Brad D. Simons

Pediatric photoscreening for strabismus and refractive errors in a high-risk population

OBJECTIVE To determine the accuracy of the MTI Photoscreener in detecting strabismus and refractive errors in children. PARTICIPANTS One hundred children underwent MTI photoscreening followed by complete ophthalmologic examination. Six observers graded the photographs for strabismus, according to the location of the corneal light reflexes, and for refractive error, according to the size and location of the light crescent. RESULTS The sensitivity of the MTI Photoscreener in detecting any amblyogenic factor was 80% to 91%, with a specificity of 20% to 67%. The sensitivity and specificity for particular amblyogenic factors varied widely among observers. The ranges were as follows: strabismus, sensitivity = 23% to 50%, specificity = 76% to 96%; myopia, sensitivity = 89%, specificity = 48% to 76%; hyperopia, sensitivity = 20% to 80%, specificity = 88% to 96%; and astigmatism, sensitivity = 46% to 77%, specificity = 79% to 89%. CONCLUSIONS These results suggest caution in relying on photoscreening to detect strabismus and refractive errors in children.

Branch retinal vein occlusion. Axial length and other risk factors.

Objective: To determine the association between axial length, as a measurement of hyperopia, and branch retinal vein occlusion and to determine the clinical characteristics and other risk factors of patients with branch retinal vein occlusion. Methods: A case‐control study was performed using 36 patients with branch retinal vein occlusion and 36 age‐ and sex‐matched control patients selected from a list of subjects who had undergone cataract extraction. Results: There was essentially no difference in axial length between patients the disorder and control patients (23.55 mm versus 23.62 mm; P = 0.79). Although the intraocular pressure (IOP) among control eyes was somewhat higher than that in branch retinal vein occlusion eyes, the difference was not statistically significant (P = 0.32). Systemic hypertension was more common in patients with branch retinal vein occlusion (53%) than in control patients (42%) but the difference was not statistically significant (P = 0.35). Chronic open‐angle glaucoma was present in 14% of patients with branch retinal vein occlusion and 22% of control patients (P = 0.37), but this difference was not statistically significant. Diabetes mellitus was two times more common in controls (28%) than in patients with branch retinal vein occlusion (14%). This difference, however, also did not reach statistical significance (P = 0.13). Conclusions: Hyperopia as measured by axial length is not a risk factor for branch retinal vein occlusion. This study provides evidence that hypertension is a risk factor for branch retinal vein occlusion and that chronic open‐angle glaucoma and diabetes mellitus are not risk factors for branch retinal vein occlusion.

Surgical technique, visual outcome, and complications of pediatric intraocular lens implantation.

PURPOSE To evaluate retrospectively the surgical technique, visual outcome, and complications of pediatric cataract extraction (CE) and intraocular lens (IOL) implantation. METHODS Forty-three patients ages 2 to 12 underwent CE with IOL implantation with a minimum follow up of 1 month. RESULTS All IOLs were implanted in the posterior chamber with 17 (40%) in the bag, 25 (58%) sulcus fixated, and one (2%) partially in the bag (one haptic in the bag, one in the sulcus). Primary posterior capsulectomy was performed in 12 (28%) cases. A final visual acuity of at least 20/40 was achieved in 26 (60%) and at least 20/80 in 32 (74%). Posterior capsule opacification developed in 18 (42%) and pupillary capture in 7 (16%). Seventeen (40%) patients had postoperative visual acuity worse than 20/40. Of these, nine (53%) had this visual outcome as a result of presumed amblyopia. CONCLUSIONS Posterior chamber IOL implantation affords a safe and effective method of visual rehabilitation for cataractous children 2 years of age and older. Amblyopia and antecedent posterior segment trauma, rather than IOL-related or surgical complications, are the limiting factors in final visual outcome.

Latanoprost systemic exposure in pediatric and adult patients with glaucoma: a phase 1, open-label study.

OBJECTIVE To evaluate short-term safety and steady-state systemic pharmacokinetics (PK) of latanoprost acid in pediatric subjects with glaucoma or ocular hypertension who received the adult latanoprost dose. DESIGN Phase 1, open-label, multicenter study. PARTICIPANTS Pediatric patients of 3 age groups (<3, 3-<12, and 12-<18 years) and adults (≥18 years) receiving latanoprost ophthalmic solution 0.005% once daily in 1 or both eyes for ≥2 weeks. INTERVENTION Latanoprost was administered in both eyes each morning post-screening. Subjects returned 3 to 28 days later for evaluation of plasma concentrations, withholding morning latanoprost. At the clinic, a single drop of latanoprost ophthalmic solution was instilled into both eyes. Plasma latanoprost acid concentrations were collected predose and 5, 15, 30, and 60 minutes after administration. MAIN OUTCOME MEASURES Latanoprost acid plasma exposure. RESULTS The evaluable PK analysis set included data from 39 of 47 enrolled subjects. The median peak plasma concentration value was higher in the <3-year age group (166 pg/ml) versus other groups (49, 16, and 26 pg/ml for the 3-<12-year, 12-<18-year, and ≥18-year age groups, respectively). The median area under the concentration-time curve from zero to last measurable concentration value was also higher in the <3-year age group (2716 pg/min/ml) versus other groups (588, 106, and 380 pg/min/ml for the 3-<12-year, 12-<18-year, and ≥18-year age groups, respectively). Latanoprost acid was rapidly eliminated from the blood, with plasma concentrations undetectable within 10 to 30 minutes postdose in all but the <3-year age group. There were no discontinuations or dose reductions due to adverse events or treatment-emergent adverse events. CONCLUSIONS Latanoprost acid systemic exposure was higher in younger children versus adolescents and adults, attributed primarily to lower body weight and smaller blood volume. Latanoprost acid was eliminated rapidly in all age groups and resulted in only a brief period of systemic exposure after once-daily dosing. Higher systemic exposure was not accompanied by adverse events, and on the basis of extrapolation of safety data from adults, this pilot study suggests an adequate safety margin for systemic adverse effects with use of the adult topical dose of latanoprost in pediatric patients. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosures may be found after the references.

Comparison of latanoprost and timolol in pediatric glaucoma: a phase 3, 12-week, randomized, double-masked multicenter study.

OBJECTIVE To compare the efficacy and safety of latanoprost versus timolol in pediatric patients with glaucoma. DESIGN Prospective, randomized, double-masked, 12-week, multicenter study. PARTICIPANTS Individuals aged ≤18 years with glaucoma. METHODS Stratified by age, diagnosis, and intraocular pressure (IOP) level, subjects were randomized (1:1) to latanoprost vehicle at 8 am and latanoprost 0.005% at 8 pm or timolol 0.5% (0.25% for those aged <3 years) twice daily (8 am, 8 pm). At baseline and weeks 1, 4, and 12, IOP and ocular safety were assessed and adverse events were recorded. Therapy was switched to open-label latanoprost pm and timolol am and pm for uncontrolled IOP. MAIN OUTCOME MEASURES Mean IOP reduction from baseline to week 12. Latanoprost was considered noninferior to timolol if the lower limit of the 95% confidence interval (CI) of the difference was >-3 mmHg. A proportion of responders (subjects with ≥15% IOP reduction at weeks 4 and 12) were evaluated. Analyses were performed in diagnosis subgroups: primary congenital glaucoma (PCG) and non-PCG. RESULTS In total, 137 subjects were treated (safety population; 12-18 years, n=48; 3-<12 years, n=55; 0-<3 years, n=34). Mean age was 8.8±5.5 years, and mean baseline IOP was 27.7±6.17 mmHg; 125 subjects completed the study, and 107 subjects were in the per protocol population. Mean IOP reductions for latanoprost and timolol at week 12 were 7.2 and 5.7 mmHg, respectively, with a difference of 1.5 mmHg (95% CI, -0.8 to 3.7; P=0.21). Responder rates were 60% for latanoprost and 52% for timolol (P=0.33). Between-treatment differences in mean IOP reduction for PCG and non-PCG subgroups were 0.6 mmHg (95% CI, -2.3 to 3.4) and 2.6 mmHg (95% CI, -0.8 to 6.1), respectively. Responder rates for latanoprost versus timolol were 50% versus 46% for the PCG group and 72% versus 57% for the non-PCG group. Both therapies were well tolerated. CONCLUSIONS Latanoprost 0.005% is not inferior (i.e., is either more or similarly effective) to timolol and produces clinically relevant IOP reductions across pediatric patients with and without PCG. Both latanoprost and timolol had favorable safety profiles over the duration of this 3-month trial. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

A pars plana approach for cataract surgery in posterior lenticonus.

PURPOSE To report the management and outcome of cataract surgery and intraocular lens placement in a child with unilateral posterior lenticonus. METHODS Case report. A 7-year-old boy with a best-corrected visual acuity of RE, 20/200, posterior lenticonus, and cataract underwent a pars plana lensectomy, vitrectomy, posterior chamber intraocular lens insertion into the ciliary sulcus, and central anterior capsulotomy. RESULT At 2 years of follow-up, best-corrected visual acuity was RE, 20/40. CONCLUSION This technique allowed complete removal of the opaque posterior lenticonus plaque while preserving the peripheral anterior capsule for sulcus fixation of the posterior chamber intraocular lens.

Impact of Age, Diagnosis, and History of Glaucoma Surgery on Outcomes in Pediatric Patients Treated With Latanoprost

Purpose:To evaluate the impact of age, glaucoma-specific diagnosis, and history of prior glaucoma surgery on outcomes in pediatric patients treated with latanoprost monotherapy. Patients and Methods:Prospective, randomized, double-masked 12-week, multicenter study included individuals 18 years or younger with glaucoma. Subjects stratified by age (0 to <3, 3 to <12, 12 to 18 y), diagnosis [primary congenital glaucoma (PCG) vs. non-PCG], and baseline intraocular pressure (IOP; 22 to <27, 27 to 31, >31 mm Hg), and randomized (1:1) to latanoprost vehicle (8 AM) and latanoprost 0.005% (8 PM) or timolol 0.5% (or 0.25% for those less than 3 y old; 8 AM/8 PM). IOP and safety assessments performed and adverse events recorded at baseline, weeks 1, 4, 12. Post hoc analyses in age-specific and diagnosis-specific groups of latanoprost-treated subjects were conducted (intent-to-treat population). Results:Sixty-eight subjects were treated with latanoprost (0 to <3, n=17; 3 to <12, n=26; 12 to 18, n=25); 82%, 42%, and 24%, respectively, had a primary diagnosis of PCG. Among Non-PCG subjects, 0% (0/3), 47% (7/15), and 63% (12/19) had a primary diagnosis of juvenile open-angle glaucoma in the 0 to <3, 3 to <12, and 12 to 18 year cohorts, respectively. Mean percent IOP reductions from baseline at week 12 were 22%, 24%, and 30% in the youngest through oldest age groups, respectively (P=0.3600). At week 12, a higher responder rate (≥15% IOP reduction) was observed in the non-PCG than in the PCG group (70% vs. 45%, respectively; P=0.0361). Latanoprost was well tolerated. Conclusion:All age and diagnosis subgroups showed clinically relevant (>20%) mean IOP reduction at week 12 with latanoprost monotherapy.

Surgical management of ocular motor cranial nerve palsies.

This article reviews the various surgical treatment approaches currently used in the management of ocular motor cranial nerve palsies. Regardless of the approach, the final goal is improved alignment, especially in the primary and reading positions.