Marla Shainberg

The Infant Aphakia Treatment Study: Design and Clinical Measures at Enrollment

OBJECTIVE To compare the use of contact lenses and intraocular lenses (IOLs) for the optical correction of unilateral aphakia during infancy. METHODS In a randomized, multicenter (12 sites) clinical trial, 114 infants with unilateral congenital cataracts were assigned to undergo cataract surgery with or without IOL implantation. Children randomized to IOL treatment had their residual refractive error corrected with spectacles. Children randomized to no IOL treatment had their aphakia treated with a contact lens. MAIN OUTCOME MEASURES Grating acuity at 12 months of age and HOTV visual acuity at 4 1/2 years of age. APPLICATION TO CLINICAL PRACTICE This study should determine whether either treatment for an infant with a visually significant unilateral congenital cataract results in a better visual outcome. RESULTS Enrollment began December 23, 2004, and was completed January 16, 2009. The median age at the time of cataract surgery was 1.8 months. Fifty patients were 4 to 6 weeks of age at the time of enrollment; 32, 7 weeks to 3 months of age; and the remaining 32, more than 3 to less than 7 months of age. Fifty-seven children were randomized to each treatment group. Eyes with cataracts had shorter axial lengths and steeper corneas on average than the fellow eyes. CONCLUSIONS The optimal optical treatment of aphakia in infants is unknown. However, the Infant Aphakia Treatment Study was designed to provide empirical evidence of whether optical treatment with an IOL or a contact lens after unilateral cataract surgery during infancy is associated with a better visual outcome.

Stereopsis Results at 4.5 Years of Age in the Infant Aphakia Treatment Study

PURPOSE To determine whether stereopsis of infants treated for monocular cataracts varies with the type of optical correction used. DESIGN Randomized prospective clinical trial. METHODS The Infant Aphakia Treatment Study randomized 114 patients with unilateral cataracts at age 1-7 months to either primary intraocular lens (IOL) or contact lens correction. At 4.5 years of age a masked examiner assessed stereopsis on these patients using 3 different tests: (1) Frisby; (2) Randot Preschool; and (3) Titmus Fly. RESULTS Twenty-eight patients (25%) had a positive response to at least 1 of the stereopsis tests. There was no statistically significant difference in stereopsis between the 2 treatment groups: Frisby (contact lens, 6 [11%]; IOL, 7 [13%]; P = .99), Randot (contact lens, 3 [6%]; IOL, 1 [2%]; P = .62), or Titmus (contact lens, 8 [15%]; IOL, 13 [23%]; P = .34). The median age at surgery for patients with stereopsis was younger than for those without stereopsis (1.2 vs 2.4 months; P = .002). The median visual acuity for patients with stereopsis was better than for those without stereopsis (20/40 vs 20/252; P = .0003). CONCLUSION The type of optical correction did not influence stereopsis outcomes. However, 2 other factors did: age at surgery and visual acuity in the treated eye at age 4.5 years. Early surgery for unilateral congenital cataract and the presence of visual acuity better than or equal to 20/40 appear to be more important than the type of initial optical correction used for the development of stereopsis.

Vision Therapy and Orthoptics

Vision therapy by orthoptists is a form of treatment to restore binocular single vision and to enhance the control of a deviation using prisms and convergence therapy. It is differentiated from optometric behavioral vision therapy (BVT) as a form of treatment to decrease rates of juvenile recidivism and to improve learning disabilities using colored overlays and tools such as trampolines. Evidence-based findings of randomized controlled clinical trials versus conclusions drawn from nonrandomized, poorly controlled studies of various forms of vision therapy are explored. Concrete evidence in the mainstream literature supports the positive effects of eye exercises in patients with convergence insufficiency and yoked prisms in patients with neurologic deficits. Vision therapy for juvenile delinquents and patients with dyslexia is unsubstantiated.

Nonsurgical Treatment of Teenagers with High AC/A Ratio Esotropia

Nonsurgical treatment options commonly prescribed for teenagers with high AC/A ratios are progressive lens spectacles, single vision lens spectacles, bifocal contact lenses, and monovision. The gold standard treatment for high AC/A ratios in patients with esotropia is bifocal spectacles, but they are not cosmetically acceptable for most teenagers. However, excellent binocularity is often sacrificed with the alternative treatment options. Quality of life surveys acknowledge that poor cosmesis can have a negative psychosocial impact on individuals. Therefore, it is often necessary for practitioners to strike a balance between good psychosocial health and best visual potential with treatment options other than bifocal spectacles.

The Efficacy of Botulinum Toxin Treatment for Children with a Persistent Esotropia Following Bilateral Medial Rectus Recessions and Lateral Rectus Resections

Background and Purpose To report on the outcomes of treating children with a persistent esotropia with an injection of botulinum toxin in a medial rectus muscle. Patients and Methods The medical records were reviewed of all children at one institution with a persistent esotropia after bilateral medial rectus recessions and bilateral lateral rectus resections then treated with a botulinum toxin injection. Results Five patients with a mean preoperative esotropia of 37Δ (range 25-50Δ) underwent bilateral medial rectus recessions and then bilateral lateral rectus resections. Their residual esotropia (mean of 25Δ; range 18-35Δ) was then treated with a single injection of 3-5 units of botulinum toxin into one medial rectus muscle. The patients were then followed for a mean of 34 months (range 14-79 months). At last follow-up, two patients had an esotropia <10Δ. The other three patients had no long-term improvement in their ocular alignment. Two of these patients then underwent additional strabismus surgery. In both cases, they then developed a consecutive exotropia. Conclusion Treatment with a single injection of botulinum toxin was beneficial in 2 of 5 children. Botulinum toxin treatment alone did not result in a consecutive exotropia in any patients treated.

Associated systemic and ocular disorders in patients with congenital unilateral cataracts: the Infant Aphakia Treatment Study experience.

PurposeFive-year prospective data on children enrolled in the Infant Aphakia Treatment Study (IATS) provided an opportunity to explore ocular and systemic associations in patients with a unilateral congenital cataract.MethodsInfants <7 months of age with a unilateral cataract were eligible for IATS screening. We reviewed data pertaining to the exclusion of patients as well as data collected on standardized study forms used at any time for documentation of ocular or systemic disorders.ResultsOverall, 227 infants were referred for possible enrollment. Of these, 10 had insignificant cataracts and 32 refused to participate. Of those excluded, 3 were premature, 27 had significant ocular disease (usually persistent fetal vasculature (PFV) or corneal diameter <9 mm), and 4 had systemic disorders. An additional 26 were excluded at the time of the first EUA, most often because of PFV or variants thereof. On follow-up, in the 114 enrolled patients, the following disorders were diagnosed: Stickler syndrome (1), mitochondrial disease (1), autism (1), and presumed congenital rubella syndrome (1). No patient developed a cataract in the fellow eye.DiscussionSome conditions that can feature unilateral cataracts are diagnosed at birth or very early in life, but others may be diagnosed at varying periods thereafter. PFV and its variants are the most common associated ocular findings in about a quarter of cases of unilateral congenital cataracts.ConclusionAlthough patients with a unilateral cataract may have significant associated abnormalities in the affected eye, most commonly PFV and its variants, the prevalence of associated significant systemic disease is quite low.

Concordance between child and parent-proxy report on a new self-report tool of vision related quality of life for children with JIA-associated uveitis – “Effects of Youngsters’ Eyesight on QOL -EYE-Q”

Concordance between child and parent-proxy report on a new self-report tool of vision related quality of life for children with JIA-associated uveitis – “Effects of Youngsters’ Eyesight on QOL -EYE-Q” Sheila T Angeles-Han, Sampath Prahalad, Lori Ponder, Kerrie Fields, Rachel Robb, Marla Shainberg, Larry B Vogler, Phoebe Lenhart, Amy Hutchinson, Sunil K Srivastava, Scott R Lambert, Carolyn Drews-Botsch