimal surgical outcome criteria at 3 years (treatment group difference of BLRc minus R&R, 12%; 95% CI, -1% to 25%). CONCLUSIONS We did not find a statistically significant difference in suboptimal surgical outcome by 3 years between children with IXT treated with BLRc compared with those treated with R&R. Based on these findings, we are unable to recommend one surgical approach over the other for childhood IXT.

Involution of Threshold Retinopathy of Prematurity after Diode Laser Photocoagulation: Author reply

OBJECTIVE To characterize the process of involution of threshold retinopathy of prematurity after transpupillary diode laser photocoagulation. DESIGN Retrospective case series. PARTICIPANTS Neonates with threshold retinopathy who underwent diode laser photocoagulation of the peripheral avascular retina. METHODS A retrospective chart review was done of the weekly examination records of infants treated for threshold disease. Features that were studied included the presence of residual stage 3 neovascularization, plus disease, and development of retinal detachment (RD). MAIN OUTCOME MEASURES Timing of full involution and/or development of an RD. RESULTS Of 262 eyes of 138 infants treated, full involution without RD was seen in 8%, 43%, 64%, 73%, and 86% of eyes at postoperative weeks 1, 2, 3, 4, and 9+/-3, respectively. Retinal detachments were diagnosed cumulatively in 0%, 1.5%, 4.2%, 6.5%, and 14% of eyes at weeks 1, 2, 3, 4, and 9+/-3, respectively. CONCLUSIONS Full involution of laser-treated threshold retinopathy of prematurity required more than 2 weeks in more than half of treated eyes. Most RDs were not detected until > or =3 weeks after treatment.