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We evaluated whether doses of bilateral medial rectus recessions greater than Parks's tables yielded superior outcomes for adult-onset divergence insufficiency. Forty-two patients underwent bilateral medial rectus recessions. Dose was analyzed as the average total per muscle (surgery + suture adjustment if performed) and compared with the standard dose tables (based on preoperative distance esodeviation), as difference between dose performed and dose indicated by Parks's tables. Each participant was classified as having received either Parks's dose (within 0.5 mm) or a dose greater than Parks's dose. Success was defined as "rarely" or "never" diplopia in distance straight-ahead gaze and reading. For patients classified as success, the mean difference between actual surgical dose performed and Parks's dose was calculated. Success was 91% (29/32) in those receiving greater than Parks's dose versus 67% (6/9) with Parks's dose (difference = 24%; 95% CI, -5% to 60%). The mean surgical dose was 1.0 mm greater than Parks's tables for the 35 successes (at 10 weeks) versus 0.7 mm greater for the 6 failures (difference = 0.4 mm; 95% CI, -0.2 to 0.9). For medial rectus recessions in adult-onset divergence insufficiency-type esotropia, a surgical dose 1 mm greater than Parks's tables, for each muscle, is a reasonable strategy., (Copyright © 2024 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To report 2-year ocular and developmental outcomes for infants receiving low doses of intravitreal bevacizumab for type 1 retinopathy of prematurity (ROP)., Methods: A total of 120 premature infants (mean birthweight, 687 g; mean gestational age, 24.8 weeks) with type 1 ROP were enrolled in a multicenter, phase 1 dose de-escalation study. One eye per infant received 0.25 mg, 0.125 mg, 0.063 mg, 0.031 mg, 0.016 mg, 0.008 mg, 0.004 mg, or 0.002 mg of intravitreal bevacizumab; fellow eyes when treated received one dosage level higher. At 2 years, 70 of 120 children (58%) underwent ocular examinations; 51 (43%) were assessed using the Bayley Scale of Infant and Toddler Development., Results: Correlation coefficients for the association of total dosage of bevacizumab with Bayley subscales were -0.20 for cognitive (95% CI, -0.45 to 0.08), -0.15 for motor (95% CI, -0.41 to 0.14), and -0.19 for language (95% CI, -0.44 to 0.10). Fourteen children (21%) had myopia greater than -5.00 D in one or both eyes, 7 (10%) had optic nerve atrophy and/or cupping, 20 (29%) had strabismus, 8 (11%) had manifest nystagmus, and 9 (13%) had amblyopia., Conclusions: In this study cohort, there was no statistically significant correlation between dosage of bevacizumab and Bayley scores at 2 years. However, the sample size was small and the retention rate relatively low, limiting our conclusions. Rates of high myopia and ocular abnormalities do not differ from those reported after larger bevacizumab doses., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: To determine whether smartphone photographs of children's eyelids are reliable for diagnosing the presence of chalazia., Methods: In this prospective cross-sectional study, 60 participants, 7 months to 16.5 years of age, at four sites were enrolled; all participants had a chalazion measuring at least 2 mm on at least one eyelid based on an in-person clinical examination by a pediatric eye care professional. Smartphone photographs taken by the parent during the office visit were uploaded to the study website. A masked reader assessed each photograph for the presence or absence of chalazia; results were compared with the gold standard clinical examination results. Sensitivity and specificity for the presence of chalazion by eyelid were calculated., Results: Photographs were available for 240 eyelids; 85 had at least one chalazion and 155 were without a chalazion based on clinical examination. The masked reader correctly classified 68 of 85 eyelids with at least one chalazion and 151 of 155 eyelids without chalazia for a sensitivity of 80% (95% CI, 72%-86%) and a specificity of 97% (95% CI, 94%-99%). Sensitivity improved to 89% for chalazia 5 mm or larger and 94% when superficially located within the eyelid., Conclusions: Parental smartphone photographs appear to be useful in assessing chalazia in children as an alternative to in-office follow-up examinations. These photographs may be a valuable outcome measure in future clinical trials of chalazia treatment, especially when assessing larger lesions., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

A test of suppression was developed to provide a standardized approach to detecting and grading density of suppression in children with intermittent exotropia when manifestly exotropic. This new Office Suppression Test is a three-step procedure to grade suppression on a 4-point scale (from 0 for "negligible suppression" to 3 for "dense suppression"). The test was performed in 57 children 3-13 years of age with intermittent exotropia (distance angle of 16 Δ -35 Δ , with spontaneous tropia) during enrollment in a randomized trial. Of the 57 children, 51 could complete testing: 28 (55%) had dense suppression, 12 (24%) had moderate suppression, 5 (10%) had mild suppression, and 6 (12%) had negligible suppression. In a subgroup of 20 untreated children, suppression was evaluated again at 8 weeks. There was moderate agreement between suppression scores at baseline and at 8 weeks (weighted κ = 0.65 [95% CI, 0.45-0.84])., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Twenty adolescents (12-17 years old) with diplopic strabismus and 20 with nondiplopic strabismus (matched to diplopic subjects for direction and magnitude of ocular deviation) completed the Pediatric Eye Questionnaire (PedEyeQ). Children completed the Child PedEyeQ, and one parent for each child completed the Proxy PedEyeQ and Parent PedEyeQ. PedEyeQ Rasch domain scores were calculated and converted to a scale of 0 (worst) to 100 (best). Distributions of domain scores were compared between diplopic and nondiplopic cohorts using Wilcoxon tests. Diplopic adolescents had significantly lower Child PedEyeQ scores on Functional Vision (72 vs 90; P = 0.008), Bothered by Eyes/Vision (65 vs 90; P = 0.009), and Frustration/Worry (53 vs 75; P < 0.001) domains. There was no difference on the Child Social domain (85 vs 90; P = 0.22). Proxy and Parent PedEyeQ scores were similar between diplopic and nondiplopic cohorts (P > 0.06 for each comparison). These findings highlight the importance of addressing diplopia when managing childhood strabismus., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe 10-week and 12-month outcomes following treatment for divergence insufficiency-type esotropia in adults., Methods: In this prospective observational study, 110 adults with divergence insufficiency-type esotropia, with a distance esodeviation measuring 2 Δ to 30 Δ and at least 25% larger at distance than near, and binocular diplopia present at least "sometimes" at distance, were enrolled at 28 sites when initiating new treatment. Surgery, prism, or divergence exercises/therapy were chosen at the investigator's discretion. Diplopia was assessed at enrollment and at 10-week and 12-month outcome examinations using a standardized diplopia questionnaire (DQ). Success was defined as DQ responses of "rarely" or "never" when looking straight ahead in the distance, with no alternative treatment initiated., Results: Of the 110 participants, 32 (29%) were prescribed base-out prism; none had received prior treatment for esotropia. Success criteria were met by 22 of 30 at 10 weeks (73%; 95% CI, 54%-88%) and by 16 of 26 at 12 months (62%; 95% CI, 41%-80%). For the 76 (68%) who underwent strabismus surgery (82% of whom had been previously treated with prism), success criteria were met by 69 of 74 at 10 weeks (93%; 95% CI, 85%-98%) and by 57 of 72 at 12 months (79%; 95% CI, 68%-88%)., Conclusions: In this study cohort, both base-out prism as initial therapy and strabismus surgery (usually following prism) were successful in treating diplopia for most adults with divergence insufficiency-type esotropia when assessed during the first year of follow-up., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Patient-reported outcome measures such as the Pediatric Eye Questionnaire (PedEyeQ) are increasingly recognized as important in healthcare assessment. Defining normal PedEyeQ thresholds would allow classification of individual children as having reduced versus normal domain scores. We prospectively enrolled visually normal children (aged 0-17 years; n = 310) to calculate normal PedEyeQ domain thresholds. In addition, 48 children with bilateral visual impairment (VI; best-eye acuity worse than 20/70 or 20/70 or better with limited visual fields) were enrolled for validation. The Child PedEyeQ (four domains) was completed by 5- to 17-year-olds. Parents completed Proxy (five domains) and Parent PedEyeQ (four domains). Each domain was Rasch scored (converted to 0-100); normal thresholds were defined as the 5th percentile of scores in visually normal controls. For Child 5-11 PedEyeQ, 39%-78% of VI children had reduced domain scores, and 88%-100% for 12- to 17-year-olds. For Proxy PedEyeQ, proportions ranged from 55% to 100% and for Parent PedEyeQ ≥83% had reduced scores. High prevalence of reduced PedEyeQ domain scores in the VI cohort, validates the use of normal thresholds. Nevertheless, variability in child self-reporting creates challenges for identifying individual 5- to 11-year-olds with reduced scores., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine whether health-related quality of life (HRQOL) scores improved or worsened over 3 years of observation in childhood intermittent exotropia without treatment., Methods: A total of 111 children aged 3-11 years with intermittent exotropia were assigned to observation in a previously reported randomized trial comparing patching with observation. The intermittent exotropia questionnaire (IXTQ) was administered at baseline, 6 months, and 36 months. Rasch-calibrated IXTQ domain scores (Child, Proxy, Parent-psychosocial, Parent-function, and Parent-surgery) were compared between time points. The Child IXTQ was administered only to children ≥5 years of age (n = 78)., Results: Overall, Child IXTQ and Proxy IXTQ scores showed no significant change over 36 months (mean improvement from baseline to 36 months of 3.2 points [95% CI, -1.9 to 8.2] and -2.4 points [95% CI: -7.9 to 3.1], resp.). By contrast, Parent-psychosocial, Parent-function, and Parent-surgery domain scores all improved over 36 months (mean improvements of 12.8 points [95% CI, 5.9-19.6] and 14.2 points [95% CI, 8.0-20.3] and 18.5 points [95% CI, 9.7-27.3], resp.)., Conclusions: HRQOL of children with intermittent exotropia remains stable with observation over 3 years (by both child and proxy report), whereas parental HRQOL improves., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate health-related quality of life (HRQOL) after strabismus surgery in children with intermittent exotropia (IXT) and relationships between HRQOL and surgical success., Methods: A total of 197 children with IXT aged 3-11 years (and 1 parent of each child) were enrolled in a previously reported randomized clinical trial comparing two surgical procedures. The Intermittent Exotropia Questionnaire (IXTQ) was administered before surgery (baseline), and again at 6 and 36 months following surgery. The child version of the IXTQ was only completed by children 5-11 years of age (n = 123). Outcomes were classified as "resolved" (exodeviation of <10 Δ , no decreased stereoacuity, and no other nonsurgical treatment for IXT or reoperation), "suboptimal" (exotropia ≥10 Δ by simultaneous prism and cover test or constant esotropia ≥6 Δ or loss of ≥2 octaves of stereoacuity), or "intermediate." Mean changes in Rasch-calibrated IXTQ domain scores (Child, Proxy, Parent-psychosocial, Parent-function, and Parent-surgery; converted to a 0-100 scale) were compared., Results: Overall, mean IXTQ domain scores improved for all domains from baseline to 36 months after surgery, ranging from 10.7 points (Child IXTQ; P < 0.0001) to 34.5 points (Parent-surgery IXTQ; P < 0.0001). At 36 months after surgery, 62 (39%) children had resolved IXT, whereas 38 (24%) had suboptimal outcome. Greater improvement was found in all mean domain scores with resolved IXT (range, 19.8-46.0 points) compared with suboptimal outcome (all comparisons P < 0.05)., Conclusions: Successful surgery for childhood IXT results in measurable improvement in a child's quality of life, in parental assessment of the child's quality of life, and in quality of life for the parent., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate eye-related quality of life (ER-QOL) and functional vision across a wide range of pediatric eye conditions, using the Pediatric Eye Questionnaires (PedEyeQ)., Methods: A total of 1,037 children with an eye condition and 254 visually normal controls, across 0-4, 5-11, and 12-17 years age groups, completed the following questionnaires: Child PedEyeQ (Functional Vision, Bothered by Eyes/Vision, Social, Frustration/Worry domains), Proxy PedEyeQ (same domains plus Eye Care), and Parent PedEyeQ (Impact on Parent and Family, Worry about Child's Eye Condition, Worry about Child's Self-perception and Interactions, and Worry about Functional Vision domains). The primary eye condition was classified as amblyopia (n = 171), cataract (n = 99), cerebral visual impairment (CVI; n = 50), cornea (n = 20), eyelid (n = 35), glaucoma (n = 24), nystagmus (n = 57), orbital (n = 19), pupil/iris (n = 7), refractive error (n = 119), retina (n = 82), strabismus (n = 332), and uveitis (n = 22)., Results: PedEyeQ domain scores (scaled 0-100) were significantly worse across eye conditions, compared with controls. Child PedEyeQ greatest differences were on the Bothered by Eyes/Vision domain (nystagmus 5-11 years, -26 points [95% CI, -39 to -12]; nystagmus 12-17 years, -45 [95% CI, -61 to -28]). Proxy PedEyeQ differences were greatest on Functional Vision (CVI 0-4 years, -45 [95% CI, -56 to -34]; CVI 5-11 years, -58 [95% CI, -72 to -43]; nystagmus 12-17 years, -50 [95% CI, -69 to -31]). Parent PedEyeQ differences were greatest on Worry about Child's Functional Vision (CVI 0-4 years, -64; 95% CI -77 to -50)., Conclusions: The PedEyeQ detects reduced ER-QOL and functional vision across pediatric eye conditions, and across age groups, indicating its utility for clinical practice and clinical trials., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: Use of a microsensor has been suggested to monitor patching adherence. Application has been limited because the microsensor's small size makes it easy to lose and a swallowing risk. We designed the Eye Patch Assistant (EPA) to hold the small microsensor in place and reduce the risk of loss or swallowing. This study reports the accuracy, precision, ease of use, and comfort for patching with EPA (patch+EPA) to monitor adherence., Methods: Adults (N = 13) wore an adhesive patch alone or a patch+EPA for 2 hours each, recorded wear time, and completed an ease of use/comfort questionnaire; 30 children wore a patch or patch+EPA and completed the questionnaire. Sensor sampling interval was every 5 minutes or every 1 minute. Sensor accuracy and precision were evaluated by Bland-Altman analysis and 95% limits of agreement, and questionnaire scores compared by Wilcoxon tests., Results: With 5-minute sampling, we found excellent accuracy for adults (mean actual vs recorded time difference, 1.4 minutes) and children (mean difference, -0.9 min). We found high precision for both adults and children (95% limits of agreement half widths of 6.4 minutes and 1.9 minutes, respectively). In adults, the ease of use score for the patch+EPA was lower than the patch (P < 0.01), but the comfort score for the patch+EPA was higher (P < 0.01). For children, scores did not differ significantly. The patch+EPA functioned well between 45° and 82°F., Conclusions: The patch+EPA was well accepted and monitored adherence accurately and precisely., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate eye-related quality of life (ER-QOL) and functional vision in children wearing glasses using the Pediatric Eye Questionnaire (PedEyeQ)., Methods: Children 5-17 years of age with normal visual acuity who wore glasses for correction of refractive error and with no other eye condition or treatment and control subjects who did not wear glasses, along with 1 parent for each child, were prospectively enrolled. Children completed the Child 5-11 or 12-17 PedEyeQ (four domains); parents completed the Proxy 5-11 or 12-17 questionnaires (perceived effect on child; five domains) and also the Parent questionnaire (effect on parent themselves; four domains). Each domain was Rasch-scored (converted to 0-100), and scores between groups were compared., Results: A total of 40 subjects and 99 non-glasses-wearing controls, along with 1 parent for each child, were included. Children 5-11 and 12-17 years of age who wore glasses had lower PedEyeQ scores across all domains compared with controls (mean differences, -6 to -15; P ≤ 0.04 for each domain). Proxy scores were also lower for glasses wearers across age groups and domains (mean differences, -4 to -18; P ≤ 0.02), and Parent scores were lower for parents of children wearing glasses (mean differences, -6 to -18; P < 0.001 for each domain)., Conclusions: In this study, glasses wearers had reduced ER-QOL and functional vision compared with control subjects. Parents of children wearing glasses also experience reduced quality of life., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate misclassification of diplopia "success" when using a standardized diplopia questionnaire (DQ), and to report test-retest reliability of the DQ., Methods: We retrospectively identified a cohort of 100 patients with stable strabismus (<5 Δ change in prism and alternate cover test measurements at distance and near), stable visual acuity, no change in treatment, and no clinical evidence of change, with completed DQ at two consecutive office visits (median, 71 days apart; range, 5-350 days). To evaluate the rate of misclassification of "success" and "not success," we compared the second to the first administration of the DQ using two established definitions of success: (1) "rarely" or "never" for straight ahead distance and (2) "rarely" or "never" for straight-ahead distance and reading. For DQ test-retest variability, 95% limits of agreement (LOA) and intraclass correlation coefficients (ICC) were calculated on DQ scores (0-100 scale)., Results: When defining success as rarely or never diplopic for distance, misclassification occurred in 12 (12%) of 100 (95% CI, 6%-20%). When defining success as rarely or never diplopic for distance and reading, misclassification occurred in 14 (14%) of 100 (95% CI, 8%-22%). The 95% LOA for the DQ score were 35.2 points, and ICC was 0.85 (95% CI, 0.79-0.90)., Conclusions: We have quantified misclassification and test-retest variability when using the DQ dichotomously or as a continuous measure, equipping the clinician to better interpret DQ outcome data in practice and research., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe frequency of postoperative diplopia after strabismus surgery in nondiplopic adults with childhood-onset strabismus and to report health-related quality-of-life (HRQOL) outcomes., Methods: We prospectively enrolled 79 adults with no diplopia in any gaze who had childhood-onset strabismus and were scheduled for strabismus surgery. Diplopia was assessed preoperatively and at 6 weeks and 1 year postoperatively using a standardized diplopia questionnaire with 5 response options in 7 gaze positions. HRQOL was assessed using the Adult Strabismus-20 (AS-20) questionnaire, with self-perception, interactions, reading function, and general function domains., Results: Constant diplopia in straight-ahead distance and reading gaze occurred in 1 patient (1% [95% CI, 0%-7%] at 6 weeks and 2% [95% CI, 0%-10%] at 1 year). Regarding the rate of any diplopia (including rarely) in any gaze, 15 of 78 patients (19%) reported diplopia at 6 weeks, of whom 13 had diplopia in straight-ahead distance gaze; 8 (10%), in reading gaze. At 1 year, 8 of 51 patients (16%) reported any diplopia (including rarely) in any gaze, of whom 7 had diplopia in straight-ahead distance gaze and 4 (8%) in reading gaze. Mean AS-20 scores improved at 1 year overall (by 32, 19, 14, and 15 points, resp., per domain) and for the 8 diplopic patients (by 21, 13, 16, and 11 points)., Conclusions: In adults with nondiplopic strabismus, constant postoperative diplopia is rare, although the rate of intermittent diplopia is higher. Even when postoperative diplopia occurs, HRQOL often improves., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Adult strabismus is often characterized by surgical complexity. In recent years, several innovative techniques for the management of complex strabismus have been developed. Strabismus surgeons should understand the indications for various strabismus surgical techniques in the management of these difficult cases. This workshop describes several new surgical techniques to manage complex strabismus, including small-angle incomitant and very large-angle strabismus, torsional diplopia, and restrictive, paralytic, and secondary strabismus. Because strabismus surgery is an ever-evolving field, it is important to continue to refine our surgical armamentarium. Strabismus surgeons may wish to add these techniques to their surgical repertoire for select cases., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

In a previous study we performed individual interviews of adults with strabismus and identified specific health-related quality of life concerns. In this present report we provide the entire list of specific questionnaire items that were created, one for each concern articulated in the interviews. Our aim in reporting this full list of 181 individual, patient-derived questionnaire items is to provide a resource to clinicians and researchers interested in developing patient-reported outcome measures for adults with strabismus., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To identify specific health-related quality of life (HRQOL) and functional vision concerns of children with eye conditions, and create comprehensive lists of potential questionnaire items as a first step in developing patient-reported outcome measures., Methods: Children experiencing a range of pediatric eye conditions, along with one of their parents, were interviewed to identify specific concerns. Transcribed interviews were reviewed, and specific HRQOL and functional vision concerns were coded independently by two reviewers. Coded concerns were reviewed to formulate questions to address specific child concerns (derived from child and parent interviews) and specific parent concerns. Questions were grouped into bins of like questions. Two comprehensive lists of questions were formulated, one addressing child-related concerns and one addressing parent-related concerns., Results: This study included 180 children and 328 parents. A total of 614 individual child questions were grouped into 36 bins (eg, appearance, coordination, glasses, learning), and 589 parent questions were formulated and grouped into 61 bins (eg, having to assist the child, worry about deterioration, time off work, safety)., Conclusions: Using rigorous methods based on individual interviews, we identified a comprehensive list of patient- and parent-derived questionnaire items that address functional vision and HRQOL concerns of children with eye conditions and of their parents. We plan to use this large pool of potential questionnaire items to develop a formal set of pediatric outcome measures, and this pool of questions may also be a resource for future research., (Copyright © 2018 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

The double Maddox rod test is often used to measure cyclodeviations and to monitor change over time. The purpose of this study was to estimate test-retest reliability and the amount of cyclodeviation that would be considered real change using 95% limits of agreement. We retrospectively studied 86 clinically stable patients with double Maddox rod measurements 5-175 days apart (median, 69 days). The range of cyclodeviation at the first measurement was 6° incyclodeviation to 15° excyclodeviation. We calculated the half width of the 95% limits of agreement to be 4.7°, which means that a change of ≥5° in cyclodeviation would be considered a real change. The threshold of 5° should be used when assessing change between two measurements made with double Maddox rods., (Copyright © 2018 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the associations of clinical and surgical factors with atypical postoperative drift following surgery for consecutive exotropia., Methods: A total of 66 patients with consecutive exotropia (≥10 Δ at distance), after historical surgery for esotropia were retrospectively identified at a tertiary medical center. All patients underwent unilateral lateral rectus recession (on adjustable suture) with medial rectus advancement and/or resection. Immediate postoperative target angle was 4 Δ -10 Δ of esotropia at distance, anticipating mild postoperative exodrift. Actual postoperative drift was calculated as change in distance deviation from immediately postadjustment to 6 weeks. Typical drift was defined as 0 Δ -9 Δ of exodrift. Excessive exodrift was defined as ≥10 Δ . Esodrift was defined as 1 Δ or more. Univariate and multiple logistic regression analyses were performed to evaluate for associations with a wide range of clinical and surgical factors., Results: Overall there was a median exodrift (4 Δ , quartiles 0 Δ -10 Δ ). Of the 66 patients, 18 (27%) showed excessive exodrift; 15 (23%), esodrift. In multiple logistic analyses, larger preoperative distance exodeviation was associated with excessive exodrift (P = 0.01), and non-normal medial rectus attachment status (abnormal [stretched scar, pseudo-tendon], attached to pulley, or behind pulley) was associated with esodrift (P = 0.02)., Conclusions: Approximately half of patients show atypical drift following unilateral surgery for consecutive exotropia, with larger preoperative distance exodeviation associated with exodrift and non-normal medial rectus muscle status with esodrift. Knowing these associations may help when counseling patients regarding surgical outcomes., (Copyright © 2017 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the relationships between stereoacuity, control of exotropia, and angle of deviation in children with intermittent exotropia (IXT)., Methods: Data collected for 652 participants 3 to <11 years of age with IXT meeting eligibility criteria for enrollment into one of two multicenter, randomized clinical trials were used to evaluate relationships between stereoacuity, control, and angle of deviation at enrollment., Results: Any level of stereoacuity and angle of deviation could be accompanied by any level of control. Worse distance exotropia control was weakly associated with poorer distance stereoacuity (R = 0.26; 99% CI, 0.17-0.36) and larger angles of deviation at distance (R = 0.27; 99% CI, 0.17-0.36). Worse near exotropia control was weakly associated with poorer near stereoacuity (R = 0.17; 99% CI, 0.07-0.27) and moderately associated with larger angles of deviation at near (R = 0.37; 99% CI, 0.28-0.45). There was no association between stereoacuity and angle of deviation at distance (R = 0.07; 99% CI, -0.03 to 0.17) or at near (R = 0.02; 99% CI, -0.08 to 0.12)., Conclusions: Although weak and moderate associations were found between stereoacuity, control, and angle of deviation, a child may exhibit any combination of stereoacuity, control, and angle of deviation. The specific roles of control, stereoacuity, and angle of deviation in the diagnosis, management, and pathogenesis of IXT are unclear, and each appears to yield somewhat independent information., (Copyright © 2017 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe a small series of patients with glaucoma whose strabismus and binocular diplopia were due to advanced visual field loss and inability to maintain sensory and motor fusion., Methods: This study is an observational case series of 3 patients with binocular diplopia, associated with variable strabismus, which was due to advanced visual field loss., Results: Specific characteristics of the strabismus associated with advanced glaucomatous visual field loss were a subjective floating second image and marked variability of the prism and alternate cover measurements. Measured hypertropia changed in magnitude over a few seconds or a few minutes (even in 1 patient to a hypotropia), which distinguishes this specific type of strabismus from other types of comitant or incomitant strabismus associated with glaucoma. Although visual acuity was 20/400 or better in both eyes in all patients, there was advanced visual field loss in at least one eye. All patients responded poorly to prism, but their symptoms improved with a Bangerter filter applied to the spectacle lens or a MIN occlusion lens to further blur the worse-seeing eye., Conclusions: Variable strabismus associated with advanced glaucomatous visual field loss appears to be a distinct clinical entity that should be distinguished from other types of strabismus associated with glaucoma. Management of this specific type of strabismus is limited by inadequate visual field to fuse, analogous to hemifield slide, and therefore prism and/or strabismus surgery is unlikely to be successful. Primary treatment options include optical blur with Bangerter filters or a MIN occlusion lens although some patients prefer to ignore the second image., (Copyright © 2017 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To identify specific health-related quality of life and visual function concerns affecting children with bilateral visual impairment as expressed by children or one of their parents (proxy) and concerns affecting the parents themselves., Methods: A total of 37 children <16 years of age with visual impairment (visual acuity worse than 20/70 in the better eye) and one parent for each child were prospectively enrolled. Semistructured individual interviews were performed with children 5-15 years of age (n = 16) and with one parent for each child (ages 0-15 years, N = 37). Interview transcripts were analyzed using NVivo software. Categories of concern were identified from both child and parent interviews, from which broad themes were identified. The frequencies of the themes and specific categories of concerns were calculated., Results: Regarding the child's experience, categories of concern were grouped into 6 themes: visual function (expressed by 13 of 16 children [81%] and 33 of 37 parents [89%]), treatment (63% and 54%), emotions (50% and 68%), social (50% and 70%), physical discomfort (50% and 22%), and worry (38% and 8%). Concerns expressed regarding the parents' own experience were grouped into 5 themes: worry (100%), compensate-adjust for condition (89%), treatment (84%), emotions (81%), and affects family (46%)., Conclusions: Individual interviews identified a wide spectrum of concerns in children with visual impairment and their parents, affecting functional, emotional, social and physical domains. Specific concerns will be used to develop patient-derived questionnaires for quantifying the effects of visual impairment on children and parents in everyday life., (Copyright © 2017 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To identify specific health-related quality of life (HRQOL) concerns affecting children with esotropia as expressed by children or one of their parents (proxy) and concerns affecting the parents themselves., Methods: Sixty children with esotropia (0-17 years of age) and 1 parent for each child were prospectively enrolled. Individual semistructured interviews were conducted with children aged 5-17 years (n = 40) and 1 parent each for child ages 0-17 years. Transcripts of recorded interviews were evaluated using NVivo software. Specific concerns were identified from both child and parent interviews and coded. From these specific codes, broad themes were identified. Frequency of each theme was calculated, along with the frequency of specific codes within each theme., Results: Regarding the child's experience 6 broad themes were identified: visual function (mentioned by 32 of 40 children (80%) and by 50 of 60 parents (proxy assessment of child, 83%), treatment (78% and 85%), emotions (65% and 67%), social (58% and 68%), physical (58% and 32%), and worry (45% and 7%). Regarding the parents' own experience, 5 broad themes were identified: treatment (59 of 60 parents, 98%), worry (97%), emotions (82%), compensation for condition (80%), and affects family (23%)., Conclusions: A wide range of concerns were identified from interviews of children with esotropia and their parents. Concerns reflect the impact of esotropia in physical, emotional, and social domains, and specific concerns will be used for the development of questionnaires to quantify the effects of esotropia on children's and parents' quality of life., (Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate interexaminer agreement in classifying medial rectus muscle attachment in patients with consecutive exotropia., Methods: A series of intraoperative photographs of 26 eyes in 25 patients who underwent surgery for consecutive exotropia were retrospectively studied. Two examiners independently classified the medial rectus attachment as either normal, stretched scar, slipped muscle, or lost muscle. Agreement between examiners was evaluated using the weighted kappa (κ) statistic, and causes of disagreement were assessed., Results: Agreement was found in 15 of 26 eyes (58%), signifying "moderate" agreement (κ = 0.41). Approximately two-thirds of the disagreements, 7 of 11 eyes (64%), were between stretched scar and slipped muscle, with characteristics of each entity being present in the same muscle., Conclusions: The clinical distinction between stretched scar and slipped muscle appears to be obscure. We propose that they should be considered a single entity, which could be referred to as "abnormal scleral attachment.", (Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: We developed and validated the Jaeb Visual Acuity Screener (JVAS), a computerized visual acuity-based screening program for children that employs a rapid, age-specific, standardized algorithm for vision screening in the medical home that is available for download at no cost., Methods: A total of 175 children aged 3 to <8 (median, 6) years were screened with the JVAS before undergoing a complete eye examination (gold standard). The JVAS presented 2 large single surround optotypes (20/100 and 20/80) and then 5 optotypes at a predetermined, age-specific normal threshold. Failure on the gold standard examination was determined using recently published referral criteria and published visual acuity norms for age. We evaluated the sensitivity and specificity of the JVAS for detecting reduced visual acuity, amblyopia, and amblyopia risk factors. JVAS pass/fail paradigms evaluated were inability to identify 3 of 4, 3 of 5, and 4 of 5 age-appropriate optotype presentations., Results: Screening testability for the JVAS was high, at 100%. Sensitivity of the JVAS ranged from 88% to 91%, and specificity from 73% to 86%, with positive predictive value ranging from 66% to 79% and negative predictive value from 92% to 93% (ranges reflect different pass/fail paradigms)., Conclusions: The new JVAS provides an effective and practical method for screening 3- to 7-year-olds using any Windows-based computer. Providing the JVAS free-of-charge to pediatricians and school systems would standardize currently fragmented visual acuity-based screening practices., (Copyright © 2015 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: Some children have residual amblyopia after treatment with atropine eyedrops for amblyopia due to strabismus and/or anisometropia. We conducted a randomized clinical trial to evaluate the effectiveness of augmenting the effect of atropine by changing the lens over the fellow eye to plano in children with residual amblyopia., Methods: A total of 73 children 3 to <8 years of age (mean, 5.8 years) with stable residual amblyopia (range, 20/32 to 20/160, mean 20/63(+1)) were enrolled after at least 12 weeks of atropine treatment of the fellow eye. Participants were randomly assigned to continuing weekend atropine alone or wearing a plano lens over the fellow eye (while continuing atropine). The primary outcome was assessed at 10 weeks, and participants were followed until improvement ceased., Results: At the 10-week primary outcome visit, amblyopic-eye visual acuity had improved an average of 1.1 lines with the plano lens and 0.6 lines with atropine only (difference adjusted for baseline visual acuity = + 0.5 line; 95% CI, -0.1 to +1.2). At the primary outcome or later visit when the best-measured visual acuity was observed, the mean amblyopic-eye improvement from baseline was 1.9 lines with the plano lens and 0.8 lines with atropine only., Conclusions: When amblyopic-eye visual acuity stops improving with atropine treatment, there may be a small benefit to augmenting atropine therapy with a plano lens over the fellow eye. However, the effect was not statistically significant, and the large confidence interval raises the possibility of no benefit or a benefit larger than we observed. A larger study would be necessary to get a more precise estimate of the treatment effect., (Copyright © 2015 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the performance of a series of summary measures of control and to assess reliability in quantifying exodeviation control in intermittent exotropia., Methods: A large, simulated dataset of control scores for 10,000 hypothetical patients with intermittent exotropia was created using Monte Carlo simulations. These data were based on children with intermittent exotropia in whom control was assessed twice during one clinical examination, using the office control score (0-5). Each simulated patient had a baseline and 11 subsequent control scores. The repeatability of a series of summary measures of control (the mean of 2 vs the mean of 3 up to the mean of 6), was calculated using 95% limits of agreement (LOA)., Results: A total of 322 examinations in 152 patients were used to provide representative distributions of control scores. From the resultant Monte Carlo simulations, the 95% LOAs were 2.60 for 1 distance control score measure, 1.76 for the average of 3, and 1.28 for the average of 6. Therefore using the average of 3 scores, a change of <1.76 would be consistent with short-term variability, whereas a change of >1.76 would suggest a real change in control., Conclusions: The large dataset of simulated control scores allowed us to assess the variability of specific summary measures of control. We recommend the average of 3 scores (a triple control score) as a new standard for assessing control, providing improved reliability over a single measure, while remaining implementable in clinical practice., (Copyright © 2015 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: We have previously reported improvement in psychosocial scores after strabismus surgery on the patient-derived health-related quality of life (HRQOL) Adult Strabismus 20 (AS-20) questionnaire in adults with nondiplopic strabismus. Unexpectedly, we also found improvement in the function domain. The aim of the present study was to identify which specific aspects of function-related quality of life improved postoperatively., Methods: We retrospectively identified non diplopic adult patients with a history of childhood onset strabismus who underwent surgery and who had preoperative and 1-year postoperative AS-20 questionnaires (scored from 0 [worst] to 100 [best]). Change in scores for each item was evaluated using signed-rank tests., Results: A total of 20 patients were included. Of the 10 function-related AS-20 items, 9 showed significant mean improvement postoperatively (improvement ranged from 12.5 to 32.5 points, all P < 0.05). Rasch-derived mean scores improved in both reading function and general function domains (71.0 to 86.5 and 66.4 to 87.5, respectively; both P < 0.0001). Specific areas of function-related benefit were concentration, depth perception, hobbies, strain, reading, stress, and worry., Conclusions: We found specific function-related quality of life benefits after strabismus surgery in nondiplopic adult patients, particularly those with childhood onset strabismus., (Copyright © 2014 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To determine whether demographic or clinical factors are associated with the outcome of office-based nasolacrimal duct probing for the treatment of congenital nasolacrimal duct obstruction (NLDO)., Methods: In two multicenter prospective studies, 384 eyes of 304 children aged 6 to <15 months with NLDO underwent a nasolacrimal duct probing performed in the office using topical anesthesia. Treatment success, defined as no clinical signs of NLDO (epiphora, increased tear lake, or mucous discharge) and no reoperation, was assessed 1 month after probing in one study and 6 months after probing in the other study. Data from both studies were pooled to evaluate associations between baseline characteristics and treatment success., Results: Office probing was successful in 75% of eyes overall (95% CI, 70%-80%). The procedure was less successful in eyes of children with bilateral NLDO compared with unilateral NLDO (63% vs 80%; relative risk = 0.78 [95% CI, 0.66-0.92]) and in eyes that had 2 or 3 clinical signs of NLDO compared with one (71% vs 83%; relative risk = 0.88 [95% CI, 0.81-0.96]). Treatment success did not appear to be related to age, specific clinical signs of NLDO, prior treatment, or research study., Conclusions: Performing nasolacrimal duct probing in the office successfully treats NLDO in the majority of cases in children aged 6 to <15 months. The success rate is lower with bilateral disease or when more than one clinical sign of NLDO is present., (Copyright © 2014 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To compare long-term postoperative outcomes when performing an adjustment to achieve a desired immediate postoperative alignment versus simply tying off at the desired immediate postoperative alignment, when using adjustable sutures for strabismus surgery., Methods: We retrospectively identified 89 consecutive patients who underwent a reoperation for horizontal strabismus with the use of adjustable sutures and also had a 6-week and 1-year outcome examination. In each case, the intent of the surgeon was to tie off and only to adjust if the patient was not within the intended immediate postoperative range. Postoperative success was predefined on the basis of the angle of misalignment and diplopia at distance and near., Results: Of the 89 patients, 53 (60%) were adjusted and 36 (40%) were tied off. Success rates were similar between patients who were simply tied off immediately after surgery and those who were adjusted. At 6 weeks, the success rate was 64% for the nonadjusted group versus 81% for the adjusted group (P = 0.09; difference of 17%; 95% CI, -2% to 36%). At 1 year, the success rate was 67% for the nonadjusted group versus 77% for the adjusted group (P = 0.3; difference of 11%; 95% CI, -8% to 30%)., Conclusions: Performing an adjustment to obtain a desired immediate postoperative alignment did not yield inferior long-term outcomes compared with tying off to obtain that initial alignment. If patients who were outside the desired immediate postoperative range had not been adjusted, it is possible that their long-term outcomes would have been worse. Therefore, overall, an adjustable approach may be superior to a nonadjustable approach., (Copyright © 2013 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To report masked superior oblique muscle tightness as a possible mechanism causing A-pattern exotropia with intorsion after inferior rectus muscle recession in the context of thyroid eye disease., Methods: Three patients with thyroid eye disease and involvement of the superior oblique muscle are presented, along with a fourth comparison case without superior oblique muscle involvement. Intraoperative torsion assessment and exaggerated traction testing were performed after detachment of the involved rectus muscles. A surgical procedure involving recession of tight superior oblique muscle(s) when recessing inferior rectus muscle(s) is presented, along with surgical results., Results: The first case illustrated the problem of A-pattern exotropia and intorsion after inferior rectus muscle recessions and subsequent treatment with superior oblique tendon recessions. Patients 2 and 3 demonstrated signs of coexisting inferior rectus muscle involvement and superior oblique muscle involvement both preoperatively and intraoperatively, with a tight superior oblique muscle and marked intorsion, suggesting the need for superior oblique tendon recession at the time of inferior rectus recession. Postoperatively there was no symptomatic intorsion or A-pattern exotropia and both patients were heterophoric distance and near, with only rare diplopia. The fourth case, without superior oblique involvement, illustrated management with inferior rectus muscle recessions alone., Conclusions: Superior oblique muscle involvement may be masked by coexistent inferior rectus muscle involvement and if not identified and addressed at the time of the first surgery may result in symptomatic intorsion and A-pattern exotropia. The clinical finding of minimal extorsion, or frank intorsion, in the presence of a tight inferior rectus muscle, may be an important sign of masked superior oblique muscle tightness. Intraoperative assessment of torsion and superior oblique tension may also help identify patients at risk. Superior oblique tendon recession, at the time of inferior rectus muscle recession, prevented development of a postoperative A-pattern exotropia and intorsion., (Copyright © 2012 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: We describe a new surgical treatment for lateropulsion and torticollis arising from an ocular tilt reaction., Methods: Visual sensory parameters and postural abnormalities were retrospectively reviewed in a patient with a partial ocular tilt reaction who was treated with horizontal transposition of the vertical rectus muscles to surgically augment preexisting binocular torsion., Results: Torsional augmentation eliminated the sensation of lateropulsion and produced almost complete resolution of her torticollis and associated body tilt., Conclusions: Binocular torsional augmentation can be used to reduce both lateropulsion and torticollis in the setting of an ocular tilt reaction., (Copyright © 2012 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Background: Total transposition of the superior and inferior rectus muscle laterally, with augmentation sutures, may be complicated by induction of an undesirable vertical deviation. Induced vertical misalignment may be associated with changes in torsion. We have developed a simple method to monitor intraoperative torsion that may reduce the incidence of vertical deviations., Methods: We reviewed consecutive cases of total abducens palsy or esotropic Duane syndrome treated with augmented lateral transposition of the superior and inferior rectus muscles, where the 12 o'clock and 6 o'clock intraoperative positions were initially marked with a dot at the limbus using a surgical pen. The location of the marks was monitored during tying of the augmentation sutures; changes in torsion were monitored intraoperatively., Results: Records of 9 cases of augmented vertical rectus transposition were reviewed. On the basis of intraoperative assessment of torsion, by observing the position of preplaced limbal dots, the inferior rectus augmentation suture was tied less tightly than the superior rectus suture, leaving a gap of 1 to 3 mm between the inferior and lateral rectus muscles in 8 of 9 cases. The augmentation suture was totally removed in 1 case. After these intraoperative adjustments, there was no induced intraoperative torsion, whereas further tightening of the inferior suture induced extorsion. Six weeks postoperatively, 8 of 9 patients did not experience a symptomatic vertical deviation., Conclusions: When performing augmented transposition procedures, intraoperative monitoring of torsion may reduce the incidence of inadvertent vertical deviations and torsion. This technique may also be useful in other cases where correction or avoidance of torsion is needed., (Copyright © 2012 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Background: A change in the angle of deviation is often used to monitor the change in severity of intermittent exotropia over time; nevertheless, thresholds for a clinically significant change in angle have not been determined. We analyzed variability associated with test-retest differences and short-term variability in the condition, to provide thresholds for assessing clinically significant, long-term change in angle of intermittent exotropia., Methods: Twenty-six children with intermittent exotropia (median age, 7; range, 1-13 years) underwent repeat prism and alternate cover test measures during 3 or 4 examinations (2 hours apart) over the course of a day; 95% repeatability coefficients were derived to determine test-retest differences at distance and near fixation., Results: Derived 95% repeatability coefficients at distance were 3.4(Δ) (95% CI, 0.7(Δ)-6.2(Δ)) for angles ≤20(Δ) and 7.2(Δ) (95% CI, 4.4(Δ)-9.9(Δ)) for angles >20(Δ); at near, 6.6(Δ) (95% CI, 3.7(Δ)-9.6(Δ)) for angles ≤20(Δ) and 12.8(Δ) (95% CI, 5.3(Δ)-20.3(Δ)) for angles >20(Δ)., Conclusions: Test-retest reliability data in this study provide thresholds to help determine clinically significant change in angle of strabismus in children with intermittent exotropia. These data should facilitate evidence-based assessment of long-term change in intermittent exotropia over time., (Copyright © 2012 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To investigate the course of near stereoacuity in a cohort of children with untreated intermittent exotropia., Methods: A total of 95 children ages 2-16 years with untreated intermittent exotropia were identified who had measurements of near stereoacuity using the Preschool Randot (PSR) test on at least 2 successive examinations, with no intervening treatment. Deterioration was defined as a drop of at least 3 octaves, as determined by test-retest data. Alternative secondary analyses were performed defining deterioration as a drop of at least 2 octaves or as a transition from normal to subnormal. The main outcome measure was the deterioration rate calculated at 1 and 2 years using a Kaplan-Meier survival analysis., Results: For near stereoacuity, the rate of decreasing 3 or more octaves was 2% (95% CI, 0%-6%) at 1 year and 7% (95% CI, 0%-16%) at 2 years. The alternative secondary analyses revealed similar low deterioration rates. In most cases of apparent deterioration, near stereoacuity returned to baseline levels without treatment., Conclusions: For children with untreated intermittent exotropia, deterioration in near stereoacuity at 1 and 2 years is infrequent. Therefore, performing surgery for intermittent exotropia to proactively prevent deterioration of near stereoacuity cannot be justified. Retesting stereoacuity is critical to determine whether any measured decrease in stereoacuity is real., (Copyright © 2011 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To determine factors associated with pretreatment and posttreatment stereoacuity in subjects with moderate anisometropic amblyopia., Methods: Data for subjects enrolled in seven studies conducted by the Pediatric Eye Disease Investigator Group were pooled. The sample included 633 subjects aged 3 to <18 years with anisometropic amblyopia, no heterotropia observed by cover test, and baseline amblyopic eye acuity of 20/100 or better. A subset included 248 subjects who were treated with patching or Bangerter filters and had stereoacuity testing at both the baseline and outcome examinations. Multivariate regression models identified factors associated with baseline stereoacuity and with outcome stereoacuity as measured by the Randot Preschool Stereoacuity test., Results: Better baseline stereoacuity was associated with better baseline amblyopic eye acuity (P < 0.001), less anisometropia (P = 0.03), and anisometropia due to astigmatism alone (P < 0.001). Better outcome stereoacuity was associated with better baseline stereoacuity (P < 0.001) and better amblyopic eye acuity at outcome (P < 0.001). Among 48 subjects whose amblyopic eye visual acuity at outcome was 20/25 or better and within one line of the fellow eye, stereoacuity was worse than that of children with normal vision of the same age., Conclusions: In children with anisometropic amblyopia of 20/40 to 20/100 inclusive, better posttreatment stereoacuity is associated with better baseline stereoacuity and better posttreatment amblyopic eye acuity. Even if their visual acuity deficit resolves, many children with anisometropic amblyopia have stereoacuity worse than that of nonamblyopic children of the same age., (Copyright © 2011 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: There are conflicting reports about whether distance and near visual acuity are similar in eyes with amblyopia. The purpose of this study is to compare monocular distance visual acuity with near visual acuity in amblyopic eyes of children., Methods: Subjects 2 to 6 years of age were evaluated in a randomized trial of amblyopia therapy for moderate amblyopia (20/40 to 20/80) due to anisometropia, strabismus, or both. Prior to initiating the protocol-prescribed therapy, subjects had best-corrected visual acuity measured with standardized protocols at 3 meters and 0.4 meters using single-surrounded HOTV optotypes., Results: A total of 129 subjects were included. The mean amblyopic eye visual acuity was similar at distance and near (mean, 0.45 logMAR at distance versus 0.45 logMAR at near; mean difference, +0.00, 95% CI, -0.03 to 0.03). Of the 129 subjects, 86 (67%) tested within 1 line at distance and near; 19 (15%) tested more than 1 logMAR line better at distance, and 24 (19%) tested more than 1 logMAR line better at near. The mean visual acuity difference between distance and near did not differ by cause of amblyopia, age, or spherical equivalent refractive error., Conclusions: We found no systematic difference between distance and near visual acuity in 2- to 6-year-old children with moderate amblyopia associated with strabismus and/or anisometropia. Individual differences between distance and near visual acuity are likely due to test-retest variability., (Copyright © 2011 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To assess the health-related quality of life (HRQOL) of parents of children with intermittent exotropia with use of the newly developed condition-specific Parent Intermittent Exotropia Questionnaire (Parent IXTQ) and the generic PedsQL Family Impact Module (PedsQL FIM) and to compare the performance of both instruments., Methods: One parent was recruited for each of 59 children with intermittent exotropia (age range, 3-16; median, 7 years) and for each of 29 visually normal children (age range, 5-13; median, 8 years). The parent completed the Parent IXTQ and the PedsQL FIM. For each questionnaire, we compared median HRQOL scores between the intermittent exotropia group and visually normal group. We also calculated normal thresholds, which were defined as the 5th percentile score in the cohort of parents of visually normal children. The proportion of subnormal scores between questionnaires in parents of children with intermittent exotropia was compared., Results: The Parent IXTQ score was worse in the intermittent exotropia group than in the visually normal group (70.6 vs 94.1, p < 0.0001), whereas the PedsQL FIM scores were similar (97.9 vs 95.8, p = 0.8). More parents scored below normal when the Parent IXTQ was used than when the PedsQL FIM was used (31% vs 12%; p = 0.008, McNemar's test)., Conclusions: The Parent IXTQ detects subnormal HRQOL in parents of children with intermittent exotropia more often than the PedsQL FIM. It is possible that parental worry may influence management decisions in children with intermittent exotropia and therefore parental HRQOL is worthy of further study., (Copyright © 2011 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To investigate whether spectacle wear in children affects responses on the Intermittent Exotropia Questionnaire (IXTQ) or the Pediatric Quality of Life Inventory (PedsQL)., Methods: We recruited 49 children, median age 8 years (range, 5-13 years), presenting with visual acuity 20/40 or better and an otherwise-normal eye examination (no strabismus), who either had no refractive error (n=29) or had refractive error corrected with spectacles (n=20). The IXTQ and PedsQL were completed, each comprising a child report (Child IXTQ, Child PedsQL) and a parent proxy report (Proxy IXTQ, Proxy PedsQL). In addition, the IXTQ contains a parent self-report (Parent IXTQ). Each questionnaire is scored from 0 (worst health-related quality of life [HRQOL]) to 100 (best HRQOL). Median scores were compared using Wilcoxon rank-sum tests., Results: Child IXTQ and Proxy IXTQ scores were similar between groups; nevertheless, Parent IXTQ scores were lower for spectacle wearers (90.4 vs 97.1, p=0.01). Parent IXTQ questions that scored lower in the spectacle group were related to parental worry about permanent damage to their child's eyes, long-term eyesight, surgery, self-consciousness, and teasing. The PedsQL composite scores and all subscale scores were similar between spectacle wearers and nonspectacle wearers, both for Child PedsQL and Proxy PedsQL., Conclusions: Parental HRQOL, measured with the use of the Parent IXTQ, was lower for children wearing spectacles than for children who did not wear spectacles. There was no difference between spectacle and no-spectacle groups when either Child IXTQ, Proxy IXTQ, Child PedsQL, or Proxy PedsQL was used., (Copyright © 2011 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: Amblyopia in children ≥3 years has been well described, but less is known about amblyopia in children <3 years of age. Here we describe the clinical characteristics of a large cohort of children <3 years of age with amblyopia and compare them with a previously described Pediatric Eye Disease Investigator Group amblyopic cohort aged 3 to 6 years., Methods: A total of 250 consecutive children with amblyopia <3 years were referred by 16 pediatric ophthalmologists., Results: The mean age at the initial diagnosis of amblyopia was 1.2 ± 0.7 years. The cause of amblyopia was strabismus in 82%, anisometropia in 5%, and combined mechanism in 13%. Compared with the 3- to 6-year-old cohort, the proportion of amblyopia attributable to strabismus was significantly greater (p < 0.001), whereas both anisometropia and combined mechanism amblyopia were significantly less common (p < 0.001). Overall, 61% of amblyopia was diagnosed at the same visit during which strabismus and/or anisometropia was initially diagnosed; an additional 21% of amblyopia was diagnosed at the first follow-up visit 1 to 3 months later. Compared with the 3- to 6-year-old cohort, amblyopic eye refractive error was significantly lower., Conclusions: Strabismic amblyopia was diagnosed much more commonly than anisometropic and combined-mechanism amblyopia in children <3 years. Anisometropic amblyopia may be difficult to detect in children <3 years, and/or strabismic amblyopia may be overdiagnosed by fixation preference. Alternatively, anisometropia may develop more commonly after 3 years of age or may require greater duration to cause amblyopia., (Copyright © 2010 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To evaluate the psychometric properties of the original Parent and new Child Amblyopia Treatment Index (ATI), questionnaires that assess the burden of amblyopia treatment in children and families, and to compare scores between children treated with atropine or patching., Methods: Parent ATI and Child ATI were administered to 233 children 7 to <13 years old and their parents as part of a randomized trial comparing patching and atropine for amblyopia treatment. For each ATI version, construct validity was assessed using factor analysis; internal consistency reliability was assessed using Cronbach's alpha. Data from the Parent ATI and Child ATI were correlated and scores for each version were compared between treatment groups., Results: We analyzed the 3 subscales found in prior Parent ATI studies in younger children and confirmed subscales for adverse effects and treatment compliance, but not for social stigma, in both parent and child versions. Overall and subscale scores on the Parent ATI and Child ATI were moderately to well correlated except for the social stigma subscale. For both the Parent ATI and the Child ATI, children treated with atropine had better scores than those treated with patching, both overall and on treatment compliance and social stigma subscales (all p values ≤ 0.01)., Conclusions: When used for children 7 to <13 years old, the Parent ATI and Child ATI have similar factor structures to each other and to the Parent ATI for children 3 to <7 years old. Atropine treatment was found to have less negative impact than patching., (Copyright © 2010 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To compare 2 health-related quality-of-life (HRQOL) instruments: the condition-specific Intermittent Exotropia Questionnaire (IXTQ) and the generic Pediatric Quality of Life Inventory (PedsQL) in children with intermittent exotropia., Methods: Fifty-one children with intermittent exotropia (median, 7 years; range, 5-16 years) were recruited from outpatient clinics with one of their parents. All children completed age-appropriate Child IXTQ (12 items) and Child PedsQL (23 items). Parents completed parallel Proxy IXTQ and Proxy PedsQL (parent assessment of child's HRQOL). Possible scores ranged from 0 to 100 (worst to best HRQOL). Normal thresholds were defined using the 5th percentile in a control group of 47 normal nonstrabismic children. Proportions scoring below normal on each questionnaire were compared. Median scores in intermittent exotropia and control groups also were compared., Results: More scores were subnormal using Proxy IXTQ than Proxy PedsQL (55% vs 18%, p = 0.0004). When Child questionnaires were used, we found that similar proportions scored below normal (IXTQ 8% vs PedsQL 14%, p = 0.3). Median scores were lower for intermittent exotropia children compared with control patients for Child IXTQ (83 vs 92; p = 0.04), Proxy IXTQ (81 vs 98; p < 0.0001), and Proxy PedsQL (p = 0.04) but not for Child PedsQL (p = 0.3)., Conclusions: The Proxy IXTQ detects reduced HRQOL related to intermittent exotropia more often than the Proxy PedsQL. There were few subnormal scores on Child IXTQ and Child PedsQL. Children with intermittent exotropia scored, on average, lower than control patients on the IXTQ, but most individual scores fell within the normal range. The IXTQ may prove useful for clinical assessment of intermittent exotropia.

Background: Some authors have suggested that a posterior fixation suture on the lateral rectus muscle is ineffective because of the muscle's long arc of contact with the globe. We report a small case series of patients successfully treated using a lateral rectus posterior fixation suture., Methods: The surgical database of one surgeon (JMH) was reviewed for all patients undergoing lateral rectus posterior fixation surgery for mechanical or paretic strabismus. In all cases, the lateral rectus muscle was disinserted from the sclera, and a Mersilene posterior fixation suture was placed 17 mm to 19 mm back from the insertion. The lateral rectus muscle was simultaneously recessed in all cases using a novel approach to allow adjustment of the recession if needed while maintaining the posterior fixation suture. Outcome was assessed at least 1 year after surgery., Results: Three patients were identified. Adduction deficit of the affected eye was caused by previous sinus surgery in 2 cases and scleral buckle surgery in 1 case. The lateral rectus muscle posterior fixation suture on the unaffected eye induced the planned matching -1 limitation of abduction, with resulting improvement in incomitance of the exotropia and reduced angle of exodeviation on prism cover testing., Conclusions: In this case series, a lateral rectus muscle posterior fixation suture was useful in addressing incomitant exodeviations. It is unknown whether this technique is superior to alternative surgical approaches., (Copyright 2010 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: Measurement of distance stereoacuity may be useful in assessing strabismic patients, especially those with intermittent exotropia. We developed the Distance Randot Stereotest as an easily administered quantitative test for distance stereoacuity in children. By using a prototype, we reported testability, validity, and normative data. Here we report normative and validity data for the final, commercially available version of the test., Method: We administered both the Prototype and the Final Version Distance Randot Stereotest to 156 normal volunteers (2-40 years of age) and 77 strabismic patients (4-62 years of age). Test-retest data were collected for the Final Version., Results: Normative Final Version scores were similar to those obtained with the Prototype; 96% were < or = 100 arcsec. Test-retests were identical in 82% and within one disparity level in 100%. Final Version scores were correlated with Prototype scores (rs = 0.64, p < 0.001). Among strabismic patients, 62.3% had abnormal stereoacuity; those with normal scores had incomitant or intermittent deviations. Nil stereoacuity was found in 27 patients, confirmed in 90.9% of retests; 17 had measurable stereoacuity, confirmed in 96.3% of retests. Patients with constant strabismus were more likely to have nil stereoacuity than patients who had intermittent strabismus (95% vs 12.2%)., Conclusions: Distance Randot scores from normal subjects have low variability within each age group and high test-retest reliability. There is little overlap between Distance Randot scores from normal control and strabismic patients. The Distance Randot Stereotest is a sensitive measurement of binocular sensory status that may be useful in monitoring progression of strabismus and/or recovery after strabismus surgery., (Copyright 2010 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To examine the effect of preoperative alignment stability on postoperative motor outcomes in children who underwent surgery for esotropia., Methods: One hundred sixty-seven subjects (68 with infantile esotropia and 99 with acquired esotropia) aged less than 6 years had surgery after completing 18 weeks of follow-up as part of an observational study. Preoperative alignment was classified as stable, uncertain, or unstable, based on measurements taken at baseline and every 6 weeks for 18 weeks. Distance alignment measured by prism and alternate cover test was compared among stability classification groups at 6 weeks and 6 months after surgery., Results: Among subjects with infantile esotropia, median 6-week postoperative deviation was 2(Delta), 6(Delta), and 2(Delta) for subjects with stable, uncertain, and unstable preoperative alignment, respectively (p = 0.73 for stable vs unstable). Median 6-month postoperative deviation was 1(Delta), 9(Delta), and 1(Delta) for stable, uncertain, and unstable, respectively (p = 1.00 for stable vs unstable). Among subjects with acquired esotropia, median 6-week postoperative deviation was 6(Delta), 4(Delta), and 4(Delta) for subjects with stable, uncertain, and unstable preoperative alignment, respectively (p = 0.69 for stable vs unstable). Median 6-month postoperative deviation was 8(Delta), 4(Delta), and 6(Delta) for stable, uncertain, and unstable, respectively (p = 0.22 for stable vs unstable)., Conclusions: Postoperative alignment at 6 weeks and 6 months appears similar in children with stable versus unstable preoperative esotropia. Nevertheless, our finding should be interpreted with caution due to small sample size.