Kammi B. Gunton

Advances in Amblyopia: What Have We Learned From PEDIG Trials?

Amblyopia is the most common cause of preventable visual loss in children. This article reviews treatment options, durations, and efficacy in randomized multicentered trials conducted by the Pediatric Eye Disease and Investigator Group in the last decade. Parents and patients should be counseled that many forms of treatment are efficacious, allowing the option of choice of best-tolerated treatment method. Compliance is key to successful treatment. The course of treatment is likely at least 6–12 months, with yearly follow-up suggested once amblyopia has been treated to monitor for regression.

Impact of strabismus surgery on health-related quality of life in adults.

Purpose of review Adult strabismus can cause many symptoms, which have generally been divided into functional complaints and social complaints. The validity of surgical correction has historically been based on the restoration of functional improvement. In the absence of this expectation, surgery was labeled cosmetic. Yet, many studies have revealed the immense impact of ocular misalignment on psychosocial variables. The purpose of this article is to review the potential functional and psychosocial benefits of strabismus surgery and to summarize the development and status of questionnaires to help quantify these benefits. Recent findings Functional benefits of strabismus surgery have been recently summarized with a meta-analysis. Several questionnaires have been evaluated to assess the functional and psychosocial factors in adult strabismus. Two strabismus-specific questionnaires, the Amblyopia and Strabismus Questionnaire and the Adult Strabismus-20, reveal improvements in adults following surgery. The appropriate patient population, impact of comorbidities on the scores, and the timing of the administration of the questionnaire postoperatively still need to be determined. Summary Future studies of the impact of strabismus surgery in adults will need to report not only objective motor results, but also the impact on health-related quality of life to encompass all the benefits of strabismus surgery.

Prism use in adult diplopia.

Purpose of review Prismatic correction to restore binocularity in adult diplopia can be challenging. This review summarizes the results of prismatic correction in adults based on the cause of diplopia. Recent findings Satisfaction with prismatic correction is achieved in approximately 80% of all adult patients with diplopia when combining the causes. Of patients with vertical diplopia, skew deviation and fourth nerve palsy have the highest satisfaction rates, 100 and 92%, respectively. Patients with thyroid eye disease and orbital blowout fractures associated with diplopia had the lowest satisfaction rates, 55 and 8%, respectively. With regard to horizontal deviations, patients with decompensated childhood strabismus with a combination of horizontal and vertical deviations and patients with convergence insufficiency had the lowest satisfaction rates, 71 and 50%, respectively. Summary Careful selection of patients for prismatic correction, management of patients expectations, and continued follow-up to monitor the symptoms are critical to the successful use of prisms.

Diplopia in adult patients following cataract extraction and refractive surgery

Purpose of review The purpose of this article is to report the incidence and cause of diplopia following cataract surgery and laser in-situ keratomileusis (LASIK). Recent findings Ocular misalignment following cataract extraction with retrobulbar anesthesia has an incidence of approximately 7%. Diplopia ranges in this group of patients from 0.23 to 0.98%. The incidence of ocular misalignment decreases with topical anesthesia for cataract extraction to 5%, and diplopia occurs with an incidence of 0.21–0%. Although there are small case series, the incidence of diplopia following LASIK has not been reported. The causes of diplopia following cataract extraction and LASIK include decompensation of pre-existing strabismus, new-onset accommodative esotropia, concurrent onset of systemic disease, disruption of central fusion, and monocular diplopia. The leading cause for diplopia following retrobulbar anesthesia for cataract extraction is extraocular muscle paresis/restriction and is unique to this type of procedure. In cases of topical anesthesia for cataract extraction and for LASIK procedures, the leading cause of diplopia is decompensation of pre-existing strabismus. Summary Detailed history and evaluation for pre-existing strabismus can dramatically decrease the incidence of unexpected diplopia following refractive procedures.

Vertical rectus transpositions in sixth nerve palsies.

Purpose of review There are many surgical options to address a sixth nerve palsy including transpositions of the vertical recti to the lateral rectus. This review will summarize the results from variations on transpositions as they apply to sixth nerve palsies. Recent findings Transposition of both vertical recti with posterior fixation creates the greatest correction of esotropia in primary position with largest field of single vision. Transposition of the superior rectus alone preserving anterior segment circulation achieves effects similar to transposition without posterior fixation. Augmentation with partial transposition also creates similar improvement in esotropia with possibilities for adjustable sutures and circulation preservation. Summary These various options on transpositions allow options to specifically address surgeon preferences and patient needs to select the appropriate surgery.

A review of the current practice in diagnosis and management of visual complaints associated with concussion and postconcussion syndrome.

Purpose of review Concussions and their related sequelae have received significant attention given the high-profile media coverage from professional sports and recreational leagues. A better understanding of the diagnosis and symptom management may limit the long-term impact these injuries have on the affected individual. The aim of this review is to provide updated information for both diagnosis and ongoing management for visual symptoms of concussions. Recent findings New testing including a brief vestibular/ocular motor screening assessment and the importance of near point of convergence measurements may prove beneficial to the diagnosis and identification of patients at greater risk for developing postconcussion syndrome. Additionally, the development of postconcussion syndrome is more likely when symptom burden is greater upon presentation. Summary Currently, there is not a single testing method that can universally identify all individuals with concussion. Current management of concussion focuses on targeted treatment based upon symptoms and signs present at onset to decrease disease burden and help restore baseline functioning as soon as possible.

Nonaccommodative esotropia after cataract extraction in a patient with previous accommodative esotropia

We report a case of nonaccommodative esotropia developing after bilateral cataract surgery that corrected the preexisting hyperopia in a patient with accommodative esotropia since childhood. The esotropia required surgical correction despite the good visual acuity after the cataract surgery. In patients with preexisting strabismus, there is a possibility of decompensation of adaptive binocular mechanisms after cataract surgery and refractive procedures.

A pilot study using electronic reminders for amblyopia treatment

ABSTRACT Treatment compliance is the most important factor for predicting a successful outcome in amblyopia treatment. Electronic applications have been successfully employed in other medical conditions in an effort to improve compliance. Aim: To determine whether a smartphone medical adherence application (app) (RxmindMe® Prescription/Medicine Reminder and Pill Tracker) may be successfully incorporated into the treatment plan of patients 3–7 years of age who have not previously been treated for amblyopia. Methods: Children 3–7 years of age were randomized to receive electronic reminders (reminders group) or standard instructions (control group). Visual acuity and compliance with treatment was assessed at the first follow-up visit. The child’s adherence with the prescribed treatment was calculated as the reported number of hours of patching performed divided by the number of hours prescribed or compliance percentage. The validated “Amblyopia Treatment Index Parental Questionnaire” was administered to the parent/guardian to assess any differences in the compliance subscale between the two treatment groups. Any difficulties encountered with the use of the reminder app were also recorded at the follow-up visit. Results: Twenty-four participants were enrolled. Twelve participants in the reminder group (eight female, four male; mean age 4.5 ± 1.3) were compared with 12 participants in the control group (five female, seven male; mean 4.8 ± 1.1). No significant differences were found between the two groups in terms of age (p = 0.62), gender (p = 0.22), or degree of amblyopia at the start of treatment (p = 0.99). Eleven of 12 participants in the reminders group were able to incorporate the reminder app into amblyopia treatment. No participant reported malfunction of the alarm portion of the reminder app. There was no significant difference seen in degree of visual acuity improvement, reported percentage compliance or effect on the compliance subscale as assessed by the ATI questionnaire. Several participants reported the app to be “helpful” in initiating treatment. Conclusion: Our findings indicate that use of a smartphone app is feasible in this patient population. Targeting the app to specific patient demographics or when difficulty with compliance is encountered needs to be further investigated.

Impact of a Strabismus Surgery Suture Course for First- and Second-Year Ophthalmology Residents

PURPOSE To investigate the effectiveness of an eye muscle surgery course on first- and second-year postgraduate ophthalmology residents. METHODS This prospective cohort pilot study invited first- and second-year ophthalmology residents to participate in a 2-hour strabismus surgery course at Wills Eye Hospital. The course consisted of a didactic session followed by a wet laboratory session. The wet laboratory session simulated strabismus surgery using a model constructed of chicken breast followed by partial-thickness scleral suture passes in pig eyes. A structured self-assessment evaluation form and a questionnaire in the validated Ophthalmology Surgical Competency Assessment Rubric approved by the International Council of Ophthalmology (ICO-OSCAR:strabismus) were used to assess the effectiveness of the course. RESULTS A total of 12 residents, 8 (67%) first-year and 4 (33%) second-year, were enrolled for this survey. Following the course, most residents felt less anxious (73%). All residents responded that the course was helpful or somewhat helpful in preparation for strabismus surgery. Regarding the distribution of ratings on questions of subjective experience, knowledge of steps, and understanding of potential complications, the residents gave significantly higher ratings after the course (P < .029). The change in the modified ICO-OSCAR:strabismus assessments mean score was statistically significant before and after training (P = .038). CONCLUSIONS A strabismus course can play an important role in preparing residents for strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2017;54(6):339-345.].

The role of imaging in strabismus

Purpose of review To review the most recent literature regarding the clinical experience of imaging modalities in strabismus. Recent findings MRI of extraocular muscles (EOMs) has elucidated the roles of variation in compartmental contraction of EOMs and further evidence of EOM pulley heterotopy in various strabismus patterns, which may contribute to the clinical and surgical management of patients as this mode of imaging becomes more readily available. Ultrasound biomicroscopy (UBM) and anterior-segment optical coherence tomography (AS-OCT) may play a role in determining the location of EOMs which could also aid in devising a preoperative surgical plan, especially in those who have had prior strabismus surgery. Summary Although MRI, UBM, and AS-OCT show promise in the formulation of a treatment plan in complex strabismus, more research regarding the role and limitations of these imaging modalities is required before they become the mainstay of strabismus evaluation.