Cycloplegic Retinoscopy Research Articles

Longitudinal Development of Refractive Error in Children Treated With Intravitreal Bevacizumab or Laser for Retinopathy of Prematurity.

PurposeTo compare the patterns of longitudinal refractive error development during the first 3.5 years in children with severe retinopathy of prematurity (ROP) treated with intravitreal bevacizumab (IVB) or laser photocoagulation.MethodsThis prospective cohort study enrolled extremely preterm infants (birth weight < 1000 g, gestational age 23–27 weeks) with type 1 ROP from multiple hospitals in Dallas between 1999 and 2017; IVB group (N = 22); laser group (N = 26). Cycloplegic retinoscopy was conducted from 0.04 years corrected age and every 0.5 to 1.0 years thereafter until 3.5 years old. Right eye spherical equivalent (SEQ) and astigmatism, anisometropia, and better-eye visual acuity were analyzed over time.ResultsIn all children, both eyes were treated with the same modality. At the final visit, the prevalence of myopia (SEQ ≤ −1D) was 82.7% in the laser group and 47.7% in the IVB group (P < 0.05) with a mean SEQ of −8.0D ± 5.8D in the laser group versus −2.3D ± 4.2D in the IVB group (P < 0.001). Longitudinal SEQ were best fit with a bilinear model. Before one year, the rate of SEQ change was −5.0D/year in the laser group, but only −3.5D/year in the IVB group (T = −5.14, P < 0.001); after one year, there was a significant flattening of these slopes (T = 6.23, P < 0.001). Anisometropia in the IVB group was significantly less than in the laser group (P < 0.05). Final visual acuity in both groups was similar at 0.47 logMAR (∼ 20/60).ConclusionsChildren with severe ROP treated with IVB developed less myopic refractive error than those treated with laser largely because of a slower rate of refractive change during the first year of life.Translational RelevanceThese findings may inform decisions regarding ROP treatment timing and modality.

Correction of Low-Moderate Hyperopia Improves Accommodative Function for Some Hyperopic Children During Sustained Near Work.

PurposeThis study investigated whether refractive correction improved accommodative function of hyperopic children while engaged in two sustained near activities.MethodsSustained accommodative function of 63 participants (aged 5–10 years) with varying levels of uncorrected hyperopia (>/= +1.00 D and < + 5.00 D spherical equivalent in the least hyperopic eye) was measured using eccentric infrared photorefraction (PowerRef 3; PlusOptix, Germany). Binocular accommodation measures were recorded while participants engaged in 2 tasks at 25 cm for 15 minutes each: an “active” task (reading small print on an Amazon Kindle), and a “passive” task (watching an animated movie on liquid crystal display [LCD] screen). Participants also underwent a comprehensive visual assessment, including measurement of presenting visual acuity, prism cover test, and stereoacuity. Reading speed was assessed with and without hyperopic correction. Refractive error was determined by cycloplegic retinoscopy.ResultsHyperopic refractive correction significantly improved accuracy of accommodative responses in both task (pairwise comparisons: t = −3.70, P = 0.001, and t = −4.93, P < 0.001 for reading and movie tasks, respectively). Accommodative microfluctuations increased with refractive correction in the reading task (F(1,61) = 25.77, P < 0.001) but decreased in the movie task (F(1,59) = 4.44, P = 0.04). Reading speed also significantly increased with refractive correction (F(1,48) = 66.32, P < 0.001).ConclusionsCorrecting low-moderate levels of hyperopia has a positive impact on accommodative performance during sustained near activity in some schoolchildren. For these children, prescribing hyperopic correction may benefit performance in near vision tasks.

Agreement Between Retinoscopy, Autorefractometry and Subjective Refraction for Determining Refractive Errors in Congolese Children.

ObjectiveTo assess the agreement between retinoscopy and autorefractometry and between subjective refraction and both retinoscopy and autorefractometry in Congolese children.Patients and MethodsFifty-four children (6–17 years old) were enrolled consecutively in this cross-sectional study. Refraction was evaluated before and after cycloplegia (1% cyclopentolate) with retinoscopy and autorefractometry. Readings were compared (paired t-test) and agreement assessed with Bland–Altman plots. Subjective refraction was compared with the two methods to determine which one provides better reference estimates for subjective refraction.ResultsUnder cycloplegia, the spherical power was comparable between retinoscopy and autorefractometry (1.12 ± 1.37 D vs 1.22 ± 1.06D, P = 0.70), cylinder power was significantly more myopic on retinoscopy than autorefractometry (0.80 ± 1.10D vs −0.62 ± 0.66, P = 0.019), and SE was greater on autorefractometry than retinoscopy (0.91 ± 1.10D vs 0.72 ± 1.00D, P = 0.014). Retinoscopy and autorefractometry overestimated the power of spherical (P = 0.022 and 0.002, respectively) and cylindrical components (all P < 0.001). There was an agreement between retinoscopy and autorefractometry in measuring spherical (bias: 0.09 ± 0.16D; limit of agreement, LoA: −0.40 to 0.22D) and cylindrical power (bias: −0.18 ± 0.20D; LoA: −0.57 to 0.21D). Subjective refraction agreed with cycloplegic retinoscopy for determining SE power (bias: 0.11D; LoA: −0.51 to 0.73D).ConclusionRetinoscopy and autorefractometry can be used interchangeably in children for determining the power of spherical and cylindrical components. Cycloplegic retinoscopy is better than autorefractometry to obtain SE reference values for subjective refraction in children.

Accuracy of Photorefraction and Wavefront-Based Autorefraction in Children Under 3 Years of Age.

Objectives:This study was designed to assess the accuracy of photorefraction and wavefront-based autorefraction in children under 3 years of age.Methods:A cross-sectional study was performed with children who had no ocular abnormalities other than a refractive error and were less than 3 years old. Spot Vision Screener (Welch Allyn Inc., Skaneateles Falls, NY, USA) was used for photorefraction and SureSight Vision Screener (Welch Allyn, Skaneateles Falls, NY) was used for autorefraction. The measurements were performed with both devices before and after cycloplegia. The results were compared with those obtained using cycloplegic retinoscopy. The assessments were performed in terms of spherical equivalent (SE) values and Jackson cross-cylinder power values (J0 and J45).Results:A total of 305 children with a mean age of 15.1±10.4 months were included. The mean SE values measured with the Spot Vision and SureSight before cycloplegia were 0.43±0.75 D and 0.90±0.86 D, respectively. Following cycloplegia, the mean SE values were 1.80±1.25 D and 1.55±1.40 D, respectively. The mean SE value obtained with cycloplegic retinoscopy was 1.53±1.34 D. The mean SE values measured with both devices prior to cycloplegia were significantly lower than that measured with cycloplegic retinoscopy (p<0.001). No significant difference was observed between the cycloplegic SE values obtained with SureSight and retinoscopy (p=0.66). Spot Vision yielded significantly higher cycloplegic SE values compared with cycloplegic retinoscopy (p<0.001).Conclusion:Both devices underestimated SE values in comparison with cycloplegic retinoscopy in children under 3 years of age. Wavefront-based autorefraction performed with cycloplegia may be an alternative to cycloplegic retinoscopy, but needs confirmation.

Comparison of photorefraction by photoscreener (PlusoptiXA12R) with autorefractometer and cycloplegic retinoscopy in children between 5 and 15 years

Aim: The aim of the study is to compare the photorefraction values by photoscreener (PlusoptiXA12R, PO) with those of autorefractometer (AR) (TOPCON RM800) and cycloplegic retinoscopy (CR) in children. Methods: It was an observational cross-sectional analytical study with a sample size of 1000 eyes conducted over a duration of one year in a tertiary eye care center. Children in the age group of 5–15 years with refractive error were screened using photoscreener and AR in noncycloplegic state followed by CR. Interclass correlation and agreement were assessed for measurements taken by all three modalities. Sensitivity and specificity were analyzed. P < 0.05 was taken significant for all statistical tests. Positive likelihood ratio, negative likelihood ratio, positive predictive value, and negative predictive value were statistically analyzed. Receiver operative characteristic curve and area under the curve were plotted. Results: Refraction measurements by photoscreener had a strong positive correlation with measurements from CR and AR. Bland-Altman plots depicted the agreement for measurements taken by all three modalities. Sensitivity and specificity of values were high for photoscreener (PlusoptiXA12R) when compared with CR and AR. Conclusion: We conclude that photoscreener is a reliable alternative to AR and CR for detection of refractive error in children between 5 and 15 years of age.

Co-existence of myopia and amblyopia in a guinea pig model with monocular form deprivation.

BackgroundForm deprivation myopia is a type of ametropia, with identifiable causes in humans, that has been induced in many animals. The age of onset of myopia induced by monocular form deprivation coincides with the period of visual development in guinea pigs. However, visual acuity of form-deprived eyes in guinea pigs is not understood yet. In this study, we investigated whether monocular form deprivation would affect visual acuity in infant guinea pigs by evaluating the development of myopia and amblyopia after monocular form deprivation, and whether form deprivation myopia and amblyopia occurred simultaneously or successively.MethodsTwenty pigmented guinea pigs (2 weeks old) were randomly assigned to two groups: monocularly form-deprived (n=10), in which facemasks modified from latex balloons covered the right eye, and normal controls (n=10). Refraction, axial length, and visual acuity were measured at 4 intervals (after 0, 1, 4, and 8 weeks of form deprivation), using cycloplegic streak retinoscopy, A-scan ultrasonography (with an oscillation frequency of 10 MHz), and sweep visual evoked potentials (sweep VEPs), respectively. Sweep VEPs were performed with correction of the induced myopic refractive error.ResultsLonger deprivation periods resulted in significant refractive errors in form-deprived eyes compared with those in contralateral and normal control eyes; the axial lengths of form-deprived eyes increased significantly after 4 and 8 weeks of form deprivation. These results revealed that myopia was established at 4 weeks. The acuity of form-deprived eyes was unchanged compared to that at the pretreatment time point, while that of contralateral eyes and eyes in normal control guinea pigs improved; there were significant differences between the deprived eyes and the other two open eyes from 1 to 8 weeks of form deprivation, showing that amblyopia was possibly established during 1 week of form deprivation.ConclusionsThis study demonstrated the feasibility of using sweep VEPs to estimate the visual acuity of guinea pigs. Further, our results revealed that amblyopia likely occurred earlier than myopia; amblyopia and myopia coexisted after a long duration of monocular form deprivation in guinea pigs. Understanding this relationship may help provide insights into failures of treatment of amblyopia associated with myopic anisometropia.

Ocular disorders in children with learning disabilities in a tertiary Hospital, Pondicherry

Aim: To assess the visual function of the children with disabilities and to identify the preventable and treatable ocular abnormalities. Materials and Methods: This was a cross sectional hospital based study which included the children aged between 3 to 16 years with learning disabilities (cLDs, previously referred to as mentally challenged) who were on speech and occupational therapy sessions. After consent from parents or guardian who accompanied the child, relevant medical history was taken. Detailed ocular examination, visual acuity assessment, cycloplegic retinoscopy of all children was done. Spectacles and low vision aids were prescribed appropriately. Results: A total of 116 children with learning disabilities were enrolled. There were 79 (68.1%) males as compared to 37 (31.9%) females in the study. Eighty eight children (76%) had ocular disorder, 31 children had more than one ocular abnormality and 51 of them were not cooperative for assessment. The most common ocular disorders seen in these children were 48 (54.5%) children had refractive errors, strabismus in 17 (19.3%) children, followed by nystagmus in 15 (17%) children, Only 7 of the 48 children (14.6%) with refractive error were using spectacles. Conclusion: The prevalence of ocular abnormalities is higher among the children with disabilities than in general population. Their flawed verbal, poor communication and cooperation add on to the burden of their disabilities as the ocular abnormalities go unnoticed. Therefore there is a need for strategies regarding increasing awareness, annual comprehensive ophthalmic assessments, early detection and treatment of the ocular disorders to assist these children in their learning process. Keywords: Children with learning disabilities, Refractive error, Strabismus, Special needs.

ON THE ROLE OF MICRO ANISOMETROPIA (THE “BUTTERFLY” EFFECT) IN THE OCCURRENCE OF ESOTROPIA IN CHILDREN

Purpose: This report presents 3 cases of esotropia in children and an attempt is made to explain the cause of the development of esotropia in these children.Methods: A comprehensive ophthalmic examination was carried out in the following order: photorefraction using the Plusoptix A09 photoscreener without cycloplegia; orthoptic examination with the alternate prism cover test; anterior segment assessment using a slit lamp; fundus examination and cycloplegic retinoscopy; and, for autorefractometry measurements, Sure-Sight.Results: Threecases of esotropia in children are presented. In all cases, a slight microanisometropia was observed along the cylindrical component ofthe squinting eye.Conclusion:Our three examples show how a slight degree of ametropia can cause a deviation of the eyeball. Therefore, case-by-case analysis can be more informative than large statistical studies. Thus, it is appropriate to evaluate eachcase from these new perspectives. The timely elimination of a small degree of anisometropia in the astigmatic or spherical components can lead to the restoration of the symmetrical position of the eyes

Performance of Plusoptix A09 Photo Screener in Refractive Error Screening in School Children Aged between 5 and 15 Years in the Southern Part of India.

Purpose:To evaluate the performance of Plusoptix A09 in detecting ametropia, warranted against frequently-used technique of retinoscopy in children attending school (5–15 years) and its probability as a screening tool.Methods:This study was the subset of a larger epidemiological study visual acuity refractive error squint conducted in schools to determine the prevalence of ocular morbidity among the 5–15 years' school children population. Every 7th student in the class (each school had mean value of 100 students) was randomly selected for this study after ascertaining their eligibility as per the inclusion criteria. A cohort of a total of 150 children within the age group of 5–15 (mean, 10.21 ± 2.83) years were recruited from 11 schools of Udupi district. Students with best corrected visual acuity of 20/20, refractive error within ±5.00 diopter (D), without any eccentric fixation, and no history of ocular pathology or seizures were recruited. Refractive error was tested by Plusoptix photorefractor followed by non-cycloplegic and cycloplegic retinoscopic techniques. The examiners performing these tests were masked and unware of the findings. Bland Altman plotted the agreement between the techniques, followed by the receiver operating characteristic curve (ROC), and sensitivity of Plusoptix.Results:One-way analysis of variance calculated statistical differences among Plusoptix, objective retinoscopy, and cycloplegic retinoscopy for mean spherical value (1.12 ± 1.16 D, 0.65 ± 0.69 D, and 0.8 ± 0.82 D), cylindrical value (−0.83 D ± 1.27, −0.32 D ± 0.86, and −0.34 D ± −0.93), and spherical equivalent value (0.71 D ± 1.06, 0.45 D ± 0.7, and 0.61 D ± 0.81), with P = 0.0001, 0.0001, and 0.097, respectively. Bland Altman plots showed good agreement for spherical equivalent values of Plusoptix and objective retinoscopy. However, the area under the ROC curve (0.386) suggests that lower diagnostic ability of this device in this age group population in comparison to retinoscopy (0.575) with the sensitivity and specificity of Plusoptix was 69.2% and 84.8%.Conclusions:This study fails to report ideal sensitivity mandated for a screening tool, although good specificity and agreement are observed. Along with retinoscopy, this tool will be effective in screening a children's population aged between the age group of 5 and 15 years.

The Difference of Refraction Between the Cycloplegic Retinoscopy and Non-Cycloplegic Subjective Refraction in Children Aged 6 to 15 Years

Objective: To determine the difference of refraction measured by cycloplegic retinoscopy (CR) and non-cycloplegic subjective refraction (NS). Materials and Methods: The present descriptive study included normal children aged 6 to 15 years with refractive error. The refractive status was measured by CR and cycloplegic autorefractometer (CA) at the initial visit. At 2-week follow-up, the refraction was measured with non-cycloplegic autorefractometer (NA) and NS. The spherical equivalent (SE) from participants’ right eye was used in the data analyses. Results: Forty-four participants were included in this study with a mean age of 9±3 years and 22 (50%) were male. Overall, the median (Q₁, Q₃) of SE by CR, CA, NS, and NA were –1.00 (–2.50, 0.25), –1.63 (–2.63, –0.50), –1.63 (–2.50, –1.00), and –1.88 (–2.88, –1.13) diopters (D), respectively. The SE by CR was 0.56 D more than NS (p&lt;0.001), and 0.38 D more than CA (p&lt;0.001). The SE by NS was 0.25 D more than NA (p=0.008). By using the CR method, 11 (25%) participants were classified in the hyperopic group (positive SE) and 33 (75%) in the myopic group (negative SE). In the hyperopic group, the median (Q₁, Q₃) of SE by CR and NS were 0.75 (0.50, 1.75) and –0.63 (–1.00, 1.38) D, respectively. The refraction by CR was 1.50 D more than by NS (p=0.003). In the myopic group, the median (Q₁, Q₃) of SE by CR and NS were –1.50 (–2.50, –0.75) and –2.00 (–3.25, –1.50) D, respectively. The refraction by CR was 0.50 D more than NS (p&lt;0.001). Conclusion: The refraction in children aged 6 to 15 years measured by CR was significantly more than NS in the participants. The authors should decrease the number of refractions obtained from CR when prescribing glasses to hyperopic children. Keywords: Refractive error, Children, Cycloplegic retinoscopy, Subjective refraction, Cycloplegic autorefractor, Manifest autorefractor

Detection of Amblyogenic Refractive Error Using the Spot Vision Screener in Children.

Vision screenings are conducted to detect significant refractive errors, amblyopia, and ocular diseases. Vision screening devices are desired to have high testability, sensitivity, and specificity. Spot has demonstrated high testability, but previous reports suggest that the Spot has low sensitivity for detecting amblyogenic hyperopia and moderate sensitivity for amblyogenic astigmatism. This study assessed the concurrent validity of detecting amblyogenic refractive errors by the Spot (v.1.1.50; Welch Allyn Inc., Skaneateles Falls, NY) compared with cycloplegic retinoscopy. A total of 475 subjects (24 to 96 months) were screened by Spot and then received a masked comprehensive examination. Sensitivity and specificity, Bland-Altman plot, receiver operating characteristic area under the curve, and paired t test were evaluated by comparing the results of the Spot (v1.1.50) using the manufacturer referral criteria with the results of the comprehensive examination using the 2013 American Association for Pediatric Ophthalmology and Strabismus criteria. The Spot (v.1.1.50) referred 107 subjects (22.53%) for the following: 18.73% (89/475) astigmatism, 4.63% (22/475) myopia, 0.42% (2/475) hyperopia, and 2.11% (10/475) anisometropia. The sensitivity and specificity of the Spot vision screener for detecting amblyogenic risk factors were 86.08% (95% confidence interval [CI], 76.45 to 92.84%) and 90.15% (95% CI, 86.78 to 92.90%). Areas under the curve were 0.906 (95% CI, 0.836 to 0.976) for hyperopia, 0.887 (95% CI, 0.803 to 0.972) for spherical equivalent, and 0.914 (95% CI, 0.866 to 0.962) for astigmatism. A modified hyperopia criteria cutoff of greater than +1.06 D improved the sensitivity from 25 to 80% with 90% specificity. The current cutoff criterion, greater than -1.75 D, for astigmatism seemed optimal. This study shows that the Spot vision screener accurately detects low spherical refractive errors and astigmatism. Lowering the hyperopia cutoff criteria from the current Spot screener referral criteria improves the sensitivity with desired (high) specificity.

Comparison of open-field autorefraction, closed-field autorefraction, and retinoscopy for refractive measurements of children and adolescents in Taiwan

To evaluate the accuracy and effectiveness of noncycloplegic and cycloplegic autorefraction using two types of autorefractors (ARs) compared with retinoscopy in children and adolescents. This cross-sectional study included 308 students (6-17 years old) from eastern Taiwan. Noncycloplegic and cycloplegic refractive measurements were obtained using open-field AR (Shin-Nippon NVision-K 5001), closed-field AR (Topcon KR-800), and cycloplegic retinoscopy. Three optical components emerged from the measurements: spherical equivalent (M) and two Jackson cross-cylinder values (J0 and J45). Agreement between both ARs and retinoscopy was evaluated using intraclass correlation coefficient. Measurement discrepancies from retinoscopy among different ARs and cycloplegic status were compared using repeated measures ANOVA and receiver operating characteristic curve analysis. Compared with retinoscopy, measurements obtained before and after cycloplegia with both ARs showed excellent reliability for evaluating M and J0 and fair to good results for J45. More myopic results were obtained using KR-800 before cycloplegia; more hyperopic results were obtained using KR-800 and NVision-K 5001 after cycloplegia(all p<0.05). J45 data obtained using NVision-K 5001 were closest to those obtained by retinoscopy; J0 data obtained using both ARs were comparable with retinoscopy after cycloplegia. NVision-K 5001 outperformed KR-800 in refractive measurements, particularly in hyperopia diagnosis among younger children. Both autorefractors showed great agreement with retinoscopy. Results obtained using NVision-K 5001 without cycloplegia were most similar to those by retinoscopy, especially for oblique astigmatism and hyperopia detection in younger children. For large vision screening in elementary school, Shin-Nippon NVision-K 5001 might be a more suitable autorefractor.

Accuracy of Autorefraction in Children: A Report by the American Academy of Ophthalmology

The purpose of this assessment is to evaluate the accuracy of autorefraction compared with cycloplegic retinoscopy in children. Literature searches were last conducted in October 2019 in the PubMed and the Cochrane Library databases for studies published in English. The combined searches yielded 118 citations, of which 53 were reviewed in full text. Of these, 31 articles were deemed appropriate for inclusion in this assessment and subsequently assigned a level of evidence rating by the panel methodologists. Four articles were rated level I, 11 were rated level II, and 16 were rated level III articles. The 16 level III articles were excluded from this review. Thirteen of the 15 studies comparing cycloplegic autorefraction with cycloplegic retinoscopy found a mean difference in spherical equivalent or sphere of less than 0.5 diopters (D); most were less than 0.25 D. Even lower mean differences were found when evaluating the cylindrical component of cycloplegic autorefraction versus cycloplegic retinoscopy. Despite low mean variability, there was significant individual measurement variability; the 95% limits of agreement were wide and included clinically relevant differences. Comparisons of noncycloplegic with cycloplegic autorefractions found that noncyloplegic refraction tends to over minus by 1 to 2 D. Cycloplegic autorefraction is appropriate to use in pediatric population-based studies. Cycloplegic retinoscopy can be valuable in individual clinical cases to confirm the accuracy of cycloplegic autorefraction, particularly when corrected visual acuity is worse than expected or the autorefraction results are not consistent with expected findings.

The performance of visual photoscreening for Chinese preschool children aged 4 to 5 years

Objective: To assess the accuracy of photoscreening for detecting refractive amblyopia risk factors (ARFs) in Chinese preschool children aged 4 to 5 years. Methods: A cross-sectional study. Comprehensive ocular examinations were conducted for preschool children in Nanjing, China from September to December, 2016. Photoscreening (Plusoptix A12C) was applied for refractive screening without cycloplegia. Voluntary children and children suspected of eyes abnormalities received cycloplegic retinoscopy (CR). Results of photoscreening and CR were compared using Wilcoxon signed rank test, and Bland-Altman plot were used to assess the agreement between the photoscreener and CR. According to the updated preschool vision screening guidelines from American Association for Pediatric Ophthalmology and Strabismus (AAPOS) in 2013, CR was adopted for identifying children with ARFs, which was considered as a golden standard. Based on the golden standard, the accuracy of 5 sets of referral criteria (including sensitivity standard, Matta/Silbert standard, AAPOS2013 standard, Alaska Blind Child Discovery standard, specificity standard) for photoscreener were tested. Receiver operating characteristics curves were constructed applied to evaluate the quality of the photoscreener in refractive ARFs detection and to find probably the best cut-off points. Results: In total, 1 986 children [mean age, (4.57±0.29) years] received comprehensive examinations, including 1 084 boys and 902 girls. The test ability of photoscreening was 99.04% (1 967/1 986) in the preschool children, and 96.56%(1 827/1 892) of the children got a reliable result within three screening attempts. In 538 children who had data of CR, refractive error of one child exceeded the upper limit of the photoscreener value setting, which was directly categorized as hyperopia, so in the end, 537 children were included to analyze the comparison between the two tests. The measurement values of photoscreening were lower than those of CR in sphere, cylinder and spherical equivalent [(0.75 (0.50, 1.25) D vs. 1.25 (1.00, 1.75) D, Z=-10.36, P<0.01; -0.50 (-0.75, -0.25) D vs. -0.25 (-0.75, 0.00) D, Z=-11.10, P<0.01; 0.63 (0.38, 0.88) D vs. 1.00 (0.75, 1.50) D, Z=-13.33, P<0.01]. The 95% limit of agreement cover rates between the photoscreening and CR in sphere, cylinder and spherical equivalent was 96.28% (517/537), 95.34% (512/537) and 96.65% (519/537), respectively. Based on the golden standard, 47 (8.74%) children had refractive ARFs, and the range of sensitivity, specificity, Youden index, positive predictive values and negative predictive values for detecting refractive ARFs of the 5 common used referral criteria was from 63.83% to 97.87%, from 53.36% to 97.56%, from 0.51 to 0.80, from 16.73% to 74.51% and from 96.57% to 99.62%, respectively. Considering particular refractive ARFs on the basis of the receiver operating characteristic curves, the optimal cut-off point for astigmatism was set at 1.38 D. Conclusion: Photoscreening could be an applicable tool to detect refractive ARFs in preschool children. (Chin J Ophthalmol, 2020, 56: 189-196).

Botulinum toxin in the treatment of partially accommodative esotropia with high AC/A ratio.

To study the outcome of botulinum toxin (BTX) treatment (group 1) in partially accommodative esotropia with high accommodative convergence/accommodation (AC/A) ratio, in comparison with bilateral medial rectus muscles recessions and posterior fixation (group 2). In a retrospective comparative study, children aged 3-8 years old treated between 2011 and 2016, with partially accommodative esotropia with high AC/A ratio, deviation at distance of 10 prism diopters or more, and at least 1 year of follow-up, were included. Visual acuity, alternate prism and cover test, stereoacuity, biomicroscopy, and cycloplegic retinoscopy were carried out at initial, baseline visit, 6 months and 1 year after BTX injection or surgery. Main outcome variables were deviation at distance and near, improvement in stereoacuity, and percentage of success. We used multiple regression or proportional odds analysis to control for potential confounding variables. Of 95 patients, 84 were eligible, 48 children in group 1 and 36 in group 2. Deviation and stereoacuity were similar in the two groups at 6 months, but significantly better in the BTX group at 1 year (median distance deviation 0 prism diopters vs 5 prism diopters, p<0.01), although differences were not clinically relevant. Percentage of success was also significantly better only at 1 year (93% vs 72%, p = 0.01). Change in distance-near disparity was not significantly different in the two groups in the period of study. Botulinum toxin could be superior to, or as effective as surgery, at middle term, in the treatment of partially accommodative esotropia with high AC/A ratio.

Mean Change in Refractive Status After Levator Muscle Resection in Patients of Simple Congenital Ptosis

Purpose: To determine the mean change in refractive status after Levator muscle resection in patients of simple congenital ptosis.&#x0D; Study Design: Quasi Experimental study.&#x0D; Place and Duration of Study: This study was carried out at Institute of Ophthalmology, King Edward Medical University, Mayo Hospital Lahore, from 2014 to 2015.&#x0D; Material &amp; Methods: Fifty patients were selected under the age of 12 years with no sex predilection presenting with simple congenital ptosis of pupil sparing type. Patients with neurogenic, aponeurotic ptosis, mechanical ptosis, Blepharophimosis syndrome, patients with previous failed ptosis surgery and patients with corneal anomalies were excluded. After history and examination, Cycloplegic retinoscopy was done, which was repeated after surgical intervention. All interventions were done by a single ophthalmic surgeon. The patients were examined and discharged on the second post operative day. All data including preoperative and postoperative recordings of spherical and cylindrical values were collected on a self-designed proforma. Follow up period was extended to 3 months. At 3rd month cycloplegic retinoscopy was done and change in character of refractive status was analyzed. Mean change in refractive status was calculated by difference of preoperative and postoperative sphere and cylinder values.&#x0D; Results: Mean age of patients was 4.26 ± 3.78 years. Mean change in spherical value after treatment was 0.447 ± 0.339. This difference was statistically significant with p-value = 0.000. While mean change in cylindrical value after treatment was 0.640 ± 0.580. This difference in cylinder value after treatment was also statistically significant with p-value = 0.000.&#x0D; Conclusion: Levator muscle resection has a significant effect on refractive status of the patients with congenital ptosis.

Commentary: Impact of the COVID-19 pandemic on digital eye strain in children.

The authors have highlighted the impact of increasing usage of digital devices during the ongoing COVID-19 pandemic on ocular health in an online survey conducted for adults.[1] Whereas there is no arguing about the ill-effects of this phenomenon in adults owing to changes forcefully affected by the lockdown, an equally or perhaps a more vulnerable cohort that is silently suffering this onslaught of increased digital device use, are children. Children today are growing up in an increasingly visually demanding world. Electronic devices, video games, e-readers, tablets, and laptops, and the ubiquitous mobile phone were already exploited for entertainment and leisure. The COVID-19 pandemic has increased this burden by leaving schools with no choice but to adapt to e-learning platforms. Children now spend an average of 8–12 h a day on some form of digital device. This has increased the threat of digital eye strain (DES), making it an emerging public health problem with an estimated prevalence in the community reported between 22.3% and 39.8%.[2] Our group has reported that approximately 80% of outpatient visits in the pediatric ophthalmology department in March and April 2020 (at the start of the lockdown) were refractive errors, of which 79% were for myopia.[3] With no definitive end in sight for the pandemic, we are potentially facing an explosive scenario of this “quarantine myopia.” There are predictions of a worsening of the myopic epidemic worldwide and is estimated that over 50% of the world's population will have myopia by 2050.[4] Besides myopic progression, accommodative dysfunction in children is also on the rise due to digital device usage.[5] Accommodation spasm and sudden onset esotropia are important causes. The former presents with an acute, rapid increase in myopia and requires dynamic, cycloplegic retinoscopy, and a comprehensive assessment of the binocular visual field. Receded near the point of convergence, large near exophoria, reduced near the point of accommodation, and lag of accommodation greater than +1.25 diopter sphere demand further assessment for nonstrabismic binocular vision dysfunction.[6] Vision therapy plays a significant role in managing these anomalies. We have been using three exercises in our practice to manage accommodative dysfunction in children with good results. 1) The Lens Flipper at a distance of 0.4 m [Fig. 1]– flip and re-flip a set of +2.0/−2.0D lens flipper ensuring that the text is clear with each flip.[7]2) The Hart Chart—a pair of similar charts, one at 6 m [Fig. 2a] and the other at 40 cm [Fig. 2b] are read alternately with one eye occluded. This improves focus for both near and far.[8]3) Brock String [Fig. 3]—a white string (3–10 feet long) with 3–5 beads of different colors. One end of the Brock string is held at the tip of the nose while the other is tied to a fixed point.[9] The child is asked to fixate on one of the further beads to begin with and should see one bead (indicating focus to a single point). The next step is to alternate from bead to bead, working closer and back to exercise the convergence muscles.Figure 1: FlippersFigure 2: (a) Hart Chart for Distance. (b) Hart Chart for NearFigure 3: Brock stringForced gadget breaks, restriction of online classes with breaks in between sessions, promoting (permitted) outdoor activities, encouraging “family” time with non-gadget-based learning and entertainment are some measures that can be adopted. Sensitizing teachers and parents about these practices can help to check the growing ill-effects of DES.[10] As eye health care providers, we need to promptly identify those children who are at a higher risk of DES and progression of myopia to manage them appropriately. A public awareness campaign to improve safety measures, enhance early detection of DES, and promote good eye health measures in our young citizens is the need of the hour. 2.1 Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. 2.2 Financial support and sponsorship Nil. 2.3 Conflicts of interest There are no conflicts of interest.

Distribution of Refractive Errors among Healthy Infants and Young Children between the Age of 6 to 36 Months in Kuala Lumpur, Malaysia-A Pilot Study.

Uncorrected refractive error, especially myopia, in young children can cause permanent visual impairment in later life. However, data on the normative development of refractive error in this age group is limited, especially in Malaysia. The aim of this study was to determine the distribution of refractive error in a sample of infants and young children between the ages of 6 to 36 months in a prospective, cross-sectional study. Cycloplegic retinoscopy was conducted on both eyes of 151 children of mean age 18.09 ± 7.95 months. Mean spherical equivalent refractive error for the right and left eyes was +0.85 ± 0.97D and +0.86 ± 0.98D, respectively. The highest prevalence of refractive error was astigmatism (26%), followed by hyperopia (12.7%), myopia (1.3%) and anisometropia (0.7%). There was a reduction of hyperopic refractive error with increasing age. Myopia was seen to emerge at age 24 months. In conclusion, the prevalence of astigmatism and hyperopia in infants and young children was high, but that of myopia and anisometropia was low. There was a significant reduction in hyperopic refractive error towards emmetropia with increasing age. It is recommended that vision screening be conducted early to correct significant refractive error that may cause disruption to clear vision.

The Effects of High Lighting on the Development of Form-Deprivation Myopia in Guinea Pigs.

To investigate the effects of high ambient lighting on refraction and ocular biometry in guinea pig models of form-deprivation myopia (FDM). Forty 3-week-old guinea pigs were randomly assigned to groups exposed to either high light (HL, 10,000 lux) or normal light (NL, 500 lux) with normal vision or form deprivation. Throughout the 10-week rearing period, animals were exposed to high light or normal light for 12 hours with a 12-hour light/dark cycle. Refraction, axial length (AL), and radius of corneal curvature (CCR) were measured by cycloplegic retinoscopy, A-scan ultrasonography, and keratometer, respectively. At the end of treatment, form-deprived eyes under high ambient lighting exhibited more hyperopic refraction and shorter AL than those under normal ambient lighting (2.06 ± 1.68 diopters [D; mean ± SD] vs. -0.59 ± 1.56 D, P < 0.001; 8.36 ± 0.13 mm vs. 8.56 ± 0.16 mm, P < 0.001). Deprived eyes under high ambient lighting were relatively more myopic than their contralateral control eyes at the end of treatment (2.06 ± 1.68 D vs. 5.44 ± 0.66 D, P < 0.001). High lighting induced a significant hyperopic shift in normal eyes after 4 weeks of exposure. There were no significant differences in CCR between eyes exposed to high and normal light, nor between deprived eyes and contralateral eyes. High ambient lighting could retard, but not fully inhibit, the development of FDM. High light levels contributed to a greater hyperopic shift in normal eyes during the first 4 weeks of treatment. Corneal curvature was unaffected by either high ambient lighting or form deprivation.

Brain abnormalities in infantile esotropia as predictor for consecutive exotropia

ABSTRACT Cerebral palsy, neurological abnormalities, prematurity or periventricular lesions may affect motor and sensory fusion mechanisms that favorably control eye alignment. White matter damage of immaturity (WMDI) is a form of white matter brain injury characterized by the necrosis of white matter near the lateral ventricles. In these cases, it is difficult to establish fusion after strabismus surgery and consecutive deviations may be seen more frequently especially in association with WMDI. The aim of this study is to evaluate and compare the cerebral magnetic resonance imaging (MRI) findings in operated infantile esotropia cases with and without consecutive exotropia and to relate them to the occurance of consecutive exotropia. Seventeen patients that had consecutive exotropia after bilateral medial rectus recession surgery for infantile esotropia were included in this study (group 1) and patients that were operated with the same diagnosis with a successful surgical outcome (≤10 PD of deviation) were recruited as group 2. Age, sex, consanguinity, associated systemic and neurological diseases, prematurity, visual acuity, angle of deviations at first visit, at last and follow-up visit and after surgery, cycloplegic retinoscopy, fundus and cerebral MRI findings were recorded. Demographic and clinical findings of patients in two groups and MRI findings were evaluated and compared. The mean age at the time of first examination was 8.21 ± 6.62 and 7.45 ± 4.94 months in infantile esotropia patients with (group 1) and without consecutive exotropia (group 2), respectively. The mean cycloplegic refractive errors (+1.92 ± 1.57 D vs. +2.30 ± 1.10 D), the mean preoperative angle of deviation (46.33 ± 18.8 PD vs. 34.8 ± 12.5 PD), sex, percentage of consanguinity, percentage of prematurity, presence of latent nystagmus, dissociated vertical deviation and amblyopia and fundus findings were similar in both groups. Patients with consecutive exotropia had a mean deviation angle of 37.5 ± 9.48 PD postoperatively. Cerebral MRI findings were consistent with WMDI (three patients), myelinization delay (one patient), septooptic dysplasia (one patient) and periventricular cysts (one patient) in group 1. Cerebellar hemispheres and vermis hypoplasia (one patient), myelinization delay (one patient), cerebellar atrophy (one patient) were the MRI findings of patients in group 2. White matter damage of immaturity was only present in the consecutive exotropia group. This finding may suggest that WMDI can be a risk factor for consecutive deviation in infantile esotropia patients.