Shira L. Robbins

Validity of the convergence insufficiency symptom survey: a confirmatory study.

Purpose. The objectives of the present study were to evaluate whether investigator bias influenced the Convergence Insufficiency Symptom Survey (CISS) scores of children with normal binocular vision (NBV) in our original validation study, reevaluate the usefulness of the cutoff score of 16, and reexamine the validity of the CISS. Methods. Six clinical sites participating in the Convergence Insufficiency Treatment Trial (CITT) enrolled 46 children 9 to <18 years with NBV. Examiners masked to the child’s binocular vision status administered the CISS. The mean CISS score was compared with that from the children with NBV in the original, unmasked CISS study and also to that of the 221 symptomatic convergence insufficiency (CI) children enrolled in the CITT. Results. The mean (±standard deviation) CISS score for 46 subjects with NBV was 10.4 (±8.1). This was comparable with our prior unmasked NBV study (mean = 8.1 (±6.2); p = 0.11) but was significantly different from that of the CITT CI group (mean = 29.8 ± 9.0; p < 0.001). Eighty-three percent of these NBV subjects scored <16 on the CISS, which is not statistically different from the 87.5% found in the original unmasked study (p = 0.49). Conclusions. Examiner bias did not affect the CISS scores for subjects with NBV in our prior study. The CISS continues to be a valid instrument for quantifying symptoms in 9 to <18-year-old children. These results also confirm the validity of a cut-point of ≥16 in distinguishing children with symptomatic CI from those with NBV.

Functional magnetic resonance imaging of a child with Alice in Wonderland syndrome during an episode of micropsia.

BACKGROUND Alice in Wonderland syndrome is a perceptual disorder involving brief, transient episodes of visual distortions (metamorphopsia) and can occur in conjunction with certain viral infections. We used functional magnetic resonance imaging to examine visual processing in a 12-year-old boy with viral-onset Alice in Wonderland syndrome during an episode of micropsia (reduction in the perceived size of a form). METHODS Functional magnetic resonance imaging was conducted in response to a passive viewing task (reversing checkerboard) and an active viewing task (line-length decisions in the context of the Ponzo illusion). RESULTS In both tasks, the child with Alice in Wonderland syndrome showed reduced activation in primary and extrastriate visual cortical regions but increased activation in parietal lobe cortical regions as compared with a matched control participant. CONCLUSIONS The active experience of micropsia in viral-onset Alice in Wonderland syndrome reflects aberrant activity in primary and extrastriate visual cortical regions as well as parietal cortices. The disparate patterns of activity in these regions are discussed in detail.

Vision testing in the pediatric population

The goal of office testing of the child remains the same as it is for the adult--to gather as much information as efficiently as possible. Clinical testing of the child requires familiarity with the limitations available tests. Perhaps most important is the ability choose the proper test to use at every development stage. Cooperation may be surprisingly good in to hands of experienced examiners, though very young children can be unpredictable. The general ophthalmologist should not fear having young patients but rather take joy in the interaction with them. Armed with as many tools as possible, the challenge of testing children can be converted to the reward of helping families.

Ophthalmic manifestations of tuberous sclerosis: a review.

Tuberous sclerosis or tuberous sclerosis complex (TSC), one of the phakomatoses, is characterized by hamartomas of the heart, kidney, brain, skin and eyes. Ophthalmologic examinations are required in all cases of TSC. Retinal hamartomas are the most common ocular finding in tuberous sclerosis. The majority of hamartomas are non‐progressive; however, lesions with subretinal fluid and progression have been reported. This paper details the genetics, clinical features and ocular findings of TSC and reviews potential therapeutic options for ophthalmic manifestations.

Solutions in pediatric cataracts

Purpose of review Modern pediatric cataract surgical techniques combined with a greater understanding of the natural history of aphakia and pseudophakia have changed the approach to the surgery of pediatric cataracts. Recent findings Advanced surgical techniques, new pharmacologic options and long-term refractive planning have improved surgical success. Summary It is essential that the ophthalmic surgeon who cares for children with cataracts is aware of these issues.

Comparison of the Efficacy of Medial Rectus Recession and Lateral Rectus Resection for Treatment of Divergence Insufficiency.

PURPOSE Surgical approaches for divergence insufficiency esotropia include medial rectus recession and lateral rectus resection. A retrospective chart review compared the efficacy of each. METHODS Eighteen patients older than 50 years with divergence insufficiency esotropia who were operated on between 2005 and 2012 by two surgeons were reviewed. RESULTS Nine patients underwent medial rectus recession and nine underwent lateral rectus resection. The average distance esotropia decreased from 19.75 to 3.2 prism diopters in the medial rectus recession group (P = .001) and from 17.7 to 2.6 prism diopters in the lateral rectus resection group (P = .0002). The disparity between distance and near alignment decreased from 7.3 to 3.4 in the medial rectus recession group (P = .019) and from 9 to 5.4 prism diopters in the lateral rectus resection group (P = .004). CONCLUSIONS Both medial rectus recession and lateral rectus resection are effective treatment for divergence insufficiency, with both decreasing distance-near disparity.

Breaking bad news: A communication competency for ophthalmology training programs

As the ophthalmology accreditation system undergoes major changes, training programs must evaluate residents in the 6 core competencies, including appropriately communicating bad news. Although the literature is replete with recommendations for breaking bad news across various non-ophthalmology specialties, no formal training programs exist for ophthalmology. There are many valuable lessons to be learned from our colleagues regarding this important skill. We examine the historic basis for breaking bad news, explore current recommendations among other specialties, and then evaluate a pilot study in breaking bad news for ophthalmology residents. The results of this study are limited by a small number of residents at a single academic center. Future studies from multiple training programs should be conducted to further evaluate the need and efficacy of formal communication skills training in this area, as well as the generalizability of our pilot training program. If validated, this work could serve as a template for future ophthalmology resident training and evaluation in this core competency.

Measurement of Axial Length in an Office Setting Versus Under General Anesthesia in Infants and Toddlers: A Comparative Study.

PURPOSE To examine whether axial length measurement in awake infants and toddlers is feasible, and whether there is a difference in axial length measurement between an office setting and under general anesthesia. METHODS This prospective comparative case study was conducted at the Goldschleger Eye Institute, Sheba Medical Center, Israel. Using the same instruments, axial length measurements were obtained using a standard applanation technique twice: once in an office setting when the infant/toddler was awake and once under general anesthesia in the operating room. A paired t test was used to test for differences between measurements. RESULTS Thirty-three eyes of 19 participants younger than 28 months were examined; 24 (73%) eyes had cataracts and the remainder had clear lenses. One child was excluded from the study due to lack of cooperation during axial length measurement in the office setting and another due to the lengthy gap between measurements. Of the remaining 31 children, the average age was 9 months. Average axial length measurements were shorter by 0.12 mm in the office setting than under general anesthesia (P = .14). No adverse effects were observed after axial length measurements in the office setting. CONCLUSIONS Axial length measurement in an office setting is generally reasonable to obtain. The results showed no significant difference in the axial length measured in the two settings.

Steroid-induced glaucoma in the pediatric population

Steroid medications may cause elevation of intraocular pressure, sometimes with permanent damage to the optic nerve. These therapies, via various routes of administration, are commonly prescribed for children, but the potential sequelae of elevated intraocular pressure and glaucomatous optic nerve damage can be even more severe and devastating in children than in adults. This review discusses the pathophysiology and potential risk factors, including the impact of intraocular pressure elevation via the different common routes of administration of steroids, clinical evaluation, and management of steroid response and steroid-induced glaucoma in children.

A baby with a lot of nerve

An infant presented with bilateral disk edema and an acute left sixth cranial nerve (CN VI) palsy because of pseudotumor cerebri (PTC). PTC is rare in infants where it is often associated with endocrine abnormalities, medications, viral infections, systemic conditions, and nutritional etiologies such as vitamin A toxicity. We report a case of PTC in an infant associated with hypervitaminosis A with an unlikely source-a common prenatal vitamin.