Sjoukje E. Loudon

Electronically measured compliance with occlusion therapy for amblyopia is related to visual acuity increase

Abstract Purpose. We set out to determine whether the children who have low compliance (measured electronically) with occlusion therapy for amblyopia are those with insufficient increase of visual acuity. Methods. In 14 newly identified amblyopic children (mean age 4.3±1.9 years), compliance was measured electronically over a period of 1 week, 6 months after the start of occlusion therapy. Compliance was measured with an Occlusion Dose Monitor (ODM). The measurements took place during planned domiciliary visits. The children were diagnosed with anisometropia (n=5), strabismus (n=4) and anisometropia and strabismus (n=5). Compliance was expressed in percentages of the electronically registered time compared with the prescribed occlusion time. Satisfactory acuity increase following 6 months of occlusion therapy was defined on reaching any of the following criteria: acuity increase expressed as a ratio between acuity of the amblyopic eye and acuity of the good eye of more than 0.75, acuity of the amblyopic eye exceeding 0.5 as measured on the E-Chart or Landolt-C, or three LogMAR lines of increase in acuity. Results. Measured compliance averaged 80% in the eight children who had a satisfactory acuity increase and 34% in the six children who had an unsatisfactory visual acuity increase. Children with low acuity increase had statistically significantly lower compliance (P=0.038). Conclusion. The general assumption among orthoptists, that compliance with occlusion therapy for amblyopia is low in children with insufficient acuity increase, has been validated by electronic, objective means.

A preliminary report about the relation between visual acuity increase and compliance in patching therapy for amblyopia.

PURPOSE The aim of this study was to establish a relation between visual acuity increase and compliance in children who have been prescribed patching therapy for their amblyopic eye. METHODS AND MATERIALS In 14 new amblyopic children (mean age 4.3 ± 1.9 years) compliance was measured electronically during one week, six months after starting patching therapy, with an Occlusion Dose Monitor (ODM), distributed through house visits. The children were diagnosed with anisometropia (5), strabismus (4) and anisometropia and strabismus (5). The degree of amblyopia was expressed as the ratio between the acuity of the amblyopic eye and the acuity of the good eye. Satisfactory increase in acuity was assessed by means of the following three criteria: acuity amblyopic eye / acuity good eye >75%, acuity exceeding 0.5 E-chart, three lines LogMAR acuity increase. RESULTS Fourteen reliable recordings were obtained, which showed that children who did not patch, or were patched inconsistently, did not reach satisfactory acuity increase. CONCLUSION There is indeed a statistically significant relation between acuity increase and measured compliance.

Psychological causes of non-compliance with electronically monitored occlusion therapy for amblyopia

Aim: To analyse psychological causes for low compliance with occlusion therapy for amblyopia. Method: In a randomised trial, the effect of an educational programme on electronically measured compliance had been assessed. 149 families who participated in this trial completed a questionnaire based on the Protection Motivation Theory after 8 months of treatment. Families with compliance less than 20% of prescribed occlusion hours were interviewed to better understand their cause for non-compliance. Results: Poor compliance was most strongly associated with a high degree of distress (p<0.001), followed by low perception of vulnerability (p = 0.014), increased stigma (p = 0.017) and logistical problems with treatment (p = 0.044). Of 44 families with electronically measured compliance less than 20%, 28 could be interviewed. The interviews confirmed that lack of knowledge, distress and logistical problems resulted in non-compliance. Conclusion: Poor parental knowledge, distress and difficulties implementing treatment seemed to be associated with non-compliance. For the same domains, the scores were more favourable for families who had received the educational programme than for those who had not.

Electronic recording of occlusion treatment for amblyopia: potential of the new technology

BackgroundApproximately one third of all amblyopic eyes do not reach visual acuity of 20/40 in spite of occlusion therapy. One of the reasons is a lack of adherence to therapy, which, however, could not be quantified in the past. Experience with new devices (occlusion dose monitors, ODMs) for electronic recording of occlusion has recently been reported. The aim of the present study was to evaluate the potential of the ODMs developed in the Netherlands. Various features were tested, including the reliability of the ODM recordings compared to diaries, two ODMs used simultaneously on one patch, the influence of the ambient temperature, and the specificity of the recording pattern for measurements on the eye.MethodsThe ODMs were taped to the outside of the standard occlusion patch and measured the temperature difference between their front and back surfaces. Members of the research group and the families of two patients kept occlusion diaries while using the ODMs. Recorded and written occlusion periods were compared. Measurements were carried out under various conditions: patch with one ODM tightly on the eye or detached (allowing peeping); ODMs taped to various parts of the body; two ODMs simultaneously on one patch; variation of room temperature.ResultsThere was good correspondence between the occlusion times recorded by the ODMs and those from the diaries, as well as between the recordings of two ODMs used simultaneously on one patch. High ambient temperatures (33°C to 37°C) prevented reliable ODM measurements. Measurements on other parts of the body were misclassified with probabilities between P=0.099 and P=0.325 as measurements with the patch tightly on the eye.ConclusionsIn spite of some technical limitations, the ODMs provide a chance for reliable assessment of compliance and therefore objective information on dose–response function for occlusion therapy. This will lead to a more evidence-based treatment for amblyopia.

Prevalence of amblyopia and refractive errors in an unscreened population of children.

Purpose To describe the frequency of refractive errors and amblyopia in unscreened children aged 2 months to 12 years from a rural town in Poland. Methods Five hundred ninety-one children were identified by medical records and examined in a standardized manner. Visual acuity was measured using LogMAR charts; refractive error was determined using retinoscopy or autorefraction after cycloplegia. Myopia was defined as spherical equivalent (SE) ⩽−0.50 D, emmetropia as SE between −0.5 D and +0.5 D, mild hyperopia as SE between +0.5 D and +2.0 D, and high hyperopia as SE ≥+2.0 D. Amblyopia was classified as best-corrected visual acuity ≥0.3 (⩽20/40) LogMAR, in combination with a 2 LogMAR line difference between the two eyes and the presence of an amblyogenic factor. Results Refractive errors ranged from 84.2% in children aged up to 2 years to 75.5% in those aged 10 to 12 years. Refractive error showed a myopic shift with age; myopia prevalence increased from 2.2% in those aged 6 to 7 years to 6.3% in those aged 10 to 12 years. Of the examined children, 77 (16.3%) had refractive errors, with visual loss; of these, 60 (78%) did not use corrections. The prevalence of amblyopia was 3.1%, and refractive error attributed to the amblyopia in 9 of 13 (69%) children. Conclusions Refractive errors are common in Caucasian children and often remain undiagnosed. The prevalence of amblyopia was three times higher in this unscreened population compared with screened populations. Greater awareness of these common treatable visual conditions in children is warranted.

An Educational Cartoon Accelerates Amblyopia Therapy and Improves Compliance, Especially among Children of Immigrants

PURPOSE We showed previously that an educational cartoon that explains without words why amblyopic children should wear their eye patch improves compliance, especially in children of immigrant parents who speak Dutch poorly. We now implemented this cartoon in clinics in low socioeconomic status (SES) areas with a large proportion of immigrants and clinics elsewhere in the Netherlands. DESIGN Clinical, prospective, nonrandomized, preimplementation, and postimplementation study. PARTICIPANTS Amblyopic children aged 3 to 6 years who started occlusion therapy. METHODS Preimplementation, children received standard orthoptic care. Postimplementation, children starting occlusion therapy received the cartoon in addition. At implementation, treating orthoptists followed a course on compliance. In low SES areas, compliance was measured electronically during 1 week. MAIN OUTCOME MEASURES The clinical effects of the cartoon-electronically measured compliance, outpatient attendance rate, and speed of reduction in interocular-acuity difference (SRIAD)-averaged over 15 months of observation. RESULTS In low SES areas, 114 children were included preimplementation versus 65 children postimplementation; elsewhere in the Netherlands, 335 versus 249 children were included. In low SES areas, mean electronically measured compliance was 52.0% preimplementation versus 62.3% postimplementation (P=0.146); 41.8% versus 21.6% (P=0.043) of children occluded less than 30% of prescribed occlusion time. Attendance rates in low SES areas were 60.3% preimplementation versus 76.0% postimplementation (P=0.141), and 82.7% versus 84.5%, respectively, elsewhere in the Netherlands. In low SES areas, the SRIAD was 0.215 log/year preimplementation versus 0.316 log/year postimplementation (P=0.025), whereas elsewhere in the Netherlands, these were 0.244 versus 0.292 log/year, respectively (P=0.005; the SRIADs improvement was significantly better in low SES areas than elsewhere, P=0.0203). This advantage remained after adjustment for confounding factors. Overall, 25.1% versus 30.1% (P=0.038) had completed occlusion therapy after 15 months. CONCLUSIONS After implementation of the cartoon, electronically measured compliance improved, attendance improved, acuity increased more rapidly, and treatment was shorter. This may be due, in part, to additional measures such as the course on compliance. However, that these advantages were especially pronounced in children in low SES areas with a large proportion of immigrants who spoke Dutch poorly supports its use in such areas.

Sociocultural and psychological determinants in migrants for noncompliance with occlusion therapy for amblyopia

BackgroundCompliance with occlusion therapy for amblyopia in children is low when their parents have a low level of education, speak Dutch poorly, or originate from another country. We determined how sociocultural and psychological determinants affect compliance.MethodsIncluded were amblyopic children between the ages of 3 and 6, living in low socio-economic status (SES) areas. Compliance with occlusion therapy was measured electronically. Their parents completed an oral questionnaire, based on the “Social Position & Use of Social Services by Migrants and Natives” questionnaire that included demographics and questions on issues like education, employment, religion and social contacts. Parental fluency in Dutch was rated on a five-point scale. Regression analysis was used to describe the relationship between the level of compliance and sociocultural and psychological determinants.ResultsData from 45 children and their parents were analyzed. Mean electronically measured compliance was 56 ± 44 percent. Children whose parents had close contact with their neighbors or who were highly dependent on their family demonstrated low levels of compliance. Children of parents who were members of a club and who had positive conceptualizations of Dutch society showed high levels of compliance. Poor compliance was also associated with low income, depression, and when patching interfered with the child’s outdoor activity. Religion was not associated with compliance.ConclusionsPoor compliance with occlusion therapy seems correlated with indicators of social cohesion. High social cohesion at micro level, i.e., family, neighbors and friends, and low social cohesion on macro level, i.e., Dutch society, are associated with noncompliance. However, such parents tend to speak Dutch poorly, so it is difficult to determine its actual cause.

How Dutch orthoptists deal with noncompliance with occlusion therapy for amblyopia.

Background: We previously found that compliance with occlusion therapy for amblyopia is poor, especially among children of non-native parents who spoke Dutch poorly and who were low educated. We investigated conception, awareness, attitude, and actions to deal with noncompliance among Dutch orthoptists. Methods: Orthoptists working in non-native, low socioeconomic status (SES) areas and a selection of orthoptists working elsewhere in the Netherlands were studied. They were observed in their practice, received a structured questionnaire, and underwent a semi-structured interview. Finally, a short survey was sent to all working orthoptists in the Netherlands. Results: Nine orthoptists working in non-native, low-SES areas and 23 working elsewhere in the Netherlands participated. One hundred and fifty-one orthoptists returned the short survey. Major discrepancies existed in conception, awareness, and attitude. Opinions differed on what should be defined as noncompliance and on what causes noncompliance. Some orthoptists found noncompliance annoying, unpleasant, and hard to imagine, others were more understanding. Many pitied the noncompliant child. Almost all thought that the success of occlusion therapy lies both with the parents and the orthoptist, but one third thought that noncompliance was not solely their responsibility. Patients’ compliance was estimated at 69.3% in non-native, low-SES areas (electronically, 52% had been measured), at 74.1% by the other 23 orthoptists, and at 73.8% in the short survey. Actions to improve compliance were diverse; some increased occlusion hours whereas others decreased them. In non-native, low-SES areas, 22% spoke Dutch moderately to none; the allotted time for a patient’s first visit was 21′; the time spent on explaining to the parents was 2’30” and to the child 10”. In practices of the other 23 orthoptists, 6% spoke Dutch moderately to none (P<0.0001), the time for a patient’s first visit was 27’24” (P=0.47), and the periods spent explaining were 2’51” (P=0.59) and 26” (P=0.17), respectively. Conclusion: Conception, awareness, attitude, and actions to deal with noncompliance varied among orthoptists. In non-native, low-SES areas, time spent on explanation was shorter, despite a lower fluency in Dutch among the parents.

Comfort of Wear and Material Properties of Eye Patches for Amblyopia Treatment and the Influence on Compliance

Background: Occlusion therapy for amblyopia has been the mainstay of treatment for centuries, however, acceptance of the patch is often lacking. This study evaluated comfort of wear of the eye patch and assessed the mechanical properties in order to achieve a more individualized prescription. Methods: For 8 consecutive days, parents used each of the four main brands of patches for 2 consecutive days in a randomized fashion. After 2 days a 21-item questionnaire was completed to evaluate comfort of wear for each patch. Compliance was measured electronically using the Occlusion Dose Monitor (ODM). In addition, breathing capacity at 23°C and 33°C, resistance to water penetration, opacity, and strength of adhesion to the skin were measured. Results: Twenty-four children participated. Overall, satisfaction was moderate: large differences in discomfort when removing the patch, skin reaction, and cosmetic appearance were found. In the material measurements large differences were found in opacity and strength of adhesion to the skin. In all brands breathing capability was minimal. Answers given by the parents matched the physical properties of the eye patch. There was no difference in electronically measured compliance between patches. Conclusions: We found large differences in comfort of wear and mechanical properties. Therefore, when prescribing a certain brand of patch, the wide variety needs to be taken into account. Further study into these properties seems warranted; especially breathing capability requires improvement since children often wear the patch for a longer period of time. This could contribute to increasing satisfaction and consequently may improve compliance.

Blinded by shiga toxin-producing o104 escherichia coli and hemolytic uremic syndrome

10-month-oldinfantpresentedwith asevere hemolytic uremic syndrome and stool positive for the Shiga toxinproducing O104 Escherichia coli. She developed lethargy and anuria that necessitated admission to our intensive care unit. We started 300 mg of eculizumab and dialysis, but plasmaferesis could not be performed because of severe hypotension. In this period, the patient began rubbing her eyes frequently and crying forcefully. At neurologic examination, she was E4M5V2, did not fixate or follow objects, and pupils were 4+/4+. There was hypotonia of the left leg and arm and a choreodystonic movement of the right arm. Magnetic resonance imaging of the cerebrum showed diffuse atrophy and decreased signal intensity in the putamen and globus pallidus on both sides as a sign of ischemia and necrosis of the basal ganglia (Figure 1 ,A ; available at www.jpeds.com). A “vertical nystagmus” was first noticed on the 23rd day of admission. Ophthalmologic investigation showed inverse ocular bobbing and funduscopy revealed retinal and choroidal infarction (Figure 2). Six weeks after the onset of disease, magnetic