Nicola Anstice

Effect of Dual-Focus Soft Contact Lens Wear on Axial Myopia Progression in Children

PURPOSE To test the efficacy of an experimental Dual-Focus (DF) soft contact lens in reducing myopia progression. DESIGN Prospective, randomized, paired-eye control, investigator-masked trial with cross-over. PARTICIPANTS Forty children, 11-14 years old, with mean spherical equivalent refraction (SER) of -2.71 ± 1.10 diopters (D). METHODS Dual-Focus lenses had a central zone that corrected refractive error and concentric treatment zones that created 2.00 D of simultaneous myopic retinal defocus during distance and near viewing. Control was a single vision distance (SVD) lens with the same parameters but without treatment zones. Children wore a DF lens in 1 randomly assigned eye and an SVD lens in the fellow eye for 10 months (period 1). Lens assignment was then swapped between eyes, and lenses were worn for a further 10 months (period 2). MAIN OUTCOME MEASURES Primary outcome was change in SER measured by cycloplegic autorefraction over 10 months. Secondary outcome was a change in axial eye length (AXL) measured by partial coherence interferometry over 10 months. Accommodation wearing DF lenses was assessed using an open-field autorefractor. RESULTS In period 1, the mean change in SER with DF lenses (-0.44 ± 0.33 D) was less than with SVD lenses (-0.69 ± 0.38 D; P < 0.001); mean increase in AXL was also less with DF lenses (0.11 ± 0.09 mm) than with SVD lenses (0.22 ± 0.10 mm; P < 0.001). In 70% of the children, myopia progression was reduced by 30% or more in the eye wearing the DF lens relative to that wearing the SVD lens. Similar reductions in myopia progression and axial eye elongation were also observed with DF lens wear during period 2. Visual acuity and contrast sensitivity with DF lenses were not significantly different than with SVD lenses. Accommodation to a target at 40 cm was driven through the central distance-correction zone of the DF lens. CONCLUSIONS Dual-Focus lenses provided normal acuity and contrast sensitivity and allowed accommodation to near targets. Myopia progression and eye elongation were reduced significantly in eyes wearing DF lenses. The data suggest that sustained myopic defocus, even when presented to the retina simultaneously with a clear image, can act to slow myopia progression without compromising visual function. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.

Neonatal Glycemia and Neurodevelopmental Outcomes at 2 Years

BACKGROUND Neonatal hypoglycemia is common and can cause neurologic impairment, but evidence supporting thresholds for intervention is limited. METHODS We performed a prospective cohort study involving 528 neonates with a gestational age of at least 35 weeks who were considered to be at risk for hypoglycemia; all were treated to maintain a blood glucose concentration of at least 47 mg per deciliter (2.6 mmol per liter). We intermittently measured blood glucose for up to 7 days. We continuously monitored interstitial glucose concentrations, which were masked to clinical staff. Assessment at 2 years included Bayley Scales of Infant Development III and tests of executive and visual function. RESULTS Of 614 children, 528 were eligible, and 404 (77% of eligible children) were assessed; 216 children (53%) had neonatal hypoglycemia (blood glucose concentration, <47 mg per deciliter). Hypoglycemia, when treated to maintain a blood glucose concentration of at least 47 mg per deciliter, was not associated with an increased risk of the primary outcomes of neurosensory impairment (risk ratio, 0.95; 95% confidence interval [CI], 0.75 to 1.20; P=0.67) and processing difficulty, defined as an executive-function score or motion coherence threshold that was more than 1.5 SD from the mean (risk ratio, 0.92; 95% CI, 0.56 to 1.51; P=0.74). Risks were not increased among children with unrecognized hypoglycemia (a low interstitial glucose concentration only). The lowest blood glucose concentration, number of hypoglycemic episodes and events, and negative interstitial increment (area above the interstitial glucose concentration curve and below 47 mg per deciliter) also did not predict the outcome. CONCLUSIONS In this cohort, neonatal hypoglycemia was not associated with an adverse neurologic outcome when treatment was provided to maintain a blood glucose concentration of at least 47 mg per deciliter. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others.).

Association of Neonatal Glycemia With Neurodevelopmental Outcomes at 4.5 Years

Importance Hypoglycemia is common during neonatal transition and may cause permanent neurological impairment, but optimal intervention thresholds are unknown. Objective To test the hypothesis that neurodevelopment at 4.5 years is related to the severity and frequency of neonatal hypoglycemia. Design, Setting, and Participants The Children With Hypoglycemia and Their Later Development (CHYLD) Study is a prospective cohort investigation of moderate to late preterm and term infants born at risk of hypoglycemia. Clinicians were masked to neonatal interstitial glucose concentrations; outcome assessors were masked to neonatal glycemic status. The setting was a regional perinatal center in Hamilton, New Zealand. The study was conducted from December 2006 to November 2010. The dates of the follow-up were September 2011 to June 2015. Participants were 614 neonates born from 32 weeks’ gestation with at least 1 risk factor for hypoglycemia, including diabetic mother, preterm, small, large, or acute illness. Blood and masked interstitial glucose concentrations were measured for up to 7 days after birth. Infants with hypoglycemia (whole-blood glucose concentration <47 mg/dL) were treated to maintain blood glucose concentration of at least 47 mg/dL. Exposures Neonatal hypoglycemic episode, defined as at least 1 consecutive blood glucose concentration less than 47 mg/dL, a severe episode (<36 mg/dL), or recurrent (≥3 episodes). An interstitial episode was defined as an interstitial glucose concentration less than 47 mg/dL for at least 10 minutes. Main Outcomes and Measures Cognitive function, executive function, visual function, and motor function were assessed at 4.5 years. The primary outcome was neurosensory impairment, defined as poor performance in one or more domains. Results In total, 477 of 604 eligible children (79.0%) were assessed. Their mean (SD) age at the time of assessment was 4.5 (0.1) years, and 228 (47.8%) were female. Those exposed to neonatal hypoglycemia (280 [58.7%]) did not have increased risk of neurosensory impairment (risk difference [RD], 0.01; 95% CI, −0.07 to 0.10 and risk ratio [RR], 0.96; 95% CI, 0.77 to 1.21). However, hypoglycemia was associated with increased risk of low executive function (RD, 0.05; 95% CI, 0.01 to 0.10 and RR, 2.32; 95% CI, 1.17 to 4.59) and visual motor function (RD, 0.03; 95% CI, 0.01 to 0.06 and RR, 3.67; 95% CI, 1.15 to 11.69), with highest risk in children exposed to severe, recurrent, or clinically undetected (interstitial episodes only) hypoglycemia. Conclusions and Relevance Neonatal hypoglycemia was not associated with increased risk of combined neurosensory impairment at 4.5 years but was associated with a dose-dependent increased risk of poor executive function and visual motor function, even if not detected clinically, and may thus influence later learning. Randomized trials are needed to determine optimal screening and intervention thresholds based on assessment of neurodevelopment at least to school age.

The measurement of visual acuity in children: an evidence-based update

Over the past decade, a number of large clinical trials have provided important information relating to the reliability and repeatability of commonly used paediatric tests of vision and their role in the diagnosis and management of paediatric ocular diseases. The aim of this review is to summarise recent findings on the use of paediatric visual acuity tests in clinical practice and to discuss the validity and accuracy of visual acuity measurements in infants and young children. We provide a broad overview of the benefits and challenges of measuring visual acuity in children and then discuss age‐appropriate tests for measuring visual acuity in infants through to school‐age children. We also discuss normative values for visual acuity in each age group and, where possible, provide comparisons of results between tests with a particular focus on the importance of optotype design.

Global Motion Perception in 2-Year-Old Children: A Method for Psychophysical Assessment and Relationships With Clinical Measures of Visual Function

PURPOSE We developed and validated a technique for measuring global motion perception in 2-year-old children, and assessed the relationship between global motion perception and other measures of visual function. METHODS Random dot kinematogram (RDK) stimuli were used to measure motion coherence thresholds in 366 children at risk of neurodevelopmental problems at 24 ± 1 months of age. RDKs of variable coherence were presented and eye movements were analyzed offline to grade the direction of the optokinetic reflex (OKR) for each trial. Motion coherence thresholds were calculated by fitting psychometric functions to the resulting datasets. Test-retest reliability was assessed in 15 children, and motion coherence thresholds were measured in a group of 10 adults using OKR and behavioral responses. Standard age-appropriate optometric tests also were performed. RESULTS Motion coherence thresholds were measured successfully in 336 (91.8%) children using the OKR technique, but only 31 (8.5%) using behavioral responses. The mean threshold was 41.7 ± 13.5% for 2-year-old children and 3.3 ± 1.2% for adults. Within-assessor reliability and test-retest reliability were high in children. Childrens motion coherence thresholds were significantly correlated with stereoacuity (LANG I & II test, ρ = 0.29, P < 0.001; Frisby, ρ = 0.17, P = 0.022), but not with binocular visual acuity (ρ = 0.11, P = 0.07). In adults OKR and behavioral motion coherence thresholds were highly correlated (intraclass correlation = 0.81, P = 0.001). CONCLUSIONS Global motion perception can be measured in 2-year-old children using the OKR. This technique is reliable and data from adults suggest that motion coherence thresholds based on the OKR are related to motion perception. Global motion perception was related to stereoacuity in children.

Global motion perception is independent from contrast sensitivity for coherent motion direction discrimination and visual acuity in 4.5-year-old children.

Global motion processing depends on a network of brain regions that includes extrastriate area V5 in the dorsal visual stream. For this reason, psychophysical measures of global motion perception have been used to provide a behavioral measure of dorsal stream function. This approach assumes that global motion is relatively independent of visual functions that arise earlier in the visual processing hierarchy such as contrast sensitivity and visual acuity. We tested this assumption by assessing the relationships between global motion perception, contrast sensitivity for coherent motion direction discrimination (henceforth referred to as contrast sensitivity) and habitual visual acuity in a large group of 4.5-year-old children (n=117). The children were born at risk of abnormal neurodevelopment because of prenatal drug exposure or risk factors for neonatal hypoglycemia. Motion coherence thresholds, a measure of global motion perception, were assessed using random dot kinematograms. The contrast of the stimuli was fixed at 100% and coherence was varied. Contrast sensitivity was measured using the same stimuli by fixing motion coherence at 100% and varying dot contrast. Stereoacuity was also measured. Motion coherence thresholds were not correlated with contrast sensitivity or visual acuity. However, lower (better) motion coherence thresholds were correlated with finer stereoacuity (ρ=0.38, p=0.004). Contrast sensitivity and visual acuity were also correlated (ρ=-0.26, p=0.004) with each other. These results indicate that global motion perception for high contrast stimuli is independent of contrast sensitivity and visual acuity and can be used to assess motion integration mechanisms in children.

Review of preschool vision screening referrals in South Auckland, New Zealand

Background:  Limited data are available on the causes of visual impairment in preschool children in New Zealand. We aimed to review demographic and visual parameters in children referred to the Ophthalmology Department, Manukau Super Clinic from vision screening programs in South Auckland.

Prenatal exposure to recreational drugs affects global motion perception in preschool children

Prenatal exposure to recreational drugs impairs motor and cognitive development; however it is currently unknown whether visual brain areas are affected. To address this question, we investigated the effect of prenatal drug exposure on global motion perception, a behavioural measure of processing within the dorsal extrastriate visual cortex that is thought to be particularly vulnerable to abnormal neurodevelopment. Global motion perception was measured in one hundred and forty-five 4.5-year-old children who had been exposed to different combinations of methamphetamine, alcohol, nicotine and marijuana prior to birth and 25 unexposed children. Self-reported drug use by the mothers was verified by meconium analysis. We found that global motion perception was impaired by prenatal exposure to alcohol and improved significantly by exposure to marijuana. Exposure to both drugs prenatally had no effect. Other visual functions such as habitual visual acuity and stereoacuity were not affected by drug exposure. Prenatal exposure to methamphetamine did not influence visual function. Our results demonstrate that prenatal drug exposure can influence a behavioural measure of visual development, but that the effects are dependent on the specific drugs used during pregnancy.

Optical treatment of amblyopia in older children and adults is essential prior to enrolment in a clinical trial

Optical treatment alone can improve visual acuity (VA) in children with amblyopia, thus clinical trials investigating additional amblyopia therapies (such as patching or videogames) for children require a preceding optical treatment phase. Emerging therapies for adult patients are entering clinical trials. It is unknown whether optical treatment is effective for adults with amblyopia and whether an optical correction phase is required for trials involving adults.

Effect of simulated refractive error on adult visual acuity for paediatric tests

Although vanishing optotype preferential‐looking tasks are commonly used to measure visual acuity (VA), the relative sensitivity of these tests to refractive error is not well understood. To address this issue, we determined the effect of spherical and astigmatic simulated refractive errors on adult VA measures obtained using vanishing optotypes, picture optotypes and Sloan letters.