Don W. Lyon

Accommodative lag by autorefraction and two dynamic retinoscopy methods.

Purpose. To evaluate two clinical procedures, Monocular Estimate Method (MEM) and Nott retinoscopy, for detecting accommodative lags 1.00 diopter (D) or greater in children as identified by an open-field autorefractor. Methods. One hundred sixty-eight children 8 to <12 years old with low myopia, normal visual acuity, and no strabismus participated as part of an ancillary study within the screening process for a randomized trial. Accommodative response to a 3.00 D demand was first assessed by MEM and Nott retinoscopy, viewing binocularly with spherocylindrical refractive error corrected, with testing order randomized and each performed by a different masked examiner. The response was then determined viewing monocularly with spherical equivalent refractive error corrected, using an open-field autorefractor, which was the gold standard used for eligibility for the clinical trial. Sensitivity and specificity for accommodative lags of 1.00 D or more were calculated for each retinoscopy method compared to the autorefractor. Results. One hundred sixteen (69%) of the 168 children had accommodative lag of 1.00 D or more by autorefraction. MEM identified 66 children identified by autorefraction for a sensitivity of 57% (95% CI = 47 to 66%) and a specificity of 63% (95% CI = 49 to 76%). Nott retinoscopy identified 35 children for a sensitivity of 30% (95% CI = 22 to 39%) and a specificity of 81% (95% CI = 67 to 90%). Analysis of receiver operating characteristic curves constructed for MEM and for Nott retinoscopy failed to reveal alternate cut points that would improve the combination of sensitivity and specificity for identifying accommodative lag ≥1.00 D as defined by autorefraction. Conclusions. Neither MEM nor Nott retinoscopy provided adequate sensitivity and specificity to identify myopic children with accommodative lag ≥1.00 D as determined by autorefraction. A variety of methodological differences between the techniques may contribute to the modest to poor agreement.

Interprofessional education at a pediatric optometry clinic

To create safer systems and improve patient outcomes, leaders in health care have emphasized the need to improve lines of communication among all providers through interprofessional education (IPE). While some schools of nursing have begun IPE initiatives between nursing and medical students using tools such as TeamSTEPPS, the Institute of Medicine recommends that to best address the population’s health promotion and disease prevention needs, IPE models should include a wider variety of professionals. Leaders in nursing also called for educators to radically reshape prelicensure clinical education from a predominantly acute-care, hospital-based model to one that is centered around common health problems and includes a variety of care settings. The need to transform pediatric clinical education is especially urgent. Children comprise approximately a quarter of the nation’s population, but 17% have less than optimal health. Nurses, skilled in the care of children, can help improve care outcomes, but this care is increasingly happening in settings outside acute care. Inpatient pediatric units have been running at 73% capacity for several years, while at the same time visits to other outpatient care settings have increased by 26%. Experts in pediatric nursing affirm that children’s health preferred future is dependent on the delivery of health promotion, disease and injury prevention, and healthy development where children live, learn, and play. Thus, aligning pediatric clinical education to the points where families access care is important. Vision care is an important aspect of pediatric health promotion. Healthy People 2020 sets 3 objectives for improvingvision in children: increasing thenumberofpreschoolers who receive vision screening by 10%, reducing blindness and visual impairment in children and adolescents by 10%, and increasing the use of personal protective eyewear in hazardous situations among children and adolescents by 10%. Nurses often perform initial screenings and make referrals; thus, achieving Healthy People 2020 pediatric vision care objectives requires strong collaborative efforts between eye care specialists and nursing.

Feasibility of a clinical trial of vision therapy for treatment of amblyopia.

Purpose We conducted a pilot randomized clinical trial of office-based active vision therapy for the treatment of childhood amblyopia to determine the feasibility of conducting a full-scale randomized clinical trial. Methods A training and certification program and manual of procedures were developed to certify therapists to administer a standardized vision therapy program in ophthalmology and optometry offices consisting of weekly visits for 16 weeks. Nineteen children, aged 7 to less than 13 years, with amblyopia (20/40–20/100) were randomly assigned to receive either 2 hours of daily patching with active vision therapy or 2 hours of daily patching with placebo vision therapy. Results Therapists in diverse practice settings were successfully trained and certified to perform standardized vision therapy in strict adherence with protocol. Subjects completed 85% of required weekly in-office vision therapy visits. Eligibility criteria based on age, visual acuity, and stereoacuity, designed to identify children able to complete a standardized vision therapy program and judged likely to benefit from this treatment, led to a high proportion of screened subjects being judged ineligible, resulting in insufficient recruitment. There were difficulties in retrieving adherence data for the computerized home therapy procedures. Conclusions This study demonstrated that a 16-week treatment trial of vision therapy was feasible with respect to maintaining protocol adherence; however, recruitment under the proposed eligibility criteria, necessitated by the standardized approach to vision therapy, was not successful. A randomized clinical trial of in-office vision therapy for the treatment of amblyopia would require broadening of the eligibility criteria and improved methods to gather objective data regarding the home therapy. A more flexible approach that customizes vision therapy based on subject age, visual acuity, and stereopsis might be required to allow enrollment of a broader group of subjects.