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Background: Amblyopia is the most common cause of vision loss in children. Amblyopia has been associated with impaired depth perception but little attention has been paid to the extent to which amblyopia increases the risk of obesity. Methods: Public-use data from the 1999-2008 National Health and Nutrition Examination Survey were used. Analyses were limited to children aged 12-18, who had a visual examination, and a best corrected visual acuity (BCVA) of at least 20/40 in the better-seeing eye. Amblyopia was defined as two or more-line interocular difference in BCVA. Obesity was defined as Body Mass Index (BMI) or body fat percentage (BFP) ≥95th percentile for age and gender. Sedentary lifestyle was defined as cardiovascular fitness level (CFL) rating of "low." We used Mantel-Haenszel odds ratios (ORs) to examine the relative prevalence of obesity in children with/without amblyopia. Results: Adolescents with amblyopia ( n = 360) were more likely than those without ( n = 7935) to have a high BMI [OR = 1.56; 95% confidence interval (CI): 1.24-1.98; p < 0.001]. The associations with either high BFP (OR = 1.20; 95% CI: 0.86-1.56, p = 0.167) or low CFL (OR = 1.15; 95% CI: 0.83-1.57; p = 0.267) were not statistically significant but in the direction of a priori hypotheses. Conclusions: This analysis of population-based data suggests that adolescents with amblyopia may be at higher risk of having obesity. Given the high prevalence of amblyopia and the range of morbidities associated with childhood obesity, targeted interventions to reduce the risk of obesity among children with amblyopia could be warranted.

Objective: The goal of these analyses is to provide evidence that can help parents and health care providers determine whether or not to continue occlusion therapy once a reliable measure of optotype acuity can be obtained in children who are born with a unilateral congenital cataract., Design: Data from the Infant Aphakia Treatment Study (IATS) are used in a cohort design., Participants: 105 children who participated in the IATS and did not have a vision-threatening adverse event., Methods: We assessed the relationship between visual acuity at age 10.5 years and average daily hours of patching reported by caregivers on quarterly 48-hour recall interviews and annual 7-day patching diaries obtained between 48 and 60 months of age., Main Outcomes: Monocular visual acuity was assessed at the clinic visit closest to 48 months of age using the Amblyopia Treatment Study-HOTV protocol. Final visual acuity was measured at age 10.5 years using the E-ETDRS testing protocol., Results: Visual acuity measurements obtained at age 4 were reliable, with a single measure intraclass correlation coefficient of 0.83 (95% CI 0.78,0.88) and were predictive of those obtained at age 10.5 (r Spearman = 0.83 (p<0.01)). Forty percent (n=48) of the children, the visual acuity measured at age 10.5 years was within +0.15 logMAR of the measurement obtained at age 4. The amount of patching that was received between the 4 th and 5 th birthdays was unrelated to changes in visual acuity., Conclusions: These analyses suggest that optotype acuity measures obtained early in the 5 th year of life are reliable and are predictive of final visual outcomes. Additionally, our results suggest that less aggressive patching protocols, or discontinuing patching altogether, may be justified in some children, particularly those with poor vision, once optotype acuity can be measured. However, the potential impact of latent nystagmus on uniocular visual acuity measurement and the effect of patching on the child's quality of life, family relationships, and binocular visual field need to be considered before discontinuing occlusion therapy., (Copyright © 2024. Published by Elsevier Inc.)

Purpose: To report the cumulative incidence of complications and to describe refractive error and visual acuity (VA) outcomes in children undergoing secondary intraocular lens (IOL) implantation after previous surgery for nontraumatic cataract., Design: Pediatric cataract registry., Participants: Eighty children (108 eyes: 60 bilateral, 48 unilateral) undergoing lensectomy at younger than 13 years of age., Methods: Annual data collection from medical record review through 5 years after lensectomy., Main Outcome Measures: Cumulative incidence of newly emergent complications after secondary IOL implantation; refractive error and VA by 5 years after lensectomy., Results: Median follow-up after secondary IOL implantation was 2.7 years (interquartile range [IQR], 0.8-3.3 years; range, 0.6-5.0 years) for bilateral and 2.1 years (range, 0.5-6.4 years) for unilateral cases. A common complication after secondary IOL implantation was a glaucoma-related adverse event (GRAE; glaucoma or glaucoma suspect); the cumulative incidence was 17% (95% confidence interval [CI], 3%-29%) in bilateral cases and 12% (95% CI, 0%-23%) in unilateral cases. The cumulative incidence of surgery for visual axis opacification was 2% (95% CI, 0%-7%) for bilateral cases and 4% (95% CI, 0%-10%) for unilateral cases. The median prediction error within 90 days of implantation was 0.88 diopter (D; IQR, -0.50 to +3.00 D) less hyperopic than intended among 21 eyes for bilateral cases and 1.50 D (IQR, -0.25 to +2.38 D) less among 19 unilateral cases. The median spherical equivalent refractive error at 5 years (at a median of 5.1 years of age) in eyes receiving a secondary IOL was +0.50 D (IQR, -2.38 to +2.94 D) for 48 bilateral cases and +0.06 D (IQR, -2.25 to +0.75 D) for 22 unilateral cases. Median monocular VA at 5 years was 20/63 (IQR, 20/50-20/100) for bilateral cases (n = 42) and 20/400 (IQR, 20/160-20/800) for unilateral cases (n = 33)., Conclusions: Eyes with secondary IOL implantation have a risk of developing new GRAEs. Five years after lensectomy (approximately 2.5 years after secondary IOL implantation), the average refractive error was less hyperopic than desired given the anticipated further myopic shift before refraction stabilizes., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: With the expansion of neonatal care in sub-Saharan Africa (SSA), an increasing number of premature babies are at risk to develop retinopathy of prematurity (ROP). Previous studies have quantified the cost-effectiveness of addressing ROP in middle-income countries, but few have focused on SSA. This study estimates the cost of a national program for ROP screening and anti-VEGF injection treatment in Rwanda compared to the status quo., Methods: Medical cost data were collected from King Faisal Hospital in Rwanda (July 2022). Societal burden of vision loss included lost productivity and quality-adjusted life years (QALYs). Published data on epidemiology and natural history of ROP were used to estimate burden and sequelae of ROP in Rwanda. Cost of a national program for screening and treating a one-year birth cohort was compared to the status quo using a decision analysis model., Results: Cost of ROP screening and treatment was $738 per infant. The estimated equipment cost necessary for the startup of a national program was $58,667. We projected that a national program could avert 257 cases of blindness in the cohort and increase QALYs compared to the status quo. Screening and treatment for ROP would save an estimated $270,000 for the birth cohort from reductions in lost productivity., Conclusion: The cost of screening and anti-VEGF treatment for ROP is substantially less than the indirect cost of vision loss due to ROP. Allocating additional funding towards expansion of ROP screening and treatment is cost-saving from a societal perspective compared to current practice.

Background: To address the threat of retinopathy of prematurity (ROP) in Sub-Saharan Africa (SSA), the Stop Infant Blindness in Africa (SIBA) project introduced a comprehensive program, including subspecialty training and oxygen management equipment., Methods: A before-and-after retrospective cohort study compared preterm infants < 1750 g or < 34 weeks' gestation before (2022) and after (2023) program implementation. Outcomes included: the proportion with severe ROP, the proportion with Zone III vascularization on first examination, and factors associated with severe ROP., Results: Overall, 140 infants were screened before and 122 after program implementation. The proportion with Zone III vascularization increased from 16.1% (N = 11) pre-intervention to 44.9% (N = 32) post-intervention (p = 0.001). The proportion with severe ROP decreased from 27.8% (N = 19) to 12.8% (N = 9, p = 0.03). Factors predicting severe ROP on adjusted analyses were gestational age and blood transfusion., Conclusion: In SSA, introduction of a comprehensive program to prevent and treat ROP can decrease the risk of severe ROP., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Importance: Parents may be concerned about the adverse outcomes of occlusion therapy in children treated for unilateral congenital cataract (UCC)., Objective: To determine whether occlusion therapy in children treated for UCC with poor visual outcomes is negatively associated with poorer child and/or family functioning., Design, Setting, and Participants: This cohort study was conducted in 2023 using data collected between 2006 and 2016 in the Infant Aphakia Treatment Study (IATS). IATS participants with a visual acuity (VA) of 20/200 or worse were included. Statistical analysis was performed from July 2022 to October 2023., Exposure: Caregivers reported the mean daily minutes of patching during the 12 months prior to the VA assessment at 4.5 years of age. Patching was categorized as minimal (<15 minutes per day), moderate (15 to <120 minutes per day), or extensive (≥120 minutes per day)., Main Outcome Measures: At 4.25 and 10.5 years of age, caregivers reported stress associated with the parenting role using the Parenting Stress Index and the Ocular Treatment Index and child behavior problems using the Achenbach Child Behavior Checklist. Motor skills were assessed at age 54 months using the Movement Assessment Battery for Children-Second Edition. Children completed the Harter Self-Perception Profile for Children at age 10.5 years. One-way analysis of variance and χ2 tests were used to compare outcomes by amount of patching., Results: Patching data were available for 47 of 53 children (88.7%) with a VA of 20/200 or worse. Among these 47 children with patching data included in the study, 20 (42.5%) were female, 27 (57.5%) were male, 12 (25.5%) were reported to have been patched fewer than 15 minutes per day, 11 (23.4%) were patched 16 to 119 minutes per day, and 24 (51.1%) were patched at least 120 minutes per day. Parenting stress, child behavior problems, motor functioning, and child self-perception were similar in all groups. For example, after adjusting for gender and insurance status, there was a nonsignificant difference between mean stress scores of 11.0 (95% CI, -4.5 to 26.5) points for parents who reported minimal patching vs parents who reported patching at least 120 minutes per day, and there was no significant difference in children's report of their global self-worth (0.0 [95% CI, -0.4 to 0.3] points)., Conclusions and Relevance: Occlusion therapy was not negatively associated with family or child functioning. Although the sample size was limited, these results do not support changes to the current practice guidelines.

Purpose: To investigate the types of strabismus surgeries performed and the reoperation rate in patients with Duane retraction syndrome (DRS)., Design: Retrospective cohort analysis., Participants: An insurance claims data set was used to identify patients diagnosed with DRS between 2007 and 2021., Methods: We recorded the type of strabismus surgery performed and the timing and frequency of reoperations. The hazard ratios (HRs) for reoperation were estimated according to the surgical methods using Cox regression analysis., Results: Of the 9435 patients diagnosed with DRS, 1023 (10.8%) underwent ≥ 1 strabismus operation. The median age at surgery was 5.0 years, and patients were followed for an average of 3.8 ± 3.0 years after their initial strabismus surgery. Most of the surgeries only involved horizontal muscle(s) (n = 734 [71.7%]). However, some patients underwent surgeries on vertical muscle(s) (n = 132 [12.9%]), vertical muscle(s) with transposition (n = 102 [10.0%]), and horizontal muscle with transposition (n = 51 [5.0%]). The estimated 5-year rate of reoperation was 18.2% (95% confidence interval [CI], 15.0%-22.2%). Compared with surgery on horizontal muscle(s) only, vertical muscle surgery (HR, 2.01; 95% CI, 1.30-3.11; P  = 0.002) and vertical muscle surgery coupled with transposition (HR, 1.79; 95% CI, 1.06-3.02; P  = 0.03) had an increased risk of reoperation., Conclusions: Strabismus surgery on ≥ 1 horizontal muscles is the most common type of strabismus surgery performed on patients with DRS. Approximately 1 in 7 patients with DRS who had strabismus surgery underwent a reoperation. Patients who underwent vertical muscle surgery had a higher risk of undergoing a reoperation., Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (© 2024 by the American Academy of Ophthalmology.)

Unilateral congenital cataracts lead to deprivation amblyopia, which can be severe. Until the 1970s, they were believed to be always associated with poor visual outcomes. However, advances in our understanding of the plasticity of the infant brain and the development of better surgical techniques allowed good visual outcomes to be obtained in a few of these patients. The Infant Aphakia Treatment Study (IATS) was conducted to provide empirical evidence regarding the best type of optical correction to be used following surgical extraction of the cataract. Specifically, infants were randomly assigned to either be left aphakic and to wear contact lenses or an intraocular lens (IOL) was implanted and the residual refractive error was corrected with spectacles. The study found that good visual acuity and stereopsis could be achieved in some patients in both treatment groups. Early cataract surgery, consistent optical correction and part-time patching of the fellow eye are important elements needed to achieve good visual outcomes. However, excess patching of the fellow eye may interfere with the development of stereopsis. More adverse events occurred after IOL implantation, particularly visual axis opacification, compared with the infants who were left aphakic. Glaucoma-related adverse events occurred in 40% of eyes after a 10-year follow-up and were not associated with IOL implantation. Further research is needed to increase the percentage of children with unilateral congenital cataracts who achieve good visual outcomes., (Copyright © 2023 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate causes of childhood blindness in the United States using the IRIS® Registry (Intelligent Research in Sight)., Design: Cross-sectional study., Participants: Patients ≤ 18 years of age with visual acuity (VA) 20/200 or worse in their better-seeing eye in the IRIS Registry during 2018., Methods: Causes of blindness were classified by anatomic site and specific diagnoses., Main Outcome Measures: Percentages of causes of blindness., Results: Of 81 164 children with 2018 VA data in the IRIS Registry, 961 (1.18%) had VA 20/200 or worse in their better-seeing eye. Leading causes of blindness were retinopathy of prematurity (ROP) in 301 patients (31.3%), nystagmus in 78 patients (8.1%), and cataract in 64 patients (6.7%). The retina was the leading anatomic site (47.7%) followed by optic nerve (11.6%) and lens (10.0%). A total of 52.4% of patients had treatable causes of blindness., Conclusions: This analysis offers a unique cross-sectional view of childhood blindness in the United States using a clinical data registry. More than one-half of blind patients had a treatable cause of blindness., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the characteristics and prevalence of strabismus and nystagmus in children diagnosed with cataracts using a national insurance claims database., Design: Population-based retrospective cohort study., Methods: Patients aged <13 years diagnosed with cataracts (traumatic cataracts excluded) and enrolled continuously in their health care program for ≥5 years after their first cataract diagnosis were identified in a retrospective review of 66 million charts in Optum's de-identified Clinformatics Data Mart Database between 2003 and 2015. Patients were categorized based on age of their first diagnosed cataract, and if cataract surgery was performed. Clinical and demographic factors associated with the occurrence of strabismus and nystagmus were evaluated., Results: Of 1636 children diagnosed with cataract, 434 (26.5%) and 109 (6.7%) were diagnosed with strabismus and nystagmus, respectively. Both strabismus and nystagmus were more common in those who underwent cataract surgery (P < .001) and in patients diagnosed with cataract at ≤12 months of age (P < .001). Survival analysis demonstrated that strabismus and nystagmus may be diagnosed 8 years after the initial cataract diagnosis. Cox proportional hazard regression analyses revealed strabismus was associated with cataract surgery, nystagmus, and the diagnosis with cataract at ≤12 months and cataract surgery at >12 months., Conclusions: As strabismus and nystagmus occur more frequently in children diagnosed with cataracts necessitating cataract surgery, regular long-term follow-up is crucial for these children to monitor for the development of strabismus and nystagmus., (Copyright © 2022. Published by Elsevier Inc.)

Background: Traumatic brain injury (TBI) is one of the common causes of ocular motor nerve (oculomotor nerve [CN3], trochlear nerve [CN4], and abducens nerve [CN6]) palsies, but there has been no large study of ocular motor nerve palsy caused by TBI. This study aimed to investigate the characteristics of and differences in ocular motor nerve palsy after TBI, according to patient age and severity of TBI., Methods: This was a population-based retrospective cohort study that included patients who had ocular motor nerve palsy after TBI with ≥6 months of continuous enrollment using claims data from the IBM MarketScan Research Databases (2007-2016). We assessed sex, age at the first diagnosis of TBI, the severity of TBI, and the rates of strabismus procedures according to the age and severity of TBI. The rates of muscle transposition surgery and chemodenervation in CN3, CN4, and CN6 palsy were investigated., Results: A total of 2,606,600 patients with TBI met the inclusion criteria. Among them, 1,851 patients (0.071%) had ocular motor nerve palsy after TBI. The median age of the patients was 39 (Q1-Q3: 19-54) years, and 42.4% of the patients were female. The median continuous enrollment period after the first diagnosis of TBI was 22 (Q1-Q3: 12-38) months. Of the 1,350,843 children with TBI, 454 (0.026%) had ocular motor nerve palsy. Of the 1,255,757 adults with TBI, 1,397 (0.111%) had ocular motor nerve palsy. Among these 1,851 patients, CN4 palsy (697, 37.7%) occurred most frequently, and strabismus procedures were performed in 237 patients (12.8%). CN6 palsy developed most frequently in children. More children (16.5%) underwent strabismus surgeries than adults (11.6%) ( P = 0.006). The proportion of CN4 palsy (52.3%) was higher while the proportion of CN3 palsy (15.5%) was lower in patients with mild TBI than in patients with moderate-to-severe TBI ( P < 0.001)., Conclusions: CN4 palsy developed most frequently among patients of all ages, and only approximately 13% of the patients underwent strabismus procedures for ocular motor nerve palsy after TBI. The rate of development of ocular motor nerve palsy was approximately 4.3 times lower in children than adults, and children most frequently had CN6 palsy after TBI., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 by North American Neuro-Ophthalmology Society.)

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. Not only do the epidemiologic determinants and distributions of patients with ROP vary worldwide, but clinical differences have also been described. The Third Edition of the International Classification of ROP (ICROP3) acknowledges that aggressive ROP (AROP) can occur in larger preterm infants and involve areas of the more anterior retina, particularly in low-resource settings with unmonitored oxygen supplementation. As sub-specialty training programs are underway to address an epidemic of ROP in sub-Saharan Africa, recognizing characteristic retinal pathology in preterm infants exposed to unmonitored supplemental oxygen is important to proper diagnosis and treatment. This paper describes specific features associated with various ROP presentations: oxygen-induced retinopathy in animal models, traditional ROP seen in high-income countries with modern oxygen management, and ROP related to excessive oxygen supplementation in low- and middle-income countries: oxygen-associated ROP (OA-ROP).

Purpose: To determine the cumulative incidence of strabismus surgery after pediatric cataract surgery and identify the associated risk factors., Design: US population-based insurance claims retrospective cohort study., Participants: Patients ≤ 18 years old who underwent cataract surgery in 2 large databases: Optum Clinformatics Data Mart (2003-2021) and IBM MarketScan (2007-2016)., Methods: Individuals with at least 6 months of prior enrollment were included, and those with a history of strabismus surgery were excluded. The primary outcome was strabismus surgery within 5 years of cataract surgery. The risk factors investigated included age, sex, persistent fetal vasculature (PFV), intraocular lens (IOL) placement, nystagmus and strabismus diagnoses before cataract surgery, and cataract surgery laterality., Main Outcome Measures: Kaplan-Meier estimated cumulative incidence of strabismus surgery 5 years after cataract surgery and hazard ratios (HRs) with 95% confidence intervals (CIs) from multivariable Cox proportional hazards regression models., Results: Strabismus surgery was performed on 271/5822 children included in this study. The cumulative incidence of strabismus surgery within 5 years after cataract surgery was 9.6% (95% CI, 8.3%-10.9%). Children who underwent strabismus surgery were more likely to be of younger age at the time of cataract surgery, of female sex, have a history of PFV or nystagmus, have a pre-existing strabismus diagnosis, and less likely to have an IOL placed (all P < 0.001). Factors associated with strabismus surgery in the multivariable analysis included age 1 to 4 years (HR, 0.50; 95% CI, 0.36-0.69; P < 0.001) and age > 5 years (HR, 0.13; 95% CI, 0.09-0.18; P  < 0.001) compared with age < 1 year at time of cataract surgery, male sex (HR, 0.75; 95% CI, 0.59-0.95; P  < 0.001), IOL placement (HR, 0.71; 95% CI, 0.54-0.94; P  = 0.016), and strabismus diagnosis before cataract surgery (HR, 4.13; 95% CI, 3.17-5.38; P < 0.001). Among patients with strabismus diagnosis before cataract surgery, younger age at cataract surgery was the only factor associated with increased risk of strabismus surgery., Conclusions: Approximately 10% of patients will undergo strabismus surgery within 5 years after pediatric cataract surgery. Children of younger age, female sex, and with a pre-existing strabismus diagnosis undergoing cataract surgery without IOL placement are at greater risk., Financial Disclosures: The author(s) have no proprietary or commercial interest in any materials discussed in this article., (© 2023 Published by Elsevier Inc. on behalf of American Academy of Ophthalmology.)

Purpose: To determine the relative contribution of intraocular lens (IOL) calculation accuracy and ocular growth variability to the long-term refractive error predicted following pediatric cataract surgery., Methods: Pseudophakic eyes of children enrolled in the Infant Aphakia Treatment Study (IATS) were included in this study. Initial absolute prediction error (APE) and 10-year APE were calculated using the initial biometry, IOL parameters, postoperative refractions, and mean rate of refractive growth. The cohort was divided into children with a low-initial APE (≤1.0 D) and a high-initial APE ( >1.0 D). The 10-year APE was compared between the two groups using the Mann-Whitney U test. Linear regression was used to estimate the variability in prediction error explained by the initial IOL calculation accuracy., Results: Forty-two children with IOL placement in infancy were included. Seventeen eyes had a low initial APE, and 25 eyes had a high initial APE. There was no significant difference in APE 10 years following surgery between individuals with a low initial APE (median, 2.67 D; IQR, 1.61-4.12 D) and a high initial APE (median, 3.45 D; IQR, 1.64-5.10 D) (P = 0.7). Initial prediction error could explain 12% of the variability in the prediction error 10 years following surgery., Conclusions: IOL calculation accuracy contributed minimally to the refractive error predicted 10 years after cataract surgery in the setting of high variability in the rate of refractive growth., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. All rights reserved.)

Purpose: To correlate the diagnosis of glaucoma among children in the Infant Aphakia Treatment Study (IATS) by age 10 years with anterior segment optical coherence tomography (AS-OCT) findings., Methods: A multicenter randomized controlled trial of 114 infants with unilateral congenital cataract who were 1-6 months of age at surgery. Data on long-term glaucoma-related status and outcomes were collected when children were 10.5 years old. Participants were randomized at cataract surgery to either primary intraocular lens (IOL) or no IOL implantation (contact lens [CL]). AS-OCT findings in eyes with glaucoma were compared to eyes which did not have glaucoma and to the fellow eyes, between fellow and treated eyes, and between the IOL and CL groups., Results: There were no significant differences in the mean nasal and temporal anterior chamber angle (ACA) or mean nasal and temporal angle opening distance (AOD) for nonglaucomatous, glaucomatous, and fellow eyes (P = 0.31, 0.16, 0.43, 0.08 resp.). There were also no significant differences in mean nasal and temporal ACA and AOD between fellow and treated eyes (P = 0.44, 0.67, 0.57, 0.38 resp.), or between IOL and CL groups (P = 0.36, 0.35, 0.49, 0.44, resp.)., Conclusions: AS-OCT confirmed that eyes with glaucoma in IATS had predominantly open angles with similar ACA and AOD to eyes without glaucoma and to fellow eyes. Furthermore, congenital cataract surgery with or without an IOL did not result in a significant difference in ACA or AOD compared to fellow eyes in IATS., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate types of surgeries performed to treat a presumed congenital superior oblique palsy (SOP) and the reoperation rate., Methods: This was a population-based retrospective cohort study using claims data from the United States. Patients who underwent strabismus surgery for a presumed congenital SOP with ≥ 3 months of continuous enrolment after the initial surgery were included. We investigated age, surgical methods and the time interval between the initial surgery and reoperation. The hazard ratios for reoperation were estimated according to the surgical methods using Cox regression analysis., Results: A total of 3,998 patients underwent surgery for presumed congenital SOP; 2,981 (74.6%) on only one vertical muscle (excluding superior oblique). Reoperation was performed on 427 patients (10.7%). Compared to patients who underwent unilateral surgery on one vertical muscle (excluding superior oblique muscle), patients who underwent surgery that included the superior oblique muscle (unilateral 2.08; 95% CI, 1.61-2.67, p < 0.001; bilateral 2.44; 95% CI, 1.40-4.28, p = 0.002) and two or more vertical muscles (excluding the superior oblique muscle) (unilateral 2.99; 95% CI, 2.00-4.49, p < 0.001; bilateral 1.68; 95% CI, 1.23-2.28, p = 0.001) had increased hazard ratios for reoperation. The median period between the initial surgery and reoperation was 168.0 [Q1-Q3 84.0-407.8] days and negatively correlated with patient age at initial surgery (r = -0.199, p < 0.001)., Conclusion: The reoperation rate for presumed congenital SOP was 10.7%. Patients who underwent surgery on two or more vertical muscles or the superior oblique muscle had an increased risk of reoperation., (© 2021 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Infantile cataracts remain one of the most treatable causes of lifelong visual impairment. While the chance of improving vision for children with infantile cataracts has never been better, significant global and socioeconomic disparities still exist in their early management. Recent epidemiological studies reveal a stable prevalence of infantile cataracts in high-income countries and highlight challenges in determining the prevalence of infantile cataracts in low-income countries. Detailed descriptions of cataract morphology may inform us as to etiology, provide guidance with regards to surgical approach, and have prognostic value. Molecular genetics is providing new insights into the hereditary bases and potential systemic associations of infantile cataracts. For visually significant infantile cataracts requiring surgery to clear the visual axis, surgical techniques continue to evolve based on the experiences and research efforts of skilled teams worldwide. The most common complications of cataract surgery performed in infancy are visual axis opacification and, in about a third of patients, the long-term development of glaucoma. Children with unilateral cataracts generally see well given the presence of a healthy fellow eye. Better visual outcomes in operated eyes, however, are achieved in the setting of early presentation, bilateral infantile cataracts, absence of nystagmus or strabismus, and consistent amblyopia therapy. While intraocular lenses for infants less than 6 months can result in good visual outcomes, contact lenses may be preferred in situations in which they are available and practical. Many studies have demonstrated the benefits of early surgery for infantile cataract. We must strive for the continued evolution of technologies and strategies that have the potential to further improve these outcomes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To compare the rate of refractive growth (RRG3) of the crystalline lens ("lens") versus the eye excluding the lens ("globe") for the fellow, noncataractous eyes of participants in the Infant Aphakia Treatment Study., Design: Retrospective cohort study., Subjects: A total of 114 children who had unilateral cataract surgery as infants were recruited. Biometric and refraction data were obtained from the normal eyes at surgery and at 1, 5, and 10 years. Subjects were included if complete data (axial length [AL], corneal power, and refraction) were available at surgery and at 10 years of age., Methods: At surgery and at 1, 5, and 10 years, AL, corneal power, and cycloplegic refraction were measured in the normal eyes. For each eye, the RRG3 was defined by linear regression of refraction at the intraocular lens (IOL) plane against log 10 (age + 0.6 years). The RRG3 for the globe was based on IOL power for emmetropia; the RRG3 for the lens was based on IOL power calculated to give the observed refractions. Intraocular lens powers were calculated with the Holladay 1 formula. The means were compared with a paired 2-tailed t test, and linear regression was used to look for a correlation between RRG3 of the lens globe., Main Outcome Measures: The RRG3 of the lens and globe., Results: Complete data were available for 107 normal eyes. The mean RRG3 of the lenses was -12.0 ± 2.5 diopters (D) and the mean RRG3 of the globes was -14.1 ± 2.7 D ( P < 0.001). The RRG3 of the lens correlated with the RRG3 of the globe ( R 2  = 0.25, P < 0.001)., Conclusions: The RRG3 was 2 D more negative in globes compared with lenses in normal eyes. Globes with a greater rate of growth tended to have lenses with a greater rate of growth., (© 2022 by the American Academy of Ophthalmology.)

Purpose: To characterize long-term strabismus outcomes in children in the Infant Aphakia Treatment Study (IATS)., Methods: This study was a secondary data analysis of long-term ocular alignment characteristics of children aged 10.5 years who had previously been enrolled in a randomized clinical trial evaluating aphakic management after unilateral cataract surgery between 1 and 6 months of age., Results: In the IATS study, 96 of 109 children (88%) developed strabismus through age 10.5 years. Half of the 20 children who were orthophoric at distance through age 5 years maintained orthophoria at distance fixation at 10.5 years. Esotropia was the most common type of strabismus prior to age 5 years (56/109 [51%]), whereas exotropia (49/109 [45%]) was the most common type of strabismus at 10.5 years (esotropia, 21%; isolated hypertropia, 17%). Strabismus surgery had been performed on 52 children (48%), with 18 of these (35%) achieving microtropia <10 Δ . Strabismus was equally prevalent in children randomized to contact lens care compared with those randomized to primary intraocular lens implantation (45/54 [83%] vs 45/55 [82%]; P = 0.8). Median visual acuity in the study eye was 0.56 logMAR (20/72) for children with orthotropia or microtropia <10 Δ versus 1.30 logMAR (20/400) for strabismus ≥10 Δ (P = 0.0003)., Conclusions: Strabismus-in particular, exotropia-is common irrespective of aphakia management 10 years following infant monocular cataract surgery. The delayed emergence of exotropia with longer follow-up indicates a need for caution in managing early esotropia in these children. Children with better visual acuity at 10 years of age are more likely to have better ocular alignment., (Copyright © 2022. Published by Elsevier Inc.)

Objective: Pediatric uveitis can lead to sight-threatening complications and can impact quality of life (QoL) and functioning. We aimed to examine health-related QoL, mental health, physical disability, vision-related functioning (VRF), and vision-related QoL in children with juvenile idiopathic arthritis (JIA), JIA-associated uveitis (JIA-U), and other noninfectious uveitis. We hypothesized that there will be differences based on the presence of eye disease., Methods: A multicenter cross-sectional study was conducted at four sites. Patients with JIA, JIA-U, or noninfectious uveitis were enrolled. Patients and parents completed the Pediatric Quality of Life Inventory (PedsQL; health-related QoL), the Revised Childhood Anxiety and Depression Scale (RCADS; anxiety/depression), the Childhood Health Assessment Questionnaire (C-HAQ; physical disability), and the Effects of Youngsters' Eyesight on Quality of Life (EYE-Q) (VRF/vision-related QoL). Clinical characteristics and patient-reported outcome measures were compared by diagnosis., Results: Of 549 patients, 332 had JIA, 124 had JIA-U, and 93 had other uveitis diagnoses. Children with JIA-U had worse EYE-Q scores compared to those with JIA only. In children with uveitis, those with anterior uveitis (JIA-U and uveitis only) had less ocular complications, better EYE-Q scores, and worse C-HAQ and PedsQL physical summary scores compared to those with nonanterior disease. In children with anterior uveitis, those with JIA-U had worse PedsQL physical summary and C-HAQ scores than anterior uveitis only. Further, EYE-Q scores were worse in children with bilateral uveitis and more visual impairment. There were no differences in RCADS scores among groups., Conclusion: We provide a comprehensive outcome assessment of children with JIA, JIA-U, and other uveitis diagnoses. Differences in QoL and function were noted based on underlying disease. Our results support the addition of a vision-specific measure to better understand the impact of uveitis., (© 2021 American College of Rheumatology.)

Background: The refraction prediction error (PE) for infants with intraocular lens (IOL) implantation is large, possibly related to an effective lens position (ELP) that is different than in adult eyes. If these eyes still have nonadult ELPs as they age, this could result in persistently large PE. We aimed to determine whether ELP or biometry at age 10½ years correlated with PE in children enrolled in the Infant Aphakia Treatment Study (IATS)., Methods: We compared the measured refraction of eyes randomized to primary IOL implantation to the "predicted refraction" calculated by the Holladay 1 formula, based on biometry at age 10½ years. Eyes with incomplete data or IOL exchange were excluded. The PE (predicted - measured refraction) and absolute PE were calculated. Measured anterior chamber depth (ACD) was used to assess the effect of ELP on PE. Multiple regression analysis was performed on absolute PE versus axial length, corneal power, rate of refractive growth, refractive error, and best-corrected visual acuity., Results: Forty-three eyes were included. The PE was 0.63 ± 1.68 D; median absolute PE, 0.85 D (IQR, 1.83 D). The median absolute PE was greater when the measured ACD was used to calculate predicted refraction instead of the standard A-constant (1.88 D [IQR, 1.72] D vs 0.85 D [IQR, 1.83], resp. [P = 0.03]). Absolute PE was not significantly correlated with any other parameter., Conclusions: Variations in ELP did not contribute significantly to PE 10 years after infant cataract surgery., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. All rights reserved.)

Purpose: To determine the cumulative incidence of retinal detachment (RD) repair following pediatric cataract surgery and identify the associated risk factors., Design: US population-based insurance claims retrospective cohort study., Participants: Patients ≤ 18 years old who underwent cataract surgery in 2 large databases: Optum Clinformatics (2003-2021) and IBM MarketScan (2007-2016)., Methods: Individuals with ≥ 6 months of prior enrollment were included, and those with a history of RD, RD repair, traumatic cataract, spherophakia, or ectopia lentis were excluded. The primary outcome was time between initial cataract surgery and RD repair. The risk factors investigated included age, sex, persistent fetal vasculature (PFV), prematurity, intraocular lens (IOL) placement, and pars plana lensectomy approach., Main Outcome Measures: Kaplan-Meier estimated cumulative incidence of RD repair 5 years after cataract surgery and hazard ratios (HRs) with 95% confidence intervals (CIs) from multivariable Cox proportional hazards regression models., Results: Retinal detachment repair was performed on 47 of 3289 children included in this study. The cumulative incidence of RD repair within 5 years of cataract surgery was 2.0% (95% CI, 1.3%-2.6%). Children requiring RD repair were more likely to have a history of prematurity or PFV and less likely to have an IOL placed (all P  < 0.001). Factors associated with RD repair in the multivariable analysis included a history of prematurity (HR, 6.89; 95% CI, 3.26-14.56; P < 0.001), PFV diagnosis (HR, 8.20; 95% CI, 4.11-16.37; P < 0.001), and IOL placement (HR, 0.44; 95% CI, 0.21-0.91; P  = 0.03). Age at surgery, sex, and pars plana lensectomy approach were not significantly associated with RD repair after adjusting for all other covariates., Conclusions: Approximately 2% of patients will undergo RD repair within 5 years of pediatric cataract surgery. Children with a history of PFV and prematurity undergoing cataract surgery without IOL placement are at the greatest risk., (© 2022 by the American Academy of Ophthalmology.)

Purpose: To examine risk factors for strabismus surgery reoperation in patients with thyroid eye disease (TED)., Design: Retrospective cohort study., Methods: An insurance claims database was used to identify patients with TED who underwent at least one strabismus operation between 2003 and 2019. We recorded specific muscles operated on, as well as the timing and frequency of reoperations. Cox regressions were used to estimate associations between time to reoperation and patient and primary surgery characteristics., Results: Of the 448 patients who met inclusion criteria, 111 (24.8%) underwent a reoperation. Patients were followed for an average of 5.4 ± 3.0 years after their initial strabismus surgery. The rates of reoperation among patients whose initial surgery involved horizontal muscles only, vertical muscles only, and horizontal and vertical muscles were 29 of 120 (24.2%), 33 of 169 (19.5%), and 49 of 159 (30.8%) respectively (P = .05). The number of muscles operated on initially was the only independent predictor for undergoing a strabismus surgery reoperation (odds ratio, 1.27; 95% confidence interval, 1.03-1.57; P = .03). The number of muscles operated on initially was also associated with shorter time to first reoperation (hazard ratio, 1.22; 95% confidence interval, 1.02-1.46; P = .03). Age at first surgery, time between diagnosis of TED and first strabismus surgery, gender, race, and use of adjustable sutures were not associated with time to reoperation., Conclusions: Approximately 1 in 4 patients with TED require reoperation after strabismus surgery. The number of muscles operated on was the only independent predictor for both undergoing a reoperation and time to first reoperation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Refraction predictions from intraocular lens (IOL) calculation formulae are inaccurate in children. We sought to quantify the relationship between age and prediction error using a model derived from the biometry measurements of children enrolled in the Infant Aphakia Treatment Study (IATS) when they were ≤7 months of age. We calculated theoretical predicted refractions in diopters (D) using axial length, average keratometry, and IOL powers at each measurement time point using the Holladay 1 formula. We compared the predicted refraction to the actual refraction and calculated the absolute prediction error (APE). We found that the median APE was 1.60 D (IQR, 0.73-3.11 D) at a mean age (corrected for estimated gestational age) of 0.20 ± 0.14 years and decreased to 1.11 D (IQR, 0.42-2.20 D) at 10.60 ± 0.27 years. We analyzed the association of age with APE using linear mixed-effects models adjusting for axial length, average keratometry, and IOL power and found that as age doubled, APE decreased by 0.25 D (95% CI, 0.09-0.40 D). The accuracy of IOL calculations increases with age, independent of biometry measurements and IOL power., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. All rights reserved.)

A total of 167 cases (0.111%) of infectious complications (endophthalmitis, orbital cellulitis, preseptal cellulitis, and postoperative infection) were identified in patients after strabismus surgery. The incidence of postoperative endophthalmitis was approximately 1 per 13,700 strabismus surgeries (0.007%) among 151,011 strabismus surgeries in US claims databases., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: Retinopathy of Prematurity (ROP) has been suggested to be increasing in Africa. However, it was only previously documented as a cause of blindness in 8 of 48 (16.7%) sub-Saharan African countries. The purpose of this study was to better understand the magnitude and breadth of blindness from ROP in sub-Saharan Africa., Methods: A questionnaire was sent to 455 ophthalmologists practicing in sub-Saharan Africa; the questionnaire was available in English, French and Portuguese., Results: Responses were received from 132 of 455 (29%) ophthalmologists to whom the survey was sent. Eighty-three respondents were identified as ROP-involved ophthalmologists and were from 26 of 48 (54%) sub-Saharan African countries. Ophthalmologists in 23 countries reported that they examined at least one child who was blind from ROP during the last 5 years. Sixteen of these countries had not previously reported cases of blindness from ROP in the literature. The perceived occurrence of Type 1 or more severe ROP was reported to be increasing by 31 of 77 (40%) ROP-involved ophthalmologists. ROP-involved pediatric ophthalmologists and retinal surgeons reported the number of infants they examined annually with Type 1 or more severe ROP increased from a median of 1 (range: 0-15) to a median of 4 (range: 0-40) from 2015 to 2019. ROP was estimated to be the cause of blindness for 10% of all blind children examined by ROP-involved pediatric ophthalmologists and retinal surgeons during 2019., Conclusions: ROP is becoming a more important and widespread cause of childhood blindness in sub-Saharan Africa.

Purpose: The aim of this study was to assess the effect of corneal crosslinking on vision and keratometry in children and young adults with progressive keratoconus., Methods: A retrospective medical records review of patients aged 22 years or younger with keratoconus who underwent corneal crosslinking between January 2013 and November 2019 at Byers Eye Institute at Stanford University was conducted. Outcome measures included logarithm of the Minimum Angle of Resolution corrected distance visual acuity (CDVA); keratometry, including maximum keratometry (Kmax); pachymetry; and total wavefront aberration. Measurements were taken at baseline and at 12 and 24 months postoperatively., Results: Fifty-seven eyes of 49 patients aged 12 to 22 years were assessed. The mean preoperative CDVA was logarithm of the Minimum Angle of Resolution 0.38 ± 0.32 (20/48), with a mean postoperative CDVA of 0.29 ± 0.31 (20/39) and 0.31 ± 0.31 (20/41) at 12 and 24 months postoperatively, respectively. Compared with preoperative mean Kmax, there was an improvement of -0.8 diopters (D) to a mean postoperative Kmax of 59.1 ± 9.1 D at 12 months and -1.3 D to 59.7 ± 8.8 D at 24 months. Subanalysis excluding the second eye of patients who underwent bilateral crosslinking showed similar results. Linear mixed modeling showed significant improvement in Kmax at both 12 and 24 months postoperatively. Minimum central corneal thickness initially decreased but stabilized at 24 months after crosslinking. Total wavefront aberration remained stable., Conclusions: Corneal crosslinking stabilizes, and in some cases improves, visual and corneal parameters in pediatric and young adult patients with keratoconus. The procedure is safe and well-tolerated and may prevent keratoconus progression in young patients., Competing Interests: E. E. Manche is a consultant for Avedro, Inc and Johnson and Johnson Vision, Inc. He owns equity in Placid0, Inc, RxSight, Inc, and VacuSite, Inc. He performs sponsored research for Alcon Inc, Allergan, Inc, Avedro, Inc, Carl Zeiss Meditec, Johnson and Johnson Vision, Inc, and Presbia. The remaining authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The Effects of Youngsters' Eyesight on Quality of Life (EYE-Q) questionnaire measures vision-related functioning (VRF) and vision-related quality of life (VRQoL) in children with uveitis. Our aim was to revise the alpha version of the EYE-Q to refine VRF and VRQoL subscales and to assess the validity of the EYE-Q., Methods: Children with juvenile idiopathic arthritis (JIA), JIA-associated uveitis, and other noninfectious uveitis were enrolled. Patients and parents completed the EYE-Q, Pediatric Quality of Life Inventory (overall quality of life), and Childhood Health Assessment Questionnaire (physical functioning). The development site completed the alpha version of the EYE-Q, and the composite sites completed the beta version. We compared item-subscale correlations, internal consistency, and construct and discriminant validity among the different versions., Results: Of the 644 patients enrolled, 61.6% completed the alpha version, and 38.4% the beta version of the EYE-Q. Mean ± SD patient age was 11.1 ± 4.2 years, and 70% were female. Fewer White patients (73.5%) completed the alpha version compared to the beta version (86.2%; P < 0.001). With the exception of patient-reported VRF, both versions had similar item-subscale correlations. Version comparisons on scale internal consistencies indicated significant differences for parent- and patient-reported VRF, but each scale had a Cronbach's α of >0.80 beta. When data were combined, the EYE-Q showed significant differences between JIA-only and uveitis patients on all parent and patient scores, except for patient-reported VRF., Conclusion: The EYE-Q appears to be a valid measure of VRF and VRQoL in pediatric uveitis. Our results suggest it may be used as an outcome measure in multicenter pediatric uveitis studies., (© 2020 American College of Rheumatology.)

Importance: Cataract is an important cause of visual impairment in children. Data from a large pediatric cataract surgery registry can provide real-world estimates of visual outcomes and the 5-year cumulative incidence of adverse events., Objective: To assess visual acuity (VA), incidence of complications and additional eye operations, and refractive error outcomes 5 years after pediatric lensectomy among children younger than 13 years., Design, Setting, and Participants: This prospective cohort study used data from the Pediatric Eye Disease Investigator Group clinical research registry. From June 2012 to July 2015, 61 eye care practices in the US, Canada, and the UK enrolled children from birth to less than 13 years of age who had undergone lensectomy for any reason during the preceding 45 days. Data were collected from medical record reviews annually thereafter for 5 years until September 28, 2020., Exposures: Lensectomy with or without implantation of an intraocular lens (IOL)., Main Outcomes and Measures: Best-corrected VA and refractive error were measured from 4 to 6 years after the initial lensectomy. Cox proportional hazards regression was used to assess the 5-year incidence of glaucoma or glaucoma suspect and additional eye operations. Factors were evaluated separately for unilateral and bilateral aphakia and pseudophakia., Results: A total of 994 children (1268 eyes) undergoing bilateral or unilateral lensectomy were included (504 [51%] male; median age, 3.6 years; range, 2 weeks to 12.9 years). Five years after the initial lensectomy, the median VA among 701 eyes with available VA data (55%) was 20/63 (range, 20/40 to 20/100) in 182 of 316 bilateral aphakic eyes (58%), 20/32 (range, 20/25 to 20/50) in 209 of 386 bilateral pseudophakic eyes (54%), 20/200 (range, 20/50 to 20/618) in 124 of 202 unilateral aphakic eyes (61%), and 20/65 (range, 20/32 to 20/230) in 186 of 364 unilateral pseudophakic eyes (51%). The 5-year cumulative incidence of glaucoma or glaucoma suspect was 46% (95% CI, 28%-59%) in participants with bilateral aphakia, 7% (95% CI, 1%-12%) in those with bilateral pseudophakia, 25% (95% CI, 15%-34%) in those with unilateral aphakia, and 17% (95% CI, 5%-28%) in those with unilateral pseudophakia. The most common additional eye surgery was clearing the visual axis, with a 5-year cumulative incidence of 13% (95% CI, 8%-17%) in participants with bilateral aphakia, 33% (95% CI, 26%-39%) in those with bilateral pseudophakia, 11% (95% CI, 6%-15%) in those with unilateral aphakia, and 34% (95% CI, 28%-39%) in those with unilateral pseudophakia. The median 5-year change in spherical equivalent refractive error was -8.38 D (IQR, -11.38 D to -2.75 D) among 89 bilateral aphakic eyes, -1.63 D (IQR, -3.13 D to -0.25 D) among 130 bilateral pseudophakic eyes, -10.75 D (IQR, -20.50 D to -4.50 D) among 43 unilateral aphakic eyes, and -1.94 D (IQR, -3.25 D to -0.69 D) among 112 unilateral pseudophakic eyes., Conclusions and Relevance: In this cohort study, development of glaucoma or glaucoma suspect was common in children 5 years after lensectomy. Myopic shift was modest during the 5 years after placement of an intraocular lens, which should be factored into implant power selection. These results support frequent monitoring after pediatric cataract surgery to detect glaucoma, visual axis obscuration causing reduced vision, and refractive error.

Background: Double Maddox rod (DMR), the gold-standard method for in-office measurement of cyclodeviation, requires an examiner and specialized equipment. The objective of this study was to develop a virtual reality (VR) technique for measurement of cyclodeviation and validate this against the DMR., Methods: A VR-DMR was implemented using a smartphone and commercially available VR viewer. The app displayed a line to each eye and accepted touch inputs from the user to rotate the lines into perceived alignment. VR-DMR cyclodeviation measurements were compared with traditional DMR (T-DMR) cyclodeviation measurements in adults with and without strabismus and children without strabismus., Results: Thirty-one subjects were studied (age 5-88 years, 20 with strabismus). VR-DMR had similar test-retest reliability as T-DMR. VR-DMR was highly correlated with T-DMR (r2 = 0.94, linear regression slope 1.12) with a slight positive bias (linear regression y intercept 1°). VR-DMR was preferred by 54% of subjects with 29% having no preference., Conclusions: A VR method of ocular cyclodeviation measurement using sensory techniques was implemented using commercially available hardware. VR measurements compared favorably with gold-standard DMR measurements, and user feedback was positive. The VR methodology has application for in office and home use by nonexperts for purposes of strabismus monitoring., Competing Interests: The authors report no conflicts of interest, (Copyright © 2021 by North American Neuro-Ophthalmology Society.)

Background: Delayed treatment of congenital or infantile cataracts can cause deprivation amblyopia. Prompt diagnosis and surgical intervention is critical for optimal outcomes. This study assessed referral patterns for congenital or infantile cataracts in two regions of the United States., Methods: The medical records of children 0-1 years of age with congenital or infantile cataracts at Stanford University (2008-2018) and Emory University (2010-2015) were reviewed retrospectively., Results: A total of 111 children were included. Of these, 82 (74%) were initially evaluated by a primary care doctor, of whom 40 (49%) were referred directly to a pediatric cataract surgeon. Of 61 newborns 0-2 months of age, 9 (15%) were initially referred to an eye care provider before 6 weeks of age, but the initial evaluation by a pediatric cataract surgeon was delayed until after 6 weeks of age. Referral patterns were similar between the two institutions (P = 0.06)., Conclusions: Many children with congenital of infantile cataracts are initially referred by a primary care doctor to an eye care provider who does not perform pediatric cataract surgery. Nevertheless, the majority of newborn infants with cataracts were evaluated by a pediatric cataract surgeon before 6 weeks of age., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To review the scientific literature that evaluates the effectiveness of adjustable sutures in the management of strabismus for adult and pediatric patients., Methods: Literature searches were performed in the PubMed database through April 2021 with no date limitations and were restricted to publications in English. The searches identified 551 relevant citations, of which 55 were reviewed in full text. Of these, 17 articles met the inclusion criteria and were assigned a level of evidence rating by the panel methodologist. The search included all randomized controlled studies regardless of study size and cohort studies of 100 or more patients comparing the adjustable versus nonadjustable suture technique, with a focus on motor alignment outcomes or reoperation rates., Results: The literature search yielded no level I studies. Of the 17 articles that met the inclusion criteria, 11 were rated level II and 6 were rated level III. Among the 12 studies that focused on motor alignment outcomes, 4 small randomized clinical trials (RCTs) did not find a statistically significant difference between groups, although they were powered to detect only very large differences. Seven of 8 nonrandomized studies found a statistically significant difference in motor alignment success in favor of the adjustable suture technique, both overall and in certain subgroups of patients. Successful motor alignment was seen in both exotropia (in 3 studies that were not limited to children) and esotropia (in 1 study of adults and 2 of children). The majority of included studies that reported on reoperation rates found the rates to be lower in patients who underwent strabismus surgery with adjustable sutures, but this finding was not uniformly demonstrated., Conclusions: Although there are no level I studies evaluating the effectiveness of adjustable sutures for strabismus surgery, the majority of nonrandomized studies that met the inclusion criteria for this assessment reported an advantage of the adjustable suture technique over the nonadjustable technique with respect to motor alignment outcomes. This finding was not uniformly demonstrated among all studies reviewed and warrants further investigation in the development and analysis of adjustable suture techniques., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

In this population-based retrospective cohort study, the Optum claims dataset was used to identify children <4 years of age with the diagnosis of nasolacrimal duct obstruction during the period 2003-2016. A total of 156,044 children were identified, of whom 16,538 (9.43%) underwent a surgical procedure. There was a downward trend for the frequency of all types of treatments but particularly for facility-based probings., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the effect of age on the reoperation rate in children undergoing exotropia surgery., Methods: This was a population-based retrospective cohort study using claims data that included children ≤ 12 years who had undergone exotropia surgery as the first strabismus operation and had ≥ 3 years of continuous enrolment were selected from the Optum de-identified Clinformatics Data Mart Database (2003-2019). Patient age at the first exotropia surgery was grouped into three categories; 0-3, 4-6, and 7-12 years. We assessed the sex, race, age, surgical methods, continuous enrolment period after the first surgery, and the time between the first surgery and reoperation. Cox regression analysis was used to estimate the risk of reoperation at different ages. The hazard ratio of reoperation in children undergoing exotropia surgery according to the age at the first exotropia surgery., Results: Among 2015 children, 312 (15.5%) underwent one or more reoperations. A reoperation was more often performed for recurrent exotropia (n = 231) than for consecutive esotropia (n = 81). The time between the first surgery and reoperation was shorter for reoperation for consecutive esotropia (376 days) than for recurrent exotropia (672 days) (p < 0.001). Younger children showed a higher reoperation hazard ratio than older children (p < 0.001). In reoperation for consecutive esotropia, the patients aged 0-3 years showed a high hazard ratio (2.82; 95% CI, 1.59-5.01)., Conclusion: Children undergoing exotropia surgery at a younger age have a higher reoperation rate than those undergoing surgery at an older age., (© 2021 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Objectives: To provide more comprehensive data on the management of oxygen supplementation in neonates in sub-Saharan Africa., Study Design: An online survey on the management of oxygen supplementation for infants in neonatal units was sent to 278 healthcare personnel in sub-Saharan Africa., Results: One hundred and nine responses from 82 neonatal care units in 54% (26/48) sub-Saharan African countries were received. All units had the capacity to provide oxygen supplementation. However, only 50% (38/76) had access to blend oxygen with medical air and 1% (1/75) had the capacity to blend oxygen/air for every infant. Although 96% (72/75) of units could monitor oxygen saturation, monitoring was mostly intermittent and only 32% (24/75) were able to monitor oxygen saturation in every infant receiving oxygen supplementation., Conclusions: Findings indicate that oxygen supplementation is inadequately managed in neonatal units in sub-Saharan Africa, which may put infants at risk of developing severe ROP., (© 2021. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Purpose: To determine the incidence of retinal detachment after lens surgery in children and young adults with nontraumatic ectopia lentis., Setting: Population-based claims data., Design: Population-based retrospective cohort study., Methods: Patients with nontraumatic ectopia lentis aged 30 years or younger who had undergone lens surgery with or without intraocular lens (IOL) implantation and had 1 year or greater continuous enrollment after lens surgery were included in the Optum deidentified Clinformatics Data Mart Database (2003 to 2019) and IBM MarketScan Databases (2007 to 2016). Both databases were assessed for sex, age, etiology of ectopia lentis, IOL implantation, and postoperative retinal detachment separately. Univariate and multivariate analyses were conducted to identify the risk factors for postoperative retinal detachment., Results: Among a total of 298 eyes (210 patients), IOL implantation was coupled with lens surgery in 151 eyes (49.8%) that underwent lens surgery for nontraumatic ectopia lentis. The median follow-up was 32 months in aphakic eyes and 29 months in pseudophakic eyes. Patients undergoing IOL implantation were older at the time of lens surgery (median age: no IOL, 6 years; IOL, 16 years; P < .001). Retinal detachment developed in 13 patients (14 eyes [4.7%]) 14 eyes (4.7%). Older age was the baseline characteristic that correlated most closely with the risk for retinal detachment (P = .05)., Conclusions: The rate of retinal detachment was similar with or without IOL implantation after lens surgery for nontraumatic ectopia lentis in children and young adults., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To describe the characteristics and incidence of children developing endophthalmitis within the first 90 days following pediatric cataract surgery., Setting: Deidentified commercial and Medicare Advantage health claims across the United States., Design: Population-based retrospective cohort study., Methods: In a retrospective review of approximately 58 million charts in Optum's deidentified Clinformatics Data Mart Database, patients aged <13 years who underwent cataract surgery in one or both eyes with or without primary intraocular lens (IOL) implantation between 2003 and 2017 were identified. Excluded were patients with traumatic cataract, <90 days of continuous insurance coverage, a prior diagnosis of endophthalmitis, and a diagnosis of endophthalmitis occurring after 90 days of cataract surgery. The main outcome measure was the incidence of endophthalmitis occurring within the first 90 days of cataract surgery and the odds ratio for developing endophthalmitis according to demographic and intraoperative factors., Results: Cataract surgery was performed on 789 eyes (52.6% male), with a median age of 4 (interquartile range 1-8) years. The rate of IOL implantation at the time of cataract surgery was 66.8%. Endophthalmitis was diagnosed in 4 of 789 eyes (0.51%). The median time to diagnosis of endophthalmitis was 6.5 days (range: 5-44 days). There was no significant association between endophthalmitis and age, sex, or primary IOL implantation., Conclusions: In this large insurance claims database, the incidence of endophthalmitis following pediatric cataract surgery reported was more than the rate previously reported by any study with patients of a similar age., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To determine the rate of superior oblique surgery and how often it is combined with surgery on other extraocular muscles or associated with subsequent strabismus surgeries in children and adolescents with Brown syndrome., Methods: This was a population-based retrospective cohort study using the Optum deidentified Clinformatics Data Mart Database (2004-2018) for patients ≤18 years of age diagnosed with Brown syndrome who underwent superior oblique surgery as their first strabismus surgery and had at least 6 months of continuous enrollment. We assessed sex, age, and the number of included patients by year and by age. Combined and subsequent strabismus surgeries were also investigated., Results: Of 1,007 patients diagnosed with Brown syndrome, 115 (11.4%) underwent superior oblique surgery. The rate of superior oblique surgery was relatively constant between 2004 to 2018. The superior oblique surgery rate was highest in children ≤2 years of age with a decreasing rate as age increased. In 45 of 115 patients (39.1%), other extraocular muscles were operated on in addition to the superior oblique muscle. Of 88 patients who underwent superior oblique surgery without concurrent vertical muscle surgery as the first operation, 11 patients (12.5%) subsequently underwent an additional vertical muscle surgery because of newly developed or worsening vertical misalignment., Conclusions: In this study cohort, superior oblique surgery was performed on 11.4% of children and adolescents with Brown syndrome. The number of patients with Brown syndrome and the rate of superior oblique surgery decreased as age increased to age 10 years., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: Prediction of refraction after cataract surgery in children is limited by the variance in rate of refractive growth (RRG3). This study compared RRG3 in aphakic and pseudophakic eyes with their fellow, normal eyes in the Infant Aphakia Treatment Study., Setting: Twelve clinical sites in the United States., Design: Randomized clinical trial., Methods: Infants randomized to unilateral cataract extraction had RRG3 calculated based on biometric data (axial length and keratometry) at cataract surgery and at 10 years of age, for both the normal and cataract eyes. Subjects were included if complete biometric data from both eyes were available both at surgery and at 10 years. Variance in RRG3 was compared between the groups with Pitman test for equality of variance between correlated samples., Results: Longitudinal biometric data were available for 103 of the 114 patients enrolled. RRG3 was -15.00 diopters (D) (3.00 D) for normal eyes (reported as mean [SD]), -17.70 D (6.20 D) for aphakic eyes, and -16.70 D (6.20 D) for pseudophakic eyes (P < .0001 for comparison of variances in RRG3 between normal and all operated eyes). Further analysis found differences in the variance in axial length growth (P < .0001) between operated and normal eyes; the variance in keratometry measurement change did not reach significance., Conclusions: The standard deviation in the RRG3 of normal eyes in our study was half of that found in eyes that underwent cataract surgery., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)