1. science
2. medicine
3. pediatrics

Table of Contents
Meeting at a Glance
Inside Front Cover
AAPOS Past Presidents2
AAPOS Board of Directors3
AAPOS Honor Award Recipients
4
AAPOS Committee Meetings Schedule
4
CME Credit Information5
Overall Meeting Goals5
Specific Learning Objectives5
FDA Disclaimer Information5
Educational Mission Statement6
Costenbader Lecturer7
Apt Lecturer9
Participant Financial Disclosures11
Program Schedule – Scientific Paper Program
17 (Blue Section)
Scientific Paper Abstracts27
Scientific Poster Program (First Set)
47 (Blue Section)
Scientific Poster Abstracts (First Set)
49
Scientific Poster Program (Second Set)
63 (Blue Section)
Scientific Poster Abstracts (Second Set)
65
Scientific Electronic Poster Program
81 (Blue Section)
Scientific Electronic Poster Abstracts
91
Workshop Program157 (Blue Section)
Workshop Abstracts 161
AAPOS Committees179
Index of Authors183
Floor Plan of Meeting Area
187
Future AAPOS meetings
Inside Back Cover
Blank “notes” pages are included at the end of each section of abstracts.
1
AAPOS Past Presidents
Marshall M. Parks, MD
1974-75
Lake Tahoe
Robert D. Reinecke, MD1975-76Bermuda
Jack C. Crawford, MD
1976-77
San Francisco
Robison D. Harley, MD1977-78Williamsburg
David S. Friendly, MD1978-79Toronto
Phillip Knapp, MD1979-80San Diego
Webb Chamberlain, MD1980-81Orlando
Arthur Jampolsky, MD1981-82Monterey
Alfred G. Smith, MD1982-83Vancouver
John A. Pratt-Johnson, MD
1983-84
Vail
Eugene R. Folk, MD
1984-85
Puerto Rico
Thomas D. France, MD1985-86Maui
Gunter K. von Noorden, MD 1986-87
Scottsdale
Arthur L. Rosenbaum, MD
1987-88
Boston
William E. Scott, MD1988-89Kiawah
Eugene M. Helveston, MD
1989-90
Lake George
Henry S. Metz, MD1990-91Montreal
John T. Flynn, MD1991-92Maui
Forrest D. Ellis, MD
1992-93
Palm Springs
David L. Guyton, MD1993-94Vancouver
Malcolm L. Mazow, MD1994-95Orlando
John D. Baker, MD1995-96Snowbird
Earl A. Palmer, MD1996-97Charleston
John W. Simon, MD
1997-98
Palm Springs
Marilyn T. Miller, MD1998-99Toronto
Maynard B. Wheeler, MD
1999-2000
San Diego
Albert W. Biglan, MD2000-01Orlando
Jane D. Kivlin, MD2001-02Seattle
Joseph H. Calhoun, MD2002-03Hawaii
George S. Ellis, Jr., MD
2003-04
Washington DC
Susan H. Day, MD2004-05Orlando
Michael X. Repka, MD2005-06Keystone
Christie L. Morse, MD2006-07Seattle
Edward G. Buckley, MD
2007-08
Washington DC
Bradley C. Black, MD
2008-09
San Francisco
C. Gail Summers, MD2009-10Orlando
David A. Plager, MD
2010-11
San Diego
Steven E. Rubin, MD
2011-12
San Antonio
K. David Epley, MD2012-13Boston
Sharon F. Freedman, MD
2013-14
Palm Springs
2
AAPOS Board of Directors
PresidentSherwin J. Isenberg, MD
Executive Vice President
Christie L. Morse, MD
Vice PresidentM. Edward Wilson, MD
Vice President-Elect
Robert E. Wiggins, Jr., MD
Secretary-TreasurerKatherine A. Lee, MD, PhD
Secretary for Program
Sean P. Donahue, MD, PhD
Director-At-LargePamela E. Williams, MD
Director-At-LargeMohamad S. Jaafar, MD
Director-At-LargeDerek T. Sprunger, MD
Past PresidentSharon F. Freedman, MD
AAPOS Councilor to the AAO
David A. Plager, MD
AAPOS Program Committee
Scientific Program Committee Chair
Sean P. Donahue, MD, PhD
Scientific Program Committee Members
Oscar A. Cruz, MD
K. David Epley, MD
Nancy A. Hamming, MD
Scott A. Larson, MD
Graham E. Quinn, MD
Tina Rutar, MD
Scientific Program Coordinator
Maria A. Schweers, CO
AAPOS thanks the following companies for providing unrestricted
educational grants for the 2015 AAPOS Annual Meeting.
Alcon
Bausch + Lomb
Gobiquity
Retrophin
3
AAPOS Lifetime Achievement Award
Graham E. Quinn, MD
AAPOS Senior Honor Awards
Arlene V. Drack, MD
Gregg T. Lueder, MD
AAPOS Honor Awards
Gil Binenbaum, MD, MSCE
Eileen E. Birch, PhD Yasmin S. Bradfield, MD
Rebecca S. Braverman, MD
Arif O. Khan, MD
Eric A. Lichtenstein, MD
AAPOS Committee Meetings
Willaim Walker Motley, MD
Mae Millicent W. Peterseim, MD
Michael C. Struck, MD
Ann U. Stout, MD
Barry N. Wasserman, MD
Pamela E. Williams, MD
Wednesday, March 25, 2015
7:00 AM - 8:30 AM
Finance Committee
Imperial 11
12:15 PM - 1:45 PM
Council of Committee Chairs
Imperial 11
2:30 PM - 4:30 PM
Professional Education Committee
Imperial 5d
3:00 PM - 4:30 PM
IPOSC
Imperial 11
3:30 PM - 5:30 PM
Socioeconomic Committee
Imperial 5a
4:00 PM - 5:00 PM
Fellowship Training Compliance Committee
Imperial 3
4:30 PM - 6:00 PM
Interorganizational Relations Committee
Imperial 10
5:00 PM - 6:00 PM
Fellowship Directors Meeting
Imperial 9
6:00 PM - 7:00 PM
Membership Committee
Imperial 4
Thursday, March 26, 2015
2:30 PM - 4:00 PM
Corporate Relations Committee
Imperial 3
2:30 PM - 4:30 PM
International Affairs Committee
Imperial 5b
2:30 PM - 4:30 PM
Legislative Committee
Imperial 5a
2:30 PM - 3:30 PM
Vision Screening Committee
Imperial 10
4:00 PM - 5:30 PM
Young Ophthalmology Committee
Imperial 5d
5:00 PM - 7:00 PM
Learning Disabilities and Vision Therapy Task Force
Imperial 3
Public Information Committee
Imperial 10
1:00 PM - 2:00 PM
Bylaws and Rules Committee
Imperial 7
1:00 PM - 2:15 PM
JAAPOS Editorial Board Meeting
Foster 1
1:00 PM - 2:00 PM
Research Committee
Imperial 3
2:30 PM - 4:30 PM
India Program Committee Meeting
Imperial 5a
5:00 PM - 6:00 PM
Online Media Committee
Imperial 4
Friday, March 27, 2015
6:00 PM - 7:30 PM
Saturday, March 28, 2015
4
This activity has been planned and implemented in accordance with the Essential Areas and policies of the
Accreditation Council for Continuing Medical Education through the joint providership of the American
Academy of Ophthalmology and American Association for Pediatric Ophthalmology and Strabismus.
The American Academy of Ophthalmology is accredited by the ACCME to provide continuing medical
education for physicians.
The American Academy of Ophthalmology designates this enduring material for a maximum of 26.25
AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of
their participation in the activity.
Overall Meeting Goals
Upon completion of this activity, participants will be able to:
• Describe recent medical advances in the diagnosis, management, and treatment of conditions encountered in the practice of pediatric ophthalmology and strabismus
• Apply improved techniques, compare/contrast methods, and review clinical research and advances in order to provide the best possible treatment options and care to patients
• Describe aspects of professionalism that will assist in practice of pediatric ophthlamology and strabismus
• Describe new techniques in select aspects of surgery pertinent to pediatric ophthalmology and strabismus
Specific Learning Objectives
1. Cite most recent data from randomized controlled clinical trials in the diagnosis and management of
amblyopia.
2. Describe new preoperative evaluation techniques and surgical strategies to improve outcomes in patients
with comitant, non-paretic strabismus.
3. Compare new surgical techniques for complicated strabismus (restrictive, paretic, miswiring syndromes,
scarring, incomitance, etc) to decrease reoperation rate.
4. Outline up-to-date patient selection criteria to identify children undergoing cataract surgery who should
receive intraocular lenses.
5. Recognize new treatment techniques for pediatric glaucoma, retinal, and oculoplastic and orbital disease
and make appropriate sub-subspecialty referrals for such cases.
6. Describe new treatment strategies to decrease the incidence of significant visual loss from high risk ROP.
7. Recognize pediatric ophthalmic disease of neurologic origin and describe the process for appropriate
referrals to pediatric neurology.
8. Utilize the latest resources for discussion of visual development, epidemiology of pediatric eye disease,
learning disabilities, vision screening strategies with other physicians and members of the lay community.
9. Identify current coding rules and regulations for pediatric eye diseases.
10. Recognize current laboratory research with potential translation applicability to pediatric ophthalmology.
FDA Status Disclaimer: The FDA has stated that it is the responsibility of the physician to determine the FDA status
of each drug or device he or she wishes to use in clinical practice, and to use these products with appropriate patient
consent and in compliance with applicable law. The AAPOS provides the opportunity for material to be presented for
educational purposes only. The material represents the approach, ideas, statement, or opinion of the presenter and/or
author, not necessarily the only or best method or procedure in every case, nor the position of AAPOS. The material is
not intended to replace a physician’s own judgement or give specific advice for case management. AAPOS specifically
disclaims any and all claims that may arise out of the use of any technique demonstrated or described in any material
by any presenter and/or author, whether such claims are asserted by a physician or any other person. Please note: The
AAPOS requires all presenters and/or authors to disclose any drug or device that is not approved for use by the FDA in
the manner discussed during any oral presentation and/or on all written materials.
5
AAPOS Educational Mission Statement
The purpose of the American Association for Pediatric Ophthalmology and Strabismus’ (AAPOS) educational activities is to
present pediatric ophthalmologists and strabismologists with the highest quality lifelong learning opportunities that promote
improvement and change in physician practices, performance, or competence through joint sponsorship with the American
Academy of Ophthalmology (AAO), thus enabling such physicians to maintain or improve the competence and professional
performance needed to provide the best possible eye care for their patients.
Due to the nature of the subspecialty, the largest component of AAPOS’ educational program focuses on strabismus, amblyopia,
visual development and binocular function. However, the content also emphasizes the other Practice Emphasis Areas (PEAs)
that have been defined by the American Board of Ophthalmology (ABO) for their Maintenance of Certification (MOC) process
with emphasis on these disease processes in children, and adults with strabismus and eye movement disorders. These include:
•
•
•
•
•
•
•
•
Cataract and Anterior Segment
Cornea and External Disease
Glaucoma
Neuro-ophthalmology and Orbit
Oculoplastics and Orbit
Refractive Management and Intervention
Retina and Vitreous
Uveitis
Additionally, AAPOS’ educational program provides content for topics such as effective management of a pediatric
ophthalmology practice, medical ethics, risk management, and other areas deemed relevant by the needs of the membership.
Types of educational activities provided at the annual AAPOS meeting include:
• Didactic lectures
• Original research in the form of free papers and posters
• In-depth focused workshops and symposia on specific topics
• Small-group discussion opportunities with speakers and researchers
All meeting content is reviewed by the AAPOS Program Committee and Secretary for Program with respect to education
qualify and utility. Members are routinely queried regarding their assessment of quality and content, as well as needs for future
meetings, and comments are reviewed by the Program Committee and Board of Directors, with necessary changes incorporated
into future programs.
The expected result of AAPOS’ educational activities is a broad array of ophthalmic knowledge that contributes to the lifelong
learning of members and advances physician performance or competence. Ongoing assessment of the impact of AAPOS’
educational program is important in determining modifications to existing activities and the development of new activities.
Specific expected results include increased knowledge across the ophthalmic community, activities designed to increase
competence and performance with evidence-based standards, current practices, and methods of diagnosis, therapies, and
disease prevention.
6
42nd Annual Frank D. Costenbader Lecturer
Decisions for Children with Glaucoma
David S. Walton, MD
Thursday, March 26, 2015 - 8:20 - 8:45 am
The Costenbader Lecture is supported by the Children’s Eye Foundation
David Walton has devoted his career to improving care and outcomes
for children with glaucoma. He grew up in Brigantine, New Jersey,
where he was shown both the skill of boat racing and humanity in being
a meaningful physician by Dr. Robison Harley. The young Dr. Walton
studied engineering at Haverford College, and then came south to
study medicine at Duke Medical Center. After residency in pediatrics
at Boston’s Children’s Hospital Medical Center, Dr. Walton served in
the US Marine Corps and Navy Medical Corps, before continuing
on to Ophthalmology (MEEI) residency and Glaucoma fellowship at
Massachusetts Eye and Ear Infirmary. Board certified in both pediatrics
and ophthalmology, Dr. Walton joined the faculty at MEEI, where he
mentored and inspired countless trainees, while pursuing clinical care
and research related to childhood glaucoma. Dr. Walton rose to the
rank of Clinical Professor of Ophthalmology at Harvard Medical School,
and has served Ophthalmology and Pediatric Ophthalmology and
Glaucoma both nationally and internationally. A few examples include
Program Chair for AAPOS, President of the Chandler Grant Society,
and Section Editor for the Journal of Pediatric Ophthalmology and
Strabismus. Awards have included Senior Achievement Award from the
American Academy of Ophthalmology and International Service award
from Rofeh International. He has authored more than 100 peer reviewed
papers and chapters, many of them greatly advancing our understanding
of glaucoma in children. He early on presented a comprehensive
framework for classification of childhood glaucomas, which he has
refined and expanded over decades of careful personal experience and
observation. He established and is President of the Children’s Glaucoma
Foundation, dedicated to supporting programs that benefit children with
glaucoma. Above all, Dr. Walton’s generosity toward patients, mentees,
and colleagues is under-recognized but truly legend, known only to those
of us who have been recipients of this bounty. Dr. Walton is a master
clinician and surgeon, an inspirational mentor, and easily the world’s
leading expert on childhood glaucoma. He is also certainly the most
humble.
7
The Frank D. Costenbader Lecture
The Frank D. Costenbader Lecture was inaugurated in 1974 at the Annual Meeting of the Costenbader Society to honor Dr. Costenbader. The
American Association for Pediatric Ophthalmology, later the American Association for Pediatric Ophthalmology and Strabismus was created at this
meeting. From its inception, AAPOS undertook to sponsor the Costenbader Lecture as the keynote presentation at its annual meeting. Due to failing
health, Dr. Costenbader was unable to attend any of the lectures which honored him.
Dr. Costenbader was born and educated in Virginia and was a true Virginia Gentleman. He received his undergraduate education at Hampton-Sydney
College, his medical degree from the University of Virginia and completed his residency at the Episcopal Eye, Ear and Throat Hospital in Washington,
DC.
Dr. Costenbader started practice in 1932 in the depression and began a lifetime commitment to teaching, which set the stage for the tremendous
influence he had on ophthalmology when he began to only see children. In 1933, Dr. Costenbader was appointed Instructor in Ophthalmology at
Georgetown University and he became Special Lecturer and Conferee there in 1964. He also was on the faculty of George Washington University
advancing to the rank of Clinical Professor. He was known for his enormous patience, generous with his time, always offering complete answers to
even the weakest questions, and he rarely lost his equanimity. He changed the Children’s Hospital Clinic from one of service only to teaching and
clinical care. He committed a full day a week to teaching for many years, spending Tuesday afternoons at Children’s and another half day a week at the
Episcopal EET Hospital. In 1946, the Episcopal residents started rotating at Children’s, and he was able to focus his teaching efforts there.
Dr. Costenbader is referred to as the Father of Pediatric Ophthalmology. That designation is because of his decision in 1943 to limit his practice to
pediatric ophthalmology, and he was the first ophthalmologist to do so. He moved his office to a stately brownstone townhouse on 22nd Street in
Washington, DC. His waiting room was referred to as Dr. Costenbader’s living room by many of his young patients because of its small furniture.
He had two exam rooms on the first floor, which he used, and there were additional exam rooms on the lower level for his orthoptist, Ms. Dorothy
Bair, and associates, fellows and preceptors. It was a center for wonderful patient care and the first real education or training center for pediatric
ophthalmology. His exam tools were limited. Dr. Costenbader had a picture of an airplane and a phone on a rotating box at the end of his room and
kids would beg to come in and see his airplane and talk to him about it. The patient’s examination chair was a kitchen chair placed on a small wooden
platform.
When asked why he limited his practice to pediatrics, the first thing Dr. Costenbader would say was that kids are just so much more fun. He also was
fascinated with the eye problems of children and at that time, ophthalmologists interested in strabismus were more interested in adults and older
children and in cosmetic alignment.
Dr. Costenbader was an advocate for children. His concern for their health and the financial welfare of families in providing for the health of their
children led him to establish and financially support the Eye Fund at Children’s Hospital to pay for indigent patient surgery. This fund is now used to
support the training program at the Children’s National Medical Center in Washington, DC.
Continuing with his concern for providing for children’s health care, he was co-founder of the Medical Service Plan (today Blue Shield) of the District
of Columbia and was the first president from 1946 to 1951. He remained on the board for many years. In addition, he started having parents be with
their child in the anesthesia induction room before surgery, he eliminated bandages on eyes following strabismus surgery, and he changed strabismus
surgery from two inpatient nights to same-day surgery. Dr. Costenbader was Chief of Ophthalmology at Children’s Hospital of Washington, DC, now
The Children’s National Medical Center from 1938 to 1965. He had a remarkable effect on children’s eye care and children’s health in general.
This lecture memorializes the man who had the foresight and the courage to begin a subspecialty in ophthalmology and the talent and dedication to
train and mold the next generation according to his ideals.
Past Costenbader Lectures
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
Los Angeles
Lake Tahoe
Bermuda
San Francisco
Williamsburg
Toronto
San Diego
Orlando
Monterey
Vancouver
Vail
Puerto Rico
Maui
Scottsdale
Boston
Kiawah
Lake George
Montreal
Maui
Palm Springs
Vancouver
Marshall M. Parks, MD
Robert N. Shaffer, MD
Lorenz E. Zimmerman, MD
T. Keith Lyle, MD
Jules Francois, MD
Robison D. Harley, MD
David G. Cogan, MD
Philip Knapp, MD
Joseph Lang, MD
Jack C. Crawford, MD
Gunter K. von Noorden, MD
Arthur J. Jampolsky, MD
Robert M. Ellsworth, MD
John E. Wright, MD
Alan B. Scott, MD
Kenneth C. Swan, MD
John T. Flynn, MD
John A. Pratt-Johnson, MD
Eugene M. Helveston, MD
Henry S. Metz, MD
William E. Scott, MD
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
8
Orlando
Snowbird
Charleston
Palm Springs
Toronto
San Diego
Orlando
Seattle
Hawaii
Washington, DC
Orlando
Keystone
Seattle
Washington, DC
San Francisco
Orlando, FL
San Diego
San Antonio
Boston
Palm Springs
Eugene R. Folk, MD
Marilyn T. Miller, MD
Robert D. Reinecke, MD
David L. Guyton, MD
Malcolm L. Mazow, MD
David R. Stager, Sr., MD
Forrest Daryel Ellis, MD
Creig S. Hoyt, MD
Burton J. Kushner, MD
Arthur L. Rosenbaum, MD
Albert W. Biglan, MD
Earl A. Palmer, MD
John D. Baker, MD
Edward G. Buckley, MD
Richard A. Saunders, MD
A. Linn Murphree, MD
Susan H. Day, MD
Michael X. Repka, MD
M. Edward Wilson, MD
John F. O’Neill, MD
2015 Leonard Apt Lecturer
How the Ground is Shifting in Child Abuse
Alex V. Levin, MD, MHSc, FAAP, FAAO, FRCSC
Saturday, March 28, 2015 - 8:35 – 8:55 am
After graduating from Muhlenberg College in Allentown, Pennsylvania
and Jefferson Medical College in Philadelphia, Dr. Levin completed
a pediatric residency at Children’s Hospital of Philadelphia and
continued on at CHOP as a staff child abuse pediatrician before doing an
ophthalmology residency at Wills Eye Hospital in Philadelphia. This was
followed by a pediatric ophthalmology fellowship at The Hospital for Sick
Children in Toronto where he continued as a staff ophthalmologist and
Professor in the Departments of Pediatrics, Genetics and Ophthalmology
and Vision Science at the University of Toronto for over 16 years where
he was also the Director of the Pediatric Ophthalmology Fellowship
program. He completed a MHSc in Bioethics at the University of Toronto.
At The Hospital for Sick Children he also served from 2002-2008 as a
child abuse pediatrician on the SCAN team. In 2008 he relocated back
to Philadelphia to become Chief of Pediatric Ophthalmology and Ocular
Genetics at Wills Eye Hospital. He is Professor in the Departments of
Pediatrics and Ophthalmology at the Sidney Kimmel Medical College of
Thomas Jefferson University.
Dr. Levin has a long-standing interest in child abuse that has continued as
a major clinical and academic focus throughout his career. His research
focus has been the pathophysiology and differential diagnosis of retinal
hemorrhages. In addition to his clinical studies in this area, he has
conducted research on woodpecker, rat and computer models. He has
published 217 peer reviewed papers and 146 book chapters. He has given
1150 invited lectures and visiting professorships internationally many of
which are on topics related to retinal hemorrhage and child abuse. Much
of his published work addresses topics related to child abuse including the
American Academy of Ophthalmology Focal Points on the ophthalmic
manifestations of child abuse, the AAO policy statement and the
American Academy of Pediatrics policy statement on eye examinations
in cases of suspected abuse. He is currently the Chair of the International
Advisory Board of the National Center on Shaken Baby syndrome and
a Charter Member of the Ray E. Helfer Society. Like Dr. Apt, he is one
of less than 10 double boarded pediatrician pediatric ophthalmologists
worldwide. In 2009 he became a board certified child abuse pediatrician
in the inaugural year that those boards were offered.
9
The Leonard Apt Lecture
The Leonard Apt Lecture was established and first presented in 2000 by the American Academy of Pediatrics (AAP) Section on
Ophthalmology to honor Leonard Apt, MD, for his dedication and contributions in the fields of pediatrics and pediatric ophthalmology.
Dr. Apt was born in Philadelphia on June 28, 1922. He entered college at the age of 14 at the University of Pennsylvania, and
trained in pediatrics after completing medical school at Jefferson Medical College in Philadelphia. Physicians everywhere will
recall the “Apt Test” for detecting gastrointestinal bleeding in newborns, invented by young pediatrician Leonard Apt in 1955.
Over the objections of leading physicians of the day who thought that pediatric ophthalmology was conceptually absurd, he then
trained in ophthalmology at Harvard, the University of Cincinnati, and the National Institutes of Health. Dr. Apt became the first
physician board-certified in both pediatrics and ophthalmology. As the first National Institutes of Health Special Fellow in Pediatric Ophthalmology mentored by Drs. Frank Costenbader and Marshall Parks, he organized the first formal training program for
the new specialty.
Dr. Apt served as the first Research Fellow in Pediatric Ophthalmology at Wills Eye Hospital. In 1961, at UCLA, Dr. Apt established the first full-time service in pediatric ophthalmology at a United States medical school, predating both the AAP Section on
Ophthalmology and AAPOS. For many years, Dr. Apt served as the principal ophthalmology consultant for the AAP. He organized local and national courses on pediatric eye topics and spoke at Annual Meetings of the AAP. Dr. Apt became a founding
member of UCLA’s Jules Stein Eye Institute.
Every ophthalmologist owes an intellectual debt to Dr. Apt. This towering intellectual figure developed the coating that first
enabled the use of synthetic absorbable sutures for ocular surgery. In 1963, Dr. Apt reported on the use of povidone-iodine as a
potent, safe antiseptic on the eye and surrounding skin area. It eventually became the preferred method of ophthalmic surgical
preparation. In recent years, Dr. Apt and his colleague, Dr. Sherwin Isenberg, used povidone-iodine in developing countries to
prevent and treat blinding eye infections in infants and children.
Dr. Apt authored more than 300 scientific and medical publications. To his numerous honors from professional societies, Harvard, Jefferson Medical College, and the University of Pennsylvania have recently been added the 2009 UCLA Emeritus Professorship Award, the 2010 AAP Lifetime Achievement Award, and the 2010 Castle Connolly National Physician of the Year Award
for Lifetime Achievement. Beyond medicine, Dr. Apt was active as a founder, board member, and a major contributor to the arts,
theater, music, humanitites, and sports. His philanthropic gifts to UCLA have created the “Leonard Apt Fellowship in Pediatric
Ophthalmology” and the “Leonard Apt Chair in Pediatric Ophthalmology.”
Dr. Apt died of natural causes in Santa Monica, California, on February 1, 2013. The Leonard Apt Lecture pays continuing
tribute to the late Dr. Leonard Apt not only for his monumental educational and scientific contributions, but also for his pioneering
leadership in creation of pediatric ophthalmology as a medical subspecialty.
Past Apt Lectures
2000
San Diego
J. Bronwyn Bateman, MD
2001
Orlando
Bennett A. Shaywitz, MD & Sally E. Shaywitz, MD
2002SeattleMark Siegler, MD
2003HawaiiLinda J. Mason, MD
2005OrlandoEdwin M. Stone, MD, PhD
2007SeattleCarol D. Berkowitz, MD, FAAP
2009
San Francisco
Sherwin J. Isenberg, MD
2011
San Diego
Carol L. Shields, MD & Jerry A. Shields, MD
2013
Boston
Joseph L. Demer, MD, PhD
10
Participant Financial Disclosures
Category
Code
Description
Consultant/
Advisor
C
Consutant fee, paid advisory boards or fees forattending a meeting (for the past 1 year)
Employee
E
Employed by a commercial entity
Lecture Fees
L
Lecture fees (honoraria), travel fees or reimbursements when speaking at the invitation of a
commercial entity (for the past 1 year)
Equity Owner
O
Equity ownership/stock options of publicly or privately traded firms (excluding mutual funds)
with manufacturers of commercial ophthalmic products or commercial ophthalmic services
Patents/
Royalty
P
Patents and/or royalties that might be viewed as creating a potential conflict of interest
Grant
Support
S
Grant support for the past 1 year (all sources) and all sources used for this project if this form is
an update for a specific talk or manuscript with no time limitation
The following individuals have no
financial interests to disclose:
Abcouwer, Steven
Abdelhafez, Moustafa
Abrahams, Katherine
Acera, Erika
Acevedo-Gonzalez, Pedro
Achim, Catherine
Adebona, Olumuyiwa
Adesina, Ore-ofe
Agarkar, Sumita
Agarwal, Swati
Alamos, Bernardita
Albert, Desiree
Alfreihi, Shatha
AlHarkan, Dora
Ali, Asim
Alniemi, Saba
Altschwager, Pablo
Anand, Shweta
Andorf, Jeaneen
Apple, Annie
Araneda, Sylvia
Archer, Steven
Areaux, Raymond
Armstrong, Greg
Ashworth, Jane
Avery, Robert
Avilés, Claudia
Aznauryan, Erik
Aznauryan, Igor
Bacal, Darron
Bahl, Reecha
Bakri, Sophie
Balasanyan, Victoria
Barker-Griffith, Ann
Barnett, Joshua
Barry, Gerard
Bartiss, Michael
Bates, Adam
Baumritter, Agnieshka
Bdolah-Abram, Tali
Beck, Allen
Ben Zion, Itay
Berry, Shauna
Bhatt, Amit
Bhattacharyya, Jina
Bhoiwala, Devang
Bhoompally, Venkateshwar
Billinghurst, Lori
Binder, Nicholas
Bishop, John
Bitner, Derek
Black, Bradley
Black, Graeme
Boente, Charline
Bolon-Canedo, Veronica
Bonsall, Dean
Borbolla-Pertierra, Ana
Borchert, Mark
Bosch-Canto, Vanessa
Bothun, Erick
Bowsher, James
Bragg, Tara
Branson, Bonnie
Bratton, Monica
Braverman, Rebecca
Breazzano, Mark
Bregman, Jana
Briceland, Daniel
Broening, James
Brooks, Steven
Brown, Lisa
Buckley, Edward
Bunce, Catey
Byington, Christopher
Calderwood, Julie
Camero, Kathryn
Cao, Jennifer
Capo, Hilda
Carden, Susan
Carlsson, Birgitta
Carrai, Mariapaola (Paola)
Cavuoto, Kara
Cerda, Ashlee
Chamblee, Denise
11
Chandrasekharan, Anjali
Chang, Melinda
Chang, Yoon-Hee
Chaudhri, Imran
Cheeseman, Edward
Cheng, Kenneth
Chernodrinska, Violeta
Chisholm, Smith Ann
Choe, Ja-yoon Uni
Choi, Catherine
Choi, Young Je
Ciardella, Antonio
Cimino, Heather
Clark, Tiana
Coakley, Rebecca
Coats, Brittany
Coats, David
Cobb, Patricia
Cohen, Ali
Coleman, Anne
Collinge, Janine
Colon, Beth
Contractor, Dilshad
Conway, Miriam
Corn, Anne
Cotten, C Michael
Crockett, Charlene
Cruz, Oscar
Cunningham, Emmett
Curtis, Theodore
Dale, Talitha
Damarjian, Tina
Dang, Sabin
Daniel, Ebenezer
Dao, Lori
Daugherty, William
Davidson, Jennifer
Davidson, Stefanie
Davis, Ryan
Day, Susan
de Alba, Manuel
De La Cruz, Angie
Dean, Trevano
Dean, William
Dearwater, Brandy
DeBenedictis, Caroline
Del Monte, Monte
Delman, Noa
DeLuca, Adam
Demer, Joseph
Demny, Ann
DeRespinis, Patrick
Desai, Roshani
Devould, Chantel
Diao, Wei
Diehl, Nancy
Dikova, Stela
Ding, Kai
Ditta, Lauren
Dodobara, Luz
Donaldson, Dana
Doshi, Poonam
Dotan, Gad
Downing, Eric
Droste, Patrick
Duncan, Jared
Eisenberg, Marina
Ekdawi, Noha
Ela-Dalman, Noa
Elbaz, Uri
Eldweik, Luai
Elliott, Alexandra
Ellis, Forrest
Ellis Jr, George
Enweronu-Laryea, Christabel
Epley, David
Erdogmus, Deniz
Erenler, Feyza
Estephane, Noura
Evans, Shaun
Fabian, Ido Didi
Faron, Nicholas
Farris, Bradley
Fasiuddin, Airaj
Fecarotta, Christopher
Fierson, Walter
Forbes, Brian
Forcina, Blake
Forster, Richard
Fredrick, Douglas
Freedman, Sharon
Freeman, Richard
Friess, Amanda
Fritz, Traci
Gaffar, Majida
Gajdosova, Eva
Galli, Jay
Galli, Marlo
Gandham, Sai
Gandhi, Nandini
Gasper, Catherine
Geloneck, Megan
Ghasia, Fatema
Gil, Arminda
Gillespie, Rachel
Gilmore, John
Glasgow, Ben
Gode, Vaibhav
Gofman, Nina
Goldchmit, Mauro
Gordillo, Luz
Gore, Charlotte
Grace, Sara
Graeber, Carolyn
Grannis, Charity
Grant, Simon
Graves, Emily
Greebel, Gennifer
Greenberg, Marc
Greenberg, Matthew
Griepentrog, Gregory
Griffith, Joseph
Gunton, Kammi
Guo, Suqin
Habib, Larissa
Haering, Celia
Hahn-Parrott, Laurie
Haider, Kathryn
Hamming, Nancy
Handler, Sheryl
Hans, Amneet
Hansberry, David
Hariharan, Luxme
Hartmann, E Eugenie
Hassan, Mohamed
Hellgren, Kerstin
Hellström, Ann
Hendler, Karen
Hendricks, Dorothy
Henson, Karl
Herrmann, Alyssa
Hilely, Assaf
Ho, Tiffany
Hoehn, Mary Ellen
Hoekel, James
Holgado, Sandra
Holmstrom, Gerd
Hoover, Darren
House, Robert
House, Ryan
Hsu, Benson
Huang, Jiayan
Hug, Denise
Hull, Jennifer
Huston, Pamela
Hutchinson, Amy
Hynes, Patrick
Iannaccone, Alessandro
Ireland, Kathryn
Isaac, Maram
Ismaiel, Noor
Issaho, Dayane
Jaafar, Mohamad
Jackson, Jorie
Jaganathan, Bithiah Grace
Jain, Piyush
Jain, Saurabh
Jakobsson, Peter
Jensen, Anne
Jewsbury, Hugh
Jin, Jing
Jiramongkolchai, Kim
John, Ann
John, Elizabeth
Johnston, Julia
Jonas, Karyn
Jones, Alistair
12
Juarez-Echenique, Juan Carlos
Jung, Jennifer
Jung, Ji Sung
Kalashnikova, Mariya
Kaliki, Swathi
Källén, Karin
Kalpathy-Cramer, Jayashree
Karp, Karen
Karr, Daniel
Katz, Scott
Kauffman, Levi (David)
Kay, Matthew
Kazlas, Melanie
Keeffe, Jill
Kekunnaya, Ramesh
Kellogg, Clint
Kemp, Pavlina
Kemper, Alex
Kerr, Natalie
Khan, Muhammad Saad
Kim, Anna
Kim, Dae Hyun
Kinori, Michael
Klein, Shelley
Klufas, Michaek
Ko, Ashley
Koller, Harold
Kong, Lingkun
Kotecha, Sailesh
Kothari, Mihir
Kovarik, Jessica
Kowal, Lionel
Kozak, Jennifer
Kraker, Raymond
Krishan Dave, Nisha
Krishnamoorthy, Mala
Kruger, Stacey
Kruglyakova, Jacqueline
Kumar, Atul
Kumar, Priyanka
Lally, MD, Sara E.
Lambert, Scott
Larson, Scott
Lavrich, Judith
Lawrence, Linda
Lazar, Elizabeth
Lee, Rachel
Lee, Thomas
Lee, Vivian
Leenheer, Rebecca
Lehman, Sharon
Leiba, Hana
Lenahan, Deborah
Lenius, Laura
Lenk, Mary Anne
Li, Simone
Lichtenstein, Eric
Lim, Shin
Lindner, Heather
Ling, Maya
Lizama, Macarena
Lo, Phey Feng
Lodhia, Vaishali
Löfqvist, Chatarina
Logan, April
Loh, Allison
Longmuir , Susannah
Losch, Tim
Lueck, Amanda
Lueder, Gregg
Lundgren, Pia
Lusk, Kelly
Lynch, Anne
Lyon, Brooke
Lyon, David
MacKinnon, Sarah
Magdalene, Damaris
Mahomed, Faheem
Mali, Yasmin Poustchi
Manchandia, Ajay
Manley, Donelson
Mannis, Tova
Mantagos, Iason
Marsh, Justin
Martin, Daniel F
Martin, Lisa
Martin, Taliva
Matalia, Jyoti
Mawrie, Darilang
Mayo Ortega, Liliana
McCannel, Colin
McCannel, Tara
McCourt, Emily
McDonald, Russell
McKeown, Craig
Mehravaran, Shiva
Melnik, Pesah
Melvin, Patrice
Merrill, Kimberly
Mezad-Koursh, Daphna
Mezer, Eedy
Miller, Ellen
Miller, Kyle
Mills, Monte
Minakaran, Neda
Minato, Gina
Mireskandari, Kamiar
Mohney, Brian
Monsalve, Pedro
Morale, Sarah
Morales, Cristóbal
Morara, Mariachiara
Morgado, Alvaro
Morrison, David
Motley, William
Moya, Dianna
Mungan, Nils
Murchison, Ebony
Musa, Pablo
Mutchnick, Ian
Nallasamy, Sudha
Nash, Bertha
Nejad, Mitra
Nelson, Leonard B.
Nguyen, Matthew
Nihalani-Gangwani, Bharti
Niles, Philip
Nti, Akosua
O’Hara, Mary
Ofori-Darko, Asiedua Akua
Ohno-Matsui, Kyoko
Okeya, Marian
Olayanju, Jessica
Olitsky, Scott
Olson, Richard
Ordaz-Favila, Juan Carlos
Orge, Faruk
Ostmo, Susan
Owen, Leah
Owings, Sandy
Oyama Ganiko, Rosa Yemi
Packer, Roger
Padovani-Claudio, Dolly
Paez, Juan Homar
Papa, Carrie
Papadopoulos, Maria
Parikh, Ruby
Park, Sunju
Parness Yossifon, Reut
Parucci, Nick
Patel, Jinali
Patel, Samir
Patel, Sejal
Patterson, Barron
Patthoff, Mayme
Paulos, Michael
Paysse, Evelyn
Peragallo, Jason
Peterseim, Mae Millicent
Petru, MD, Ann
Pham, Chengde
Pichi, Francesco
Pineles, Stacy
Pistilli, Maxwell
Pogrebniak, Alexander
Prabhu, Sanjay
Pritchard, Cindy
Puente Jr, Michael A
Qureshi, Hanya M.
Rachdan, Diyaa
Radinson Alvarado, Ivonne
Raghu, Preethi
Rahmani, Bahram
Rainey, Melinda
Rajjoub, Raneem
Ramasubramanian, Aparna
Ramsden, Simon
Ramsey, Jean
Ramskold, Louise
Read, Sarah
Reddy, Anvesh
Reese, J. Jeffrey
Reid, Julia
Repka, Michael
Roberts, Gavin
Rodrigues, Ana Paula Silverio
Rodríguez, María Teresa
Romano, Simona
Roper-Hall, Gill
Rosenberg, Jamie
Rosenthal, Elyssa
Rotberg, Leemor
Rothman, Adam
Rotruck, Jill
Rovick, Lisa
Ruben, James
Rutar, Tina
Ruttum, Mark
Ryan, Michael
Sabah, Judith
Sachdeva, Virender
13
Sadiq, Mohammad Ali A
Salgado, Cristian
Salunkhe, Nitesh
Salvin, Jonathan
Sanhueza, Felipe
Sarin, Neeru
Saunders, Richard
Saunte, Jon Peiter
Saxena, Rohit
Schenkman, Nathan
Schliesser, Joshua
Schmitt, Melanie
Schwartz, Terry
Schwarzlose, Rebecca
Schweers, Maria
Schweigert, Anna
Scott, William
Serafino, Massimiliano
Serenius, Fredrik
Sethi, Shivani
Shaffer, James
Shah, Ankoor
Shah, Dipal
Shah, Pulin
Shaikh, Aasef
Shainberg, Marla
Shanmugam, Sumathi
Sharma, Aman
Sharma, Pradeep
Sheeley, Megan
Sheth, Shivanand
Shields, Carol
Shields, Jerry
Shinwell, Eric
Shirer, Kinsey (Sarah)
Silverstein, Evan
Simmer-Beck, Melanie
Simmons, Steven
Simon, John
Singh, Jasleen
Sloper, John
Smith, Heather
Snitzer MSW, LSW, Melanie
Solanes, Federica
Song, Yong Ju
Spierer, Abraham
Spierer, Oriel
Sprunger, Derek
Stafford, Lucy
Stager Jr, David
Stager, Sr, David
Steinkuller, Paul
Stjernqvist, Karin
Stolovitch, Chaim
Strauss, Nicholas
Strominger, Mitchell
Struble, Roger
Strungaru, Marcela Hermina
Suh, Soh Youn
Sulewski, Melanie
Surti, Kavita
Sussenbach, Evan
Suttle, Catherine
Suwannaraj, Sirinya
Tadros, Dina (Sabry)
Tae, Tara
Tai, Vincent
Tailor, Vijay
Tan, Roland Joseph D.
Tarczy-Hornoch, Kristina
Tawse, Kirstin
Tehrani, Nasrin
Terveen, Daniel
Todani, Amit
Tornqvist, Kristina
Tran, Hang
Tran-Viet, Du
Trimboli-Heidler, Carmelina
Trower, Joyce
Tsui, Irena
Tsukikawa, Mai
Tufty, Geoffrey
Turlapati, Namratha
Turner, Reid
Tychsen, Lawrence
Unkrich, Kelly
Utz, Virginia
Vaughan, Joannah
Velez, Federico
Vicchrilli, Sue
Vickers, Laura
Vieson, Kelli
Villanueva, Ana
Wade, Kelly
Wagner, Brandie
Walton, David
Wan, Michael
Wang, Daniel
Wang, Serena
Wang, Yi-Zhong
Warner, Naomie
Watkins, William
Watts, Patrick
Way, Amanda
Weakley, David
Weaver, Daniel
Weber, Paul
Weed, Matthew
Weil, Natalie
Weiner, Rachel
Weng, Frank
Whitlow, Bryan
Williams, Pamela
Wilson, Machelle
Wilson, Rhonda
Winkler, Kathryn
Wong, Inez
Wong, Ryan
Wong, Susie
Wong, Wan Ling
Woodward, Lee
Wu, Chris
Wygnanski-Jaffe, Tamara
Yang, Michael
Yanovitch, Tammy
Yen, Kimberly
Young, William
Yu, Fei
Zobal-Ratner, Jitka
Zou, Di
The following individuals have
financial interests to disclose:
Adams, Gillian
S – Birmingham Eye Foundation
Alcorn, Deborah
C – Gobiquity
Antonetti, David
S – Grant Support Unspecified
Chung, Daniel
E – Spark Therapeutics
Chung, Sophia
S – Eli Lilly and Company
Clark, Robert
S – National Eye Institute
Arnoldi, Kyle
S – Research to Prevent Blindness
Clayton-Smith, Jill
C – FDNA (facial recognition app)
Scientific Advisory Board, annual
honorarium for research funding
S – National Institute of Craniofacial and
Dental Research (NICDR)
S – National Institute of Health Research
Ataer-Cansizoglu, Esra
P – Mitsubishi Electric Research
Laboratory
E – Northeastern University
Dagi, Linda
O – Vittamed (company working on
developing non-invasive intracranial
pressure monitor)
Berrocal, Audina
C – Allergan
C – Alcon
Dahlmann-Noor, Annegret
S – Moorfields Special Trustees
S – Action Medical Research
S – Newlife Foundation
Arnold, Robert
O – Glacier Medical Software, Inc
Bhola, Rahul
L - Alcon
Binenbaum, Gil
S – National Institutes of Health
S – Bayer Pharmaceutical
S – Pan American Ophthalmological
Foundation
Birch, Eileen
S – National Eye Institute
S – Thrasher Research Fund
S – Exxon Mobil Foundation
S – DSM Nutritional Products
Biswas, Susmito
L – Raptor Pharmaceuticals
Celano, Marianne
S – National Eye Institute/National
Institutes of Health U10 EY013272
Chan, Robison V. Paul
C – Alcon Surgical
Chang, Ta Peter
C – Retrophin, Inc.
C – Entopsis, Inc.
Chiang, Michael
S – National Institutes of Health
S – Research to Prevent Blindness
C – Clarity Medical Systems (unpaid
member of Scientific Advisory Board)
Christiansen, Stephen
S – National Eye Institute – Jaeb Center
for Health Research (PEDIG)
Subcontract
14
Dhannawat, Sneh
S – National Institutes of Health
EY018810
S – Research to Prevent Blindness
S – Mayo Foundation
Donahue, Sean
C, O – Gobiquity
C – Retrophin
Drack, Arlene
S – Vision for Tomorrow Foundation
S – Research to Prevent Blindness
Physician Scientist Award
S – National Institutes of Health
Drews-Botsch, Carolyn
S – National Institutes of Health/National
Eye Institute
Eagle, Ralph
O – Merck
Edmond, Jane
L – Alcon
El-Dairi, Mays
C – Prana Pharmaceuticals
Enzenauer, Robert
C – Clear Donor
Erzurum, Sergul
S – PEDIG Research Group
Essuman, Vera
S – Univeristy of Ghana Research Fund
Eustis, H Sprague
O – Ocular Therapeutics
Felius, Joost
S – Orix Foundation
Jung, Jaeho
S – National Institutes of Health
EY018810
S – Research to Prevent Blindness
S – Mayo Foundation
Granet, David
P – American Academy of Pediatrics
P – Vision Screening Patent
C – Alcon Labs
C – Diopsys
Kassem, Iris
E – Abbvie (Spouse is an emplyoee with
stock options)
S – National Institutes of Health
S – Knights Templar Eye Foundation
Greene, Alan
O – Gobiquity
O – Greene Ink, Inc.
O – Scanadu
Kehl, Sue
C – Hologic
L – Meridian Diagnostics
Guyton, David
P – REBIScan
S – Hartwell Foundation
Hatt, Sarah
S – National Institutes of Health
S – Research to Prevent Blindness
S – Mayo Foundation
Heidary, Gena
S – Knights Templar Eye Foundation
Hess, Robert
P – McGill University
Hildebrand, Peter Lloyd
C, P – Inoveon Corporation
O – Nantiox Corporation
Holmes, Jonathan
S – National Institutes of Health
S – Research to Prevent Blindness
S – Mayo Foundation
Hubbard, G. Baker
C – VisionQuest Biomedical LLC
Hunter, David
P – Boston Children’s Hospital
P – Johns Hopkins University
P – Lippincott Williams Wilkins
P – Slack, Inc.
C, O – REBIScan, Inc.
Kelly, Krista
S – National Eye Institute EY022313
Khan, Arif
C – Retrophin
Lal, Garima
C – Modernizing Medicine EMR
Lang, Richard
O – Muregen
Lenhart, Phoebe
L – Liberty Sport
Leske, David
S – National Institutes of Health
EY018810, EY024333
S – Research to Prevent Blindness
S – Mayo Foundation
Levin, Alex
C – have testified for both defense and
prosecution in both criminal and civil
cases
Lloyd, I Christopher
S – Fight for Sight (UK Charity)
Lynn, Michael
S – National Eye Insitute
Martinez-Helfman, Sarah
E – Eagles Youth Partnership
Isenberg, Sherwin
C – Foresight Biotherapeutics
McClatchey, Scott
P – United States Navy
Jordan, Catherine
E – Boston Foundation for Sight,
501(c)3
S – The Ohio Lions Eye Research
Foundation
Miller, Aaron
L – Alcon
Jost, Reed
S – Thrasher Research Fund #9491
S – National Institutes of Health
EY022313
Moke, Pamela
S – National Insitutes of Health
EY013095
Morris, Caleb
S – Research to Prevent Blindness to
the Duke Eye Center
15
Morse, Christie
E – AAPOS Executive Vice President
(Independent Contractor)
C – AAPOS
Neely, Daniel
C – Orbis International
C – Infacare Pharmaceuticals
Nucci, Paolo
C, S – Safilo
C, L – Novartis
C, L, S – Thea
S – Allergan
Pearson, Denise
S – Children’s Hospital of Philadelphia
Pfeifer, Wanda
E – iScreen Vision
Pihlblad, Matthew
S – Research to Prevent Blindness
Plager, David
C – Omeros
C – Retrophin
S – Bausch and Lomb
S – Vertex
Pond, Michael
E – Wills Eye Hospital (paid employee
for the purpose of the program)
Prakalapakorn, S. Grace
S – National Institutes of Health
K23EY024268, EY016333
S – Research to Prevent Blindness to
Duke Eye Center
Quinn, Graham
S – National Eye Institute, National
Institutes of Health
Racette, Lyne
S – BrightFocus Foundation
S – Prevent Blindness America
S – Indiana University
Raufi, Nikolas
S – National Institutes of Health
K23EY024268
S – Research to Prevent Blindness to
Duke Eye Center
Reiser, Bibiana
C – Omeros
C, - Allergan
C, S – Bausch & Lomb
C – Retrophin
Reynaud, Alexandre
P – McGill University
Reynolds, James
S – Research to Prevent Blindness
S – National Institutes of Health
Robbins, Shira
P – American Academy of Pediatrics
C – US Department of Health and
Human Services
Rogers, David
S – Ohio Lions Eye Research Foundation
Rubin, Steven
C – various law firms and governmental
jurisdictions for whom he has testified for
the defense and plaintiff/prosecution in
criminal and civil matters
SantaMaria, Kathleen
C – Wills Eye Hospital
Schnall, Bruce
L – Alcon
Senft, Susan
C – Ellex International
Siatkowski, R. Michael
S – National Eye Institute
Silbert, David
C, L – Kaneka
C, L – Quest Medical
C, O – Gobiquity
Stone, Edwin
S – Howard Hughes Medical Institute
S – Foundation Fighting Blindness
Stout, Ann
C – Retrophin
Toth, Cynthia
S – Bioptigen
S - Genentech
P – Alcon Laboratories
Traboulsi, Elias
C – Sanofi
C – Retrophin
Trivedi, Rupal
C – Retrophin
VanderVeen, Deborah
S – Ophtec
L – Retrophin
Wagner, Rudolph
L – Alcon
Wallace, David
P – ROPtool software
Sindt, Christine
C, O, P – EyePrint Prosthetics
Wang, Jingyun
S – Showalter Foundation
S – Research to Prevent Blindness
S – Knights Templar Foundation
S – Indiana CTSI
S – National Eye Institute
Smith, Lois
C – Shire
Wasserman, Barry
O – RPS, Inc
Sowell, Michael
L – Allergan
Weikert, Mitchell
C – Zeimer, Inc.
West, Constance
C – Alcon
P – Slack, Inc.
C, E – REBIScan, Inc.
P – Lippincott Williams Wilkins
P – Johns Hopkins University
P – Boston Children’s Hospital
Wiggins, Robert
C – Ophthalmic Mutual Insurance
Company
C – American Academy of
Ophthalmology
Wilson, M. Edward
P – Lippincott, Williams & Wilkins
Publishing
P – Springer Publishing
Wright, Kenneth
P – Titan Surgical
P – Oxford University Press
P – American Academy of Pediatrics
Yamada, Tomohiko
S – National Institutes of Health
EY018810
S – Research to Prevent Blindness
S – Mayo Foundation
Ying, Gui-shuang
C – Janssen Research & Development, LLC
Young, Terri
S – National Institutes of Health,
National Eye Institute
The American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus
(AAPOS) have determined that a financial relationship should not restrict expert scientific, clinical, or non-clinical presentation or publication, provided that appropriate disclosure of such relationship is made. As an ACCME accredited provider of CME, the Academy and AAPOS Joint Provider seeks to ensure balance, independence, objectivity, and scientific
rigor in all individual or jointly provided CME activities.
FINANCIAL RELATIONSHIP DISCLOSURE
For purposes of this disclosure, a known financial relationship with a commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed or used on patients and is defined as any financial
gain or expectancy of financial gain brought to the Contributor or the Contributor's immediate family (defined as spouse,
domestic partner, parent, child or spouse of child, or sibling or spouse of sibling of the Contributor) by:
• Direct or indirect compensation;
• Ownership of stock in the producing company;
• Stock options and/or warrants in the producing company, even if they have not been exercised or they are not currently exercisable;
• Financial support or funding to the investigator, including research support, device manufacturers, and or pharmaceutical companies; or
• Involvement with any for-profit corporation that is likely to become involved in activities directly impacting the
Academy where the Contributor or the Contributor's family is a director or recipient of a grant from said entity,
including consultant fees, honoraria, and funded travel.
16
Program Schedule
All scientific sessions and social events are held at the Hyatt Regency, New Orleans, LA
Wednesday, March 25, 2015
8:30 AM - 2:15 PM
Board of Directors Meeting
Imperial 11
12:00 PM - 8:00 PM
AAPOS Registration
Celestin Foyer
1:00 PM - 4:00 PM
Poster Set Up (First Set of Hard Board Posters)
Storyville Hall
4:00 PM - 6:00 PM
Poster Viewing (First Set of Posters & E-Posters) - Authors Not present
Storyville Hall
6:15 PM - 7:15 PM
International Attendees Reception
8 Block Kitchen and Bar PDR
7:00 PM - 9:00 PM
Opening Reception
8 Block Kitchen and Bar
6:30 AM - 5:00 PM
Registration
Celestin Foyer
6:30 AM - 7:45 AM
Poster Viewing (First Set of Posters & E-Posters) - Authors Not Present
Storyville Hall
6:30 AM - 7:45 AM
Breakfast
Storyville Hall
7:45 AM - 7:50 AM
Introduction and Welcome
Sean P. Donahue, MD, PhD
Celestin Ballroom
7:50 AM - 8:00 AM
President’s Remarks, Honor Awards, Senior Honor Awards, Lifetime
Achievement Awards, Champion for Vision Award
Sherwin J. Isenberg, MD
Celestin Ballroom
8:00 AM - 8:01 AM
Introduction of David W. Parke, II, MD
Sherwin J. Isenberg, MD
Celestin Ballroom
8:01 AM - 8:15 AM
AAPOS Address: Pediatric Ophthalmology and Quality Initiatives
David W. Parke, II, MD
Celestin Ballroom
8:15 AM - 8:48AM
Costenbader Lecture
Celestin Ballroom
Thursday, March 26, 2015
8:15 AM - 8:20 AM
Introduction of Costenbader Lecturer
Sharon F. Freedman, MD
8:20 AM - 8:45 AM
Paper #1
Costenbader Lecture (Supported by the Children’s Eye Foundation)
Decisions for Children with Glaucoma
David S. Walton, MD
8:45 AM - 8:48 AM
Presentation Ceremony
George R. Beauchamp, MD
8:50 AM - 10:00 AM
Moderators: Sherwin J. Isenberg, MD & Sean P. Donahue, MD, PhD
Celestin Ballroom
8:50 AM - 9:11 AM
Scientific Session
Glaucoma - Optic Nerve - Tumors
Celestin Ballroom
8:50 AM - 8:57 AM
Paper #2
The Macula in Pediatric Glaucoma: Quantifying the Inner and Outer Layers
Via Optical Coherence Tomography Segmentation
Evan Silverstein, MD
Kim Jiramongkolchai, MD; Sharon F. Freedman, MD;
Mays El-Dairi, MD
8:57 AM - 9:04 AM
Paper #3
Retinal Changes in Pediatric Glaucomatous and Non-Glaucomatous Optic
Atrophy
Kim Jiramongkolchai, MD
Sharon F. Freedman, MD; Mays A. El-Dairi, MD
9:04 AM - 9:11 AM
Paper #4
Intraocular Medulloepithelioma: New Observations on Clinical Features,
Pathology and Genetics
Jerry A. Shields, MD
Swathi Kaliki, MD; Ralph C. Eagle, MD; Carol L. Shields, MD
17
9:11 AM - 9:32 AM
9:32 AM - 10:00 AM
Celestin Ballroom
Scientific Session
Extraocular Muscles
9:11 AM - 9:18 AM
Paper #5
Extra Ocular Muscles and Stem Cells
Damaris Magdalene
Darilang Mawrie; Atul Kumar; Jina Bhattacharyya; Bithiah J. Grace
9:18 AM - 9:25 AM
Paper #6
Anterior Segment Optical Coherence Tomography of the Horizontal and
Vertical Extraocular Muscles with Measurement of the Insertion to Limbus
Distance
Matthew S. Pihlblad, MD
Feyza Erenler, MD; Aman Sharma, MD; Ajay M. Manchandia, MD; James D. Reynolds, MD
9:25 AM - 9:32 AM
Paper #7
Exaggerated V-Pattern Strabismus and Displacement of the Superior and
Lateral Rectus Muscles Near their Origins: Impact of Altered Boney
Morphology of the Posterior Orbit in Syndromic Craniosynostosis
Sarah E. MacKinnon, MSc, OC(C), COMT
Sanjay P. Prabhu, MBBS, FRCR; Linda R. Dagi, MD
Celestin Ballroom
Scientific Session
Strabismus Surgery
9:32 AM - 9:39 AM
Paper #8
Improvements in Binocular Summation after Strabismus Surgery
Stacy L. Pineles, MD, MS
Joseph Demer; Sherwin Isenberg; Eileen Birch; Federico Velez
9:39 AM - 9:47 AM
Paper #9
Minimal Invasive Radio Wave Technique for Strabismus Surgery
Erik Aznauryan
Igor Aznauryan; Victoria Balasanyan
9:47 AM - 10:00 AM
PANEL DISCUSSION
All Presenters
10:00 AM - 11:00 AM
Interactive Poster Session - Author Presentation and Q/A First Set of Posters (1-28)
See Hard Board Poster Tab Section for Complete List of Posters
Authors Present: Odd Numbered Posters from 10:00 - 10:35
Even Numbered Posters from 10:25 - 11:00
Storyville Hall
10:00 AM - 11:00 AM
Electronic Poster Viewing (No CME)
See Electronic Poster Tab Section for Complete List of Electronic Posters
Storyville Hall
11:05 AM - 1:00 PM
Moderators:
David A. Plager, MD & Robert E. Wiggins, Jr, MD
Celestin Ballroom
11:05 AM - 11:20 AM
Presentation of Parks Medals, Silver Medals and Children’s Eye Foundation Celestin Ballroom
Update
George R. Beauchamp, MD
11:20 AM - 12:16 PM
Scientific Session
Retinopathy of Prematurity
Public Health
Celestin Ballroom
11:20 AM - 11:27 AM
Paper #10
Postnatal Serum Insulin-Like Growth Factor 1 and Retinopathy of
Prematurity
Anne K. Jensen, MD
Gui-shuang Ying, PhD; Jiayan Huang, MS;
Graham E. Quinn, MD, MSCE; Gil Binenbaum, MD, MSCE
11:27 AM - 11:31 AM
DISCUSSION OF PREVIOUS PAPER
David G. Morrison, MD
18
12:16 PM - 1:00 PM
1:10 PM - 2:30 PM
11:31 AM - 11:38 AM
Paper #11
Validation of WINROP for Detecting High Grade Retinopathy of
Prematurity in Colorado Preterm Infants
Jennifer L. Jung, MD
Jennifer H. Cao, MD; Anne Lynch, MD, MSPH;
Ashlee Cerda, MPH; Brandie D. Wagner, PhD;
Rebecca S. Braverman, MD; Robert W. Enzenauer, MD, MPH; Jasleen K. Singh, MD; Emily A. McCourt, MD
11:38 AM - 11:45 AM
Paper #12
Colorado ROP Screening Model: A Multi-Institutional Validation Study
Jennifer H. Cao, MD
Anne Lynch, MD, MSPH; Ashlee M. Cerda, MPH;
Brandie Wagner, PhD; Ryan K. Wong, MD; Irena Tsui, MD;
Charlotte Gore, MD; Shira Robbins, MD;
Michael A. Puente, Jr, MS; David Kauffman, MS;
Lingkun Kong, MD; David G. Morrison, MD;
Emily A. McCourt, MD
11:45 AM - 11:51 AM
DISCUSSION OF TWO PREVIOUS PAPERS
Gil Binenbaum, MD, MSCE
11:51 AM - 11:58 AM
Paper #13
Evaluation of Real-Time Video Feed from the Digital Indirect
Ophthalmoscope (Keeler) for Telehealth Consultations
Tiffany C. Ho
Thomas C. Lee, MD; Ja-Yoon Uni Choe; Sudha Nallasamy, MD
11:58 AM - 12:05 PM
Paper #14
Preferences and Trends in Practices of Premature Infants for Retinopathy of
Prematurity (ROP): A Web-Based Survey
Amanda Way, MD
Swati Agarwal, MD
12:05 PM - 12:12 PM
Paper #15
Ocular Complications in Children with Diabetes Mellitus
Megan M. Geloneck, MD
Brian J. Forbes, MD; James Shaffer, MS; Gil Binenbaum, MD
12:12 PM - 12:16 PM
DISCUSSION OF PREVIOUS PAPER
Gregg T. Lueder, MD
Celestin Ballroom
Scientific Session
Horizontal Strabismus
12:16 PM - 12:23 PM
Paper #16
Over-Minus Spectiacle Correction in the Management of Intermittent
Exotropia
Shivani Sethi, MD
Noor Ismaeil, OCC; James Shaffer, MD;
Stephanie L. Davidson, MD; Monte Mills, MD; Melanie Sulewski; Gil Binenbaum, MD
12:23 PM - 12:30 PM
Paper #17
Comparison of Botulinum Toxin Versus Surgery in the Treatment of AcuteOnset, Comitant Esotropia in Children
Michael J. Wan, MD
Iason S. Mantagos, MD; Ankoor S. Shah, MD, PhD;
Melanie Kazlas, MD; David G. Hunter, MD, PhD
12:30 PM - 12:37 PM
Paper #18
Intraoperative Botulinum Toxin in Large Angle Strabismus
Saurabh Jain
Shweta S. Anand; Alistair Jones
12:37 PM - 12:43 PM
DISCUSSION OF TWO PREVIOUS PAPERS
Stephen P. Christiansen, MD
12:43 PM - 1:00 PM
PANEL DISCUSSION
All Presenters
AAPOS Business Meeting
(Lunch Available for a Fee with Pre-Registration)
19
Celestin Ballroom
2:45 PM - 4:00 PM
OMIC Workshop: The Risks and Benefits of Malpractice Litigation
Weber, Chamblee, Rosenthal, Broening
See Workshop Tab Section for Details
Celestin Ballroom
3:00 PM - 4:00 PM
Interactive Poster Session - Review and Commentary from the Program Committee (First Set of Hard Board Posters)
Nancy A. Hamming, MD & Scott A. Larson, MD
Storyville Hall
4:00 PM - 6:00 PM
Exhibitor Cocktail Reception
Storyville Hall
6:00 PM - 8:00 PM
Parks Medal Reception (by Invitation)
Friday, March 27, 2015
6:30 AM - 5:30 PM
Registration
Celestin Foyer
6:30 AM - 8:00 AM
Poster Viewing (First Set of Posters & E-Posters) Authors not Present
Storyville Hall
6:30 AM - 8:00 AM
Breakfast
Storyville Hall
7:00 AM - 8:15 AM
Workshop Session A - See Workshop Tab Section for Details
Telemedicine for the Detection of Serious Acute Phase ROP: Time for
a Paradigm Shift?
Quinn, Hildebrand, Karp, Daniel, Wade, Kemper, Weaver
Celestin F-H
AOC/AACO Workshop: Sensory Evaluation and Surgical Success: Is
the Worth 4-dot Test Really Worth-Less?
Rovick, Kerr, Schweigert, Areaux, Jackson, Miller, Pritchard, Ellis, Acera, Granet, Silbert
Celestin D
The Tools of Data Analysis: Matching the Hammer to the Nail
Celestin A-C
Tarczy-Hornoch, Binenbaum, El-Dairi, Felius, Jin, Kassem, Nallasamy, Pineles, Wang
Oops What Happened? Presentation and Discussion of Cases in
Pediatric Ophthalmology and Strabismus When the Unexpected
Happened. What Happened and Why? How Can I Treat It? Prevent
It? What I Learned From It?
Wygnanski-Jaffe, Levin, Freedman, Demer, Ben-Zion,
Lueder
8:30 AM - 9:45 AM
Celestin E
Workshop Session B - See Workshop Tab Section for Details
What Pediatric Ophthalmologists Need to Know about Clinical
Quality Measurement, Registries, PQRS, and Measure Development
Chiang, Repka, Morse, Wiggins, Tarczy-Hornoch
Celestin A-C
Dyslexia: What Pediatric Ophthalmologists and Families Need to
Know
Handler, Fierson, Rainey, Young
Celestin D
The Impact of Brain Tumors on Vision and Ocular Motility
Heidary, Avery, Pineles, Edmond
Celestin F-H
Secrets to Solve Pediatric Ophthalmology Case Mysteries
Ramasubramanian, Shields C, Levin, Schnall, Shields J
Celestin E
9:45 AM - 10:30 AM
Refreshment Break and Exhibit Viewing
Ambassador Ballroom
10:30 AM - 11:45 AM
Workshop Session C - See Workshop Tab Section for Details
Neuro-Ophthalmic Manifestations of Systemic Disease, Part 2
Edmond, Siatkowski
Celestin E
Kids are NOT a Line of Vision: Pediatric Low Vision
Lawrence, Rainey, Lueck, Lusk, Daugherty
Celestin A-C
Apt Lecture Workshop: Science, Pseudoscience, and the Law in AHT
Levin, Forbes, Binenbaum, Rubin
Celestin F-H
Pediatric Ocular Tumors and Pseudotumors: Quick Cases and Clinical Celestin D
Pearls
Shields J, Shields C
20
11:30 AM - 12:00 PM
Poster Removal (First Set of Hard Board Posters)
11:45 AM - 1:00 PM
Lunch Break - On Your Own
12:00 PM - 1:00 PM
Symposium: Phenotype-Genotype Correlations in Pediatric Cataract,
Including Conditions You Don’t Want to Miss
Khan, Traboulsi
See Workshop Tab Section for Details
(Lunch Available for a Fee with Pre-Registration)
Celestin E
12:00 PM - 1:00 PM
Symposium: Meaningful Use of Physician Extenders in the Pediatric
Ophthalmology Practice
Jackson, Arnoldi, Henson, Fritz, Miller, Freeman,
Hahn-Parrott
See Workshop Tab Section for Details
(Lunch Available for a Fee with Pre-Registration)
Celestin D
1:15 PM - 2:30 PM
Workshop Session D - See Workshop Tab Section for Details
RPE65 Related Inherited Retinal Degeneration Gene Therapy Trials:
Background and Current Status, Need for Genetic Testing, and Future
Gene Therapies for Other Retinal Dystrophies
Chung, Drack
Storyville Hall
Celestin A-C
Does This Child Have Glaucoma or Something Else? Applying Newer Celestin F-H
Technologies to the Diagnosis and Management of Pediatric Glaucoma
Freedman, Beck, Levin
2:45 PM - 4:00 PM
Adult Strabismus Workshop
Granet, Guyton, Buckley, Archer, Stager Sr, Ellis, Kowal,
Hunter
Celestin E
Global Challenges in the Management of Childhood Cataracts
Lenhart, Rodrigues, Wilson, Kekunnaya, Khan,
Woodward, Lambert
Celestin D
Workshop Session E - See Workshop Tab Section for Details
Just Do It...Better: Tips for Efficiency in Clinical Practice
Leenheer, Cavuoto, Collinge, Prakalapakorn, Curtis,
Chiang, Silbert, Wright
Celestin F-H
Low Vision Rehabilitation Update: New and Innovative 2015
Schwartz, Lusk, Coakley
Celestin A-C
AAP/AAPOS Workshop: Difficult Conversations in Pediatric
Ophthalmology and Strabismus
Siatkowski, Freedman, Granet, Ellis, Pritchard, Wiggins,
Morse
Celestin D
What’s New and Important in Pediatric Ophthalmology and
Strabismus in 2015
Zobal-Ratner, Krishan-Dave, Motley, Peragallo,
Braverman, Capo, Rotberg, Rutar, Schmitt
Celestin E
3:45 PM - 4:15 PM
Poster Set Up (Second Set of Hard Board Posters)
Storyville Hall
4:00 PM - 4:30 PM
Pre-Symposium Refreshments
Celestin Foyer
4:30 PM - 6:00 PM
Symposium: Taking Care of Our Patients in a Changing Healthcare
System: A Call to Include Social Media and Patient
Advocacy Activities in Our Professional Life
Ramsey, Cheng, Black, Hariharan, Kruger, Briceland,
Williams, Hynes
See Workshop Tab Section for Details
Celestin E
5:30 PM - 6:30 PM
Administrators Meet and Greet
Imperial 9
6:00 PM - 8:00 PM
Poster Viewing (Second Set & E-Posters) - Authors Not Present
Storyville Hall
6:30 PM - 7:30 PM
Young Ophthalmologists and New Members Reception
Vitascope Hall
21
Saturday, March 28, 2015
6:30 AM - 5:00 PM
Registration
Celestin Foyer
6:30 AM - 8:00 AM
Poster Viewing (Second Set & E-Posters) - Authors Not Present
Storyville Hall
6:30 AM - 8:30 AM
Breakfast
Storyville Hall
6:30 AM
Fifth Annual AAPOS Run /Walk
Celestin Foyer
7:00 AM - 8:15 AM
Symposium: Use of Digital Photoscreeners to Detect
Amblyopia Risk Factors (ARFs), A Multidisciplinary Evidence Based
Approach; Care and Cost Implications
Silbert, Donahue, Greene, Alcorn, Arnold
See Workshop Tab Section for Details
Celestin Ballroom
8:00 AM - 12:00 PM
Practice Management Workshop - Administrators Program
Imperial 9
8:00 AM - 4:40 PM
Technician Course - Examination Skills for the Pediatric Patient
Imperial 11/12
8:30 AM - 9:55 AM
Moderators: Sharon F. Freedman, MD & Derek T. Sprunger, MD,
Celestin Ballroom
8:30 AM - 8:58 AM
Apt Lecture
Celestin Ballroom
9:00 AM - 9:55 AM
8:30 AM - 8:35 AM
Introduction of the Apt Lecturer
Harold P. Koller, MD
8:35 AM - 8:55 AM
Paper #19
Apt Lecture
How the Ground Is Shifting in Child Abuse
Alex V. Levin, MD, MHSc
8:55 AM - 8:58 AM
Presentation Ceremony
Sharon Lehman, MD
Celestin Ballroom
Scientific Session
Vertical Strabismus
9:00 AM - 9:07 AM
Paper #20
Partial Muscle Recession for Small-Angle Vertical Strabismus
Catherine S. Choi, MD
Jasleen K. Singh, MD; Steven M. Archer, MD
9:07 AM - 9:14 AM
Paper #21
Brown Syndrome Outcomes: A Forty-Year Retrospective Analysis
Scott A. Larson
Matthew Weed
9:14 AM - 9:21 AM
Paper #22
Quantitative Intraoperative Forced Torsion Traction Test
Jaeho Jung, MD, PhD
Jonathan M. Holmes, BM, BCh
9:21 AM - 9:28 AM
Paper #23
Synergistic Interaction of Inferior Oblique Weakening and Vertical Rectus
Recession for Non-Restrictive Vertical Strabismus
Melanie Kazlas
Charlotte Gore; A. Sadiq Mohammad; Linda R. Dagi;
David G. Hunter
9:28 AM - 9:35 AM
Paper #24
The Incidence of Torsional Diplopia Following Inferior Rectus Muscle
Recession in Thyroid Eye Disease
Tara Tae, BS
Chantel Devould, CO; Natalie Kerr, MD
9:35 AM - 9:39 AM
DISCUSSION OF PREVIOUS PAPER
Oscar A. Cruz, MD
9:39 AM - 9:55 AM
PANEL DISCUSSION
All Presenters
22
9:55 AM - 10:55 AM
Interactive Poster Session - Author Presentation and Q/A Second Set of Posters (29-56)
See Hard Board Poster Tab Section for Complete List of Posters
Authors Present: Odd Numbered Posters from 9:55 - 10:30
Even Numbered Posters from 10:20 - 10:55
9:55 AM - 10:55 AM
Electronic Poster Viewing (No CME)
Storyville Hall
See Electronic Poster Tab Section for Complete List of Electronic Posters
11:00 AM - 1:00 PM
Moderators: Sean P. Donahue, MD, PhD & M. Edward Wilson, MD
Celestin Ballroom
11:00 AM - 11:20 AM
Updates
Celestin Ballroom
11:20 AM - 11:45 AM
11:41 AM - 12:13 PM
11:00 AM - 11:05 AM
American Academy of Pediatrics Update
Sharon S. Lehman, MD
11:05 AM - 11:10 AM
JAAPOS Update
Edward G. Buckley, MD
11:10 AM - 11:15 AM
AAPOS International Meeting - Jaipur, India
Sean P. Donahue, MD, PhD
11:15 AM - 11:20 AM
IPOSC Update
Derek T. Sprunger, MD
Storyville Hall
Celestin Ballroom
Scientific Session
Cataract
11:20 AM - 11:27 AM
Paper #25
Pediatric Cataract Surgery: Baseline Characteristics of a North American
Pediatric Eye Disease Registry
Michael X. Repka, MD, MBA
Trevano W. Dean, MPH; Elizabeth L. Lazar, MSPH;
Sharon F. Freedman, MD; Denise Hug, MD; Phoebe D. Lenhart, MD;
Bahram Rahmani, MD; Serena X. Wang, MD; Kimberly G. Yen, MD;
Raymond T. Kraker, MSPH
11:27 AM - 11:34 AM
Paper #26
Genetic Testing for Congenital Cataracts
Matthew C. Weed, MD
Scott R. Lambert, MD; Scott A. Larson, MD; Richard J. Olson, MD;
Susannah Q. Longmuir, MD; Adam P. DeLuca, PhD;
Jeaneen L. Andorf, BA; Edwin M. Stone, MD, PhD;
Arlene V. Drack, MD
11:34 AM - 11:38 AM
DISCUSSION OF PREVIOUS PAPER
I. Christopher Lloyd
11:38 AM - 11:45 AM
Paper #27
The Association Between Patching Adherence and Visual Acuity at Age 4 1/2
in the Infant Aphakia Treatment Study
Carolyn D. Drews-Botsch, PhD, MPH
Marianne Celano, PhD; Eugenie E. Hartmann, PhD;
Scott R. Lambert, MD
Celestin Ballroom
Scientific Session
Amblyopia
11:45 AM - 11:52 AM
Paper #28
A Randomized Trial of Amblyz Liquid Crystal Occlusion Glasses vs Traditional Patching for Treatment of Moderate Unilateral Amblyopia in Children
Daniel E. Neely, MD
Jingyun Wang, PhD; Jay Galli, CO; Jessica Kovarik, MD;
James Bowsher, MD; Tina Damarjian, MD; Joshua Schliesser, MD;
Heather Smith, MD; Dana L. Donaldson, OD;
Kathryn M. Haider, MD; Gavin J. Roberts, MD;
Derek T. Sprunger, MD; David A. Plager, MD
23
12:13 PM - 1:00 PM
11:52 AM - 11:59 AM
Paper #29
Evolution of Eye-Hand Coordination Deficits in Children with Amblyopia
and Abnormal Binocular Function
John J. Sloper
Catherine M. Suttle; Miriam C. Conway; Simon Grant
11:59 AM - 12:06 PM
Paper #30
Binocular Movie Treatment of Amblyopia Improves Visual Acuity in Children
Simone L. Li, PhD
Alexandre Reynaud, PhD; Robert F. Hess, PhD;
Yi-Zhong Wang, PhD; Reed M. Jost, MS; Sarah E. Morale, BS;
Angie De La Cruz, BS; Lori Dao; David Stager, Jr;
Eileen E. Birch, PhD
12:06 PM - 12:13 PM
Paper #31
Reading Rate and Scantron® Completion Time in Children with Amblyopia
Eileen E. Birch, PhD
Reed M. Jost, MS; John F. Gilmore, III; Angie De La Cruz, BS;
Krista R. Kelly, PhD
Celestin Ballroom
Scientific Session
Vision Screening
12:13 PM - 12:20 PM
Paper #32
Detection of Strabismus by the Spot Vision Screener
Mae Millicent W. Peterseim
Jennifer D. Davidson; Rupal H. Trivedi; Edward W. Cheeseman;
M. Edward Wilson; Carrie E. Papa
12:20 PM - 12:27 PM
Paper #33
Efficacy of a Mobile Smart Phone Vision-Screening Device with Automated
Image-Processing Analysis in the Evaluation of Amblyopia Risk Factors in
Preschool Children
Robert W. Arnold
David I. Silbert
12:27 PM - 12:31 PM
DISCUSSION OF PREVIOUS PAPER
Erick D. Bothun, MD
12:31 PM - 12:38 PM
Paper #34
Validation of Photo Screening Techonology in the General Pediatrics Office
Jana A. Bregman
Barron L. Patterson, MD; Sandy Owings; Sean P. Donahue, MD, PhD
12:38 PM - 1:00 PM
PANEL DISCUSSION
All Presenters
2:00 PM - 3:15 PM
Fiscal Benchmarking Workshop - Data from CY 2013,
AAPOS Socioeconomic Committee
SEC Administrators Program & AAPOS attendees)
Lenahan, Mungan, Lichtenstein, Wiggins, Bishop, Bartiss
See Workshop Tab Section
Celestin Ballroom
3:15 PM - 4:15 PM
Interactive Poster Session - Review and Commentary from the Program
Committee (Second Set of Hard Board Posters)
Tina Rutar, MD & Ann U. Stout, MD
Storyville Hall
3:30 PM - 5:30 PM
The Ups, Downs, Ins and Out of Strabismus and Pediatric
Ophthalmology Coding
Celestin Ballroom
(Separate Registration - Additional Fee for non-administrators/managers)
Sue Vicchrilli, COT, OCS
See Workshop Tab Section for Details
5:00 PM - 8:00 PM
Poster Viewing (Second Set and E-Posters) Authors Not Present
Storyville Hall
7:00 PM - 10:00 PM
Closing Reception
Celestin Ballroom
24
Sunday, March 29, 2015
6:30 AM - 12:00 PM
Registration
Celestin Foyer
6:30 AM - 8:00 AM
Poster Viewing (Second Set & E-Posters) Authors Not Present
Storyville Hall
6:30 AM - 8:00 AM
Breakfast
Storyville Hall
7:30 AM - 11:10 AM
Scientific Session
Moderator: Sean P. Donahue, MD, PhD
Celestin Ballroom
7:30 AM - 8:30 AM
Video Demonstrations of Signs, Diseases, and Complex Surgical
Procedures in Pediatric Ophthalmology and Strabismus
Velez, Paysse, Holmes, Repka, Reiser, Kekunnaya
See Workshop Tab Section for Details
Celestin Ballroom
7:50 AM - 12:00 PM
Technician Course - Ophthalmic Technician Clinical Skills Workshop
Imperial 11/12
8:00 AM - 11:00 AM
Administrators Program
Imperial 9
8:40 AM - 8:50 AM
Young Investigator Award
Celestin Ballroom
8:40 AM - 8:42 AM
Introduction of Young Investigator Award Winner
Kristina Tarczy-Hornoch, MD
8:42 AM - 8:50 AM
Paper #35
Young Investigator Award
Fixational Eye Movements - Microsaccades in Amblyopia
Fatema Ghasia, MD
9:00 AM - 10:00 AM
Difficult Non-Strabismus Problems in Pediatric Ophthalmology
Traboulsi, Drack, Ellis, Jaafar, Utz, VanderVeen
See Workshop Tab Section for Details
Celestin Ballroom
10:10 AM - 11:10 AM
Difficult Problems: Strabismus
Donahue, Buckley, Pineles, Cruz, Dagi, Greenberg
See Workshop Tab Section for Details
Celestin Ballroom
11:10 AM
End of 2015 Meeting
11:10 AM - 11:30 AM
Poster Removal (Second Set of Hard Board Posters)
Indicates CME designated activities
25
Storyville Hall
Notes
26
2015 Frank D. Costenbader Lecture
Decisions for Children with Glaucoma
David S. Walton, MD
Paper 1
Thursday
8:20 - 8:45 am
Introduction. Care for children with glaucoma requires preparation to prepare for challenging clinical decisions. Appropriate use of goniosurgery can be very helpful for children with infantile primary congenital glaucoma, a condition that must be distinguished
from other pediatric glaucomas.
Methods. The results of goniotomy for a consecutive cohort of 145 patients and 223
eyes with infantile primary congenital glaucoma recognized in the first year of life and
followed for more than 6 months following surgery were studied. Related clinical features
were also studied for presentation.
Results. Complete Success was defined by a sustained postoperative intraocular
pressure of less than 23 mmHg. without medications, the absence of significance complications, and no additional glaucoma surgery. Failure was defined by the intraocular
pressure and/or by the performance of other glaucoma surgery. Ninety four percent
(138/145) children and 96% of eyes (214/223) experienced Complete Success. No surgical complications occurred.
Discussion. The pediatric glaucomas are caused by a large number of diverse primary
and secondary etiologies. Successful management decisions in managing these challenging glaucomas depends on personal preparation, accurate determination of their
etiology, and assessment of the severity of the patient’s glaucoma.
Conclusion. Preparation and experience with the pediatric glaucomas are the foundation for appropriate clinical decisions. The reported favorable efficacy of the standard
goniotomy procedure for infantile primary congenital glaucoma supports its continued
consideration for treatment of this childhood glaucoma.
References. 1. Costenbader FD, Kwitko ML. Congenital Glaucoma; An Analysis of Seventy-Seven Consecutive Eyes. J Pediatr Ophthalmol. 1967;
4: 9-15. 2. Lister A. The Prognosis in Congenital Glaucoma. Trans Ophthalmol Soc. U.K. 1966; 89:5-18. 3. HoCl, Walton DS, Primary Congenital Glaucoma: 2004 Update. J Ped Ophthalmol 2004; 41:271-88. 4. Al-Hazmi A, Awad A, Zwaan J, Al-Mesfer A, Al-Jodoan I, Al-Mohammed A.
Correlation between surgical success rate and severity of congenital glaucoma. Bjo.bmjjournals.com, 2006. 5. Yeung H, Walton DS. Clinical Classification of Childhood Glaucoma. Arch Ophthalmol. 2010; 128:680-84. 6. Rice NSC. The Surgical Management of the Congenital Glaucomas.
Aust J Ophthalmol. 1977; 5:174-9.
The Macula in Pediatric Glaucoma: Quantifying the Inner and Outer Layers
Via Optical Coherence Tomography Segmentation.
Evan Silverstein MD Kim Jiramongkolchai MD Sharon Freedman MD Mays El-Dairi MD
Duke University, Durham, NC
Introduction: Recent Spectralis (Heidelberg, Germany) spectral domain optical coherence
tomography research software can quantify the thickness of each individual retinal layer. There
is a suggestion that the macular ganglion cell layer(GCL) and ganglion cell complex may be
more sensitive for detecting glaucoma than the peripapillary retinal nerve fiber layer (pRNFL).1,2 Purpose: characterize/compare the thickness of each macular layer among children
with glaucoma vs. normals.
Methods: Retrospective, IRB-approved study including eyes of children with glaucoma, physiologic cupping, and normals who had optic nerve/macular imaging with Spectralis, excluding
high refractive error(±5.00D), retinal or neurologic abnormalities. The average thickness of
each of the 7 retinal layers in the macula (central 6 mm), and pRNFL were compared among
diagnostic groups.
Results: Included were 80 eyes/80 children: 12 juvenile open angle glaucoma(JOAG), 25
primary congenital glaucoma(PCG), 28 physiologic cupping and 15 normals. Eyes with glaucoma had significantly thinner nerve fiber layer(NFL), ganglion cell layer(GCL), inner plexiform
layer(IPL), and pRNFL than normals and those with physiologic cupping (mean±SD(microns):
0.82±0.24vs. 1.00±0.12; 0.93±0.22vs. 1.13±0.10; 0.80±0.14vs. 0.91±0.07; 81.59±26.49vs.
102.71±10.01, respectively, p<0.0001 for all). Compared to eyes with PCG, eyes with
JOAG had thinner GCL and pRNFL (0.99±0.19vs. 0.80±0.22, p=0.0007; 87.20±25.20vs.
69.92±26.29, p=0.011; respectively). Normals and physiologic cupping were equivalent with
all variables tested. Area under receiver operating curve(ROC-AUC) showed higher discrimination ability for GCL than pRNFL(AUC=0.78 vs.0.74, p=0.04, respectively).
Discussion: Children with glaucoma have thinning of the 3 innermost retinal layers in the
macula.
Conclusion: GCL may be more sensitive than pRNFL and NFL for the detection of glaucoma.
References: 1.
Bussel II, Wollstein G, Schuman JS. OCT for glaucoma diagnosis, screening and detection of glaucoma progression.
Br J Ophthalmol. 2014;98 Suppl 2:ii15-9. 2. Srinivasan S, Addepalli UK, Rao HL, Garudadri CS, Mandal AK. Spectral domain optical coherence
tomography in children operated for primary congenital glaucoma. Br J Ophthalmol. 2014;98(2):162-5.
27
Paper 2
Thursday
8:50 - 8:57 am
Paper 3
Thursday
8:57 - 9:04 am
Retinal Changes in Pediatric Glaucomatous and Non-Glaucomatous Optic Atrophy
Kim Jiramongkolchai MD Sharon F Freedman MD Mays A El-Dairi MD
Duke University Eye Center, Durham, NC
Introduction: Although optic atrophy can be associated with macular changes such as
inner nuclear layer cysts(INLC), their incidence and significance in children remains unknown. The purpose of this study is to describe retinal changes in pediatric glaucomatous
and non-glaucomatous optic atrophy (NGOA).
Methods: This retrospective study included children age<18yo with either NGOA or
glaucoma, who had Spectralis Spectral-Domain Optical Coherence Tomography (Heidelberg, Germany). Vision, intraocular pressure (IOP), cup-to-disc ratio, Retinal Nerve Fiber
Layer (RNFL) and macular scans were studied, excluding poor quality scans.
Results: Included were 227 eyes (227 children), 76 with NGOA and 151 with glaucoma.
Isolated INLC were found in 21/68 eyes with NGOA (5/18 optic neuritis, 11/36 anterior
visual pathway tumors, 2/9 papilledema, 3/5 other) and 2/117 eyes with glaucoma (1
uveitis; 1 prior hydrocephalus). Eyes with INLC, compared to those without INLC, had
thinner average RNFL (all eyes=52.0 ±4.8 vs. 78.2±1.8µm, p<0.0001/NGOA=49.2±5.16
vs. 68.0±3.3, p=0.0083, respectively) and worse vision (all eyes logMAR=0.65±0.09 vs.
0.33±0.04, p<0.002/NGOA logMAR=0.74±0.12 vs. 0.46+0.30, p=0.003, respectively).
Outer retinal changes were present in 8/76 NGOA eyes (1/1 intracranial and retinal vasculitis, 1/2 nerve drusen, 4/13 papilledema, 2/2 infiltrative optic neuropathy) and 34/151
glaucoma eyes (26 prior intraocular surgery, 6 uveitis, 6 primary retinopathy).
Discussion: INLC are more frequent in pediatric NGOA than glaucoma; they are associated with worse vision and thinner RNFL. Outer retinal changes were exclusively seen in
uveitis, previous intraocular surgery, papilledema, and retinopathy.
Conclusion: In children, INLC and/or outer retinal changes without prior history of intraocular surgery or uveitis should prompt further evaluation
References: [1] Wolff B, Azar G, Vasseur V, Sahel JA, Vignal C, Mauget-Faysse M. Microcystic changes in the retinal internal nuclear layer associated with optic atrophy: a prospective study. Journal of ophthalmology. 2014;2014:395189. [2] Barboni P, Carelli V, Savini G, Carbonelli M, La
Morgia C, Sadun AA. Microcystic macular degeneration from optic neuropathy: not inflammatory, not trans-synaptic degeneration. Brain : a journal of
neurology. 2013;136:e239. [3] Gills JP, Jr., Wadsworth JA. Degeneration of the inner nuclear layer of the retina following lesions of the optic nerve.
Transactions of the American Ophthalmological Society. 1966;64:66-88.
Paper 4
Thursday
9:04 - 9:11 am
Intraocular medulloepithelioma :
New observations on clinical features, pathology and genetics
Jerry A Shields MD Swathi Kaliki MD Ralph C Eagle MD Carol L Shields MD
Wills Eye Hospital
840 Walnut Street, Philadelphia, PA 19107
Introduction: Intraocular medulloepithelioma is an uncommon pediatric ocular tumor in
which there is frequent misdiagnosis and misdirected treatment, often resulting in blindness or enucleation of the affected eye.
Methods: Chart review of 41 cases seen by the authors with emphasis on clinical features, treatment, and pathology.
Results: All patients had a ciliary body mass. Related features include lens notch, iris
neovascularization, glaucoma, cataract, lens subluxation, neoplastic cyclitic membrane,
intratumoral cysts and rarely extraocular extension. In 2 cases, there was systemic
association with pleuropulmonary blastoma, but most patients were not tested for this
recently described association. Treatment included enucleation, iridocyclectomy, plaque
radiotherapy, or cryotherapy. Histopathology disclosed benign features in 20%, malignant
features in 80%, teratoid features in 37 % and nonteratoid in 63%. Tumors classified as
malignant had extremely low metastatic potential.
Discussion: Medulloepithelioma is a rare intraocular tumor. If diagnosed early enough
removal by iridocyclectomy can be successful. However, enucleation is often necessary.
Although medulloepithelioma is nonhereditary, there is a recently recognized association
with pleuropulmonary blastoma, a rare pediatric tumor on DICER 1 gene in which 35% of
patients have other dysplastic or malignant conditions, including rhabdomyosarcoma.
Conclusion: Ciliary body medulloepithelioma displays unilateral features that should
prompt the clinician to investigate further for this tumor. In some cases, there is an association with pleuropulmonary blastoma. Plaque radiotherapy and iridocyclectomy provide
satisfactory tumor control for some smaller tumors, while enucleation is necessary for
larger tumors and for smaller tumors that fail to respond to conservative treatments.
28
Extra Ocular Muscles and Stem Cells
DAMARIS MAGDALENE Dr. Darilang Mawrie Ms Atul Kumar Mr. Jina Bhattacharyya Dr
Bithiah J Grace Dr
Sri Sankaradeva Nethralaya, Guwahati- ASSAM INDIA
Paper 5
Thursday
9:11 - 9:18 am
Introduction: To isolate stem and progenitor cells from extra ocular muscle tissue and
compare it with bone marrow derived stem cells.
Methods: The Extraocular muscle tissue was obtained from more than 100 patients undergoing strabismus surgery with an average age of 21 years. The tissue was mechanically dissociated and stem cells were isolated by adherence selection. Differentiation was
analyzed by addition of specific induction factors and gene expression was analyzed by
real time PCR. The statistical significance was determined using SPSS soft ware.
Results: The cells were adherent in nature and spindle shaped, could be passaged upto
several generations and had a doubling time of 34 hours. The cells were positive for cell
surface expression of CD13,CD44,CD49b,CD49e,CD73,CD90,CD105, HLA class I and
negative for CD34,CD45,CD104,CD146,CD200 and HLA class II. The EOM cells could
be differentiated into adipocytes and osteocytes. The cells also expressed embryonic
markers such as SSEA4, and transcription factors OCT4, NANOG and SOX2. The cells
had a high expression of NESTIN and differentiated readily into neuronal cells identified
by the expression of GFAP,MAP2B and TUBBIIIB.
Discussion: Our study shows for the first time that multipotent progenitor cells are present in the human extra-ocular muscle tissues and could be successfully isolated. The
presence of multipotential stem cells in the ocular muscle tissue has significant therapeutic implications as they can be differentiated into retinal progenitor cells to treat retinal
degeneration.
Conclusion: Their superior neuronal differentiation potential and multipotent nature
make these cells highly desirable for cell therapy.
References: 1.Porter, J.D., Baker, R. S., Ragusa, R.J. and Brueckner, J.K.(1955). Extra Ocular Muscles: basic and clinical aspects of structure
and function. Surv. Ophthalmol.39, 451-484. 2.Mcloon LK and Wirtschafter. (2002). Activated Satellite Cells are present in uninjured Extra Ocular
Muscles of Mature Mice. Trans Am Ophthalmol Sci.100, 110-124. 3.Zammit PS, Partridge TA and Yablonka-Ruveni Z. (2006). The Skeletal Muscle
Satellite Cells: The Stem Cell that came in from the cold. Journal of Histochemistry and Cytochemistry. 54(11), 1177-1191.
Anterior Segment Optical Coherence Tomography of the Horizontal and Vertical
Extraocular Muscles with Measurement of the Insertion to Limbus Distance
Matthew S Pihlblad MD Feyza Erenler MD Aman Sharma MD Ajay M Manchandia MD
James D Reynolds MD
Ross Eye Institute, University at Buffalo, Buffalo, NY
Introduction: To assess the possibility of determining the insertion distance from the
limbus of horizontal and vertical extraocular muscles (EOM) with the Heidelberg Spectralis anterior segment optical coherence tomography (AS-OCT).
Methods: The right eyes of 46 subjects underwent AS-OCT. The horizontal and vertical
EOM insertion distances from the limbus were measured in a masked fashion by two pediatric ophthalmologists. The interclass and intraclass correlation coefficients were used
for statistical analysis.
Results: 42 lateral, 43 medial, 35 inferior, and 40 superior rectus muscles of right eyes
of 46 subjects were included. Insertion to limbus measurements: medial rectus – mean
5.7 ± 0.8 mm, range 4.3 - 7.8 mm; lateral rectus – mean 6.8 ± 0.7 mm, range 4.8 - 8.4
mm; inferior rectus – mean 6.0 ± 0.6 mm, range 4.8 - 7.0 mm; superior rectus – mean 6.8
± 0.6 mm, range 5.5 - 8.1 mm. The intra- and inter-examiner correlation coefficients for
medial, lateral, inferior, and superior rectus muscles’ insertion distances to limbus measurements all exceeded 0.75 (excellent correlation).
Discussion: The present study is the first to show that the Heidelberg AS-OCT is capable of imaging all four of the rectus muscle insertions, as well as the first AS-OCT to
image the superior and inferior rectus insertions.
Conclusion: The vertical and horizontal EOMs can be successfully imaged with the
Heidelberg AS-OCT, along with the insertion to limbus distance. The insertion to limbus
measurements between examiners and on repeat measurements were highly consistent
and reproducible. This has implications for the pre-operative procedure planning in previously operated patients.
References: 1. Liu X, Wang F, Xiao Y, Ye X, Hou L. Measurement of the limbus-insertion distance in adult strabismus patients with anterior segment
optical coherence tomography. Invest Ophthalmol Vis Sci. Oct 2011;52(11):8370-8373. 2. Park KA, Lee JY, Oh SY. Reproducibility of horizontal extraocular muscle insertion distance in anterior segment optical coherence tomography and the effect of head position. J AAPOS. Feb 2014;18(1):1520. 3. Apt L. An anatomical reevaluation of rectus muscle insertions. Trans Am Ophthalmol Soc. 1980;78:365-375.
29
Paper 6
Thursday
9:18 - 9:25 am
Paper 7
Thursday
9:25 - 9:32 am
Exaggerated V-pattern strabismus and displacement of the superior and lateral
rectus muscles near their origins: Impact of altered boney morphology of the
posterior orbit in syndromic craniosynostosis
Sarah E MacKinnon MSc, OC(C), COMT Sanjay P Prabhu MBBS,
FRCR Linda R Dagi MD
Boston Children’s Hospital, Boston, MA
Introduction: Excyclorotation of the extra-ocular muscles may contribute to V-pattern strabismus associated with syndromic craniosynostosis. We compared the degree of excyclorotation with severity of V-pattern and studied associated posterior orbital morphology.
Methods: Retrospective chart review of patients with Apert, Crouzon and Pfeiffer syndromes
seen from 2003-2013 identified 43 patients with available imaging. Inclusion required documentation of one of three patterns: (1) Severe V-pattern with exaggerated hyper-elevation in
adduction, inability to elevate the (contralateral) abducted eye past midline, and significant
fundus torsion (2) Moderate V-pattern retaining the ability to elevate the abducted eye and
modest fundus torsion and (3) Minimal to absent strabismus and fundus torsion.
Cyclo-rotation of the rectus muscles was measured in the coronal and quasi-coronal planes.
Boney morphology of the posterior orbit was classified as rounded, partially-crescentic, and
crescentic based on relative angulation of the greater and lesser wings of the sphenoid.
Results: Severe, moderate, and minimal V-pattern strabismus were associated with 15°,
4°, and 1° of excyclorotation, respectively. Posterior orbital morphology was crescentic in
67%, 0% and 0% and partially-crescentic in 17%, 33% and 0% in the severe, moderate, and
minimal V-pattern groups, respectively. This crescentic bowing resulted in lateral shift of the
superior rectus and infero-medial shift of the lateral rectus establishing excyclorotation at
muscle origins.
Discussion: Exaggerated V-pattern strabismus is associated with greater excyclorotation
that initiates posteriorly, near the orbital apex.
Conclusion: Strabismus procedures designed to reverse excyclorotation and remediate Vpattern may have only modest impact on motility given the very posterior origin of this excyclorotation.
Paper 8
Thursday
9:32 - 9:39 am
Improvements in Binocular Summation after Strabismus Surgery
Stacy L Pineles MD, MS Joseph Demer Sherwin Isenberg Eileen Birch Federico Velez
Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles, CA
Introduction: Binocular summation (BiS), or improvement in vision using binocular vision compared to the better eye alone, is diminished in patients with strabismus. However, it is still not known how strabismus surgery affects BiS.
Methods: Ninety-seven subjects recruited within one month before undergoing strabismus surgery underwent high and low contrast visual acuity testing binocularly and
monocularly at pre-operative and two month post-operative visits. BiS was calculated
for high contrast ETDRS and Sloan low contrast acuity (LCA) charts at 2.5% and 1.25%
levels as the difference between the binocular score and that of the better eye. Pre-operative and post-operative values were compared.
Results: There was a significant improvement in BiS at the two low contrast levels for
all subjects, and for all contrast levels in the 75 patients in whom surgery successfully
restored binocular alignment. For LCA, the proportion of subjects with BiS >5 letters
post-operatively was almost twice that pre-operatively (16% to 30% and 11% to 21% for
2.5% and 1.25% contrast, respectively). Similarly, the proportion of subjects with binocular inhibition (binocular score worse by at least 5 letters than better eye score) was
decreased post-operatively at all contrast levels (from 19% to 9% for 1.25% contrast).
Twenty-eight percent of subjects experienced improvement in BiS scores post-operatively at the lowest contrast level.
Discussion: BiS scores improved post-operatively in most subjects undergoing strabismus surgery. This occurred most frequently at the lowest contrast level.
Conclusion: Improved BiS represents a newly recognized functional benefit from surgical correction of strabismus.
References: 1.
Pineles SL, Velez FG, Isenberg SJ, et al. Functional Burden of Strabismus: Decreased Binocular Summation and Binocular Inhibition. JAMA Ophthalmol. 2013;131(11):1413-1419. 2. Pineles SL, Birch EE, Talman LS, et al. One eye or two: a comparison of binocular
and monocular low-contrast acuity testing in multiple sclerosis. Am J Ophthalmol. Jul 2011;152(1):133-140. 3. Tandon A, Velez FG, Isenberg SJ,
Demer JL, Pineles SL. Binocular inhibition in strabismic patients is associated with diminished quality of life. J AAPOS. 2014;in press.
30
Minimal invasive radio wave technique for strabismus surgery
Erik Aznauryan Igor Aznauryan Victoria Balasanyan
Association of Pediatric Ophthalmology Clinics “Yasniy Vzor”
Moscow, Russia
Paper 9
Thursday
9:39 - 9:47 am
Introduction: Surgery on eye muscles is one of the main methods of strabismus treatment that has a number of disadvantages, among which is the injury caused to connective tissue and scarring in post-operative period. The aim of this investigation is to develop a technology that would minimize post-operative scarring and rehabilitation period
Methods: We have developed a surgery technique for outer tissue dissection and eye
muscles isolation using high-frequency radio wave knife. This technique allowed to decrease the injury caused to the eye tissues during the surgery. It also allowed for almost
bloodless conduction of the surgery as well as extra sterilization of the wound. We have
conducted surgeries on 1242 patients with eye movement disorders using this method.
The age distribution was from 2 to 17 years-old. The control group consisted of 120 patients operated using traditional technique. We used vicryl 7/0 sutures
Results: A significantly smaller post-operative swelling was observed in all cases in the
first group. The wound healing time reduced 3-fold, to 3-4 days. Three months later a
post-operative scar could not be observed
Discussion: Implementation of the described minimal invasive surgery technology
allows to achieve high efficiency of the surgery and considerably decrease the injury
caused to tissues. It also leads to a bloodless conduction of the surgery as well as additional intra-operative sterilization of the wound
Conclusion: Proposed method of minimal invasive strabismus surgery using radio wave
technique allows not only to achieve high efficiency of the surgery, but also to decrease
the post-operative rehabilitation time
Postnatal Serum Insulin-Like Growth Factor I and Retinopathy of Prematurity
Anne K Jensen MD Gui-shuang Ying PhD Jiayan Huang MS Graham E Quinn MD MSCE
Gil Binenbaum MD MSCE
Introduction: Low serum insulin-like growth factor 1 (IGF-1) has been associated with
development of severe retinopathy of prematurity (ROP), but no U.S. studies have been
reported. We sought to determine the relationship between postnatal serum IGF-1 levels
and severe ROP in a racially diverse U.S. cohort.
Methods: Prospective observational cohort study of 74 infants with birth weight (BW)
<1251g at 3 Philadelphia hospitals. Weekly filter-paper bloodspot IGF-1 assays beginning
at 1 week of life through 42 weeks postmenstrual age (PMA) were measured. All infants
had a known ROP outcome.
Results: The cohort included 20 Caucasian, 45 black, 2 Asian, and 9 other infants; median gestational age (GA) 27.6 weeks (range 23-33); median BW 975g (range 490-1250).
During PMA weeks 28 to 33, mean IGF-1 was 20.0 ng/dL(SE 0.52) for no ROP (n=46),
18.0(0.49) for stage 1 or 2 (n=23), and 17.0(0.70) for stage 3 (n=5, 2 lasered) (p=0.003,
linear trend). Adjustment for BW and GA, and subgroup analysis for infants with GA>=27
weeks and GA<27 weeks, showed similar results.
Discussion: The observed association between IGF and ROP provides the pathophysiological basis for growth-based predictive models, which could improve efficiency of ROP
screening. Similar studies might help clarify ROP pathogenesis in world regions where
growth-based models perform less well, oxygen supplementation plays more dominant a
role, and more mature babies are at risk.
Conclusion: Presence and timing of an association between low postnatal serum IGF
and ROP in a racially diverse U.S. sample were found to be consistent with European
cohorts.
31
Paper 10
Thursday
11:20 - 11:27 am
Paper 11
Thursday
11:31 - 11:38 am
Validation of WINROP for Detecting High Grade Retinopathy of Prematurity in
Colorado Preterm Infants
Jennifer L Jung MD Jennifer H Cao MD Anne Lynch MD, MSPH Ashlee Cerda MPH
Brandie D Wagner PhD Rebecca S Braverman MD Robert W Enzenauer MD, MPH
Jasleen K Singh MD Emily A McCourt MD
Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus
Aurora, CO
Introduction: To validate the web-based (https://winrop.com), algorithm WINROP using
serial postnatal weight measurements, in detecting high grade (Type 1 or Type 2) retinopathy of prematurity (ROP) in a Colorado cohort of neonates at high risk for ROP.
Methods: The WINROP algorithm was applied to 483 neonates who were screened for
ROP from 2008 to 2011. Neonates were classified into categories of alarm (at risk for developing high grade ROP) and no alarm (minimal risk for high grade ROP). The WINROP
algorithm was evaluated using sensitivity and specificity.
Results: The median gestational age and birth weight at delivery were 28.2 ± 2.2 weeks
(range 23.2-31.6 weeks) and 1124.36 ± 355 g (range 385-2325 g), respectively. Alarm
occurred in 241 neonates (49.9%) with the median time from birth to alarm of two weeks.
WINROP had a sensitivity of 81.8% and specificity of 53.3% for identifying neonates with
high-grade ROP. Eight of the 44 neonates with high grade ROP were missed (five with
Type 1 and three with Type 2).
Discussion: The focus of the WINROP algorithm is the importance of weight gain in
the first few weeks of life in predicting ROP. However, the WINROP algorithm missed 8
neonates with high grade ROP in our Colorado cohort. Differences in underlying characteristics of the preterm study populations may explain the discrepancies in the WINROP
algorithm.
Conclusion: Our results suggest the need for customization of the algorithm to reflect
demographic differences in premature neonates at risk for ROP.
Paper 12
Thursday
11:38 - 11:45 am
Colorado ROP Screening Model: A Multi-institutional Validation Study
Jennifer H Cao, MD. Anne Lynch, MD, MSPH. Ashlee M Cerda, MPH.
Brandie Wagner, PhD. Ryan K Wong, MD. Irena Tsui, MD. Charlotte Gore, MD.
Shira Robbins, MD. Michael A Puente Jr, MS. David Kauffman, MS. Lingkun Kong, MD.
David G Morrison, MD. Emily A McCourt, MD.
University of Colorado , Denver, Colorado
Introduction: The purpose of this study was to perform a validation of the Colorado
Retinopathy of Prematurity screening model (CO-ROP) in a multi-institutional academic
setting. The CO-ROP model signals an alarm for ROP examination in an infant with
gestational age of less than or equal to 30 weeks, and birth weight less than or equal to
1500 grams, and a net weight gain less than or equal to 650 grams between birth and 1
month of age.
Methods: Retrospective review of 1362 infants undergoing retinopathy of prematurity
(ROP) examinations at the University of Colorado, University of California Los Angeles,
University of California San Diego, Baylor College of Medicine, and Vanderbilt University.
Sensitivity and specificity of detecting ROP using CO-ROP and 95% confidence intervals
were calculated.
Results: The CO-ROP model resulted in a sensitivity of 99.1% (95%CI 97.3-100%) for
Type I ROP, 100% (95%CI 89.1-100%) for Type 2 ROP, and 96.8% (95%CI 95.1-98.6%)
for all grades of ROP. Implementing the CO-ROP model would have eliminated 290
(21.3%) infants otherwise screened for ROP using 2013 guidelines. One infant with Type
1 ROP was missed.
Discussion: Compared to current 2013 screening criteria, the CO-ROP model resulted
in improved efficiency, but did miss one infant with Type 1 ROP.
Conclusion: The CO-ROP model uses net weight gain to improve ROP screening efficiency. In this multi-institutional study, we have validated the excellent sensitivity and
improved specificity of the model when compared to current 2013 screening criteria.
32
Evaluation of Real-Time Video Feed from the Digital Indirect Ophthalmoscope
(Keeler) for Telehealth Consultations
Tiffany C Ho1,2; Thomas C Lee MD1,2; Ja-Yoon Uni Choe2; Sudha Nallasamy MD1,2
USC Eye Institute, Keck School of Medicine of USC1; The Vision Center at Children’s
Hospital Los Angeles2
Los Angeles, California
Introduction: To evaluate the validity of using real-time video indirect ophthalmoscopy
for telehealth consultations using retinopathy of prematurity (ROP) as a model disease.
Methods: An ophthalmologist simultaneously performed and recorded routine ROP
screenings on enrolled premature infants (<31 weeks and <1500 grams) using the Keeler
digital indirect ophthalmoscope. Examinations were graded as no ROP, mild, Type 1, or
Type 2. Masked to clinical findings, another ophthalmologist reviewed and graded live
video feed transmitted at 4096 kbps. We compared the sensitivity and specificity of diagnosing ROP via live video clips to the gold standard in-person examination.
Results: 145 examinations of individual eyes from 37 babies were included. Median
postmenstrual age (PMA) at delivery was 24 weeks (range 23-34), median birth weight
630 grams (range 455-1530), and median PMA at examination 37 weeks (range 3154). Of those infants with any ROP, the sensitivity and specificity was 100% and 72.9%,
respectively. For Type 2 or worse ROP, the sensitivity and specificity was 91.67% and
84.7%. For Type 1 ROP, the sensitivity and specificity was 100% and 99.3%.
Discussion: Live video feed obtained by the Keeler system may be read with high
sensitivity and specificity to detect treatment-requiring ROP. Future studies include reevaluation of stored video clips by both graders 3 months after conclusion of enrollment
to assess intra- and inter-physician sensitivity and specificity of diagnosing ROP.
Conclusion: Real-time video indirect ophthalmoscopy via the Keeler system may be
useful as an adjunct to bedside evaluation and as a training tool for ophthalmologists to
diagnose any pediatric retinal disease.
Paper 13
Thursday
11:51 - 11:58 am
References: Prakalapakorn SG, Freedman SF, Wallace DK. Evaluation of an indirect ophthalmoscopy digital photographic system as a retinopathy
of prematurity screening tool. J AAPOS. 2014;18:36-41. Richter GM, Williams SL, Starren J, et al. Telemedicine for retinopathy of prematurity
diagnosis: evaluation and challenges. Surv Ophthalmol. 2009;54:671-85. The photographic screening for retinopathy of prematurity study (photoROP). Primary outcomes. Retina. 2008;28:S47-54.
Preferences and Trends in Practices of Premature Infants for
Retinopathy of Prematurity (ROP): A Web-based Survey
Amanda Way MD1, Swati Agarwal MD2
1
University of Pittsburgh Medical Center, Pittsburgh, PA
2
University of Florida, Gainesville, FL
Introduction: The AAP revised the guidelines for treatment and conclusion of premature infants treated with
and without anti-VEGF/laser therapy for ROP. However, some practitioners follow infants longer than currently
suggested guidelines. We studied preferences and trends in patterns for infants treated with and without antiVEGF/laser therapy for type-1 ROP.
Methods: A web-based survey was administered to active members of AAPOS, WSPOS and ASRS. 267 U.S.
and international physicians participated. The survey included questions regarding competency in lasers and
intravitreal injections, preferences in treatment with anti-VEGF bevacizumab (IVB), laser or dual therapy for type
1 ROP, frequency of follow-up, postmenstrual age (PMA) of conclusion of retinal examination, and incidence of
late recurrence or retinal detachment.
Results: 45.9% physicians felt competent in performing laser photocoagulation and 26.8% in providing injections. In infants with avascular retina without prethreshold disease or worse ROP, 54.2% continued examination
>50 weeks PMA, 23.3% discontinued at 50 weeks PMA, 3.2% preferred prophylactic laser and 5.1% preferred
fluorescein angiography and laser prior to concluding exams. 46.3% physicians preferred IVB as primary monotherapy, 37.3% laser, and 16.4% preferred both IVB and laser in type 1 ROP. Of those who preferred IVB monotherapy, 20.4% concluded examination at ≤55 weeks PMA, whereas 79.6% continued evaluation >55 weeks
PMA (range = 60 to ≥80 weeks). Of those who preferred both IVB and laser, 50.6% concluded examination at
≤50 weeks PMA, whereas 49.4% continued >50 weeks (range = 55 to ≥80 weeks).15.5% reported recurrence
or late stage retinal detachment with IVB monotherapy and 8.8% with dual therapy.
Discussion: Treatment preferences and conclusion of examination in ROP infants varies considerably among
physicians without and with treatment. Although a longer follow-up is recommended with IVB, our survey
reveals examinations beyond 50 weeks PMA in infants with persistant avascular retina without prethreshold
disease and even after laser treatment leading to unwarranted retinal examinations for fear of late complications
and medical litigations.
Conclusion: The survey highlights low competency in providing lasers/injections among physicians, and extensive follow-up examinations. Uniform care in infants with ROP is needed to limit unnecessary examinations,
and improve affordable care.
References: 1. Fierson WM. American Academy of Pediatrics Section on Ophthalmology; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Screening examination of premature infants for
retinopathy of prematurity. Pediatrics. 2013 Jan;131(1):189-95. 2. Mintz-Hittner HA, Kennedy KA, Chuang AZ; BEAT-ROP Cooperative Group.
Efficacy of intravitreal bevacizumab for stage 3+ retinopathy of prematurity.N Engl J Med. 2011 Feb 17;364(7):603-15.
3. Wang CJ, Little AA, Kamholz K, Holliman JB, Wise MD, Davis J, Ringer S, Cole C, Vanderveen DK, Christiansen SP, Bauchner H. Improving preterm ophthalmologic care in
the era of accountable care organizations. Arch Ophthalmol. 2012 Nov;130(11):1433-40.
33
Paper 14
Thursday
11:58 - 12:05 pm
Paper 15
Thursday
12:05 - 12:12 pm
Ocular complications in children with diabetes mellitus
Megan M Geloneck MD Brian J Forbes MD James Shaffer MS Gil Binenbaum MD
The Children’s Hospital of Philadelphia
Wood Ambulatory Care Bldg, 1st Floor, 34th Street and Civic Center Boulevard,
Philadelphia, PA 19104
Introduction: The effectiveness of annual diabetic eye exams in children is unclear. We
sought to determine the prevalence and onset of ocular pathology in children with diabetes mellitus(DM), identify risk factors for ocular disease, and recommend a screening
regimen for asymptomatic children.
Methods: Retrospective consecutive cohort study of children age<18 years with type
1 or 2 DM examined over a 4 year period. Primary outcomes were diabetic retinopathy,
cataract, high refractive error, and strabismus. Hemoglobin A1C(HA1C), age at diagnosis
and duration of DM were evaluated as risk factors for ocular disease.
Results: 370 children (mean age 11.2±3.7 years, range 1-17.5) had 693 examinations,
with mean DM duration 5.2±3.7 years (range 0.1-16.2 years), mean HA1C 8.6±1.9 (range
5 to ≥14). No children had diabetic retinopathy (0%, 95%CI 0-1%). 12(3.3%) had cataract, 5 of which required extraction and were identified by decreased vision, not diabetic
screening. Youngest age at cataract diagnosis was 7.5 years, 4.5 years after DM diagnosis. 19 had strabismus, only one of which was microvascular paralytic strabismus.
41(11%) had high refractive error. There were no associations between these complications and duration or control of DM.
Discussion: Current guidelines recommend annual screenings for retinopathy after
age 10. Based on our findings, frequency of examinations during childhood could be
decreased, as no children had retinopathy and other complications are identified through
existing amblyopia screening.
Conclusion: Diabetic retinopathy is extremely rare in children regardless of duration and
control of DM. Based upon our study and literature review, screening examinations could
begin at age 10 and be continued every 2-3 years until adulthood.
Paper 16
Thursday
12:16 - 12:23 pm
Over-minus spectacle correction in the management of intermittent exotropia
Shivani Sethi MD Noor Ismaeil OCC James Shaffer MS Stephanie L Davidson MD
Monte Mills MD Melanie Sulewski Gil Binenbaum MD
Children’s Hospital of Philadelphia, Philadelphia, PA
Introduction: We sought to determine the effectiveness of prescribing over-minus spectacle correction in the management of intermittent exotropia.
Methods: Retrospective consecutive cohort study of children with intermittent exotropia
over a 4 year period. Subjects were prescribed glasses with more myopic correction than
their full cycloplegic refraction in an effort to manage their deviation by stimulating accommodative convergence. Primary outcomes included control of exodeviation using
PEDIG IXT scale (0-5), refractive error change during over-minus therapy, and successful
delay of surgery.
Results: 34 children met inclusion criteria, mean age 7.4 years (range 2.1-14.8), followup 1.5 years (range 0.2-4), refraction -1.6 D (range 0 to -15), over-minus 1.1D (range
0.5-1.8). Of 26 subjects with control recorded, mean distance-IXT control was 4.2 and
69% had poor control (IXT 4 or 5) at baseline. At latest follow-up, mean control was 3.4
(p=0.02), with 47% showing improvement, and 44% remaining IXT 4-5. Surgery was
recommended for 14(41%) children with average IXT 4.7 after a mean of 1.4 years (range
0.3-3.7) of overminus. 20(59%) children continued overminus glasses without surgery
through a mean follow-up of 1.4 years(range 0.2-2.6) with an average IXT 2.6. Mean
refractive error change was -0.4D/year (range -1.5 to +0.4).
Discussion: Overminus glasses improved exotropia control in half of children, with a
sustained effect over prolonged follow-up. Surgery was successfully delayed for many
children. Myopia progression rate was similar or less than reported for myopic children in
studies unrelated to over-minus correction.
Conclusion: Over-minus correction can be used to improve control of intermittent exotropia with minimal risk of myopia progression.
34
Comparison of botulinum toxin versus surgery in the treatment of acute-onset,
comitant esotropia in children
Michael J Wan MD Iason S Mantagos MD Ankoor S Shah MD, PhD Melanie Kazlas MD
David G Hunter MD, PhD
Boston Children’s Hospital
Boston, MA
Paper 17
Thursday
12:23 - 12:30 pm
Introduction: The purpose of this study was to compare botulinum toxin to strabismus
surgery in the treatment of children with acute-onset, comitant esotropia.
Methods: Retrospective, comparative, cohort study of children < 10 years of age with
acute-onset, comitant esotropia treated at a tertiary-care hospital over a 12-year period.
Patients with abnormal neuroimaging or evidence of cranial nerve palsy were excluded.
Results: Forty-six patients were included; 13 received botulinum toxin and 33 received
strabismus surgery. There were no significant differences between the groups at baseline. The success rate for botulinum toxin versus surgery was similar at 4 months (77%
versus 61%, p = 0.49) and final follow-up (77% versus 55%, p = 0.20). The median
residual angle of esotropia was similar at 4 months (4 versus 9 prism diopters, p = 0.40)
and final follow-up (4 vs 8 prism diopters, p = 0.28). The duration of general anesthesia
(5 versus 71 min, p < 0.001) and time in the recovery room (37 versus 93 min, p < 0.001)
were significantly less in the botulinum toxin group. There were no serious or permanent
complications in any patients.
Discussion: Botulinum toxin has comparable effectiveness to surgery in the treatment
of acute-onset, comitant esotropia, while reducing the duration of general anesthesia
and time in the recovery room. Botulinum toxin can also be administered within days of
esotropia onset, thereby reducing the time of disrupted binocularity.
Conclusion: Botulinum toxin should be considered as the procedure of choice for children with acute-onset, comitant esotropia.
Intraoperative Botulinum Toxin in Large Angle Strabismus
Saurabh Jain Mr Shweta S Anand Ms Alistair Jones Mr
Royalfree London Hospitals NHS Foundation Trust, London, UK
Introduction: The management of large angle strabismus (> 50PD) involves surgery on
three or more extraocular muscles. An alternative approach is to use intraoperative botulinum
toxin (BTX) as an adjunct to the surgical recess-resect procedure. Our study aim was to determine the effectiveness of BTX in combination with surgical treatment compared to surgical
treatment alone for the correction of large-angle horizontal deviations.
Methods: We undertook a prospective, randomized case control study over a period of 18
months (August 2012 to February 2014), enrolling all patients with large angle strabismus.
Paediatric patients and patients with residual or consecutive squints were excluded. Postoperative outcome was assessed at 2 weeks and 3 months and patients were monitored for
immediate and late side effects of BTX.
Results: Sixteen patients were included in the study. Eight patients underwent recessresect procedure with or without muscle transposition with 2.5 units of BTX injection into the
recessed muscle and 8 patients underwent surgery without BTX injection. In the BTX group,
the Mean angle of deviation decreased from the preoperative value of 53.75 PD to 16.87 PD
at 6 weeks and 9.62 PD at 3 months. The Non BTX surgical group showed a decrease in the
Mean angle of deviation from 50.62 PD to 9.87 PD at 6 weeks and 8.87 PD at 3 months. No
side effects were noted in the BTX group. The overall surgical success was satisfactory with
all patients having deviations less than or equal to 8PD at 3 months.
Discussion: Contrary to expectation, our observation was that intraoperative BTX did not
result in an improved surgical outcome. Although some studies have postulated that BTX
causes permanent structural changes in the myosin heavy chain composition of the muscle
and may influence the peripheral and central nervous system via retrograde axonal transport,
we found the effect of BTX to be transient.
Conclusion: Administration of intraoperative BTX did not improve surgical outcomes in our
cohort of patients with large angle strabismus.
References: 1. Khan AO. Two horizontal rectus eye muscle surgery combined with botulinum toxin for the treatment of very large angle esotropia. A
pilot study. Binocul Vis Strabismus Q. 2005;20(1):15–20.
2.Surgery with intraoperative botulinum toxin-A injection for the treatment of large-angle
horizontal strabismus: a pilot study Nilza Minguini, Keila M. M. de Carvalho, Fábio L. S. Bosso, Fábio Endo Hirata, and Newton Kara-José,Clinics
(Sao Paulo). Mar 2012; 67(3): 279–282.
35
Paper 18
Thursday
12:30 - 12:37 pm
Paper 19
Saturday
8:35 - 8:55 am
Apt Lecture 2015
How the ground is shifting in child abuse
Alex V. Levin, MD, MHSc, FRCSC
Purpose/Relevance: As the first double board certified pediatrician pediatric ophthalmologist, Dr.
Leonard Apt was a champion of the collaboration between pediatricians and pediatric ophthalmologists. Child abuse, in particular abusive head trauma, is an area that is exemplary in its need for
such collaboration.
Target Audience: Pediatric Ophthalmologists
Current Practice: A robust scientific evidence base supports our understanding of the ophthalmic
findings in abusive head trauma. Studies on victims, accidental head injury, diseases with overlapping findings, deceased children, animals, perpetrator confessions, dummy models and finite
element analysis all inform us in a remarkably consistent manner. Yet the media and courtroom
present forums for alternate theories, in particular with regards to retinal hemorrhages, which have
led to the publication of manufactured controversies and poor science, including the advancement
of theory that Shaken Baby syndrome does not exist, which ultimately have led to recent disturbing
legal decisions, trends which attack well-meaning science-based experienced physicians, and even
fear of involvement from some pediatric ophthalmologists.
Best Practice: Cross talk between the pediatrician and pediatric ophthalmologist is now more essential than ever. Sharing science, research collaboration and mutual clinical support is necessary
to protect children and families through accurate diagnosis and proper prevention efforts. Well informed and prompt pediatric ophthalmology clinical consultation and courtroom testimony is critical.
We must stand by our pediatrician colleagues and work together to speak up in the media as well,
to combat this misdirected irresponsible attack on our knowledge, experience and training.
Expected Outcomes: The attendee will appreciate and pursue increased collaboration with pediatricians in the care of children victims of abusive heal trauma and other forms of child abuse.
Format: Didactic presentation using Powerpoint
Summary: As the media portrays a manufactured controversy and misunderstanding of the
ophthalmic findings of abusive head trauma, and as under educated judges and juries hand down
disturbing decisions regarding these cases, pediatric ophthalmologists and pediatricians must work
together to ensure accurate diagnosis, correct public messaging and responsible courtroom education.
References: Levin AV: Retinal hemorrhage in abusive head injury: state of the art review. Pediatrics 2010;126(5):961-970.
Paper 20
Saturday
9:00 - 9:07 am
Partial Muscle Recession for Small-Angle Vertical Strabismus
Catherine S Choi MD Jasleen K Singh MD Steven M Archer MD
Kellogg Eye Center
Ann Arbor, MI
Introduction: There are few reliable treatment options for small vertical deviations in
patients who prefer to be spectacle-free. A partial tendon recession procedure is one
surgical option, and this study evaluated its effectiveness in correcting small vertical
deviations.
Methods: This is a retrospective chart review of 52 procedures in 43 patients. Change
in vertical deviation in primary position was evaluated, as was prism diopter change per
millimeter of partial tendon recession. Separate analyses were performed to compare
outcomes in patients with Graves eye disease and those who underwent re-operations
on the same muscle.
Results: The average preoperative vertical deviation was 4.6 prism diopters (PD) of
deviation (SD 2.0 PD) and the average postoperative vertical deviation was 0.04 PD (SD
2.4 PD), p < 0.0001. There was an average of 1.5 prism diopters of change per millimeter of partial tendon recession. 64% of post-operative patients were orthophoric in the
overall sample. 60% of Graves patients were orthophoric post-operatively versus 65% of
non-Grave’s patients. 29% of the re-operated patients were orthophoric post-operatively
versus 69% of non-re-operated patients.
Discussion: Preoperative vertical deviation had a more significant correlation with postoperative alignment than did the actual amount of surgical recession. Our results also
suggest outcomes in re-operated muscles are less predictable. There was no significant
difference in post-operative outcome between patients with Graves disease and those
without.
Conclusion: In this sample of patients, a partial tendon recession effectively corrected
small vertical deviations and is a treatment option to consider in patients who prefer spectacle independence.
36
Brown Syndrome Outcomes: A Forty-Year Retrospective Analysis
Scott A Larson Matthew Weed
University of Iowa
Iowa City, Iowa
Paper 21
Saturday
9:07 - 9:14 am
Introduction: It has been proposed that Brown syndrome spontaneously and frequently
improves or resolves (1,2). We evaluated patient data from the University of Iowa collected over a forty-year period to determine rates of improvement and which factors may
be associated with improvement or resolution.
Methods: Review of 305 patient charts suspected of having Brown Syndrome seen from
1973 to 2012.
Results: 75 patients were included. Mean age at presentation was 11.4 years (3
months to 77 years) with mean follow-up of 3.62 years (0-20.8 years). 14 (19%) had
surgical treatment and all showed improvement at the final visit. 42 patients did not have
surgery and had at least one follow up visit. Of this group, 5 (12%) improved, 3 (7%)
resolved, 2 (5%) worsened and 32 (76%) remained unchanged. The mean initial supraduction deficit was -3.1 and mean final deficit was -3.4 (p=0.24). Surgery on the superior
oblique tendon was the most important factor associated with improvement.
Discussion: The most consistent measurement that could be used for comparison was
grading of supraduction in the affected eye. Many had no misalignment in primary position and up-gaze measurements were not consistently recorded in young patients. Interobserver variably was taken into account in our analysis (3). Brown syndrome improved
or resolved in a minority of patients when comparing supraduction deficits.
Conclusion: Although Brown syndrome does improve spontaneously, this appears to be
less common. Stability is more common than improvement among patients with Brown
syndrome that have follow-up in the strabismus clinic at the University of Iowa.
References: 1. Wilson ME, Eustis HS, Parks MM. Brown’s Syndrome. Surv Ophthalmol 1989; 34:153-172 2. Dawson E, Barry J, Lee J. Spontaneous resolution in patients with congenital Brown Syndrome. J AAPOS 2009; 13:116-118 3. Kupersmith MJ, Fazzone HE. Comparing Ocular
Muscle Limitation Tests for Clinical Trial Use. Arch Ophthalmol 2004; 122:347-348
Quantitative intraoperative forced torsion traction test
Jaeho Jung MD, PhD Jonathan M Holmes BM, BCh
Mayo Clinic
Rochester, Minnesota
Introduction: We developed a method for quantify intraoperative torsional forced ductions; the forced torsion traction test. We now describe performance of the forced torsion
traction test in patients with oblique dysfunction and in controls.
Methods: We studied 25 patients with oblique dysfunction (9 with presumed congenital
superior oblique palsy (SOP) (9 eyes), 10 with presumed acquired SOP (13 eyes), and 6
with Brown syndrome (7 eyes)) and 31 controls (entirely normal forced duction tests and
only horizontal muscle surgery (one randomly selected eye from each control, n=31)).
After induction of deep general anesthesia, the 12 and 6 o’clock positions at the limbus
were marked and a Mendez-ring was aligned with these reference marks. The limbus was
grasped with forceps, the eye was maximally excyclorotated and the angle (in degrees)
was read. This procedure was repeated for incyclorotation.
Results: Eyes with presumed congenital SOP had greater maximal excyclorotation than
controls (median 40 vs 30, p=0.003). Maximal excyclorotation in presumed acquired SOP
was similar to controls (median 30 vs 30, p=0.13). Eyes with Brown syndrome had lower
maximal excyclorotation than controls (median 10 vs 30, p<0.0001). Maximal incyclorotation of presumed congenital SOP, acquired SOP, and Brown syndrome were similar to
controls (median 30,30,30 vs 30).
Discussion: The forced torsion traction test quantitatively measures oblique muscle
tightness and laxity, and differentiates between congenital SOP, Brown syndrome and
controls.
Conclusion: The forced torsion traction test enables quantitative assessment of superior
oblique and inferior oblique tightness and laxity.
37
Paper 22
Saturday
9:14 - 9:21 am
Paper 23
Saturday
9:21 - 9:28 am
Synergistic Interaction of Inferior Oblique Weakening and Vertical Rectus
Recession for Non-Restrictive Vertical Strabismus
Melanie Kazlas Charlotte Gore A Sadiq Mohammad Linda R Dagi David G Hunter
Children’s Hospital Boston , Harvard Medical School, Boston, Massachusetts
Introduction: Few studies have examined outcomes of combined vertical rectus and
inferior oblique surgery. In this study we reviewed our experience to determine whether
the surgical nomogram should be modified for combined cases.
Methods: Retrospective chart review of patients who underwent inferior oblique weakening alone or in combination with an adjustable vertical rectus recession during a 7.5
year period. Patients with prior vertical surgery, restrictive strabismus, dissociated vertical
deviation, large horizontal deviation or follow-up <4 weeks were excluded. Main outcome
measure was the effect of inferior oblique weakening on calculated versus actual vertical
rectus recession dose response.
Results: 163 patients met inclusion criteria. 129 had inferior oblique weakening alone
and 34 had inferior oblique weakening plus an adjustable vertical rectus recession. The
average effect of inferior oblique weakening was 11.7 PD. After taking this into account,
the mean residual effect of vertical rectus muscle recession in combined surgery was
4.1 PD/mm (4.2 PD/mm for inferior rectus recession and 3.9 PD/mm for superior rectus
recession).
Discussion: The mean effect of vertical rectus recession in combination with inferior
oblique weakening is larger than the often cited 3 PD/mm effect for vertical rectus recession alone. In procedures combining inferior oblique weakening with vertical rectus
muscle recession, the impact on vertical alignment is larger than if the procedures were
performed separately.
Conclusion: Our study suggests a synergistic effect of combining inferior oblique weakening with vertical rectus recession. Appreciating the power of a dual procedure may
prove important when remediating symptomatic vertical deviations with modest vertical
fusional amplitudes.
References: Morad Y, Weinstock VM, Kraft SP. Outcome of inferior oblique recession with or without vertical rectus recession for unilateral superior
oblique paresis. Binocul Vis Strabismus Q 2001:16(1);23-28.
Paper 24
Saturday
9:28 - 9:35 am
The incidence of torsional diplopia following inferior rectus muscle recession in
thyroid eye disease
Tara Tae BS Chantel Devould CO Natalie Kerr MD
University of Tennessee Health Science Center, Memphis, TN
Introduction: The purpose of this study was to investigate the incidence of incyclotorsion following inferior rectus recession (IRc) without nasalward transposition in patients
with thyroid eye disease (TED). Prior studies have implicated superior oblique (SO)
muscle restriction as the cause of postoperative incylcotorsion following IRc, but nasalward transposition of the IR (to prevent A pattern exotropia) in these reported cases may
be the cause of incyclotropic torsional diplopia following inferior rectus muscle recession,
rather than SO restriction.
Methods: A retrospective chart review of patients with TED who had undergone unilateral or bilateral IRc without horizontal transposition was performed. Charts were reviewed
for clinically significant torsional diplopia as well as A pattern exotropia following surgery.
Results: Forty-eight patients met inclusion criteria. Incidence of torsional diplopia was
6.3% (3/48) at 2 months postoperatively and 4.2% (2/48) at last exam. Only one patient
developed incyclotorsion with A pattern exotropia postoperatively (2.1%).
Discussion: The very low incidence of incyclotorsion following IRc without horizontal
transposition in TED implicates nasalward transposition of the IRc rather than superior
oblique restriction as the most likely etiology of clinically significant postoperative incyclotropia. Also, the low incidence of A pattern exotropia indicates that nasalward transposition is not necessary to prevent this problem.
Conclusion: IRc without nasalward transposition has a low risk of postoperative incyclotorison and A pattern exotropia,
References: 1. Holmes JM, Hatt SR, Bradley EA. Identifying masked superior oblique involvement in thyroid eye disease to avoid postoperative
A-pattern exotropia and intorsion. JAAPOS 2012; 16: 280-5. 2. Kushner BJ. Torsion and pattern strabismus: potential conflicts in treatment. JAMA
Ophthalmology 2013; 131: 190-3.
38
Pediatric Cataract Surgery: Baseline Characteristics of a North American Pediatric
Eye Disease Registry
Michael X. Repka, MD, MBA; Trevano W. Dean, MPH; Elizabeth L. Lazar, MSPH;
Sharon F. Freedman, MD; Denise Hug, MD; Phoebe D. Lenhart, MD;
Bahram Rahmani, MD; Serena X. Wang, MD; Kimberly G. Yen, MD;
Raymond T. Kraker, MSPH
For the Pediatric Eye Disease Investigator Group
Tampa, Florida
Introduction: To describe children undergoing lensectomy in the United States and
Canada.
Methods: A prospective registry of children <13 years of age who underwent lensectomy
in the preceding 45 days
Results: 552 children were enrolled; 283(51%) were female. Race/ethnicity was
334(61%) white, 77(14%) African American, 79(14%) Hispanic, 15(3%) Asian, 33(6%)
mixed/other, and 14(3%) not reported. Age at surgery was <1 year in 176(32%); 1 to <4 in
112 (20%); 4 to <7 in 128 (23%); and 7 to <13 in 136 (25%). Surgery was bilateral in 172
(31%). Medical conditions were reported for 157 (28%), developmental delay in 38 (7%),
and Down syndrome in 7 (1%). Healthcare insurance was reported for 540 (98%); 43%
had Medicaid/State CHIP. Of the 689 enrolled eyes, abnormalities other than cataract
were reported in 169 (25%). An IOL was used for 254 of 380 (67%) unilateral and 97 of
172 (56%) bilateral cases. IOLs were placed in 8% of cases performed prior to 1 year of
age, more often with unilateral surgery than bilateral surgery (11% and 5%, respectively).
Mean refractive error was +1.34D among 426 eyes with an IOL and +19.03D among 263
aphakic eyes. The mean target refractive error was +1.41D (range -6.00 to +8.00D). The
mean absolute value of the IOL prediction error was +1.10D and <1D in 56%.
Discussion: About 1 in 4 children undergoing lensectomy had systemic or ocular conditions. Slightly more than half of eyes had an IOL placed..
Conclusion: Use of an IOL was common after 1 year of age for both unilateral and bilateral lensectomy. Moderate prediction error was found.
Genetic Testing for Congenital Cataracts
Matthew C Weed MD Scott R Lambert MD Scott A Larson MD Richard J Olson MD
Susannah Q Longmuir MD Adam P DeLuca PhD Jeaneen L Andorf BA
Edwin M Stone MD, PhD Arlene V Drack MD
University of Iowa, Iowa City, Iowa
Introduction: Congenital cataracts are a major cause of treatable blindness in children worldwide.
The large number of causative genes and the autosomal dominant, recessive, and X-linked recessive inheritance patterns make genetic testing complex. We present a strategy for genetic testing
of congenital cataracts.
Methods: IRB approval was obtained. Congenital cataract patients presenting to two pediatric
ophthalmology services were offered research-based genetic testing. Literature review of causative mutations published at least twice was used to develop a Sanger sequencing pre-screen of
24 exons in 11 genes (BFSP2, CRYAA, CRYBA1, CRYBB2, CRYGD, EPHA2, FAM126A, FYCO1,
NHS, PAX6 and VSX2). Negative pre-screens received exome sequencing on a lens-related
genes panel. Variants were verified by Sanger sequencing. Allele frequency, calculated effect of
mutations, and familial segregation were used to impute pathogenicity.
Results: Twenty-six probands submitted samples for research-based genetic testing. Pre-screening identified causative variants in 4 families and possible causative variants in 2. 20 probands had
exome sequencing performed. 17/20 had protein-altering mutations in one or more lens-related
genes. Each proband averaged 1.0 rare variants (range 0-3). Family segregation analysis of variants is underway and must be completed prior to concluding pathogenicity. Disease-causing genes
identified on pre-screen included CRYBA1 (1), CRYGD (2) and NHS (1). Possible disease-causing
variants are in CRYAA and FYCO1.
Discussion: Exome sequencing can be used to simultaneously screen multiple genes for diseasecausing mutations and is useful for a polygenic disease like congenital cataract. Non-disease
causing variants are common in humans, however; results must be carefully scrutinized to confirm
pathogenicity. A pre-screen test for known, common mutations decreases cost and increases testing efficiency.
Conclusion: Congenital cataract genetic testing combining a pre-screen with an exome platform
allows clinicians to provide genetic counseling, prognosis, and early differentiation of syndromic
from non-syndromic cataract.
References: 1. Gillespie RL, O’Sullivan J, Ashworth J, et al. Personalized diagnosis and management of congenital cataract by next-generation
sequencing. Ophthalmology. 2014. doi: 10.1016/j.ophtha.2014.06.006. 2. Shiels A, Hejtmancik JF. Genetics of human cataract. Clin Genet.
2013;84(2):120-127. 3. Francis PJ, Moore AT. Genetics of childhood cataract. Curr Opin Ophthalmol. 2004;15(1):10-15.
39
Paper 25
Saturday
11:20 - 11:27 am
Paper 26
Saturday
11:27 - 11:34 am
Paper 27
Saturday
11:38 - 11:45 am
The association between patching adherence and visual acuity at age 4½ in the
Infant Aphakia Treatment Study
Carolyn D Drews-Botsch PhD, MPH Marianne Celano PhD Eugenie E Hartmann PhD
Scott R Lambert MD
Emory University, Atlanta, GA
Introduction: We examine the relationship between patching and visual acuity at age 4
½ years in the Infant Aphakia Treatment Study.
Methods: Cataract extraction was performed between 28 and 209 days of age on 114
infants with a unilateral congenital cataract. 57 were randomized to receive an IOL; the
remaining 57 were left aphakic. Recognition acuity was assessed at age 4½. Patching was prescribed until age 5. Adherence to prescribed patching was assessed using
quarterly telephone interviews and annual patching diaries. Occlusion was the average
number of hours of patching reported on at least 3 adherence assessments within 5 age
bands: 0-<12 months of age, 12-<24 months, 24-<36 months, 26-<48 months, 48-<60
months.
Results: Hours of patching at each time point was correlated with patching at all other
time points. Few (n=5) caregivers reported averaging more than 3 hours of patching in
years 3-5 if they had not done so in the first 2 years. Patching was strongly correlated
with acuity. Correlation coefficients ranged from -0.32 for patching in the 5th year of life
to -0.42 for patching in the 2nd year, were similar for pseudophakic and aphakic children,
and were not confounded by adverse events, age at surgery, gender, race or type of
insurance.
Discussion: We affirm the importance of patching to visual acuity in children after unilateral cataract extraction in infancy.
Conclusion: Patching in the first years after surgery may be particularly important as
caregivers who are able to adhere to patching in infancy are more likely to adhere to
prescribed patching later.
Paper 28
Saturday
11:45 - 11:52 am
A Randomized Trial of Amblyz Liquid Crystal Occlusion Glasses vs Traditional
Patching for Treatment of Moderate Unilateral Amblyopia in Children
Daniel E Neely MD, Jingyun Wang PhD, Jay Galli CO, Jessica Kovarik MD,
James Bowsher MD, Tina Damarjian MD, Joshua Schliesser MD, Heather Smith MD,
Dana L Donaldson OD, Kathryn M Haider MD, Gavin J Roberts MD,
Derek T Sprunger MD, David A Plager MD
Glick Eye Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA
Introduction: A previous non-randomized pilot study of liquid crystal occlusion glasses suggested that this new device is an effective treatment option for amblyopia.(Spierer et al. 2010)
However, there has not been prior comparison to a traditional occlusion patch control group.
This randomized clinical trial is designed to compare the effectiveness of Amblyz™ glasses
versus adhesive occlusion patching for treating moderate, unilateral amblyopia in children.
Methods: Sixteen children ranging from 3 to 8 years of age with previously untreated, moderate, unilateral amblyopia (visual acuity of 20/40 to 20/80 in the amblyopic eye) were enrolled.
All subjects had worn optimal refractive correction for at least 12 weeks without improvement
and their amblyopia was associated with strabismus, anisometropia, or both. Subjects were
randomized into one of two treatment groups: a 4-hour daily Amblyz™ occlusion glasses
group with liquid crystal shutter set at 30-second opaque/transparent intervals, or the 2-hour
adhesive patching control group. For each patient, visual acuity was measured with ATS-HOTV methods before and after 12 weeks of treatment.
Results: At the conclusion of the first 12 week-treatment interval, visual acuity in the amblyopic eye improved an average of 2.04 lines in the 2-hour adhesive patch group and 2.01 lines
in the 4-hour Amblyz™ glasses group. This difference was not statistically significant.
Discussion: The apparent effectiveness of Amblyz™ glasses warrants further investigation
with longer follow-up and larger sample size.
Conclusion: Amblyz™ liquid crystal occlusion glasses appear to be equally effective compared to adhesive occlusion patches when treating 3-8 year old children with moderate unilateral amblyopia. This new device is a promising alternative treatment for amblyopia.
References: Spierer, A., et al., Treating amblyopia with liquid crystal glasses: a pilot study. Invest Ophthalmol Vis Sci, 2010. 51(7): p. 3395-8.
40
Evolution of eye-hand co-ordination deficits in children with amblyopia
and abnormal binocular function
John J Sloper1 Catherine M Suttle2 Miriam C Conway2 Simon Grant2
1
Moorfields Eye Hospital and 2City University, London, UK
Paper 29
Saturday
11:52 - 11:59 am
Introduction: We have previously shown that children with amblyopia and defective
binocular function have deficits of eye-hand co-ordination1. This study has examined how
these deficits evolve with age.
Methods: Movements of the child’s preferred hand to pick up cylindrical objects under
monocular and binocular viewing conditions were recorded using a 3-D motion capture
system. 55 children aged 5 to 9 years with a range of severity of amblyopia and deficient
binocular function were studied and compared to 28 control children. Movement dynamics and error rates were analyzed and compared using ANOVA and stepwise regression
analysis.
Results: When compared to age-matched controls, the movements of 5-6 year-old
amblyopic children were both much slower and contained more reach and grasp errors
when viewing with either the amblyopic or fellow eye or with both eyes open (all P<0.05;
n=30). Slow movements were mainly related to severity of amblyopia, whereas poor or
absent stereopsis was the main determinant of high error rates. For the older amblyopic
children aged 7-9 absent stereovision was the main determinant of persistent reach and
grasp errors (P<0.05; n=25).
Discussion: The strategies that children with amblyopia and deficient binocular function use for reach-to-precision grasping change with age from emphasis on visual feed
back during approach to an object at ages 5-6 to more reliance on tactile information from
object contact aged 7-9 and differ from those of normal children.
Conclusion: Loss of stereoscopic vision is the main factor in long-term deficits of eyehand co-ordination in children with strabismus and amblyopia.
References: 1. Suttle CM, Melmoth DR, Finlay AL, Sloper JJ, Grant S. Eye-Hand Coordination Skills in Children with and without Amblyopia. Invest
Ophthalmol Vis Sci. 2011; 52: 1851-64.
Binocular Movie Treatment of Amblyopia Improves Visual Acuity in Children
Simone L Li PhD Alexandre Reynaud PhD Robert F Hess PhD Yi-Zhong Wang PhD
Reed M Jost MS Sarah E Morale BS Angie De La Cruz BS Lori Dao David Stager Jr
Eileen E Birch PhD
Retina Foundation of the Southwest, Dallas, TX, USA
McGill Vision Research, Dept. of Ophthalmology, McGill University, Montréal, Québec, Canada
Pediatric Ophthalmology & Adult Strabismus, Plano, TX, USA
Dept. of Ophthalmology, UT Southwestern Medical Center, Dallas, TX, USA
Introduction: Many amblyopic patients have a structurally intact binocular visual system that can be
revealed by decreasing the fellow-eye contrast to reduce the interocular suppression. We previously
demonstrated that repeated binocular experience via at-home binocular iPad game play with reduced
fellow-eye contrast was effective in treating childhood amblyopia (ref 1 & 2) and that visual acuity was
maintained ≥12 months (ref 3). However, compliance was low in 32-38% of children, primarily due to lack
of interest in the games (ref 1 & 2). Here we investigate the effectiveness of a potentially more engaging
movie method to provide regular binocular experience via complementary dichoptic stimulation as a treatment for amblyopia.
Methods: Six amblyopic children (4-10y; 0.4-0.8 logMAR or 20/50-20/125) were invited to watch 3
dichoptic movies per week for 2 weeks. Dichoptic versions of 18 popular animated feature films were created, with a dynamic reduced contrast texture in the fellow eye. Movies were displayed on a passive 3D
display. Initial fellow eye contrast was set based on the child’s dichoptic motion coherence threshold, and
incremented by 10% at each visit. At baseline, 1- and 2-week visits, best-corrected visual acuity (BCVA)
was measured.
Results: After watching 6 dichoptic movies during a two-week period (9.0±1.1 hours), mean (±SE) amblyopic eye BCVA improved from 0.58±0.07 logMAR at baseline to 0.42±0.04 logMAR (p=0.03); i.e., 0.17
logMAR or 1.7 lines. Four children with 0.4-0.5 logMAR baseline BCVA improved 0.1 logMAR (1 line); two
children with 0.8 logMAR baseline BCVA improved 0.2-0.4 logMAR (2-4 lines). Fellow eye BCVA did not
change significantly during the study (p= 0.35).
Discussion: Binocular movie treatment yields a significant improvement in the amblyopic-eye BCVA
after 2 weeks (about 9 hours) of treatment in children. The presentation of popular animated feature films
may result in better compliance in children than binocular iPad game play.
Conclusion: Repeated binocular visual experience, with reduced fellow eye contrast, improves vision in
the amblyopic eye. Monocular improvement in the absence of fellow eye occlusion suggests that amblyopia is, at least in part, due to chronic interocular suppression.
References: 1. Li SL et al Eye (Nature) 2014; 28: 1246-53.
2. Birch EE et al. J AAPOS; in press
41
3. Li SL et al JAMA Ophthalmology; in press
Paper 30
Saturday
11:59 - 12:06 pm
Paper 31
Saturday
12:06 - 12:13 pm
Reading Rate and Scantron® Completion Time in Children with Amblyopia
Eileen E Birch PhD, Reed M Jost MS, John F Gilmore III, Angie De La Cruz BS,
Krista R Kelly PhD
Retina Foundation of the Southwest, Dallas, TX
Introduction: A handful of recent studies report that adults and children with strabismic
amblyopia perform more poorly on fine motor skill and reading tasks than normal controls. To
date, these studies failed to distinguish the effects of strabismus from the effects of amblyopia
on performance and did not include tasks typical of children’s daily activities in school.
Methods: Thirty-seven children (7-12y) with anisometropia, strabismus, or both (23 amblyopic & 14 non-amblyopic) and 14 age-matched normal control children were enrolled. Children
had eye movement recording while silent reading a grade appropriate passage of text for
comprehension binocularly (Readalyzer™), and were timed while transferring answers from a
standardized reading achievement test to a Scantron® multiple choice response form. Visual
acuity, stereoacuity, and interocular suppression were also tested. Child wore their habitual
optical correction for all testing.
Results: Reading rate for amblyopic children was significantly slower (119±33 words per
min) than for normal children (192±39; p=0.01) and for non-amblyopic children with strabismus (219±50; p<0.0001). Both the number of fixations and the number of regressive
saccades per 100 words were significantly higher for amblyopic children (p=0.007 and
0.03, respectively). Comprehension scores did not differ among groups. Reading rate was
significantly correlated with amblyopic eye visual acuity (p=0.001) and depth of suppression (p<0.0001) but not stereoacuity. Time to complete the Scantron® (sec) was significantly
greater for amblyopic children compared to normal controls (p=0.03). Scantron® completion
time was significantly correlated with depth of suppression but not with amblyopic eye visual
acuity or stereoacuity.
Discussion: Amblyopia results in slower reading rate and Scantron® completion and is associated with abnormal eye movements during reading and interocular suppression.
Conclusion: Slow reading can hamper amblyopic children in schoolwork and affect performance on timed, standardized tests. Schools may need to implement academic accommodations to allow students with amblyopia to succeed.
Paper 32
Saturday
12:13 - 12:20 pm
Detection of Strabismus by the Spot Vision Screener
Mae Millicent W Peterseim Jennifer D Davidson Rupal H Trivedi
Edward W Cheeseman M Edward Wilson Carrie E Papa
Storm Eye Institute/ Medical University of South Carolina
Charleston, South Carolina
Introduction: AAPOS guidelines for Amblyopia Risk Factors (ARF) to be detected by
automated vision screeners include manifest strabismus of 8 PD in primary position.
The Spot vision screener is a new automated screener designed for use in schools and
pediatric offices. The Spot refers children for strabismus based upon the device’s measurement of ‘gaze’. We sought to determine the efficacy of the Spot in detecting ARF
strabismus when compared to pediatric ophthalmologist examination.
Methods: In this prospective study, new and return patients seen in the pediatric
ophthalmology clinic underwent screening with the Spot vision screener, version 1.1.51,
prior to a complete examination by a pediatric ophthalmologist. A Redcap database was
created including Spot referral status and results of the examination. Patients who were
referred by the Spot for ‘gaze’ were included as test positives. Patients found to have
constant strabismus of 8 PD or greater in primary position by the physician were considered to have ARF positive strabismus.
Results: 444 patients, average age 72 months (11-221 mo) were included. 92/444
(21%) children met ARF for strabismus criteria by the pediatric ophthalmologist examination. The sensitivity of the Spot to detect ARF strabismus risk factors is 77.17% and the
specificity 93.73%. PPV is 76.34% and NPV is 94.0% in our population.
Discussion: The Spot demonstrates good sensitivity and excellent specificity for detecting AAPOS Amblyopia Risk Factor strabismus
Conclusion: The new Spot vision screener is useful in detecting strabismus in children.
References: Donahue Sean P, Arthur B, Neely DE, Arnold RW, Silbert D, Ruben JB, on behalf of the AAPOS Vision Screening Committee, Guidelines for automated preschool vision screening. J AAPOS 2013;17:4-8.
http://www.welchallyn.com/en/products/categories/physical-exam/eye-exam/vision-screeners/spot-vision-screener.html
42
Efficacy of a mobile smart phone vision-screening device with automated
image-processing analysis in the evaluation of amblyopia risk factors in
preschool children
Robert W Arnold David I Silbert
Alaska Blind Child Discovery
Anchorage, Alaska and Lancaster, Penn
Paper 33
Saturday
12:20 - 12:27 pm
Introduction: Automated vision screening can identify preschool children with amblyopia risk factors (ARFs). A smart phone platform has potential benefits of portability and
implementation. This represents an interim analysis of a prospective study to introduce
and assess a mobile smart phone (GoCheckKids) with automated image-processing
analysis for a vision-screening device.
Methods: 235 patients aged 12-72 months , were enrolled from 2 sites. Children were
consented and then evaluated using smart phone photoscreening and cycloplegic (gold
standard) refraction. Age ranged for 12-30, 31-48, and 49-72 months (n=58, 44, and 72
respectively). Only completed age ranges (49-72) reached the minimum for statistical
population requirements (n=70). Automated image-processing algorithms were optimized for maximum sensitivity/specificity to AAPOS photoscreening guidelines1 for ARFs.
Results: Optimized overall ARF sensitivity/specificity for the automated mobile photoscreener compared too cycloplegic refraction in the older children: 60%/82%. Expert
manual image grading was comparable at 60%/89%. Younger children have more
unreadable images.
Discussion: The mobile smart phone photoscreening system is effective for the detection of ARFs. These initial instrument thresholds were set for maximum specificity while
retaining reasonable sensitivity to reduce false positives.
Conclusion: Gobiquity’s mobile smart phone photoscreener with automated image
processing analysis is a viable vision-screening device in the detection of amblyopia risk
factors in preschool children.
References: 1. Donahue, S, et al. Guidelines for automated preschool vision screening: a 10-year, evidence-based update. JAAPOS 2013;17;48.
Validation of photo screening technology in the general pediatrics office
Jana A Bregman Barron L Patterson MD Sandy Owings Sean P Donahue MD
Vanderbilt University Medical Center, Nashville, TN
Introduction: Automated preschool vision screening allows for the detection of amblyopia risk factors (ARFs) in preverbal children. While most photoscreening instruments
have been validated in pediatric ophthalmology clinics and field studies, validation in the
medical home is lacking. We performed the first large scale multi-office evaluation of two
commercially available photoscreening devices in the medical home.
Methods: Nine large pediatric practices were recruited to perform photoscreening of
4500 children aged between 18 months and five years at well child examinations. Thus
far 1534 children (of anticipated 3750) were screened using SPOT while 308 (anticipated 750) were screened using Plusoptix S12. (NOTE TO Pgm Ctee: At current rates
anticipate full enrollment in December). Referred children received comprehensive eye
examination with cycloplegic refraction to determine predictive value using AAPOS VSC
guidelines. A selected sample of 2% of passed children had eye exams to calculate sensitivity and specificity.
Results: The referral rate for SPOT was 9% compared to 20% for PlusOptix. The most
common reason for referral for each instrument was suspected astigmatism (45% for
SPOT, 68% for PlusOptix). Amblyopia risk factors were confirmed in 70% of examined
referred children using SPOT compared to 40% with PlusOptix. The higher PVP for
SPOT was primarily due to a lower PVP for suspected astigmatism in patients screeed
using PlusOptix. PVP for suspected anisometropia, and suspected hypermetropia were
similarly high for both instruments; PVP for suspected strabismus remained low for both.
Discussion: This study is the first to evaluate automated vision screening in the medical
home and nearly identically replicates previously reported studies from day care settings
and preschools.
Conclusion: SPOT and PlusOptix are each effective for the detection of ARFs when
used in the pediatric outpatient setting.
References: Donahue SP et al. Guidelines for automated preschool vision screening: A 10-year, evidence-based update. J AAPOS. 2013;17(1):48.
Matta NS, Singman EL, Silbert DI. Performance of the Plusoptix vision screener for the detection of amblyopia risk factors in children. J
AAPOS. 2008;12(5)490-2. Ransbarger KM et al. Results of a community vision-screening program using the Spot photoscreener. J AAPOS.
2013;17(5)516-20.
43
Paper 34
Saturday
12:34 - 12:38 pm
Paper 35
Sunday
8:42 - 8:50 am
2015 Young Investigator Award
Fixational eye movements- Microsaccades in Amblyopia
Cole Eye Institute, Cleveland Clinic
Daroff Dell’Osso Ocular Motility Laboratory, Cleveland VA Medical Center
Introduction: Miniature eye movements such as microsaccades shift the image on the
fovea and counteract visual fading due to neural adaptation. They are also thought to
serve as an optimal sampling strategy while viewing complex visual scenes. The goal of
our study was to assess the influence of amblyopia on microsaccades.
Methods: 23 amblyopes(mild =7;moderate= 10;severe=6) and 10 controls participated
in the study. Eye movements were recorded using infrared video-oculography during amblyopic and fellow eye viewing while the subjects performed 3 tasks a)prolonged visual
fixation b)viewed a gray background c)identified picture differences.
Results: There was a decrease in the frequency of microsaccades with increasing severity of amblyopia (median:mild=1.8Hz;moderate=1.4Hz;severe=0.5Hz,AN
OVA p<0.05). The micro-saccade amplitude decreased with increasing severity of
amblyopia(median:mild=0.59°; moderate=0.57°; severe=0.49°,ANOVA p<0.05). The
frequency of microsaccades while viewing a gray background were 50% less compared
to when viewing a complex visual scene. The ability to identify picture differences was diminished (decrease correct responses with increased reaction time) in severe compared
to mild amblyopia.
Discussion: The brain increases the rate of microsaccades to aid visual exploration in
demanding tasks. The relative increase in production of microsaccades while viewing
crowded visual scene is diminished in severe amblyopes. These results suggest that
central nervous system is unable to increase the microsaccade rate to aid viewing of a
complex picture in amblyopia.
Conclusions: Microsaccades could be a novel biomarker to assess severity/treatment
response in amblyopia. Alteration in micro-saccades could explain the difficulty in perceiving details of a complex picture evident as crowding phenomenon in amblyopia.
44
Notes
45
Notes
46
Poster Schedule
1st Set of Hard Board Posters (1-28) displayed from Wednesday, March 25, 4:00 PM - Friday, March 27, 11:30 AM,
Storyville Hall
Interactive Poster Session - Author Presentation and Q/A - Thursday, March 26, 10:00 - 11:00 AM
STRABISMUS
Poster #1
Strabismus Outcomes in the Infant Aphakia Treatment Study
Erick D. Bothun, MD
Michael J. Lynn; Steve P. Christiansen, MD; Deb K. VanderVeen, MD; Dan E. Neely, MD;
Stacey J. Kruger, MD; Scott R. Lambert, MD
Poster #2
Divergence Insufficiency: Increased Incidence and Hypothesis Regarding Etiology
Justin D. Marsh
David L. Guyton
Poster #3
Treatment of Symptomatic Convergence Insufficiency (CI) with Home-Based Computerized Vergence System
(CVS) Therapy in Children Age 5 to 18 Years
Pamela A. Huston, CO
Darren L. Hoover, MD
Poster #4
Heavy Eye Syndrome (HES) and Sagging Eye Syndrome (SES) in High Myopia
Roland Joseph D. Tan, MD
Joseph L. Demer, MD, PhD
Poster #5
A Novel Finding of Amblyoidosis of Superior Oblique Tendon in Brown Syndrome
Ramesh Kekunnaya, MD, FRCS
Anjali Chandrasekharan, MS; Virender Sachdeva, MS
STRABISMUS SURGERY
Poster #6
A Tool for Evaluating Ergonomic Posture During Strabismus Surgery
Scott E. Olitsky, MD
Melanie Simmer-Beck, RDH, PhD; Bonnie S. Branson, RDH, PhD
Poster #7
Treatment of Surgical Sutures with Antiseptic or Antibiotic to Reduce Suture Contamination: An In Vitro
Experiment
Namratha Turlapati
Mark Ruttum; Sue Kehl
Poster #8
Slipping the Knot: A Comparison of Knots Used in Adjustable Suture Strabismus Surgery
Kyle E. Miller, MD
Michael Kinori, MD; Shira L. Robbins, MD; Scott K. McClatchey, MD; David B. Granet, MD
Poster #9
Effect of Horizontal Strabismus Surgery on Lateral Comitance
Carolyn Graeber, MD
David G. Hunter, MD, PhD
Poster #10
Long-Term Success in Surgically and Non-Surgically Managed Intermittent Exotropia
Sarah R. Hatt, DBO
David A. Leske, MS; Jonathan M. Holmes, BM, BCh
Poster #11
Characteristics, Surgical Management and Outcomes of Adult-Onset Cranial Nerve Six Palsy
Sara F. Grace, MD
Kara M. Cavuoto, MD; Hilda Capo, MD
RETINA
Poster #12
Retinal Dysfunction and Nerve Fiber Layer Loss in Pediatric Patients on Vigabatrin: An ERG and SD-OCT Study
Joshua M. Barnett
Natalie Kerr; Alessandro Iannaccone
Poster #13
Visual Outcomes in Congenital Foveal Toxoplasmosis
Smith Ann M. Chisholm, MD
Gregg T. Lueder, MD
Poster #14
Fluorescein Angiography versus Fundus Photography on the Diagnosis and Management of Retinopathy of
Prematurity
Samir N. Patel
Michael A. Klufas, MD; Michael C. Ryan; Karyn E. Jonas, RN; Susan Ostmo, MPH;
Audina M. Berrocal, MD; Michael F. Chiang, MD; RV Paul Chan, MD
47
Poster #15
Patterns of Retinal Hemorrhage Associated with Pediatric Cerebral Sinovenous Thrombosis
Julia E. Reid, MD
David L. Rogers, MD; Anne Jensen, MD; Brian J. Forbes, MD, PhD; Lori L. Billinghurst, MD, MSc;
Gil Binenbaum, MD, MSCE
Poster #16
Predictors for the Development of Referral-Warranted Retinopathy of Prematurity in the Telemedicine
Approaches to Evaluating of Acute-Phase ROP (e-ROP) Study
Gui-shuang Ying
Graham E. Quinn; Kelly C. Wade; Michael X. Repka; Agnieshka Baumritter; Ebenezer Daniel
Poster #17
Training Retinal Imagers for Retinopathy of Prematurity (ROP) Screening
Karen A. Karp, BSN
Agnieshka Baumritter, MS; Denise J. Pearson, COMT; Maxwell Pistilli, MEd, MS;
Gui-Shuang Ying, PhD; Graham E. Quinn, MD
Poster #18
A Closer Look at Retinopathy of Prematurity Persisting After 40 Weeks and the Costs of Applying 2013 Screening
Guidelines
Natalie C. Weil, MD
George B. Hubbard, MD; Amy K. Hutchinson, MD
Poster #19
Clinical Efficacy and Pharmacology of Bevacizumab in Treatment of Retinopathy of Prematurity: A Comparison
of Two Dosages
Lingkun Kong, MD, PhD
Amit R. Bhatt, MD; Ann B. Demny, BSN, RN; David K. Coats, MD; Paul G. Steinkuller, MD
Poster #20
Uncertainty in the Diagnosis of Pre-Plus Disease in Retinopathy of Prematurity
Allison R. Loh, MD
Michael Ryan, MPH; Katherine Abrahams; Esra Cansizoglu, BS; RV Paul Chan, MD;
Audina Berrocal, MD; Jayashree Kalpathy, PhD; Veronica Bolon, PhD; Deniz Erdogmus, PhD;
Michael F. Chiang, MD
OPTIC NERVE - NEURO-OPHTHALMOLOGY
Poster #21
Optic Nerve Morphology in Normal Children
John W. Simon, MD
Devang L. Bhoiwala; Preethi Raghu, MD; Mala Krishnamoorthy, MD; Amit Todani, MD;
Sai B. Gandham, MD; Steven T. Simmons, MD
Poster #22
Reproducibility of Retinal Nerve Fiber Layer Thickness Measures Using Eye-Tracking with Spectral-Domain
Optical Coherence Tomography in Children with Optic Neuropathy
Robert A. Avery, DO, MSCE
Raneem Rajjoub, BA; Carmelina Trimboli-Heidler; Roger J. Packer, MD
Poster #23
Pediatric Spectral Domain-Optical Coherence Tomography (SD-OCT) Normative Data for Novel Optic Nerve
Parameters Using the Heidelberg Spectralis
Gena Heidary, MD, PhD
Frank Weng, BS; Linda R. Dagi, MD
Poster #24
Visual Outcomes in Children with Dorsal Midbrain Syndrome as a Result of Pineal Tumors
Julie K. Calderwood, MD
Mary E. Hoehn, MD; Greg Armstrong, MD
ANTERIOR SEGMENT - OCULOPLASTICS
Poster #25
Measurement of Axial Length in an Office Setting versus Under General Anesthesia in Infants and Toddlers: A
Comparative Study
Michael Kinori, MD
Ido Didi Fabian, MD; Abraham Spierer, MD; Tamara Wygnanski-Jaffe, MD; Shira Robbins, MD;
David B. Granet, MD, FACS; Itay Ben-Zion, MD
Poster #26
Management of Iris Cysts in Children
Carol L. Shields, MD
Sara E. Lally, MD; Jerry A. Shields, MD
Poster #27
Clinical and Visual Outcomes of Children with Peters Anomaly
Asim Ali
Hermina Strungaru; Uri Elbaz; Kamiar Mireskandari
Poster #28
Epidemiology and Clinical Characteristics of Pediatric Eyelid Retraction
Jessica A. Olayanju, MD
Gregory J. Griepentrog, MD; Brian G. Mohney, MD
48
Strabismus Outcomes in the Infant Aphakia Treatment Study.
Erick D Bothun MD Michael J Lynn Steve P Christiansen MD Deb K Vanderveen MD
Dan E Neely MD Stacey J Kruger J MD Scott R Lambert MD
University of Minnesota, Minneapolis, Minnesota
Poster 1
Thursday
10:00 - 11:00 am
Introduction: To evaluate the characteristics of strabismus in infants who underwent
monocular cataract surgery with and without intraocular lens (IOL) implantation in the
Infant Aphakia Treatment Study.
Methods: Secondary outcome analysis was done in this randomized, multicenter, clinical trial comparing treatment of unilateral aphakia with a primary IOL or contact lens (CL)
in 114 infants. The proportion of patients who were orthotropic at distance and near at
5 years of age as well as the proportion of patients who underwent strabismus surgery
were compared between treatment groups using Fisher’s exact test.
Results: At 5 years of age, 8 of 57 (14%) children in the CL group and 14 of 56 (25%)
in the IOL group were orthotropic at distance (P=0.16) and had no history of strabismus
surgery. For near fixation, 11 vs. 11 (19% vs. 20%) were orthotropic (P = 0.99). The
number of patients requiring strabismus surgery prior to age 5 was 21 in CL group (37%)
and 24 in IOL group (43%) (P = 0.57).
Discussion: Previously presented IATS data documented a high rate (70.4%) of strabismus in the first year after cataract surgery. At the 5-year close of the study, children
in both the IOL and CL treatment groups continued to develop strabismus.
Conclusion: Intraocular lens placement does not eliminate the early development of
strabismus or the need for extraocular muscle procedures after monocular congenital
cataract surgery.
References: Ophthalmology. 2013 Jun;120(6):1227-31.
JAMA Ophthalmol. 2014 Jun;132(6):676-82.
Divergence Insufficiency: Increased Incidence and Hypothesis Regarding Etiology
Justin D Marsh David L Guyton
Introduction: For reasons unknown, age-related divergence insufficiency (DI) is being
diagnosed more frequently [1]. We sought to determine if the incidence of DI has increased, and, if so, to propose a mechanism to explain the increased incidence.
Methods: Patient records were analyzed to determine the yearly incidence of diagnosed
DI and operated cases, ages > 50. Patients were excluded with a known etiology for
strabismus or history of prior strabismus surgery.
Results: The number of new cases of DI in 1989-1992 was 3 compared with 63 in 20092012 (P < 0.001). Twenty-nine of these patients had undercorrected accommodative
demand at near. When excluding patients with esotropia at near, the distance deviation
correlated with the undercorrected accommodative demand at near (R2 = 0.46).
Five patients underwent surgery for DI in 2003-2004, compared with 12 in 2013-2014 (P
= 0.012). The median time from onset of symptoms to diagnosis during these periods
was 5.5 and 5.0 years, respectively.
Discussion: We found an increase in diagnoses and surgeries for DI over the periods analyzed. This increase in documented cases of DI does not appear to be due to
increased awareness of disease or decreased lag time between onset of symptoms and
diagnosis.
Conclusion: Increased visual demands at near, such as the viewing of desktop monitors through progressive power lenses, may activate the near triad, increase convergence tonus, and shorten the medial rectus muscles via unwanted muscle length adaptation, perhaps contributing to the minor epidemic of DI that is unexplainable by connective
tissue degeneration.
References: 1. Repka MX, Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency esotropia. JAAPOS 2014;18:370-3.
49
Poster 2
Thursday
10:00 - 11:00 am
Poster 3
Thursday
10:00 - 11:00 am
Treatment of symptomatic Convergence Insufficiency (CI) with home-based
Computerized Vergence System (CVS) therapy in children age 5 to 18 years
Pamela A Huston CO Darren L Hoover MD
Everett and Hurite Ophthalmic Association
Pittsburgh, PA
Introduction: To evaluate the efficacy of a home-based computer orthoptic program
(CVS) for symptomatic CI in children
Methods: A retrospective review of 185 subjects age 5-18 years who were prescribed
9 or 15 minutes of daily convergence exercises with the CVS program, 5 days per week
for the initial 6 weeks. All patients reported at least 1 of the following: asthenopia with
reading, diplopia at near. All subjects had a near exophoria at least 4 PD greater than at
distance, and access to a computer with a CD/DVD player.
Measures:
Objective: Near point of convergence (NPC) and near convergence amplitude (NCA) at
baseline, intermediate, and final examinations.
Subjective: Presence or absence of diplopia and asthenopia with reading at baseline and
final examinations.
Results: 74 subjects (40%) reported diplopia and all subjects reported asthenopia.
Baseline measurements were a mean NPC of 6 cm and NCA of 20 PD. 89% of subjects achieved good or excellent compliance during the initial 6 weeks of therapy. CVS
therapy duration averaged 18 weeks. Therapy was discontinued an average of 64 weeks
before the final assessment. 170 subjects (92%) were asymptomatic at final assessment. Final measures were a mean NPC of 3 cm, and mean NCA of 38 PD. 12 subjects
required other treatment modalities.
Discussion: (see conclusion)
Conclusion: Home-based CVS therapy may reduce symptoms and improve the NPC
and NCA of children age 5-18 years with symptomatic CI.
Poster 4
Thursday
10:00 - 11:00 am
Heavy Eye Syndrome (HES) and Sagging Eye Syndrome (SES) in High Myopia
Roland Joseph D Tan MD, Joseph L Demer MD, PhD
Stein Eye Institute
100 Stein Plaza, David Geffen School of Medicine at UCLA, Los Angeles, California
Introduction: HES presents with limited abduction and supraduction due to superotemporal globe shift relative to extraocular muscles. SES was described in non-myopic
patients, presenting with distance esotropia and cyclovertical strabismus due to lateral
rectus (LR) inferodisplacement caused by LR-SR band degeneration. We supposed that
SES might also cause strabismus in high myopia.
Methods: Eleven strabismic patients with axial high myopia underwent ophthalmological
examination and orbital MRI to assess the LR-SR band and displacement angles between LR and superior rectus (SR).
Results: Five highly myopic patients with mean axial length of 32±5mm had HES.
Distance esotropia averaged 68±42PD and hypertropia 26±21PD. The LR-SR band was
thinned in 6 and ruptured in 2 orbits, with superotemporal globe prolapse. The mean
angle between SR and LR centroids was 121±7°. Six highly myopic patients with mean
axial length of 32±6mm exhibited SES. Distance esotropia averaged 23±57PD and
hypertropia 2±2PD. The LR-SR band was thinned in 7 and ruptured in 5 orbits, with superotemporal soft tissue prolapse. The mean angle between SR and LR centroids was
104±11°, significantly less than in HES(P<0.001).
Discussion: SES occurs in highly myopic patients who exhibit less relative displacement between SR and LR than in HES. Unlike HES, SES exhibit superotemporal soft
tissue prolapse that may limit superotemporal globe shift. The distinction is important
because surgery for HES requires SR to LR union, while surgery for SES is conventional.
Conclusion: SES can cause strabismus in high axial myopia. Orbital MRI is useful in
differentiating SES from HES.
References: 1. Larsen PC, Gole GA. Partial Jensen’s procedure for the treatment of myopic strabismus fixus. J. AAPOS. 2004;8:393-395. 2.
Surgical procedure for correcting globe dislocation in highly myopic strabismus. Yamaguchi, Makoto et al. Am. J. Ophthalmol., 2010 Feb; 149: 341 346.
3. Rutar T, Demer, JL. “Heavy eye” syndrome in the absence of high myopia: A connective tissue degeneration in elderly strabismic patients.
J. AAPOS 2009;13:36-44. 4.Clark RA, Demer JL. Effect of aging on human rectus extraocular muscle paths demonstrated by magnetic resonance
imaging. Am. J. Ophthalmol. 2002;134:872-878.
50
A novel finding of amyloidosis of superior oblique tendon in Brown syndrome
Ramesh Kekunnaya MD,FRCS Anjali Chandrasekharan MS Virender Sachdeva MS
L V Prasad Eye Institute
Hyderabad,India
Poster 5
Thursday
10:00 - 11:00 am
Introduction: Brown syndrome is a form of restrictive strabismus characterized by
deficient elevation in adduction. We present a case series of novel finding of amyloidosis
involving superior oblique (SO) muscle in Brown syndrome
Methods: A total of three patients with Brown syndrome (5 eyes) were identified. Indications for surgery were abnormal head posture and significant strabismus in primary position. Surgical options included SO tenectomy for hypotropia and lateral rectus and medial
rectus recession for exotropia and esotropia respectively. The excised tendon of superior
oblique was sent for histopathological examination
Results: Two of three cases were had congenital Brown syndrome. Two cases were
bilateral. One patient had associated congenital ptosis. Orbital imaging performed in two
cases was normal. All patients had chin elevation of more than 5 degrees. The mean
preoperative deviation was 7 prism diopters (PD) of hypotropia, 22 PD of exotropia and
10 PD of esotropia. The mean postoperative deviation was zero PD hypotropia, 5 PD
exotropia, 3 PD esotropia. Histopathology samples of all the 3 patients revealed amyloidosis of superior oblique. None had features of systemic amyloidosis.
Discussion: Orbital amyloid deposits have been described with generalized primary
and secondary amyloidosis commonly involving the lids, conjunctiva and lacrimal apparatus. Localized orbital amyloidosis involving extraocular muscle is rare. To the best of
our knowledge this is the first report describing association of amyloidosis with superior
oblique tendon presenting as Brown’s syndrome.
Conclusion: Localized orbital amyloidosis of superior oblique may lead to secondary
changes in the tendon causing restrictive strabismus.
References: 1.Holmström GE, Nyman KG. Primary orbital amyloidosis localised to an extraocular muscle. Br J Ophthalmol. 1987 Jan;71(1):323. 2.Teoh SC, Liew GC, Yap WM. Incidental hypoglobus: primary amyloidosis of the superior rectus. Singapore Med J. 2006 Jan;47(1):65-7. 3.
8.Paula JS, Paula SA, Cruz AA, Chahud F. Superior oblique muscle amyloidosis mimicking myositis. Ophthal Plast Reconstr Surg. 2008 JanFeb;24(1):77-9
A tool for evaluating ergonomic posture during strabismus surgery
Scott E Olitsky MD Melanie Simmer-Beck R.D.H., Ph.D. Bonnie S Branson R.D.H., Ph.D.
Children’s Mercy Hospital
Kansas City, Missouri
Introduction: Surveys have shown that the incidence of musculoskeletal disorders
(MSD) is high among ophthalmologists. The cause of these disorders is thought to be
secondary to poor ergonomic posture in both the clinic and the operating room. The
incidence of MSD among dentists is considered to be even higher and the dental field
has taken steps to identify high risk activities and attempt to modify the work environment
in order to reduce this risk. Recently, an evaluation tool has been shown to be useful in
identifying dental operator postures that can be harmful. This study looked at utilizing a
similar tool to evaluate strabismus surgeons.
Methods: Strabismus surgeons were monitored during surgery and their posture was
evaluated using a tool established for examining dentists during operative procedures.
The testing process was compared to similar evaluations made during dental procedures.
Results: The evaluation process was found to be similar for the postural assessment of
strabismus surgeons during surgery to that used to examine dentists.
Discussion: Neck and back pain are common disorders among ophthalmologists.
Identifying postural habits that are ergonomically unsound can help to reduce the risk of
these problems. A previously designed dental tool can be modified to allow evaluation of
postures seen during strabismus surgery.
Conclusion: An evaluation tool which has been modified for dental use may be able
to help identify unsafe operating postures seen during strabismus surgery and suggest
operating positions and techniques that would be safer for the surgeon performing strabismus surgery.
51
Poster 6
Thursday
10:00 - 11:00 am
Poster 7
Thursday
10:00 - 11:00 am
Treatment of surgical sutures with antiseptic or antibiotic to reduce suture
contamination: an in vitro experiment
Namratha Turlapati Mark Ruttum Sue Kehl
Medical College of Wisconsin, Milwaukee, WI
Introduction: The purpose of this study is to determine if treatment of sutures used in
strabismus surgery with antibiotic or antiseptic can significantly reduce suture contamination.
Methods: Sutures (6-0 polyglactin) were divided into four groups: (1) untreated (control);
(2) 10% povidone-iodine; (3) gentamicin 2.5% solution; and (4) gentamicin ophthalmic
ointment. Treated sutures were soaked in the antibacterial agent for five minutes and
then briefly exposed to each of four bacterial species (S. pneumoniae, S. aureus, S.
epidermidis, and H. influenzae). The sutures were cultured and growth was measured in
colony forming units at 24 hours. The Kruskal - Wallis exact test was used for statistical
analysis.
Results: The 10% povidone iodine suture group had no growth following bacterial exposure. This was significantly different from the control and antibiotic treated suture groups
(p < 0.0001). In contrast, the untreated control, gentamicin 2.5% solution treated, and
gentamicin ophthalmic ointment treated groups had growth after bacterial exposure and
were not found to be significantly different.
Discussion: Suture contamination during strabismus surgery has been reported and is
the suspected mechanism of infectious post-operative endophthalmitis. The absence of
bacterial growth from the 10% povidone-iodine treated suture group suggests pre-treating
sutures with antiseptic may decrease suture contamination and theoretically could lower
the incidence of infectious endophthalmitis following strabismus surgery.
Conclusion: Treatment of sutures with 10% povidone-iodine is shown to significantly
reduce suture contamination in an in vitro setting. Further studies to determine the safety
and efficacy of this practice are required.
References: 1. Eustis et al. Suture Contamination in Strabismus Surgery. J Pediatr Ophthalmol Strabismus 2012;49:206-209. 2. Olitsky, et al.
Needle Sterility During Strabismus Surgery. J AAPOS 1998;2:151-2. 3. Rampat et al. The Effect of Commonly Used Surgical Solutions on the
Tensile Strength of Sutures. J Pediatr Ophthalmol Strabismus 2014;51(3):189-190.
Poster 8
Thursday
10:00 - 11:00 am
Slipping the knot: A comparison of knots used in adjustable suture
strabismus surgery
Kyle E Miller MD1,2 Michael Kinori MD1 Shira L Robbins MD1 Scott K McClatchey MD2
David B Granet MD1
1Anne and Abraham Ratner Children’s Eye Center at the University of California, San Diego
La Jolla, CA 2Department of Ophthalmology, Naval Medical Ceneter San Diego
Introduction: Adjustable suture strabismus surgery has been performed for many years
and multiple suture tying techniques have been developed. These tying techniques are
meant to hold the muscle in place well yet also slide to allow adjustment. The friction
related to this process has not been well characterized.
Methods: To allow the simulation of strabismus surgery tying methods a model using
6-0 polyglactin 910 suture (Vicryl, Ethicon) was created. After each knot was tied a digital
force meter was used to measure the force (gram-force, gf) required to overcome the
static friction created by the knot. Each simulation was repeated with new suture material
five times and the force required after subsequent repositioning was also recorded.
Results: The force to overcome static friction for the sliding noose knot was 226gf
[90%CI, 181-271], cinch knot: 135gf [90%CI, 99-171], and square knot: 82 gf [90% CI,
68-96]. Subsequent movement of each knot along the same suture required progressively less force with the sliding noose maintaining the most static friction.
Discussion: All knots in this study generate frictional forces greater than can be overcome by the average horizontal extraocular muscle1; however, only the sliding noose
would confidently hold the maximal force generated.1 Consideration should be taken
when moving the knot multiple times due to the decreased force required with each
movement.
Conclusion: In a strabismus surgery model the sliding noose knot had the greatest
frictional force generated and maintained the most static friction after subsequent repositioning.
References: 1. Collins CC, Carlson MR, Scott AB, and Jampolsky A. Extraocular muscle forces in normal human subjects. Invest. Ophthalmol. Vis
Sci. 1981; 20(5):652-664.
Disclaimer: The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department
of the Navy, Department of Defense, nor the U.S. Government.
52
Effect of horizontal strabismus surgery on lateral comitance
Carolyn Graeber MD David G Hunter MD, PhD
Boston Children’s Hospital
Boston, MA
Poster 9
Thursday
10:00 - 11:00 am
Introduction: Asymmetric horizontal strabismus surgery is often performed to correct
primary gaze alignment without consideration of symptoms that may result from misalignment in side gaze. In this study, we measured comitance (difference between right and
left gaze strabismus measurements) to assess change in comitance (CIC) after strabismus surgery.
Methods: Medical records of horizontal strabismus surgical procedures at a single institution over a 2-year period were retrospectively reviewed. Inclusion criteria included side
gaze measurements recorded before and after surgery. The main outcome measure was
CIC after surgery.
Results: The review identified 569 procedures meeting inclusion criteria. Of the 491
with comitant preoperative alignment, 59 developed postoperative incomitance, of whom
91% had asymmetric surgery. Of the 78 with incomitant preoperative alignment, 35 (45%)
improved to comitance postoperatively; 100% of these patients had asymmetric surgery.
Asymmetric 2-muscle surgery (recess/resect procedure) was associated with the largest
CIC while symmetric 2-muscle surgery had the smallest (P<0.0001). CIC of =25PD was
observed in 7 patients with asymmetric surgery (0 with symmetric surgery). Simultaneous
vertical muscle surgery did not significantly alter CIC.
Discussion: Asymmetric surgery had the largest effect on CIC. Symmetric surgery did
not significantly alter CIC. Some patients with asymmetric surgery had very large CIC.
Vertical surgery did not affect CIC overall.
Conclusion: Asymmetric surgery can treat patients with incomitance but can also create
incomitance in patients who were previously comitant. Surgical planning should include
consideration of potential for CIC, especially in patients who are sensitive to diplopia or to
the social implications of incomitant strabismus.
Long-term success in surgically and non-surgically managed intermittent exotropia
Sarah R Hatt DBO David A Leske MS Jonathan M Holmes BM, BCh
Mayo Clinic
Rochester, Minnesota
Introduction: Previous authors have reported high recurrence rates following surgery
for childhood intermittent exotropia (IXT). In addition it is possible that some cases may
resolve without surgery. We compared long-term success in surgically and non-surgically
managed patients.
Methods: Children with IXT and 5 years follow-up (minimum 3 years) from their first
surgery were retrospectively identified. A cohort of comparable non-surgical patients was
identified by matching each surgical patient for age at onset and age at the 5-year examination. At the exam closest to 5 years follow-up, success was defined as no manifest
tropia on examination or by history, no new monofixation (stereoacuity subnormal for age)
and no additional surgery. Success rates were compared between surgical and non-surgical groups.
Results: 33 children with IXT had surgical correction and 5 years postoperative followup, and were matched with 33 non-surgical patients (total follow-up 7.2 ± 2.6 years vs 6.8
± 2.3 years). There were no significant differences between groups for baseline angle of
deviation (P>0.4). The success rate at 5 years was 30% in the surgical group and 12% in
the non-surgical group (P=0.1; difference 18%, 95% CI -1% to 37%).
Discussion: After an average of 7 years follow-up, the majority of both surgical and nonsurgical patients continue to demonstrate a constant or intermittent manifest deviation.
Only a small proportion of patients in both groups met our definition for success.
Conclusion: In childhood intermittent exotropia, long-term success is difficult to achieve
with surgical intervention, and some patients managed non-surgically will spontaneously
resolve.
53
Poster 10
Thursday
10:00 - 11:00 am
Poster 11
Thursday
10:00 - 11:00 am
Characteristics, Surgical Management and Outcomes of Adult-Onset Cranial Nerve
Six Palsy
Sara F Grace MD Kara M Cavuoto MD Hilda Capo MD
Bascom Palmer Eye Institute
Miami, Florida
Introduction: Cranial nerve six palsy (CNVI P) is a common etiology of adult-onset strabismus. Our series describes the characteristics, surgical management and outcomes of
adult-onset CNVI P.
Methods: Retrospective chart review of 87 patients that underwent strabismus surgery
for adult-onset CNVI P in the past 15 years at a large academic center.
Results: In order of incidence, the three most common etiologies were trauma (30.3%),
intracranial masses (24.7%) and ischemia (15.7%). The mean age at diagnosis and
surgery was 50 and 54 years, respectively. Diplopia was present in 96%, with 37% using
prism correction prior to surgery. The mean deviations were 41 ± 23 prism diopters at
distance and 34 ± 23 prism diopters at near. Transposition procedures were utilized in
30%, adjustable sutures in 65% and botulinum toxin injection in 9%. The success rate (<
10 PD) was 84% in non-transposition procedures as compared to 60% in transposition
procedures (p=0.027). Resolution of diplopia was achieved in 61% of patients, with 24%
of patients undergoing additional surgery and 15% requiring prism correction.
Discussion: In our study, the majority of patients diagnosed with CNVI P were relatively
young and had trauma or brain tumors. These etiologies frequently resulted in esodeviations that were larger and less likely to improve than the ischemic palsies seen in the
elderly, which may have led to surgical correction.
Conclusion: Multiple surgical options yield good results in CNVI P. The results of transposition procedures are not as successful as non-transposition surgeries; however, this
may be attributed to their utilization in cases of more severe compromise of lateral rectus
function.
Poster 12
Thursday
10:00 - 11:00 am
Retinal Dysfunction and Nerve Fiber Layer Loss in Pediatric Patients on
Vigabatrin: An ERG and SD-OCT Study
Joshua M Barnett Natalie Kerr Alessandro Iannaccone
Hamilton Eye Institute, University of Tennessee Health Science Center
Memphis, TN
Introduction: To report on patients treated with therapeutic levels of vigabatrin (VGB)
for epilepsy followed prospectively for possible VGB-related changes in retinal nerve fiber
layer (RNFL) thickness, macular microanatomy, and retinal function.
Methods: Nine patients with VGB-treated epilepsy (age: 0.5-17 yo; mean 5.49±6.2 yo)
followed every 6 mos. (average: 1.4 yrs) were included in this observational case series.
Exams included spectral domain optical coherence tomography (SD-OCT) and full-field
flash electroretinogram (ERG), conducted under anesthesia in a hospital setting.
Results: Three of the nine patients exhibited signs of VGB-related toxicity following
treatment durations of 7.8, 11.2, and 33.6 mos. A RNFL thickness reduction of 22±5 µm
was seen in the superior quadrant. No macular SD-OCT changes were seen. Two of
these three patients exhibited also ERG changes, one had selective photopic and mixed
b-wave amplitude loss (electronegative ERG) attributable to ON-response compromise,
and another selective mixed a-wave amplitude loss, attributable to photoreceptor compromise.
Discussion: Both RNFL loss and ERG changes were documented in 3 of 9 cases followed prospectively. RNFL loss was observed over time in all cases only in the superior
quadrant. ERG changes varied, and included signs of photoreceptor toxicity (a-wave
loss) and compromise of the photoreceptor-to-ON bipolar cell synapse (or of the ON
bipolars themselves).
Conclusion: These findings confirm that VGB-treated pediatric patients are at risk of
suffering multiple changes in their visual system in conjunction to VGB use, and add
further information to the complex spectrum of the known VGB-mediated visual function
toxicity effects.
54
Visual Outcomes in Congenital Foveal Toxoplasmosis
Smith Ann M Chisholm MD Gregg T Lueder MD
Washington University in St. Louis
St. Louis, MO
Poster 13
Thursday
10:00 - 11:00 am
Introduction: Congenital macular lesions attributed to toxoplasmosis may limit potential visual acuity. The appearance and location of these scars may cause physicians to
overlook associated amblyopia. This study reviews the visual outcomes and benefits of
amblyopia therapy in children with foveal toxoplasmosis scars.
Methods: Retrospective review of ten children with presumed foveal toxoplasmosis
scars. Photographs were obtained in all patients and optical coherence tomography
(OCT) was performed in five patients.
Results: Average age at presentation was 3.8 years old and average follow-up was 6.3
years. Occlusion therapy was undertaken in nine patients. Average duration of occlusion therapy was 1.7 years. Six patients improved with occlusion therapy (average 4.6
lines gained on optotype acuity). Final visual acuity ranged from 20/20 - 20/250, with
8 patients better than 20/80. OCT confirmed macular scars in all patients, with varying
degrees of foveal architecture disruption.
Discussion: Despite the striking appearance of the lesions in some patients with foveal
toxoplasmosis, visual potential may be better than expected. The appearance of the lesions is not predictive of visual outcome. Improvement in visual acuity following occlusion therapy may occur in many patients.
Conclusion: Visual outcomes in children with foveal toxoplasmosis may be better than
predicted based on the appearance of the lesions. A trial of occlusion therapy to treat
amblyopia should be initiated in these patients to ensure that they reach their maximal
visual potential.
References: 1. Kushner BJ. Functional amblyopia associated with abnormalities of the optic nerve. Arch Ophthalmol. 1984;102:683-685. 2.
Yang LLH, Lambert SR. Reappraisal of occlusion therapy for severe structural abnormalities of the optic disc and macula. J Pediatr Ophthalmol
Strabismus. 1995;32:37-41. 3. Kushner BJ. Functional amblyopia associated with organic eye disease. Am J Ophthalmol. 1981;91:39-45.
Fluorescein Angiography versus Fundus Photography on the Diagnosis
and Management of Retinopathy of Prematurity
Samir N Patel Michael A Klufas MD Michael C Ryan Karyn E Jonas RN Susan Ostmo
MPH Audina M Berrocal MD Michael F Chiang MD R.V. Paul Chan MD
Weill Cornell Medical College, New York
Introduction: Fluorescein angiography (FA) is an imaging modality that may provide useful information regarding the retinal vasculature in the premature retina; however, little information exists
on the utility of FA in patients with retinopathy of prematurity (ROP). The purpose of this study is to
(1) examine and compare how fundus photography and FA influence the identification of the fovea
in ROP and (2) evaluate the influence of FA on the diagnosis and management of ROP.
Methods: 32 sets (16 fundus photographs; 16 fundus photographs paired with corresponding
FAs) of wide-angle retinal images obtained from 16 eyes of eight infants with ROP were compiled
on a secure web site. 9 ophthalmologists (3 pediatric ophthalmologists; 6 vitreoretinal surgeons),
with experience in ROP diagnosis and management, interpreted each image set, identified the
fovea, and provided a diagnosis of zone, stage, plus, and category. Sensitivity and specificity was
calculated using a consensus diagnosis, determined from diagnosis of the color fundus images by
three independent readers in combination with the ophthalmoscopic examination.
Results: A computer-generated diagnosis of zone based on a subject’s identification of fovea
agreed with that subject’s diagnosis of zone in 3.1 of 5 (62%) cases using fundus photographs
and in 3.4 of 5 (68%) cases using FA. When interpreting fundus photography alone versus fundus
photography and FA, mean sensitivity improves for detection of stage 3 or worse disease (39.8 to
74.1), zone I (47.2 to 61.1), type 2 or worse disease (69.4 to 86.8) and treatment requiring disease
(22.2 to 40.3). Using the kappa statistic, inter-grader agreement for identification of treatmentrequiring ROP improved significantly when viewing the fundus photographs + FA as compared to
viewing the fundus photographs alone.
Discussion: There is variability between identification of the macular center and concordance with
the subjective diagnosis of zone. FA supplementation can improve sensitivity for certain subtypes
of ROP zone, stage and category as well as increasing intergrader agreement for treatment-requiring ROP.
Conclusion: FA continues to have an evolving role in the diagnosis and management of ROP. FA
may be most helpful in determining Zone I ROP.
55
Poster 14
Thursday
10:00 - 11:00 am
Poster 15
Thursday
10:00 - 11:00 am
Patterns of Retinal Hemorrhage Associated with Pediatric Cerebral Sinovenous
Thrombosis
Julia E Reid MD David L Rogers MD Anne Jensen MD Brian J Forbes MD PhD Lori L
Billinghurst MD MSc Gil Binenbaum MD MSCE
Nationwide Children’s Hospital and The Children’s Hospital of Philadelphia
Columbus, OH and Philadelphia, PA
Introduction: To report the prevalence and characteristics of retinal hemorrhage (RH)
in children with cerebral sinovenous thrombosis (CSVT), which has been proposed as an
alternative explanation for RH in children evaluated for abusive head trauma.
Methods: Multicenter retrospective cross sectional study of children older than 6 weeks
with newly diagnosed CSVT and dilated funduscopic examination. Primary outcomes
were the presence of RH and pattern of RH.
Results: Twenty-nine children (median age 9 years, range 7 weeks to 17 years) were
studied. Eighteen retinal exams occurred within 72 hours of CSVT diagnosis; 11 were
within 4 to 10 days. Five (17%) children had RH. In 4 of 5 children, the RH was peripapillary, superficial intraretinal, and adjacent to a swollen optic disc. In the fifth child, who had
meningitis, sepsis, and multiple cerebral infarcts, there were numerous white-centered
intra-retinal hemorrhages and one preretinal hemorrhage. Eighteen (62%) children had
disc swelling. CSF opening pressure was recorded in 13 children (mean 37 cm-H20,
range 27-59). CSVT risk factors included meningitis(6), mastoiditis(5), and hypercoagulability(5).
Discussion: RH in children with CSVT was uncommon. Hemorrhages were few in number, peripapillary, and associated with optic disc swelling. One child with deeper intraretinal and one preretinal hemorrhage had florid sepsis, a recognized independent cause of
RH.
Conclusion: RH associated with pediatric CSVT is characteristically superficial and
adjacent to a swollen optic disc. When RH extends into the rest of the posterior pole or
periphery, is multilayered, or occurs in the absence of disc swelling, another etiology for
the RH should be sought.
Poster 16
Thursday
10:00 - 11:00 am
Predictors for the Development of Referral-Warranted Retinopathy of Prematurity
in the Telemedicine Approaches to Evaluating of Acute-Phase ROP (e-ROP) Study
Gui-shuang Ying Graham E Quinn Kelly C Wade Michael X Repka
Agnieshka Baumritter Ebenezer Daniel
Scheie Eye Institute, University of Pennsylvania
Philadelphia, PA
Introduction: Detection of treatment-requiring retinopathy of prematurity (ROP) involves
serial eye examinations. A ROP prediction model using predictive factors could identify
high-risk infants and reduce required eye examinations. This study is to determine predictive factors for referral-warranted ROP (RW-ROP).
Methods: Secondary analysis of data from the e-ROP Study. 1257 Infants with birth
weight (BW) <1251g had serial ROP examinations to detect RW-ROP (defined as presence of plus disease, Zone I ROP, or ROP stage 3 or greater in either eye).
Results: In a multivariate model, significant predictors [odds ratio (95% confidence
interval)] for RW-ROP were: male [1.80 (1.13–2.86)], nonblack race [2.76 (1.50–5.08) for
White vs. Black and 4.81 (2.19-10.6) for other vs. Black], low BW [5.16 (1.12–7.20) for
</=500g vs. >1100g], low gestational age [9.79 (3.49–27.5) for </=24 weeks vs. >/=28
weeks], number of quadrants with preplus disease [18.4 (4.28–79.4) for 3-4 quadrants
vs. no preplus], stage 2 ROP [4.13 (2.13–8.00)], retinal hemorrhage [4.36 (1.57–12.1)],
need for respiratory support [11.0 (2.26 – 53.8)], and slow weight gain [2.44 (1.22 – 4.89)
for weight gain </=12g/day vs. >18g/day].
Discussion: Using a ROP prediction model could identify lower risk infants who require
less frequent imaging or eye examinations and also identify highest risk infants who
require more intensive imaging and examination schedules.
Conclusion: When controlling for very low BW and prematurity, presence of preplus
disease, stage 2 ROP, retinal hemorrhage, and need for ventilation at time of first studyrelated eye exam were strong independent predictors for RW-ROP.
56
Training retinal imagers for Retinopathy of Prematurity (ROP) screening
Karen A Karp BSN Agnieshka Baumritter MS Denise J Pearson COMT
Maxwell Pistilli MEd, MS Gui-Shaung Ying PhD Graham E Quinn MD
The Children’s Hospital of Philadelphia
34th and Civic Center Blvd. Philadelphia, PA 19104
Poster 17
Thursday
10:00 - 11:00 am
Introduction: Retinopathy of prematurity (ROP) accounts for 13 % of the blindness in
children in the United States. As of 2012 the AAP’s recommendations for ROP screening
included remote retinal imaging as an acceptable screening method. The NEI-sponsored
Telemedicine System for the Evaluation of Acute-Phase Retinopathy of Prematurity
(e-ROP) Study reported the validity of retinal imaging with remote grading to screen for
referral warranted ROP (sensitivity 90%, specificity 87%).
Methods: e-ROP certified retinal imagers (CRI) were trained using a wide-angle digital
camera to obtain a pupil image and 5 retinal images for each eye, while maintaining a
safe patient environment. Data were collected to evaluate factors that might influence
image quality.
Results: Of 4205 imaging sessions, 4003 complete, 550 incomplete image sets were
submitted. Submitted images were analyzed for image quality and 92% were gradable.
Image quality was significantly affected by pupil size (<5mm: 55%, 5-6mm: 88%, and
>6mm: 93%), image frequency (low volume 87% and high volume 95%), and ventilation
mode (HFOV 68%, others 89-92%, no support 94%).
Discussion: For remote retinal imaging to have a high sensitivity and specificity, it is importance that the CRI be well trained in image acquisition, ROP, and the population. Well
dilated pupils, frequent imaging, and a well-positioned infant are all essential for successful image acquisition.
Conclusion: The training of the e-ROP imagers was successful at maintaining quality images throughout the study period. Careful training and monitoring of CRIs are key
components to using a telemedicine approach to ROP.
References: 1.Ells AL, Holmes JM, Astle WF, et al. Telemedicine approach to screening for severe retinopathy of prematurity: a pilot study. Ophthalmology 2003;110:2113-7. 2.Telemedicine Approaches to Evaluating Acute-phase Retinopathy of Prematurity Cooperative Group. Validity of a
telemedicine system for the evaluation of acute-phase ROP. JAMA Ophthalmology 2014 (published online June 26, 2014).
A Closer Look at Retinopathy of Prematurity Persisting After 40 weeks and
the Costs of Applying 2013 Screening Guidelines
Natalie C Weil MD George B Hubbard MD Amy K Hutchinson MD
Emory University School of Medicine, Atlanta, GA
Introduction: In this study we describe the course of ROP that persists beyond 40
weeks and to calculate the rate of occurrence of pre-threshold ROP after 45 weeks. Also,
to consider the monetary and intangible costs of extending ROP screening of infants with
non-prethreshold ROP from 45 to 50 weeks.
Methods: We performed a retrospective review of the medical records of outborn premature infants screened for retinopathy of prematurity at two tertiary facilities from May of
2013 to August of 2014.
Results: We identified 135 infants with ROP that persisted after 40 weeks gestational
age. Of those, 49 patients were excluded, (death, lost to follow up before screening was
complete, initial exam after 45 weeks, only one exam, other medical conditions affecting
ability to conduct exam) leaving 86 patients. Of these, 28 patients reached prethreshold
disease and 9 required treatment. The earliest documented onset of prethreshold was 33
weeks and the latest was 44.5
weeks. Twenty patients did not reach prethreshold, but were followed for >45 weeks with
a median of 2 additional visits at an additional monetary cost of 275.00 dollars per infant.
Discussion: In 2013, the 2006 screening guidelines for ROP were modified to extend
the recommended screening term for infants with non-prethreshold ROP from 45 to 50
weeks. 1,2.
Conclusion: Based on this small study we conclude that additional research should be
conducted on a large scale prior to holding physicians accountable to guidelines which
have patient safety, financial and medical legal implications.
References: 1. Ophthalmology AAOPSO, Ophthalmology AAO, OPHTHALMOLOGY AAFP, et al. Screening Examination of Premature Infants
for Retinopathy of Prematurity. PEDIATRICS 2013;131:189–195. 2. Section on Ophthalmology. Screening Examination of Premature Infants for
Retinopathy of Prematurity. PEDIATRICS 2006;117:572–576.
57
Poster 18
Thursday
10:00 - 11:00 am
Poster 19
Thursday
10:00 - 11:00 am
Clinical Efficacy and Pharmacology of Bevacizumab in Treatment of Retinopathy of
Prematurity: a Comparison of Two Dosages
Lingkun Kong MD, Ph.D Amit R Bhatt MD Ann B Demny BSN, RN David K Coats MD
Paul G Steinkuller MD
Baylor College of Medicine
6701 Fannin St, suite 610.25, Houston TX 77030
Introduction: The pharmacokinetics and the optimal dosage of bevacizumab for the
treatment of ROP are unknown.
Methods: Thirty-four infants with type 1 ROP were treated with intravitreal injection of
bevacizumab (IVB) at the dosage of 0.625 mg (22 patients) and 0.25mg (12 infants).
Blood samples were collected prior to treatment and on post-treatment days 2, 14, 42
and 60. Weekly body weights were documented from birth until 60 days post treatment.
Serum levels of bevacizumab and VEGF were measured with enzyme-linked immunosorbent assay (ELISA). Structural examinations and cycloplegic refractions were performed
at age 1 year.
Results: Serum bevacizumab level in IVB 0.25 mg group was lower than that in IVB
0.625 mg group, p=0.001. Half-life is 21 days. Serum bevacizumab levels were correlated
with ROP status at the time of treatment. Serum VEGF levels decreased significantly in
both groups 2 days post-treatment (P=0.0001) and remained at low levels. There were no
significant differences in body weight gain between the two groups. Three eyes (8.3%) in
IVB 0.625 mg group and two eyes (8.7%) in IVB 0.25mg group underwent laser treatment
for recurrence of type I ROP. Two eyes (8.7) in IVB 0.25mg group had laser treatment for
treatment failure. At 1 year of age, no retinal detachment was found in either group. The
refractive errors were -0.28±3.4 and -1.0±1.6 in IVB 0.625mg and 0.25 mg group, respectively (p=0.26).
Discussion: This is a pilot study.
Conclusion: IVB at lower dosage (0.25mg) has similar efficacy as 0.625mg dosage but
with significantly lower systemic exposure.
Poster 20
Thursday
10:00 - 11:00 am
Uncertainty in the diagnosis of Pre-plus Disease in Retinopathy of Prematurity
Allison R Loh MD, Michael Ryan MPH, Katherine Abrahams, Esra Cansizoglu BS, R.V.
Paul Chan MD, Audina Berrocal MD, Jayashree Kalpathy PhD, Veronica Bolon PhD,
Deniz Erdogmus PhD, Michael F Chiang MD
Oregon Health and Science University, Portland, OR
Introduction: “Pre-plus disease” is abnormal arterial tortuosity and venous dilation less than
the standard photograph1. One concern from clinicians is the definition of “pre-plus disease”
requires qualitative interpretation. This study measures the impact of “pre-plus” categorization
by examining diagnostic accuracy of experts, and by calculating quantitative tortuosity values.
Methods: Wide-angle retinal images captured from 73 infants during ROP-screening were
interpreted by 2 experts using a 3-level (plus/pre-plus/neither) scale. Image-based interpretations were integrated with the ophthalmoscopic exam to define a reference standard diagnosis. Images were analyzed quantitatively using a computer-based algorithm to generate a
vascular tortuosity index (TI). Diagnostic performance of each expert and the computer-generated TI were compared based on absolute agreement and receiver operating characteristic
area under the curve (AUC), with 3-level vs. 2-level (plus/not plus) classification.
Results: Absolute agreement between experts and the reference standard was 92% in the
3-level classification, and 96% in the 2-level classification. Diagnostic performance of experts
measured by AUC was 0.94 and 0.97 in the 3 and 2-level classification, respectively. Diagnostic performance of the computer-based TI measured by AUC was 0.91 in the 3-level
classification, and 0.90 in the 2-level classification. Sensitivity and specificity of computergenerated plus-disease diagnosis were 89%-Sn/81%-Sp and 100%-Sn/66%-Sp in the 3 and
2-level classification respectively.
Discussion: Diagnostic performance by experts was lower when the ROP classification
system included pre-plus disease.
Conclusion: Since diagnostic performance by experts was lower when the classification
system included pre-plus disease, additional clarification of “pre-plus disease” may improve
accuracy and consistency of diagnosis. In quantifying the spectrum between normal and plus
disease, image based analysis may aid characterization of pre-plus disease.
References: International Classification of Retinopathy of Prematurity Revisited. Arch Ophthalmol. 2005; 123(7):991-999.
58
Optic Nerve Morphology in Normal Children
John W Simon MD Devang L Bhoiwala Preethi Raghu MD Mala Krishnamoorthy MD
Amit Todani MD Sai B Gandham MD Steven T Simmons MD
Albany Medical College Department of Ophthalmology/Lions Eye Institute
Albany, New York
Poster 21
Thursday
10:00 - 11:00 am
Introduction: Although optic nerve morphology is routinely assessed in adults, no normative
database has been established for preschool children.1-3
Methods: Subjects & Methods
In a community-based, cross-sectional analysis, 77 four- to five-year- old healthy children
were recruited from pediatric practices. No subject had any known ocular disorder. Their optic
nerves were assessed using Optovue Optical Coherence Tomography (OCT). Data were
compared to the normative database obtained by Optovue for adults, ages 18-25, 40-45, and
55-60. Comparisons included retinal nerve fiber layer (RNFL) thickness, thickness of ganglion
cell complex (GCC), disc area (DA), vertical (VCD) and horizontal (HCD) cup-to-disc ratios,
and cup area (CA).
Results: In comparison to all adult age groups, the children’s optic nerves were statistically
less cupped (CA, VCD, HCD), with all p-values less than 0.0001. No statistical difference
was identified between the children and adults aged 18-25 and 40-45 with respect to RNFL or
GCC. Both RNFL and GCC were thicker in the children when compared to adults aged 55-60
(p < 0.003). Children’s DA’s were marginally smaller than the adult population.
Discussion: Our results demonstrate that young children’s optic nerves are statistically less
cupped than those of all normal adult populations. The children’s RNFL and GCC are statistically thicker than those of adults aged 55-60.
Conclusion: This study presents the first quantitative assessment of the optic nerve head,
nerve fiber layer, and ganglion cell complex in normal four- to five-year old children. Results
may help define optic nerve abnormalities in clinical practice.
References: 1. Bendschneider D, Tornow RP, Horn FK, Laemmer R, Roessler CW, Juenemann AG, et al. Retinal nerve fiber layer thickness in
normals measured by spectral domain OCT. Journal of glaucoma. 2010;19(7):475-82. PubMed PMID: 20051888. 2. Cheung N, Huynh S, Wang
JJ, Taylor B, Islam FM, Saw SM, et al. Relationships of retinal vessel diameters with optic disc, macular and retinal nerve fiber layer parameters
in 6-year-old children. Investigative ophthalmology & visual science. 2008;49(6):2403-8. PubMed PMID: 18281614. 3. Huynh SC, Wang XY,
Rochtchina E, Mitchell P. Peripapillary retinal nerve fiber layer thickness in a population of 6-year-old children: findings by optical coherence tomography. Ophthalmology. 2006;113(9):1583-92. PubMed PMID: 16949443.
Reproducibility of Retinal Nerve Fiber Layer Thickness Measures Using
Eye-Tracking with Spectral-Domain Optical Coherence Tomography in
Children with Optic Neuropathy
Robert A Avery, DO, MSCE; Raneem Rajjoub, BA; Carmelina Trimboli-Heidler;
Roger J Packer, MD
Children’s National Medical Center, Washington, DC
Introduction: To determine the intra- and intervisit reproducibility of circumpapillary retinal
nerve fiber layer (RNFL) thickness measures using eye-tracking assisted spectral domain
optical coherence tomography (SD-OCT) in children with nonglaucomatous optic neuropathy.
Methods: Circumpapillary RNFL thickness measures were acquired with the Spectralis
(Heidelberg Engineering) SD-OCT using the eye-tracking feature at two separate study visits.
Children with normal and abnormal vision (visual acuity >/= 0.2 logMAR above normal and
or visual field loss) who demonstrated clinical and radiographic stability were enrolled. Intraand intervisit reproducibility was calculated for the global average and 9 anatomic sectors by
calculating the coefficient of variation (CV) and intraclass correlation coefficient (ICC).
Results: Forty-two subjects (median age 8.6 years, range 3.9 -18.2 years) met inclusion
criteria and contributed 62 study eyes. Both the abnormal and normal vision cohort demonstrated the lowest intravisit CV for the global RNFL thickness. The papillomacular bundle
demonstrated the lowest ICC and highest CV in the intravisit analysis for both cohorts. Intervisit reproducibility remained good for those with normal and abnormal vision, although small
but statistically significant CV increases were observed for multiple anatomic sectors in both
cohorts. The magnitude of visual acuity loss was significantly associated with the global (ß =
0.026, P < .01) and temporal sector CV (ß = 0.099, P < .01).
Discussion: SD-OCT with eye tracking demonstrates highly reproducible RNFL thickness
measures, although subjects with vision loss demonstrate greater intra- and intervisit variability than those with normal vision.
Conclusion: Longitudinal changes in RNFL thickness can be reliably monitored in children
using SD-OCT with eye tracking.
59
Poster 22
Thursday
10:00 - 11:00 am
Poster 23
Thursday
10:00 - 11:00 am
Pediatric Spectral Domain-Optical Coherence Tomography (SD-OCT) Normative
Data for Novel Optic Nerve Parameters using the Heidelberg Spectralis
Gena Heidary MD, PhD, Frank Weng, BS, Linda R. Dagi, MD
Boston Children’s Hospital, Boston, MA
Introduction: SD-OCT normative data for optic nerve volume (ONV) and the peripapillary
papillomacular bundle thickness have not been reported, yet these parameters are relevant
for neuro-ophthalmic disease. The purpose of this study was to determine pediatric norms for
these parameters and expand the dataset for typical OCT parameters.
Methods: Single center, cross-sectional, prospective study of subjects aged 4-18 years. Using the Heidelberg Spectralis NSite software, ONV and peripapillary retinal nerve fiber layer
(rNFL) thickness measurements were obtained. Inclusion criteria were normal acuity and
dilated exam, birth ≥ 37 weeks, and refractive error between -4 and + 4 diopters.
Results: One hundred and fifty patients (58 % female) including 31% African American, 41%
Hispanic, and 21% Caucasian or Asian patients participated. Five equal-sized age bins were
represented. Mean total ONV was 2.48 mm3 (SD ±0.32 mm3). Average peripapillary rNFL
thickness measurements were global thickness 104.65 microns (SD ±8.53 microns), peripapillary papillomacular bundle 57.03 microns (SD ± 8.61 microns), nasal superior 120.91 microns
(SD ±20.89 microns), nasal 75.31 microns (SD ±14.32 microns), nasal inferior 120.66 microns
(SD ±22.96 microns), temporal inferior 150.13 microns (SD ±17.46 microns), temporal 73.93
microns (SD ±10.74 microns), and temporal superior 148.43 (SD ±30.54).
Discussion: This normative database using the Heidelberg Spectralis is from the largest
reported cohort of pediatric patients with substantive distribution across age and diverse
ethnicities. We introduce pediatric norms for ONV and peripapillary papillomacular bundle
thickness.
Conclusion: Normative data for SD-OCT ONV and rNFL thickness measurements are now
available to enhance our ability to manage pediatric neuro-ophthalmic disease.
References: 1Turk A., Ceylan O.M., Arici C., et al. Evaluation of the Nerve Fiber Layer and Macula in the Eyes of Healthy Children Using SpectralDomain Optical Coherence Tomography. Am. J. Ophthalmol. 2012;153: 552-559.e1. Epub 2011 Oct 22. 2Yanni S.E., Wang J., Cheng C., et al.
Normative reference ranges for the retinal nerve fiber layer, macula, and retinal thicknesses in children. Published in final edited form as: Am J
Ophthalmol. 2013 February; 155: 354-360.e1. Published online 2012 November 3. 3Kaufhold F, Kadas EM, Schmidt C, Kunte H, Hoffman J, Zimmerman H, Oberwahrenbrock T, Harms L, Polthier K, Brandt AU, Paul F. Optic nerve head quantification in idiopathic intracranial hypertension by
4
spectral domain OCT. PLOS One 2012; 7: e36965.
Wang J-K, Kardon RH, Kupersmith MJ, Garvin MK. Automated quantification of volumetric
optic disc swelling in papilledema using spectral-domain optical coherence tomography. IOVS. 2012; 53:4069-4075.
Poster 24
Thursday
10:00 - 11:00 am
Visual Outcomes in Children with Dorsal Midbrain Syndrome
as a Result of Pineal Tumors
Julie K Calderwood MD Mary E Hoehn MD Greg Armstrong MD
St. Jude Children’s Research Hospital, Memphis, Tennessee
Introduction: Dorsal Midbrain Syndrome (DMS) is a well-known complication of pineal
tumors characterized by a variety of ocular findings. The percentage of patients that develop these findings and whether treatments are needed has not been well described.
Methods: We reviewed 84 charts of patients treated for pineal tumors at our institution
since 1995. Twenty-three patients expired before they could be evaluated by ophthalmology. Thirty-five had an eye examination within 6 months of tumor diagnosis and were
included in the study. The remaining patients were either never referred to the eye clinic
or were referred more than 6 months after tumor diagnosis.
Results: We found the incidence of DMS in our population to be 57.1% (n=20). Seventeen patients had vertical gaze paresis, 15 had pupillary light-near dissociation, 9 had
convergence-retraction nystagmus, and 1 had eyelid retraction. Five patients developed
convergence insufficiency, and 8 were noted to have intermittent exotropia. Improvement of DMS findings following treatment was seen in 4 patients, and only 2 experienced
complete resolution. Strabismus surgery was recommended for 3 patients, and one was
treated with convergence exercises.
Discussion: Previous publications regarding DMS state that the findings resolve with
tumor treatment. However in our population, 90% of patients that developed DMS had
persistent ocular pathology even after treatment.
Conclusion: Patients diagnosed with pineal tumors have a high incidence of DMS. A
small number of patients with DMS will improve with tumor treatment, however most
cases will have residual findings and some will require surgery or exercises to help improve symptoms.
References: 1. Goldenberg-Cohen N, Haber J, Ron Y, et al. Long-term ophthalmological follow-up of children with Parinaud syndrome. Ophthalmic
Surg Lasers Imaging. 2010;41(4):467-71.
2. Gregory ME, Rahman MQ, Cleary M, et al. Dorsal midbrain syndrome with loss of motor fusion: a
rare association. Strabismus. 2011;19(1):17-20.
3. Buckley SA, Elston JS. Surgical treatment of supranuclear and internuclear ocular motility
disorders. Eye. 1997;11:377-80.
60
Measurement of axial length in an office setting versus under general anesthesia
in infants and toddlers: a comparative study
Michael Kinori MD Ido Didi Fabian MD Abraham Spierer MD
Tamara Wygnanski-Jaffe MD Shira L Robbins MD David B Granet MD,FACS
Itay Ben-Zion MD
Department of Ophthalmology, The Goldschleger Eye Institute, Sheba Medical Center
Tel Hashomer, Israel
Poster 25
Thursday
10:00 - 11:00 am
Introduction: One of the major obstacles facing the pediatric cataract surgeon is to obtain good quality axial length (AL) measurements for intraocular lens (IOL) power calculations in a young uncooperative patient. The typically higher IOL powers needed may not
be commonly stocked in every center. If a general anesthesia (GA) based AL is needed
this might necessitate an additional operating room session. The purpose of this study is
to examine whether AL measurement in awake infant/toddlers is feasible, and whether
there is a difference in AL measurement between an office setting and under GA.
Methods: A prospective comparative case study. Using the same instruments, AL measurements were obtained using a standard applanation technique twice; once in an office
setting when the infant/toddler was awake, and once under GA in the operating room. To
test for differences between measurements, a paired t-test was used
Results: 33 eyes of 19 participants under the age of 28 months were examined. Average AL measurements were shorter by 0.12mm in the office setting than under GA
(p=0.14). A mixed model analysis was used to generate a formula that can be used to
predict AL under GA using the measurements obtained in an office setting
Discussion: The findings here show that AL measurements in an office setting is feasible in most cases. No statistically significant difference was noted between measurements under GA compared to measurement in an office setting.
Conclusion: AL measurement in of an infant/toddler in an office setting is generally
reasonable to obtain.
Management of iris cysts in children
Carol L Shields MD Sara E Lally MD Jerry A Shields MD
Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107
Introduction: There are 2 main categories of iris cysts in children including iris pigment epithelial (IPE) custs and iris stromal cysts. Most pigment epithelial cysts are small and stable, rarely
requiring treatment. Iris stromal cysts tend to enlarge and produce photophobia and secondary
glaucoma, requiring treatment.
Methods: Review of 159 iris cysts for the outcome of type and intervention.
Results: Of 768 patients with iris cysts, 159 were children (<20 years). The types included IPE
cyst [pupillary margin (n=18, 11%), midzonal (n=29, 18%), peripheral (n=78, 49%), and dislodged
(n=2, 1%)], iris stromal cyst (n=31, 20%) and epithelial downgrowth cyst (n=1, 1%). The IPE cysts
rarely required therapy. The iris stromal cysts commonly required therapy including aspiration, additional cryotherapy, or additional alcohol sclerosis.
Discussion: In our series, 20 eyes with iris stromal cyst required aspiration and alcohol sclerosis. The cyst measured median basal diameter of 12 mm and often occupied 50% or more of the
anterior chamber. In each case, fine needle aspiration had been tried and failed, requiring further
aspiration and alcohol sclerosis. Each eye received therapy under anesthesia using the operating microscope with a T-tube set up for aspiration and injection. Two or three washes of alcohol
for maximum 2 minutes was performed at each treatment. The treatment was successful with
one administration in 15 cases, but 5 patients required more than one treatment. Of the treated
20 eyes, 19 (95%) eyes were successful with cyst collapsed at median 5 year follow up. Only 1
patient failed, with severe photophobia, requiring surgical resection. Visual acuity remained stable
or improved in 19 cases and worsened in 1 eye that developed cataract. Complications included
transient corneal edema (n=4) and transient anterior chamber inflammation (n=1), which resolved
with topical corticosteroids. There was no evidence of treatment-related glaucoma, epithelial
downgrowth, tissue necrosis, retinal toxicity, or need for enucleation.
Conclusion: Iris stromal cysts often require intervention. If aspiration alone fails, aspiration with
alcohol sclerosis can be successful, allowing collapse of cyst without the need for open resection.
References: 1. Shields CL, Kancherla S, Patel J ,Vijavargiya P, Suriano M, Kolbus E, Badami A, Sharma P, Jacobs E, Voluck M, Zhang Z, Kansal
R, Shields PW, Bianciotto CG, Shields JA, Clinical survey of 3680 iris tumors based on patient age at presentation. Ophthalmology 2012;119:40714. 2. Shields JA, Shields CL, Lois N, Mercado G. Iris cysts in children: Classification, incidence and management. The 1998 Torrence A Makley
Jr. Lecture. Br J Ophthalmol 1999,83:334-8. 3. Shields CL, Arepalli S, Lally SE, Lally EB, Shields JA. Iris stromal cyst management with absolute
alcohol-induced sclerosis in 16 patients. JAMA Ophthamol 2014; 132:703-8.
61
Poster 26
Thursday
10:00 - 11:00 am
Poster 27
Thursday
10:00 - 11:00 am
Clinical and visual outcomes of children with Peters anomaly
Asim Ali Hermina Strungaru Uri Elbaz Kamiar Mireskandari
Department of Ophthalmology and Vision Sciences, Hospital for Sick Children
University of Toronto, Toronto, Ontario, Canada.
Introduction: Peters anomaly is the most common cause of congenital corneal opacity. The
variable severity of the disease mandates a tailored management approach. Here we present
the clinical and visual outcomes of patients with Peters anomaly using such an approach.
Methods: The charts of all Peters anomaly patients at the Hospital for Sick Children were reviewed retrospectively. Visual outcomes reviewed included visual acuity and the presence of
nystagmus. Clinical outcomes included penetrating keratoplasty (PKP) survival and incidence
of glaucoma and strabismus. Data were stratified per treatment modality chosen.
Results: Sixty-four eyes in 44 patients were included in the study. Mean final best corrected
visual acuity of the medical, surgical and no-treatment groups were 0.4 ± 0.1, 1.1 ± 0.8 and
1.3 ± 1.3 logMAR, respectively. Twenty-seven eyes (42.2%) developed nystagmus. Survival
analysis of first PKP showed 83.7% probability for a clear graft at 24 months. Among the PKP
eyes, thirty-one eyes (79.5%) retained a clear graft at last follow-up. Overall, Twenty-one eyes
(32.8%) developed glaucoma. The incidence of strabismus was 56.3%.
Discussion: Previous studies1,2 reporting Peters anomaly outcomes were either focusing
on a single treatment modality or on a subgroup of Peters anomaly eyes. Our study shed light
on the visual and clinical outcomes of Peters anomaly eyes after a mean long follow-up time
over 4 years.
Conclusion: Visual rehabilitation in Peters anomaly remains a great challenge. Mild cases
necessitating monitoring or minor surgical intervention can achieve good visual outcomes.
However in cases where PKP is indicated visual acuity is poor despite encouraging graft
longevity.
References: 1. Yang LL, Lambert SR, Lynn MJ, Stulting RD. Long-term results of corneal graft survival in infants and children with peters anomaly.
Ophthalmology. 1999;106(4):833-848. 2. Zaidman GW, Flanagan JK, Furey CC. Long-term visual prognosis in children after corneal transplant
surgery for Peters anomaly type I. American journal of ophthalmology. 2007;144(1):104-108.
Poster 28
Thursday
10:00 - 11:00 am
Epidemiology and Clinical Characteristics of Pediatric Eyelid Retraction
Jessica A Olayanju MD Gregory J Griepentrog MD Brian G Mohney MD
Mayo Clinic, Rochester, MN
Introduction: Although eyelid retraction is a relatively rare form of eyelid malposition in
children, there is no population-based data on this condition. The purpose of this study
was to describe the incidence and clinical characteristics of eyelid retraction in children.
Methods: The medical records of all pediatric patients (<19 years) diagnosed with
eyelid retraction from January 1, 1976, through December 31, 2010, at Olmsted County,
Minnesota were retrospectively reviewed.
Results: A total of 62 were diagnosed during the study period, of which 15 were from
a well-defined geographic region, yielding an annual incidence of approximately 1 in
77,519 patients younger than 19 years. The median age at diagnosis was 11.5 years
(range 1 day to 18.72 years). Upper lid retraction occurred in 35 (56%) patients, lower
in 18 (29%) patients, and both upper and lower retraction in 9 (15%) patients. The most
common causes of lid retraction were thyroid eye disease (40%), trauma (15%), and
congenital lid retraction (10%). While symptoms including tearing, ocular surface irritation and photophobia were noted in 24 (38%) patients, there were no documented cases
of visual impairment secondary to eyelid retraction. Seventeen (27%) of the 62 patients
required surgical intervention with 94% improvement.
Discussion: In this 35 year cohort of pediatric eyelid retraction, approximately two-thirds
were due to thyroid eye disease, trauma, or congenital eyelid retraction. No visual disturbances were noted and only 1 in 4 patients required corrective surgery.
Conclusion: Pediatric eyelid retraction is a rare condition that is most likely associated
with a thyroid disorder and no visual abnormalities.
References: 1. Bartley GB. The differential diagnosis and classification of eyelid retraction. Ophthalmology 1996;103(1): 168-76. 2. Stout AU,
Borchert M. Etiology of eyelid retraction in children: a retrospective study. J Pediatr Ophthalmol Strabismus 1993;30(2): 96-9. 3. Katowitz WR,
Katowitz JA. Congenital and developmental eyelid abnormalities. Plast Reconstr Surg 2009;124(1 Suppl): 93e-105e.
62
Poster Schedule
2nd Set of Hard Board Posters (29-56) Displayed from Friday, March 27, 4:15 PM - Sunday, March 29 11:10 AM
Storyville Hall
Interactive Poster Session - Author Presentation and Q/A - Saturday, April 5, 9:55 - 10:55 AM
AMBLYOPIA
Poster #29
Poster Withdrawn
Poster #30
Macular Structure and Fixation Pattern in Amblyopic and Healthy Eyes
Jing Jin, MD, PhD
Annie Apple; Amanda M. Friess, OD; Sharon S. Lehman, MD; Jonathan H. Salvin, MD
Poster #31
The Analysis of Peripapillary Retinal Nerve Fiber Layer, Macular, Macular Ganglion Cell Layer Thicknesses in
Patients with Monocular Amblyopia Using SD OCT
Young Je Choi, MD
Ji Sung Jung, MD; Yong Ju Song, MD; Dae Hyun Kim, MD, PhD
Poster #32
Distinctive Features of Microsaccades in Amblyopia and Refractive Blur
Priyanka Kumar, MD
Aasef Shaikh, MD, PhD; Fatema Ghasia, MD
Poster #33
Objective Compliance for Atropine Penalization Treatment of Amblyopic Children
Jingyun Wang
Heather A. Smith; Kathryn M. Haider; Tina Damarjian; Joshua Schliesser; Derek T. Sprunger;
Gavin J. Roberts; Dana L. Donaldson; Lyne Racette; Daniel E. Neely; David A. Plager
Poster #34
Amblyogenic Factors in Children with Neurofibromatosis Type 1 and Their Relation to the Management of Optic
Pathway Gliomas
Eva Gajdosova
Susmito Biswas; Jane L. Ashworth; Christopher I Lloyd
Poster #35
Severe Corneal Complications in Children with Blepharitis
Diyaa Rachdan, MD, MSc(Oxon), FRCOphth
M. Saad Khan; Asim Ali, MD, FRCSC; Kamiar Mireskandari, MBChB, FRCSEd, FRCOphth, PhD
Poster #36
A Review of Traumatic Open Globe Injury in Young Pediatric Patients: Epidemiology and Outcomes
Sarah P. Read
Kara Cavuoto
Poster #37
Clinical Application of the ATOM2 Study: Atropine 0.01% Significantly Reduces Childhood Myopic Progression
Tiana Y. Clark
Robert A. Clark, MD
Poster #38
Excimer Laser Refractive Surgery Outcomes in 405 Children and Adolescents
Nicholas Faron
James Hoekel; Lawrence Tychsen
Poster #39
Long-Term Developmental Improvement in Children with Neurobehavioral Disorders Following Photorefractive
Keratectomy for Bilateral Isoametropic Amblyopia
Charity H. Grannis, MD
Lingkun Kong, MD, PhD; Bryan T. Whitlow, MS; Catherine Achim, MD; Daniel Wang, MD;
Mitchell Weikert, MD; David Coats, MD; Evelyn A. Paysse, MD
Poster #40
A Cost Comparison Study between Recommendations from the Americal Optometric Association and
Recommendations from the American Association for Pediatric Ophthlamology and Strabismus on the
Correction of Hyperopia in Children
Philip Niles
Ali R. Cohen; Scott A. Larson; Richard J Olson; William E. Scott
VISION SCREENING
Poster #41
Pediatric Vision Screening: The Colorado School Nurse Experience
Rebecca S. Braverman, MD
Poster #42
Vision First: A Comprehensive Screening Program for Young Children
Joseph F. Griffith, MD
Heather C. Cimino, OD; Rhonda Wilson, MA; Mayme Patthoff; Daniel F. Martin, MD;
Elias I. Traboulsi, MD
63
Poster #43
A New Computer-Based Pediatric Vision-Screening Test
David A. Leske, MS
Sarah R. Hatt, DBO; Tomohiko Yamada, OD, FAAO; Pamela S. Moke, MSPH; Nick L. Parrucci, BSCS;
J. Jeffrey Reese, BA; James B. Ruben, MD; Jonathan M. Holmes, BM, BCh
CATARACT
Poster #44
Visual Outcomes of Patients with Congenital Cataracts and Sensory Nystagmus
Charlene H. Crockett, MD
Lingkun Kong, MD, PhD; Kathryn A. Camero; Kimberly G. Yen, MD
Poster #45
Axial Growth and Clinical Outcomes of Children Operated for Bilateral Ectopia Lentis
Jennifer D. Davidson, MD
M. Edward Wilson, MD; Rupal H. Trivedi, MD; Leah A Owens, MD; Dina Sabry
Poster #46
Baseline Characteristics of the Infant Aphakia Treatment Study Population: How Well Can They Predict
Recognition Visual Acuity at 4.5 Years?
E. Eugenie Hartmann, PhD
Michael J. Lynn; Scott R. Lambert, MD
Poster #47
Endothelial Cell Counts in Children after Unilateral Cataract Surgery in the Infant Aphakia Treatment Study
David G. Morrison
Michael J. Lynn; Faruk H. Orge; Scott R. Lambert; Infant Aphakia Treatment Study Group
Poster #48
Incidence, Natural History, and Outcomes of Traumatic Cataract after Hyphema Associated with Blunt Ocular
Trauma in Children
Ankoor S. Shah, MD, PhD
Olumuyiwa T. Adebona, MBChB, MPH
Poster #49
A New Diagnostic Approach to Children with Cataract Caused by Metabolic Disease
Rachel L. Gillespie
Jane Ashworth; Susmito Biswas; Simon C. Ramsden; Jill Clayton-Smith; I. Chris Lloyd; Graeme C. Black
GLAUCOMA
Poster #50
Rebound Tonometry Over an Air-Filled Anterior Chamber in the Supine Child after Intraocular Surgery
Ryan Davis
Kim Jiramongkolchai; Evan Silverstein; Sharon F. Freedman
Poster #51
Longitudinal Evaluation of Intraocular Pressure in Pediatric Hyphema: A New Paradigm for Followup
Charlotte Gore
Olumuyiwa Adebona; Ankoor S. Shah
NYSTAGMUS
Poster #52
Surgical Outcomes Using a Modified Anderson-Kestenbaum Operation
Charline S. Boente
Faruk H. Orge; Beth J. Colon
Poster #53
Two Types of Head Oscillations in Infantile Nystagmus Syndrome
Fatema F. Ghasia, MD
Aasef G. Shaikh, MD, PhD
PUBLIC HEALTH
Poster #54
Clinicopathological Findings in Abusive Head Trauma: Analysis of 110 Infant Autopsy Eyes
Kelly H. Unkrich, MD
Mark P. Breazzano, MD; Ann E. Barker-Griffith, MD
Poster #55
Pediatric Eye Injuries Due to Nonpowder Guns in the United States, 2002-2012
Rachel H. Lee, BS
Douglas Fredrick, MD
Poster #56
Residency Factors that Affect Residents’ Pursuit of Pediatric Ophthalmology
Elizabeth S. John, BA
Airaj F. Fasiuddin, MD; Bertha A. Nash, MA
64
Poster 29
Saturday
9:55 - 10:55 am
Poster Withdrawn
Macular Structure and Fixation Pattern in Amblyopic and Healthy Eyes
Jing Jin MD, PhD Annie Apple Amanda M Friess OD Sharon S Lehman MD
Jonathan H Salvin MD Dorothy H Hendricks MD
Nemours A. I. duPont Hospital for Children
1600 Rockland Road, Wilmington, DE 19803
Introduction: To compare macular thickness and fixation behavior of amblyopic eyes,
fellow eyes and normal eyes.
Methods: Spectral-Domain OCT images of the macula were obtained from both eyes
of each patient. Thickness measurements of the fovea and surrounding quadrants were
recorded. When the fixation point and fovea did not coincide, shift distances between
these two points were measured.
Results: This study included 72 children with amblyopia (53 refractive and 16 strabismic
or combined) and 47 children with normal examination. Eyes were placed in 3 groups:
amblyopic (n = 73), fellow (n = 71) and normal (n = 94). One-way ANOVA was performed
to compare retina thickness and no significant differences were found in the means
across the groups. Pearson correlation tests indicate that the fixation shift distance has a
negative relationship with visual acuity (R= -0.258, p= 0.005) and a positive relationship
with stereopsis (R= 0.371, p=0.000). The mean shift distance for amblyopic eyes (272.85
±466.62 µ) is significantly different from that for fellow eyes (40.58 ± 122.86, p = 0.000),
and for normal eyes (16.84±69.33, p = 0.000).
Discussion: The study found no detectable morphological difference in central retina
thickness among amblyopic, fellow and normal eyes by spectral-domain OCT. Amblyopic
eyes showed greater fixation shift distance than the fellow and normal eyes.
Conclusion: The pathophysiology of amblyopia is not a structural imperfection in the
retina. Fixation shift is present in refractive and strabismic amblyopia. Shift distance may
be used as an indicator of visual function.
65
Poster 30
Saturday
9:55 - 10:55 am
Poster 31
Saturday
9:55 - 10:55 am
The Analysis of peripapillary retinal nerve fiber layer, macular, macular ganglion
cell layer thicknesses in patients with monocular amblyopia using SD OCT
Young Je Choi MD Ji Sung Jung MD Yong Ju Song MD Dae Hyun Kim MD, PhD
Department of Ophthalmology, Chosun University Hospital
Seoseok-dong, Dong-gu, Gwangju, Korea
Introduction: To determine whether peripapillary retinal nerve fiber layer (PRNFL),
macular, macular ganglion cell layer (MGCL) thicknesses differ in the amblyopic and
normal eyes of unilateral amblyopic patients using spectral domain(SD) OCT.
Methods: 160 eyes from 80 patients were researched. 17 patients with Strabismic
amblyopia, control group of 17 patients with strabismic non-ambylopia, 23 patients with
anisometropic ambylopia and control group of 23 patients with anisometropic nonambylopia. PRNFL, macular and MGCL thicknesses were obtained by SD-OCT, and the
interocular thickness differences of each groups were analyzed. After treatments, amblyopic patients were evaluated in the changes of parameters.
Results: Average PRNFL and MGCL of amblyopic eyes were thicker than normal eyes in total amblyopic 40 patients, but no differences in macular thicknesses
(p<0.001,p<0.001,p=0.835). In 23 patients with anisometropic ambylopia, average
PRNFL, MGCL of amblyopic eyes were thicker than normal eyes, but no differences in
macular thicknesses (p=0.008,p<0.001,p=0.986). In 17 patients with strabismic ambylopia, only average PRNFL of amblyopic eyes were thicker than normal eyes, but no differences in macular, MGCL thicknesses (p=0.016, p=0.752, p=0.241). No interocular thickness difference was observed in control groups. After treatment, no change of parameter
was observed in amblyopic eye.
Discussion: In monocular amblyopia, there were differences of thicknesses in average
PRNFL, MGCL between amblyopic eyes and normal eyes, but no differences in macular
thicknesses. The differences in parameters among amblyopic patients however, remained same after the treatments.
Conclusion: This study showed the inner retina is anatomically related with ambylopia
in location and the outer retina has no relation with ambylopia.
Poster 32
Saturday
9:55 - 10:55 am
Distinctive Features of Microsaccades in Amblyopia and Refractive Blur
Priyanka Kumar MD Aasef Shaikh MD, PhD Fatema Ghasia MD
Cole Eye Institute, Cleveland Clinic Foundation
Cleveland, Ohio, USA
Introduction: Miniature eye movements like microsaccades shift the image on the fovea
and counteract visual fading that occurs from neural adaptation. They are also thought
to serve as an optimal sampling strategy while viewing complex visual scenes. The goal
of the study was to assess the influence of a) simple visual blur induced by uncorrected
refractive error (RE) and b) amblyopia on microsaccades.
Methods: Ten healthy controls (HC) with RE and best-corrected vision of 20/20 and 22
amblyopes (mild =7;moderate= 10;severe=3) held their gaze on a stationary visual target. Eye movements were recorded using infrared video-oculography in a) HC with and
without correction of RE and b) amblyopes during amblyopic and fellow eye viewing.
Results: The microsaccade frequency in HC in corrected RE (median =2.3Hz) versus
uncorrected RE (median=2.1Hz) was unchanged (Wilcoxin-rank test p=0.3). The microsaccade amplitude was higher in the uncorrected RE (median=0.8°) versus corrected
RE (median=0.7°) (K-S test p<0.05). The percentage increase in amplitude correlated
with the increase in uncorrected RE (linear regression R2=0.68, p=0.02). There was a
systematic decrease in the frequency of microsaccades with increasing severity of amblyopia (median:mild = 1.8Hz; moderate = 1.4Hz; severe =0.5Hz, ANOVA p < 0.05). The
microsaccade amplitude decreased with increasing severity of amblyopia (median:mild =
0.59°; moderate = 0.57°; severe =0.49°, ANOVA p<0.05).
Discussion: Abnormal visual processing and circuitry reorganization results in altered
microsaccades in amblyopia. These changes in fixational eye saccades cannot be explained by simple visual blur.
Conclusion: Microsaccades can be an objective disease marker for amblyopia.
66
Objective compliance for atropine penalization treatment of amblyopic children
Jingyun Wang Heather A Smith Kathryn M Haider Tina Damarjian Joshua Schliesser
Derek T Sprunger Gavin J Roberts Dana L Donaldson Lyne Racette Daniel E Neely
David A Plager
Glick Eye Institute, Department of Ophthalmology, Indiana University School of Medicine
Indianapolis, Indiana
Poster 33
Saturday
9:55 - 10:55 am
Introduction: Self-reported subjective compliance to atropine penalization ranges from 59%
to 94%.[1-3] Objective measurement of compliance to atropine penalization has not been
reported. This study aims to investigate objectively-measured compliance to atropine penalization treatment in amblyopic children.
Methods: Twelve amblyopic children (3-8yr; 20/40-20/125 in the amblyopic eye) were
enrolled. None were treated with atropine previously. We used Medication Event Monitoring
System (MEMS) caps to objectively measure compliance. The MEMS caps are designed
to record the time and date when the bottle was opened. Participants were also provided a
calendar log to report compliance. They were scheduled for return visits at 4 and 12 weeks.
Objective compliance was calculated as the ratio of MEMS weekly recording times to weekly
regimen. Weekly regimen was based on physicians’ prescription, either twice per week or
daily treatment.
Results: At 4-weeks, objective compliance averaged 78% (range 57-100%), while subjective
compliance was reported to be 84% (range 64-100%). At 12-weeks, the average objective
compliance was 62% (range 41-100%), while subjective compliance was 84% (range 78100%). Interestingly, we found that the twice a week regimen had significantly higher objective compliance than the daily regimen (p=0.03).
Discussion: Objective compliance with atropine instructions can be monitored with MEMS,
which may facilitate more effective communication between clinicians and patients.
Conclusion: Objective compliance with atropine penalization instructions decreases over
time and varies with regimen. On average, subjective parental reporting of compliance is
overestimated.
References: 1. Scheiman MM, Hertle RW, Kraker RT, et al. Patching vs atropine to treat amblyopia in children aged 7 to 12 years: a randomized
trial. Archives of ophthalmology 2008;126:1634-1642.
2. Pediatric-Eye-Disease-Investigator-Group. Pharmacological plus optical penalization
treatment for amblyopia: results of a randomized trial. Archives of ophthalmology 2009;127:22-30. 3. Pediatric-Eye-Disease-Investigator-Group. A
randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. Archives of ophthalmology 2002;120:268-278.
Amblyogenic factors in children with Neurofibromatosis Type 1 and their relation
to the management of optic pathway gliomas.
Eva Gajdosova, Susmito Biswas, Jane L Ashworth, Christopher I Lloyd
Manchester Royal Eye Hospital, Manchester Academic Health Science Centre
Manchester, United Kingdom
Introduction: We wished to determine occurrence of amblyogenic factors in patients
(pts.) with Neurofibromatosis Type 1 (NF1) and its relation to the management of the
patients with optic pathway glioma (OPG).
Methods: Retrospective case note review of pts. with NF1, age 0-18 years, referred to a
newly set up NF1 clinic between Jan 2013 and July 2014 was performed. Age at referral,
visual acuity, amblyogenic factors and presence of OPG was recorded and analysed by
descriptive statistical methods.
Results: We identified 56 pts. (25 females, 31 males), 5 pts. age <2 years, 25 pts. age
=2<8 years, 26 pts. age =8<18 years. 27/56 pts. had at least one amblyogenic factor
(significant ametropia or anisometropia 33%, ptosis 22%, strabismus 19% and strabismus with ametropia 22%, and early acquired nystagmus 4%). OPG was present in 46%
pts. (26/56). Amblyogenic factors were identified in 16 pts. with OPG and 11 pts. without
known OPG. There were 13 pts. under 8 years of age (6/16 with OPG) currently treated/
monitored for amblyopia. 4/6 pts. with OPG responded to amblyopia treatment. 2/16 did
not respond and MRI scanning confirmed OPG. 1/16 developed papilloedema. In total
there was 185 clinical appointments (average 3 app./pt., range 1-8).
Discussion: In this small series 48% of pts. with NF1 had at least one amblyogenic factor. It is important to manage amblyopia in all patients undergoing screening for possible
OPG or active monitoring because of OPG.
Conclusion: Identification and treatment of amblyopia can possibly avert unnecessary
use of chemotherapy in some pts. with OPG.
67
Poster 34
Saturday
9:55 - 10:55 am
Poster 35
Saturday
9:55 - 10:55 am
Severe corneal complications in children with blepharitis
Diyaa Rachdan MD, MSc(Oxon), FRCOphth; M . Saad Khan; Asim Ali MD, FRCSC;
Kamiar Mireskandari MBChB, FRCSEd, FRCOphth, PhD
The Hospital for Sick Children, Toronto, Canada
Introduction: Blepharitis is a chronic inflammation of lid margins that can lead to
spectrum of ocular surface involvement such as phlyctenules, neovascularization, lipid
deposits, scarring and irregular astigmatism. In children, these may compromise visual
acuity and lead to amblyopia (1,2). In this study we report the visual outcome and corneal
complications in pediatric blepharitis.
Methods: Records of all children with blepharitis seen between 2006-13 were reviewed.
Inclusion criteria were corneal lesions due to blepharitis (new vessels, inflammation,
opacity, thinning, or lipid deposits) and follow-up of >/=6 months. Other ocular pathologies that might affect vision were excluded. Initial and final BCVA, medications and surgical procedures were recorded.
Results: We identified 123 patients with mean age of 8.0 years (0.8 - 17.3) and followup of 30.4 months. Central pathology was present in 35% of all eyes and 60% of patients
needed systemic antibiotics. Final visual acuity worse than 20/40 was associated with
requiring corneal surgery (odds ratio: 4.69), presence of central pathology (OR; 3.05),
and needing topical steroids (OR: 1.57). Eleven patients required surgical intervention.
Discussion: Blepharokeratoconjunctivitis is a serious disease in children and may
affects central cornea early and without peripheral lesions in a significant proportion of
children. A heightened level of vigilance and early intervention is required to prevent vision loss.
Conclusion: Pediatric BKC causes central scars in a third of eyes resulting in poor visual outcome and need for topical steroids and surgery. Lamellar corneal surgery restores
media clarity but vision can be limited by amblyopia in half of cases.
References: 1. Daniel S. Choi, and Ali Djalilian, Oral azithromycin combined with topical anti-inflammatory agents in the treatment of blepharokeratoconjunctivitis in children. J AAPOS. 2013 February ; 17(1): 112-113
2. Gupta N, Dhawan A, Beri S, and D’souza P. Clinical spectrum of
pediatric blepharokeratoconjunctivitis.J AAPOS 2010 Dec;14(6):527-9
Poster 36
Saturday
9:55 - 10:55 am
A Review Of Traumatic Open Globe Injury in Young Pediatric Patients:
Epidemiology And Outcomes
Sarah P Read Kara Cavuoto
Department of Ophthalmology, Bascom Palmer Eye Institute
University of Miami Miller School of Medicine, Miami, FL, USA
Introduction: Open globe injury is one of the most common causes of monocular blindness in children. To date, there is little data addressing the effects of pediatric open globe
trauma on long-term complications and visual prognosis, especially in younger pediatric
patients. In this study we aim to correlate presentation and intervention with visual outcomes in young children at high risk for amblyopic complications.
Methods: Retrospective chart review of patients age 0-6 years old presenting with open
globe injury from 2000-2013.
Results: Epidemiology revealed that subjects were 61% male with a mean age of
4.2 years old. Glass was the most common mechanism of injury. Associated findings
included uveal prolapse (93%), choroidal detachment (39%), hyphema (32%), and retinal
detachment (11%). Cataract (p<0.005) and a wound greater than 6 mm (p<0.05) were
found to be associated with a final visual acuity worse than 20/40. There was a statistically significant improvement in visual acuity in patients who started patching less than
20 days after injury (p<0.05).
Discussion: Patients age 0-6 years with open globe injuries present a unique population with different risk factors for poor outcome. We propose a novel algorithm for
predicting indicators of poor visual outcome (less than 20/40) with a 92% sensitivity and
81% specificity.
Conclusion: A different prognostic algorithm that does not rely on presenting visual
acuity is needed in young children. Factors that increase amblyopia are more indicative
of poor outcome than in other age groups. Patching immediately after surgery correlates
with improved outcomes.
68
Clinical Application of the ATOM2 Study: Atropine 0.01% Significantly Reduces
Childhood Myopic Progression
Tiana Y Clark Robert A Clark MD
Family Eye Medical Group, Long Beach, CA
Poster 37
Saturday
9:55 - 10:55 am
Introduction: Atropine 0.01% drops have been shown to slow childhood myopic progression in selected populations. We studied its effects on an ethnically diverse population over a broad range of myopia.
Methods: A retrospective case-control study was performed on 56 children (6-15 years)
with initial myopic spherical equivalents from -0.25 to -8.00. The primary measure was
the rate of myopic progression per year. Secondary measures were the proportions of
subjects with minimal or rapid myopic progression and atropine-related side effects.
Results: The average initial age (10.2 years) and refraction (-2.0 D) were identical
between groups. After 1.1±0.3 years follow up, atropine subjects had significantly lower
rates of myopic progression (-0.1±0.6 D/yr) than controls (-0.6±0.4 D/yr) (p=0.001),
including 20/28 (71%) with myopic progression ≤ -0.25 D/yr versus only 5/28 (18%)
controls. Three atropine and four control subjects had myopic progression ≥ -1.00 D/yr.
For subjects with low initial myopia (≤-1.00 D), 7/9 (78%) atropine subjects had plano or
slightly hyperopic refractive changes after one year, while 9/9 (100%) controls were more
myopic. Only three atropine subjects complained of intermittent blur or light sensitivity,
not symptomatic enough to discontinue treatment.
Discussion: Atropine 0.01% significantly reduced the rate of myopic progression over
one year with minimal side effects. It appears most effective in subjects with low initial
myopia and may not control rapid myopic progression in some patients.
Conclusion: Atropine 0.01% reduces childhood myopic progression and should be considered for lower levels of myopia. Stronger concentrations of atropine may be required
to slow rapid myopic progression.
References: 1. Chua W, Balakrishnan V, Chan Y, Ling Y, Quah B, Tan D. Atropine for the treatment of childhood myopia. Ophthalmology.
2006;113:2285-91. 2. Chia A, Chua W, Cheung Y, Wong W, Fong A, Tan D. Atropine for the treatment of childhood myopia: Safety and efficacy
of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. 2012;119:347-54. 3. Chia A, Chua W, Wen L, Fong
A, Goon Y, Tan D. Atropine for the treatment of childhood myopia: Changes after stopping atropine 0.01%, 0.1%, and 0.5%. Am J Ophthalmol.
2014;157:451-7.
Excimer Laser Refractive Surgery Outcomes in 405 Children and Adolescents
Nicholas Faron James Hoekel Lawrence Tychsen
St. Louis Children’s Hospital at Washington University Medical Center
St. Louis, MO
Introduction: Reports of using the excimer laser to treat myopic & hyperopic refractive
errors in children have been limited to case reports. We analyze outcomes in 405 ametropic children who were noncompliant with spectacles or contact lenses.
Methods: Clinical outcome data were collated prospectively in 231 myopic children (371
eyes) and 174 hyperopic children (283 eyes) treated for isoametropic or anisometropic
refractive error using excimer laser keratectomy. 86% of the patients had a preexisting
neurobehavioral disorder and/or visuomotor co-morbidities. The mean age at refractive surgery was 11.3 years (range 3 to 20); mean follow-up was 3.6 years (range 1-13
years).
Results: Myopic spherical refractive error averaged -4.91±3.08D (range -0.50 to -14.50)
and hyperopic spherical refractive error averaged 3.84±1.51D (range 0.50 to 6.75). 96%
of myopic & 91% of hyperopic eyes were corrected to within ±1D of their target value.
After 5 years, refractive regression was -0.10D/yr in myopes and +0.10D/yr in hyperopes.
Myopic & hyperopic BCVA improved 0.12 logMAR & 0.08 logMAR; UCVA improved 0.44
logMAR and 0.26 logMAR, respectively. 91% of myopic & hyperopic eyes treated with
mitomycin-C had no haze (no child with postoperative haze lost BCVA). 51% of children
treated had a gain in at least one level of binocular fusion. Retreatment was conducted in
1.5% of the treated eyes.
Discussion: Refractive error and visual acuity substantially improved from preoperative
measurements.
Conclusion: Excimer laser surgery is an effective means for improving visual function
and quality of life in moderately ametropic children who have difficulties wearing spectacles.
69
Poster 38
Saturday
9:55 - 10:55 am
Poster 39
Saturday
9:55 - 10:55 am
Long-Term Developmental Improvement in Children with Neurobehavioral Disorders Following Photorefractive Keratectomy for Bilateral Isoametropic Amblyopia
Charity H Grannis MD Lingkun Kong MD, PhD Bryan T Whitlow MS Catherine Achim MD
Daniel Wang MD Mitchell Weikert MD David Coats MD Evelyn A Paysse MD
Baylor College of Medicine, Houston, TX
Introduction: To assess long-term impact of PRK correction of severe isoametropia on
the development of children with neurobehavioral problems.
Methods: This is a prospective, interventional case series. Children with neurobehavioral disorders and severe isoametropia unwilling to use refractive correction underwent
PRK surgery. Developmental status was evaluated preoperatively and at 6, 12, 24 and
36 months posoperatively. The main outcome measure was developmental quotient
(DQ). Secondary outcome measures were uncorrected visual acuity and cycloplegic
refraction.
Results: Fifteen children aged 2-8 years were included. Twelve were myopic
(-9.8±3.9D), two hyperopic (+5.8 ± 0.4D) and one astigmatic (+3.5D). Significant DQ
improvement was found in receptive, expressive and written communication (p=0.001,
0.05, 0.04 respectively), domestic daily living skills (p=0.03) and interpersonal socialization skills (p=0.02) for the first 12 months, which then plateaued. Improvement in visual
perception and motor coordination occurred at 36 months postoperatively. Uncorrected
visual acuity improved after PRK (logMAR +1.25 ± 0.6 to +0.55 ±0.4). Mean spherical
equivalent refractive error was significantly improved at 6 and 36 months at -0.6 ± 1.5D
and -1.7 ± 2.2D for the myopic group, +1.4 ± 1.1D and +2.0 ± 1.1D for hyperopic group
and +1.6 ± 0.5D and +2.4 ± 0.2D for the astigmatic patient.
Discussion: Long-term improvement in development, visual acuity and refractive error
was found in children with neurobehavioral disorders following PRK.
Conclusion: PRK can enhance the quality of life of children with neurobehavioral disorders with severe isoametropia.
Poster 40
Saturday
9:55 - 10:55 am
A Cost Comparison Study between Recommendations from the American Optometric Association and Recommendations from the American Association for Pediatric Ophthalmology and Strabismus on the Correction of Hyperopia in Children
Philip Niles Ali R Cohen Scott A Larson Richard J Olson William E Scott
University of Iowa Department of Ophthalmology and Visual Sciences, Iowa City, IA
Introduction: There are many different recommendations to guide ophthalmologists and optometrists when
prescribing hyperopic correction in children. This study examines the difference in healthcare costs between
the recommendations from the American Optometric Association (AOA) and the recommendations from the
American Association for Pediatric Ophthalmology and Strabismus (AAPOS).
Methods: Race-specific population data was retrieved from 2010 US Census Bureau records for children
ages 2- to 6-years-old. The prevalence of children for each dioptric refraction was calculated using race- and
age- specific data from the Baltimore Pediatric Eye Disease Study. The number of children who would meet
AOA and AAPOS prescription recommendations was determined. AOA recommends correcting for +3.00D or
more of hyperopia for children up to age 10-years-old. AAPOS recommends correcting for +4.00D or more of
hyperopia in 2- to 7-year-old children[M1] . The total one-time cost of each association’s recommendations
was then determined by multiplying the number of children who would receive spectacle correction[M2] by the
median cost of pediatric spectacles, which was determined from a 2013 industry survey of 171 independent
optical retailers. The cost of glasses wear was conservatively limited to the initial purchase price of one pair of
spectacles.
Results: There were 21,558,917 American children between the ages of 2- and 6-years-old, inclusively. There
was an expected prevalence of: 1,225,070 children with a refraction of +3.00D but less than +4.00D, 351,311
children with +4.00D but less than +5.00D, and 410,688 children with +5D or greater. The median cost for
pediatric frames is $125 and the median cost for lenses is $120. The total cost would be $486.8 million using
AOA recommendations and $186.7 million using AAPOS recommendations. AAPOS recommendations would
decrease healthcare costs by $300.1 million (62%) compared to AOA recommendations.
Discussion: Different recommendations for hyperopic correction between AOA and AAPOS lead to a significant cost difference on hyperopic correction in 2- to 6-year-old children. This difference would be even larger if
the cost of glasses wear accounted for the need for subsequent glasses and spectacle repair.
Conclusion: There is a large cost difference between AOA’s and AAPOS’s hyperopic correction recommendations. The cost of healthcare recommendations should be taken into consideration when making healthcare
policy.
References: 1. American Optometric Association. Optometric clinical practice guideline: Care of the patient with hyperopia. St. Louis, MO: American Optometric Association; 1997, Revised 2008 2. Miller JM, Harvey EM. Spectacle prescribing recommendations of AAPOS members. Journal
of Pediatric Ophthalmology and Strabismus 1998;35:51-52
3. U.S. Census Bureau, Population Division. Estimates of the Resident Population by
Sex, Single Year of Age, Race Alone or in Combination, and Hispanic Origin for the United States: April 1, 2010 to July 1, 2011. Release Date: May
2012 4. Giordano, Lydia, et al. “Prevalence of refractive error among preschool children in an urban population: the Baltimore Pediatric Eye Disease Study.”Ophthalmology 116.4 (2009): 739-746.
5. Nicola G. “Kidz Statz: A Serious Business that Keeps on Growing.” 20/20’s KidzBiz (20/20
Magazine KidzBiz supplement). 2014;July:38-40. available online at: http://bt.e-ditionsbyfry.com/article/KIDZ_STATZ/1751528/1215860/article.html.
70
Pediatric Vision Screening: The Colorado School Nurse Experience
Rebecca S Braverman M.D.
University of Colorado School of Medicine
Aurora, Colorado
Poster 41
Saturday
9:55 - 10:55 am
Introduction: Colorado law mandates school vision screening and referral to an eye
care specialist if deficiencies are identified. The purpose of this study is to elucidate the
vision screening experience of school nurses in Colorado.
Methods: A questionnaire was sent to 774 members of the Colorado Department of
Education School Nurse listserv in 2014.
Results: 218 of 774 (28%) questionnaires were completed. 88 % of the respondents
were public school nurses.
Discussion: The majority of respondents followed the vision screening and referral
guidelines recommended by AAPOS/AAO/AAP and the Colorado Department of Education(1-2). Most nurses did not use instrument based screening. Screening accuracy may
be reduced since less than 1% of respondents used occlusive patches and 78% allowed
the child to hold the occluder during monocular vision testing. Reported screening challenges included: poor student cooperation/inability to screen, inadequate testing space &
lighting, insufficient personnel and poor parental compliance with referrals.
Conclusion: Colorado school nurses report significant challenges in the implementation of vision screening programs. Poor parental/guardian compliance with referrals is a
significant threat to the effectiveness of vision screening(3).
References: 1. American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology, Vision Screening
for Infants and Children. 2013. http://www.aapos.org//client_data/files/2014/337_visionscreeningforinfantsandchildren_2013.pdf. 2. Guidelines
for school vision screening programs: Kindergarten through Grade 12. 2006. http://www.cde.state.co.us/sites/default/files/documents/healthandwellness/download/nurvisionguidelines.pdf. 3. Tjiam AM, Groenewoud JH, Passchier J, et al. Determinants and outcome of unsuccessful referral after
positive screening in a large birth-cohort study of population-based vision screening. J AAPOS. 2011;15(3):256-62.
Vision First: a Comprehensive Screening Program for Young Children
Joseph F Griffith MD Heather C Cimino OD Rhonda Wilson MA Mayme Patthoff Daniel F
Martin MD Elias I Traboulsi MD
Cole Eye Institute, Cleveland, Ohio
Introduction: Recent vision screening research has focused on technology-based approaches to identify preschool children with amblyopia risk factors. Here we present data
derived from Vision First, an established program for vision screening and eye examinations in children in the amblyogenic age group.
Methods: Children aged 4-8 years underwent screening by an ophthalmic technician
and/or optometrist in a customized van that visits elementary schools in Cleveland, Ohio.
Examinations included assessment of monocular near and distance visual acuity, stereoacuity, alignment, extraocular movements, pupils, color vision (males only), and external
abnormalities. Children meeting the 2003 American Academy of Pediatrics vision screening failure criteria underwent cycloplegic retinoscopy and ophthalmoscopy on site by the
optometrist and were dispensed glasses. Those with more than simple errors of refraction
were referred to a pediatric ophthalmologist.
Results: 63,841 examinations were performed between 2002 and 2014. 6,386 (10.0%)
of children met one or more failure criteria, 5,355 (8.39%) were prescribed glasses, 873
(1.37%) had amblyopia, and 1125 (1.76%) had strabismus. The cost per child was approximately $26.00, excluding initial capital expenses and the cost of dispensing glasses.
Discussion: The Vision First model targets 4-8 year-olds and employs eye care professionals to use gold-standard examination techniques. This model ensures treatment of
errors of refraction and referral of those with amblyopia and strabismus.
Conclusion: Amblyopia, strabismus, and refractive errors are common pediatric eye
diseases in Cleveland, OH and a van-based model has been effective in screening and
treating young children in underserved communities.
71
Poster 42
Saturday
9:55 - 10:55 am
Poster 43
Saturday
9:55 - 10:55 am
A new computer-based pediatric vision-screening test
David A Leske MS Sarah R Hatt DBO Tomohiko Yamada OD, FAAO
Pamela S Moke MSPH Nick L Parrucci BSCS
J. Jeffrey Reese BA James B Ruben MD Jonathan M Holmes BM, BCh
Mayo Clinic, Rochester, Minnesota
Introduction: We developed and validated a new Windows-based visual acuity screening test (the Jaeb Visual Acuity Screener - JVAS) for age-specific vision screening in
schools and physician offices, presenting 2 large optotypes and up to 5 screening optotypes at age-specific thresholds.
Methods: We screened 187 children ages 3 to <8 years who presented to an eye clinic
for a complete eye exam. We evaluated the ability of the JVAS to detect gold-standard
failures, based on 2013 AAPOS screening criteria and published age-normal visual acuity thresholds. Three JVAS screening paradigms were evaluated (3 of 4 correct, 3 of 5
correct, or 4 of 5 correct to pass).
Results: Testability of the JVAS was 100%. 68 of 187 children met gold-standard failure
criteria. 47% failed for uncorrected refractive error with reduced visual acuity, 10% for
unilateral amblyopia, 13% for bilateral amblyopia, 15% for unexplained reduced visual
acuity, 12% for refractive error without reduced visual acuity, and 3% for alignment alone.
Depending on JVAS screening paradigm, JVAS sensitivity ranged from 88% to 91% and
specificity ranged from 73% to 86%. Positive predictive value ranged from 66% to 78%
and negative predictive value ranged from 93% to 94%. Requiring 3 correct out of 5 presentations resulted in the best combination of sensitivity and specificity (88% and 86%).
Discussion: The JVAS is an effective screening method for reduced visual acuity due to
refractive error and amblyopia.
Conclusion: The JVAS optotype vision screening application is available free of charge
and has the potential for wide use in schools and physician offices.
Poster 44
Saturday
9:55 - 10:55 am
Visual Outcomes of Patients with Congenital Cataracts and Sensory Nystagmus
Charlene H Crockett MD Lingkun Kong MD, PhD Kathryn A Camero Kimberly G Yen MD
Texas Children’s Hospital / Baylor College of Medicine
Houston, Texas
Introduction: To evaluate the visual outcomes of patients presenting with bilateral congenital cataracts and sensory nystagmus.
Methods: Sixteen patients less than 18 years of age who underwent cataract surgery
between 9/2002 and 2/2014 were included. Data collected included best-corrected postoperative visual acuity (BCVA), etiology of cataracts, associated systemic/ocular conditions, status of strabismus, surgical complications, and characteristics of the nystagmus.
Results: All patients had bilateral congenital cataracts and sensory nystagmus at time
of presentation. Age at diagnosis was 7.9 ± 10.1 months. Age at time of surgery was 8.5
± 10.1 months. Average length of follow up was 32.8 ± 36.2 months. Thirteen patients
were left aphakic while 3 patients received intraocular lenses bilaterally. 8/16 patients
had fix and follow visual acuity at last visit; of the remaining patients, six of 8 (75%) had
BCVA > 20/60 in at least one eye. Nystagmus was not observed in 4/16 patients (25%)
at last follow up. Patients without associated ocular conditions, such as strabmismus,
microcornea, amblyopia, or microphthalmos, were more likely to have resolution of nystagmus (p=0.02). Better visual acuity did not necessarily correlate with resolution of the
nystagmus.
Discussion: The presence of sensory nystagmus does not preclude good visual outcomes in patients with congenital cataracts.
Conclusion: The presence of sensory nystagmus should not affect the decision to
perform timely cataract surgery for congenital cataracts as favorable visual outcomes are
still possible. Patients without ocular comobidities have a higher chance of resolution of
the nystagmus.
72
Axial growth and clinical outcomes of children operated for bilateral ectopia lentis
Jennifer D Davidson MD M. Edward Wilson MD Rupal H Trivedi MD Leah A Owen MD
Dina Sabry
Poster 45
Saturday
9:55 - 10:55 am
Medical University of South Carolina Storm Eye Institute
Charleston, SC
Introduction: To report outcomes of children operated for bilateral ectopia lentis.
Methods: Charts of 94 eyes from patients who underwent anterior lensectomy for ectopia lentis by one surgeon were reviewed. Pre and postoperative best corrected visual
acuity (BCVA), axial length (AL) at surgery and follow up, etiology of ectopia lentis, and
complications were reviewed. We excluded unilateral surgery, <3 months of follow-up
and age at last follow-up <4 years. Treatment outcomes (aphakia vs. IOL) were not
included due to confounding factors. Age at the
time of lensectomy, group 1 = < 4yrs, group 2 = 4-8yrs and group 3 = > 8yrs.
Results: 70 eyes of 35 patients (21 Male) met inclusion criteria. Average follow-up was
5.3 yrs. 19 patients had a diagnosis of Marfan syndrome. Average age at surgery was
6.9yrs (SD 4.4), (3 mo to 18.8 yrs), 7.8yrs for Marfan and 5.9yrs for non-Marfan. Axial
growth was 0.5, 0.2 and 0.1 mm/yr for the three groups respectively. 0.2mm/yr for Marfan
and 0.28mm/yr for non-Marfan. 3 eyes had retinal detachment: all with marfan diagnosis.
1 in group 1; 2 in group 2. 10 had glaucoma: 2 Marfan; 8 non-Marfan, 7 in group 1, 1 in
group 2, 2 group 3. The median post-op BCVA was 20/40 for Marfan and 20/30 for nonMarfan and 20/40, 20/30 and 20/30 for the three age groups respectively.
Conclusion: Average age of surgery was younger in patients without Marfan syndrome.
Glaucoma was more common with younger age at surgery and in the non-Marfan group.
Retinal detachment was more common in patients with Marfan syndrome. Visual outcomes were similar in all groups regardless of age at surgery or etiology.
References: Utz, VM, Coussa, RG, Traboulsi, EL. Surgical management of lens subluxation in Marfan syndrome. J AAPOS 2014;18:140-146
Baseline Characteristics of the Infant Aphakia Treatment Study Population: How
well can they predict recognition visual acuity at 4.5 years?
E Eugenie Hartmann PhD Michael J Lynn Scott R Lambert MD
University of Alabama at Birmingham
Birmingham, Alabama
Introduction: The intensive protocol for treatment of monocular congenital/infantile
cataracts, which includes surgery, optical correction and years of occlusion therapy, is a
significant financial and emotional investment for families and clinicians. The purpose of
our present analysis was to identify patient baseline characteristics that predict recognition acuity at 4.5 years of age in the Infant Aphakia Treatment Study.
Methods: A total of 114 infants were enrolled in the Infant Aphakia Treatment Study. All
participants underwent cataract surgery between 1 and 7 months of age. Recognition
acuity was assessed monocularly using the Amblyopia Treatment Study HOTV testing
protocol at 4.5 years of age. Participant baseline characteristics were specified and the
relationship between these factors and visual acuity at 4.5 years was evaluated using
linear regression.
Results: Characteristics evaluated included 1) Characteristics of the treated eye; 2)
Physiological characteristics of infant and 3) Sociological characteristics of family. Only
age at surgery and presence of private insurance were individually associated with visual
acuity. The multivariate analysis demonstrated that only the availability of private insurance was statistically significant and accounted for 12% of the variance.
Discussion: This analysis concurs with previous studies that early surgery is important
for good visual outcomes in patients with unilateral congenital cataracts. Previously we
found an association between private insurance and adherence to patching, which may
in part explain the present findings 1.
Conclusion: However, the multivariate analysis accounts for only 12% of the variance,
suggesting that predicting visual outcome for these patients is complicated at best, requiring more information than is available at baseline.
References: 1. Drews-Botsch CD, Celano M, Kruger S, Hartmann EE, Study IAT. Adherence to occlusion therapy in the first six months of follow-up
and visual acuity among participants in the Infant Aphakia Treatment Study (IATS). Invest Ophthalmol Vis Sci 2012;53:3368-3375.
73
Poster 46
Saturday
9:55 - 10:55 am
Poster 47
Saturday
9:55 - 10:55 am
Endothelial cell counts in children after unilateral cataract surgery in the Infant
Aphakia Treatment Study
David G Morrison Michael J Lynn Faruk H Orge Scott R Lambert
Infant Aphakia Treatment Study Group
Vanderbilt University
Nashville, TN
Introduction: The Infant Aphakia Treatment Study (IATS) is a randomized trial of the
treatment of unilateral cataract with aphakic contact lens (CTL) versus primary intraocular lens implant (IOL). We report endothelial cell (EC) counts of IATS patients at the
5-year exam.
Methods: Non-contact specular microscopy was performed and endothelial cell density,
coefficient of variation (CV), and percent hexagonal cells were measured. Fellow eyes
served as controls. Mean differences between treated and fellow eyes of CT and IOL
groups were compared with an independent groups t test.
Results: 80 patients were included (38 CTL, 42 IOL). Mean cell density of treated eyes
was 3921 and 3445 cells/mm2 for the CTL and IOL groups, respectively and 3495 and
3487 for corresponding controls (p=0.0009). Mean CV was 27 and 25 for CTL and IOL
and 24 for both controls (p=0.069). Mean percent hexagonal cells was 72% and 73% for
CTL and IOL groups and 76% for both controls (p=0.30).
Discussion: Although IOL patients may appear worse as EC cell counts are lower,
these results may be paradoxical. IOL cell counts are similar to the control groups. More
cells may be present in CTL patients due to a greater CV. Corneal polymegathism is a
condition where endothelial cells form rosettes of smaller, less regular cells. Thus, more
cells are counted in a given area. Polymegathism may result from oxygen deprivation
associated with extended wear CTL use.
Conclusion: Cataract extraction during infancy was not associated with a reduced EC
count in treated compared to fellow eyes.
Poster 48
Saturday
9:55 - 10:55 am
Incidence, natural history, and outcomes of traumatic cataract after hyphema
associated with blunt ocular trauma in children
Ankoor S Shah MD, PhD and Olumuyiwa T Adebona MBChB, MPH
Boston Children’s Hospital and Harvard Medical School
Boston, MA, USA
Introduction: Hyphema is a common manifestation of blunt ocular trauma in children.
Traumatic cataracts are a known complication, but their incidence, natural history, and
outcomes are sparsely reported. This study addresses these gaps in the literature leading to better patient counseling and management.
Methods: A retrospective, cohort study of patients at a single, tertiary-care, pediatric
hospital was performed. Patients less than 18 years of age presenting for blunt ocular
trauma with hyphema between 2002 and 2011 were included. The mechanism of trauma, socio-demographic information, and ophthalmic examination data were abstracted.
Results: Seventeen of 128 (13%) developed cataract at a median of 14 days (range
2-113) after injury. The median age was 9 years (range 4-17). Thirteen were male.
High-velocity projectile objects were implicated in 9/17 (53%) of cases. Greater than 3+
anterior chamber cells occurred in 10/17 (58%). All cataracts were anterior or posterior
capsular cataracts on initial diagnosis. The median duration of follow-up was 29 months
and ranged from 5-97 months. Median visual acuity was 20/245 initially and 20/25 at
final visit (p=0.0001). Seven patients required surgery at a median of 54 days (range
20-698).
Discussion: Cataract after blunt ocular trauma with hyphema occurs in the pediatric
population commonly and typically presents early after the injury. These cases are associated with good visual outcomes. Approximately ~40% of cases require surgery.
Conclusion: Traumatic cataracts after blunt ocular injury with hyphema typically occur
within 2 weeks, and they are generally associated with good outcomes.
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A new diagnostic approach to children with cataract caused by metabolic disease
Rachel L Gillespie Jane Ashworth Susmito Biswas Simon C Ramsden
Jill Clayton-Smith I. Chris Lloyd Graeme C Black
Manchester Centre for Genomic Medicine, The University of Manchester
Manchester, UK
Poster 49
Saturday
9:55 - 10:55 am
Introduction: Inborn errors of metabolism account for a subset of congenital cataract
(CC) cases. For some of these children, therapeutic intervention to prevent disease
progression may be possible. As such, early diagnosis is critical. Genetic heterogeneity and technological limitations have traditionally precluded diagnosis and a battery
of complicated biochemical tests are often ordered to try to reach a precise diagnosis.
Advanced next generation sequencing (NGS) methodologies are currently revolutionizing the use of genomic information and can guide a personalized approach to assessing
prognosis, management and treatment.
Methods: We have successfully implemented an NGS target enrichment to screen, in
parallel, 115 genes associated with all forms of CC.
Results: We have determined the genetic cause of CC in 75% of individuals within
our cohort.[1] 18% of identified mutations cause CC as a result of an underlying metabolic disease, indicating that these conditions may be more prevalent than the literature
suggests and under diagnosed due to lack of awareness. Six metabolic conditions
were identified, including lathosterolosis, cerebrotendinous xanthomatosis, peroxisomal
biogenesis disorder 14B, a new cholesterol biosynthesis disorder, GLUT1 deficiency and
galactokinase deficiency.
Discussion: Our results show that the use of targeted-NGS as a frontline test for the
diagnosis of CC not only reduces the need for the battery of complicated tests typically
used in the pre-genomic era, but is also an efficient method for diagnosing metabolic
conditions complicated by CC.
Conclusion: Targeted NGS as a frontline test for CC will improve clinical outcomes as a
result of subsequent implementation of more precise medical intervention.
References: 1. Gillespie, RL, O’Sullivan, J, Ashworth, J, et al. Personalized Diagnosis and Management of Congenital Cataract by Next-Generation
Sequencing. Epub Jul 29, 2014. Ophthalmology 2014; doi: 10.1016/j.ophtha.2014.06.006.
Rebound tonometry over an air-filled anterior chamber in the supine child after
intraocular surgery
Ryan Davis Kim Jiramongkolchai Evan Silverstein Sharon F Freedman
Duke Eye Center
Durham, North Carolina
Introduction: To evaluate the usefulness/accuracy of a position-independent rebound tonometer (Icare Pro) to measure IOP intraoperatively in pediatric eyes with intracameral air, by
comparing with applanation tonometry(TonopenXL) as gold standard.
Methods: Ongoing prospective, IRB-approved study of sequential children having intraocular surgery. IOP was measured immediately following general anesthesia induction, by both
Icare PRO rebound tonometry (Rt, Icare Finland Oy,Helsinki) and TonopenXL tonometry (At,
Medtronic,Inc,Minneapolis,MN), with instrument order randomized, in the supine child’s eye.
At intraocular surgery completion, and after standard placement of intracameral air, IOP was
measured with Icare PRO and TonopenXL (same order as pre-operatively). Analysis included
IOP (by At and Rt) and Bland-Altman analysis (mean difference[change in IOP(At- Rt)],
95%Confidence Interval[CI]).
Results: Indications for surgery (26 eyes enrolled to date) included: glaucoma(15), cataract(10), and post-trauma secondary IOL(1). Mean pre-operative IOP (n=26) by At vs. Rt
was 21.50+8.48 vs. 17.93 + 6.56 mmHg, respectively (p=0.002). Mean IOP over intracameral
air at surgery conclusion by At (n=25) vs Rt (n=26) was 13.48+5.43 vs. 13.17+5.28 mmHg,
respectively (p=0.86). One eye had post-operative IOP unrecordable by At but 7.9mmHg by
Rt. Bland-Altman analysis showed: pre-operative mean change in IOP(At- Rt)=3.57mmHg
[CI=1.49;5.65]; vs. post-operative mean change in IOP(At- Rt)=0.10mmHg [CI=-1.091;1.291].
Discussion: Position-independent rebound tonometry (IcarePRO) easily measured IOP in
supine children’s eyes pre- and post-intraocular surgery, and correlated well with applanation
(TonopenXL), especially post-operatively over intracameral air. In eyes with low IOP, rebound
tonometry was more readily obtained than applanation.
Conclusion: Position independent rebound tonometry may be useful in monitoring IOP immediately following intraocular surgery even with intracameral air.
75
Poster 50
Saturday
9:55 - 10:55 am
Poster 51
Saturday
9:55 - 10:55 am
Longitudinal Evaluation of Intraocular Pressure in Pediatric Hyphema:
A New Paradigm for Followup
Charlotte Gore Olumuyiwa Adebona Ankoor S Shah
Children’s Hospital Boston , Harvard Medical School
Boston, Massachusetts
Introduction: The initial follow-up for pediatric hyphema focuses on identifying increased intraocular pressure (IOP). The standard follow-up is commonly prescribed as
daily appointments for 3 days and a 1-week visit. This is a costly endeavor. We perform
a longitudinal evaluation of IOP trends in pediatric hyphema patients to develop a more
tailored follow-up plan.
Methods: We performed a retrospective chart review of all pediatric patients with traumatic hyphema during an 11-year period. Raised IOP was defined as IOP>22 mmHg
within 90 days of injury.
Results: A total of 133 cases were identified with median follow-up time of 15 months.
Forty-three (32%) developed ocular hypertension and their median time to IOP peak
was 6 days (range 0-35). The median IOP was 29 mmHg (range 22-57) for patients who
developed ocular hypertension and 19 mmHg (range 10-21) for those who did not. Having a past ocular history and sustaining a concurrent intraocular injury were significantly
correlated with development of ocular hypertension. The amount of anterior chamber
hyphema did not correlate to ocular hypertension.
Discussion: Ocular hypertension develops at a median of 6-days after injury. Based on
these data, one could argue that daily IOP checks may not be necessary and the followup visits can be modified by presentation clinical exam.
Conclusion: We propose a new paradigm of follow-up for pediatric hyphema patients.
For those with ocular co-morbidities at presentation, we suggest follow-up at 1-, 3-, and
7-days post injury. And for those without, we suggest follow-up at 1- and 7-days post
injury.
Poster 52
Saturday
9:55 - 10:55 am
Surgical outcomes using a modified Anderson-Kestenbaum operation
Charline S Boente Faruk H Orge Beth J Colon
Department of Ophthalmology and Visual Sciences, Case Western Reserve University
and University Hospitals Rainbow Babies and Children’s Hospital
Cleveland, OH
Introduction: A variety of modifications and augmentations to the Anderson-Kestenbaum operation for null point nystagmus have been developed. Results have been varied, frequently resulting in residual head turn. We discuss the surgical results of a unique
modification originally introduced in 1979 by Flynn and Dell’Osso using equal numbers of
recession and resection (e.g. 5-5-5-5 mm), directly correlating with the gaze angle of the
anomalous head positioning.
Methods: This study was conducted as a retrospective case series chart review of six
patients seen in our clinic between January 2008 and September 2013. Patients who underwent surgical correction for nystagmus using equal numbers of recession and resection were included in the study, and pre- and post-operative data from clinic visits were
reviewed, including eye movement recording data, if available.
Results: Post-operative measurements showed minimal residual to resolved anomalous
head positioning in all subjects. In addition, decreased nystagmus intensity and improved
visual acuity measurements in primary gaze were observed without any additional alignment deviations or ocular motility restrictions.
Discussion: The major advantage to the surgeon is the ease of pre-surgical planning
that this approach affords. The challenge continues to rest on understanding the relationship between the neurological control system and the mechanical forces of extraocular
muscles for null point nystagmus.
Conclusion: The modified Anderson-Kestenbaum operation using equal numbers of
recession and resection can provide a simple and efficient alternative for surgical planning, and has demonstrated favorable outcomes of resolved anomalous head positioning
and decreased nystagmus intensity in our series of patients.
76
Two types of head oscillations in Infantile Nystagmus Syndrome
Fatema F Ghasia MD Aasef G Shaikh MD PhD
Cole Eye Institute, Cleveland Clinic
Cleveland OH
Poster 53
Saturday
9:55 - 10:55 am
Introduction: Infantile Nystagmus Syndrome (INS) is a common congenital disorder of
eye movement. Head oscillations have been rarely described in INS patients. We quantitatively characterized eye and head oscillations in INS patients.
Methods: Video-based tracker (Eyelink 1000) was used to record eye and head movements simultaneously in ten INS patients (4= Idiopathic, 6= oculocutaneous albinism).
Results: Two types of head oscillations were present. The first type was irregular with
frequency between 1-3 Hz. The second type was regular and sinusoidal with a frequency
range of 5-8 Hz. Irregular low-frequency oscillations were seen in all INS patients, but the
high-frequency oscillations were only present in seven of them. High-frequency oscillations were episodic whereas irregular low-frequency oscillations were always present.
There was no correlation between peak velocity of the head oscillations and eye velocity
of nystagmus to suggest the influence of head oscillations on foveation.
Discussion: We found two types of head oscillations in INS patients. Lack of correlation
between the foveation period of nystagmus and peak head velocity during oscillations
suggests, in our cohort that the head oscillations were a co-existing pathological phenomenon rather than a compensatory mechanism to improve the visual acuity.
Conclusion: Head holding disorders are common in patients with Infantile Nystagmus
Syndrome and likely represent a pathologic tremor. They are present in patients with
idiopathic infantile nystagmus syndrome as well as those with afferent visual pathway
abnormalities.
Clinicopathological findings in abusive head trauma:
analysis of 110 infant autopsy eyes
Kelly H Unkrich MD Mark P Breazzano MD Ann E Barker-Griffith MD
State University of New York, Upstate Medical University
Syracuse, New York
Introduction: To investigate the histopathology in a large series of autopsy eyes from
children with abusive head trauma (AHT).
Methods: Design: Retrospective case-control series.
Methods: One-hundred-and-ten autopsy eyes from fifty-five cases examined at an academic tertiary referral center over twenty-one years were tabulated for histopathology:
subdural hemorrhage, intrascleral hemorrhage, any retinal hemorrhage, ora-extended
hemorrhage, cherry hemorrhage, perimacular ridge and internal limiting membrane (ILM)
tear. Select tissues with cherry hemorrhage were further examined by transmission electron microscopy (TEM).
Results: Sixty eyes were identified as ‘AHT’ (cases), forty-six ‘alternative cause’ (controls) and four ‘AHT survivor’. AHT was legally verified or confirmed by confession for
all cases except one. All ocular pathology was similar or more frequent in AHT infants
younger than 16 months of age. A perimacular ridge was found in 42% and cherry hemorrhage in 40% of AHT eyes, all having an ILM tear. Both AHT survivor cases demonstrated
severe optic nerve atrophy and macular ganglion cell loss.
Conclusion: Younger infants may be even more susceptible to damage from vitreomacular traction by rotational and/or acceleration-deceleration forces. Identifying cherry hemorrhages may aid AHT diagnosis. Survivor AHT pathology demonstrates unique, irreversible macular and optic nerve damage.
References: American Journal of Ophthalmology December 2014; 158: 1146-1154. Published by Elsevier Inc. All rights reserved. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
77
Poster 54
Saturday
9:55 - 10:55 am
Poster 55
Saturday
9:55 - 10:55 am
Pediatric eye injuries due to nonpowder guns in the United States, 2002-2012
Rachel H Lee B.S. Douglas Fredrick M.D.
Stanford University
Palo Alto, CA
Introduction: To identify epidemiologic trends in nonpowder gun-related pediatric eye
injuries and to determine factors associated with severe injury requiring hospital admission.
Methods: US emergency department data on pediatric eye injuries between 2002
through 2012 were reviewed using the National Electronic Injury Surveillance System.
Literature review was conducted to determine trends in visual outcomes after treatment
and use of eye protection.
Results: In 2012, roughly 3,161 children were treated in US emergency departments for
nonpowder gun-related eye injuries. Since 2010, rates of severe nonpowder gun pediatric
eye injury have increased by over 500% (P = 0.039). Specifically, while rates of hospital
admission due to paintball gun eye injury have dropped precipitously (P = 0.0077), rates
of admissions for air gun eye injuries have increased by over 600% since 2010 (P =
0.033). Children sustaining eye injury due to air guns are more likely to be diagnosed and
admitted with foreign body or ocular puncture injury. Roughly 28% of documented cases
of airsoft or BB gun-related injury had visual acuity worse than 20/50 after initial treatment. Over 98% of injuries occurred without eye protection.
Discussion: Air guns, and not paintball guns, are rising in popularity, and account for the
majority of pediatric eye injuries requiring hospital admission. The majority of eye injuries
occur without ocular protection, and may lead to permanent eye injury.
Conclusion: Air guns can cause severe, yet preventable, eye injury among the pediatric
population. Increasing regulations for eye protection, sales, and usage of air guns are
needed to prevent serious pediatric eye injuries.
Poster 56
Saturday
9:55 - 10:55 am
Residency Factors that Affect Residents’ Pursuit of Pediatric Ophthalmology
Elizabeth S John BA Airaj F Fasiuddin MD Bertha A Nash MA
University of Central Florida College of Medicine
Orlando, FL
Introduction: While the pediatric population comprises 26.7% of our population (1), in
2013 only 62% of pediatric ophthalmology (PO) fellowship positions were filled (2), there
is an urgent need to understand what factors influence residents’ decisions to pursue a
PO fellowship.
Methods: A 16-item questionnaire about the structure of PO rotations, perceptions of
faculty and experiences in residency programs was distributed to current ophthalmology
residents in the U.S.
Results: Ninety-six responses were received; 60% of the participants reported ‘no interest in working with children’ or ‘no interest in pediatric ophthalmology’, thus excluded
from analysis (N = 38). Five residents (13%) were definitely pursuing pediatric ophthalmology: All (100%) perceived faculty in their program as interested in teaching, felt they
had adequate exposure to strabismus surgery, and had spent 2-6 months in pediatric
ophthalmology rotations. Further analysis revealed a positive relationship between time
in rotations and feelings of adequate exposure (r = .34, p < .05) and a non-significant
association between an ‘interest in pediatric ophthalmology’ and ‘pursuing a fellowship’
(X2= 2.452, p = 0.11).
Discussion: The role of a mentor and surgical exposure were important to residents
choosing a fellowship in pediatric ophthalmology, suggesting that an interest in the practice of ophthalmology, is not the only deciding factor.
Conclusion: As the pediatric population is increasing (3), and the number of pediatric
ophthalmologist decreasing, it has become more important to understand what residency
program directors can do to fill this gap. In this study, we found that mentorships and
exposure are factors worth addressing in existing curriculum.
References: 1. U.S. Census Bureau. Age and Sex Composition in the United States: 2012. Available at: http://www.census.gov/population/age/
data/2012comp.html. Accessed February 14, 2014
2. San Francisco Matching Program. Ophthalmology Fellowship Match Report. San Francisco: Author; 2013. 3. Lee P, Hoskins HD Jr, Smith RE, Hutchinson BT, Wong BA. Access to eye care: response of the American Academy of
Ophthalmology and its members to societal needs now and in the future. Arch Ophthalmol. 2007;125:403-5.
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Notes
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Notes
80
Electronic Posters
All Electronic Posters Displayed from Wednesday, March 25, 4:00 PM - Sunday, March 29 11:10 AM
Storyville Hall
Electronic Poster Viewing is not eligible for CME
AMBLYOPIA
E-Poster #1
Lash Ptosis as a Complication of Patching for Treatment of Amblyopia
Moustafa S. Abdelhafez, FRCS, MD
E-Poster #2
Amblyopia Occlusion Therapy Compliance: Amblyz™ Liquid Crystal Glasses Versus Traditional Adhesive Patches
Tina Damarjian, MD;
Heather A. Smith, MD; Daniel E. Neely, MD; Jingyun Wang, PhD; Jay Galli; Jessica Kovarik, MD;
James Bowsher, MD; Joshua Schliesser, MD; Kathryn M. Haider, MD; Gavin J. Roberts, MD;
Dana Donaldson, OD; Derek Sprunger, MD; David A. Plager, MD
E-Poster #3
Prevalence of Amblyopia in Children in Bulgaria
Stela P. Dikova, MD
Violeta S. Chernodrinska, MD, PhD
E-Poster #4
False Positive Amblyopia Prediction During Fixation Preference Testing of Strabismic Patients
(“pseudoamblyopia”) Correlates with Ocular Dominance
Arif O. Khan, MD
Dora H. AlHarkan, MD
E-Poster #5
Atropine Penalization in the Management of Amblyopia in Children: Survey of UK Pediatric Ophthalmologists
Neda Minakaran
Saurabh Jain
E-Poster #6
Binocular Dichoptic Video Content Treatment for Amblyopia - Pilot Study
Chaim Stolovitch, MD
Gad Dotan, MD; Noa Delman, MD; Daphna Mezad, MD
E-Poster #7
Measurement Tool for Assessing Visual Function in Patients with Amblyopia
Kathryn P. Winkler, MD
Sabin Dang, MD; Rebecca Schwarzlose, PhD; Reecha S. Bahl, MD
E-Poster #8
Alternate Occlusion for Bilateral Ametropic Amblyopia
Di Zou
Lucy Stafford; Saurabh Jain
ANTERIOR SEGMENT
E-Poster #9
Using Anterior Segment Imaging as a Guide for the Surgical Management of Pediatric Corneal Opacities
Luxme Hariharan, MD, MPH
Dilshad Contractor, MBS; Julia Johnston, MPAP; Tova Mannis, MD; Bibiana Jin Reiser, MD, MS
E-Poster #10
Effect on Blink Rate During Videogame Related Activities and Reading in School-Aged Children
Catherine O. Jordan, MD
David L. Rogers, MD
E-Poster #11
Episodic Excessive Blinking in Children
Yasmin P. Mali, MD
John W. Simon, MD; Imran A. Chaudhri; Jitka Zobal-Ratner, MD; Gerard P. Barry, MD
E-Poster #12
Peters Anomaly Phenotypic Spectrum - From Mild to Severe Disease
Kamiar Mireskandari
Uri Elbaz; Hermina Strungaru; Asim Ali
E-Poster #13
Lamellar Keratoplasty for Excision of Limbal Dermoids
Oriel Spierer, MD
Richard K. Forster, MD
CATARACTS
E-Poster #14
Endophthalmitis after Cataract Surgery in Children
Sumita Agarkar, MD
Roshni Desai, MD
81
E-Poster #15
Manifest Nystagmus in Children with Monocular Congenital Cataract
Luai T. Eldweik
Deborah VanderVeen
E-Poster #16
Pentacam and OCT Imaging Techniques in Pseudophakic Eyes of Children
Catherine Gasper, BS
M. Edward Wilson, MD; Rupal H. Trivedi, MD
E-Poster #17
Preferred Practice Patterns for Pediatric Cataract Surgery and Post-Operative Management
Gennifer J. Greebel, MD
Majida A. Gaffar, MD
E-Poster #18
Traumatic Cataract in Children: A Long Term Follow-Up - A Retrospective Observational Review
Assaf Hilely, MD
Hana Leiba, MD; Reut Parness-Yossifon, MD
E-Poster #19
Visual Acuity and Refractive Outcome in Pediatric IOL Implantation with Initial Low vs High Hyperopia
Dayane C. Issaho
Serena Wang; Monica Bratton; David Weakley
E-Poster #20
Structural Changes of the Anterior Chamber Following Cataract Surgery During Infancy
Matthew Nguyen, MD
Scott Lambert, MD; Allen Beck, MD; Marla Shainberg, CO
E-Poster #21
Refractive Growth in Pseudophakic Children Age 2-6 Years
Bharti Nihalani-Gangwani, MD
Deborah K. VanderVeen, MD
E-Poster #22
Bilateral Pediatric Cataracts: Nystagmus, Strabismus and Visual Outcome: A 10-Year Data Analysis
Judith R. Sabah
Nandini Gandhi; Machelle Wilson; Mary O’Hara
E-Poster #23
Ocular Axial Growth in Pseudophakic Eyes of Patients Operated for Monocular Infantile Cataract: A
Comparison of Operated and Fellow Eyes Measured at Surgery and 5 or More Years Later
Dina Tadros, MD
Rupal H. Trivedi, MD; M. Edward Wilson, MD; Jennifer Davidson, MD; Leah Owen, MD
E-Poster #24
Associated Systemic and Ocular Disorders in Patients with Congenital Unilateral Cataracts - The IATS Experience
Elias I. Traboulsi, MD, MEd
Deborah VanderVeen, MD; David Morrison, MD; Carolyn D. Drews-Botsch, MD; Michael Lynn;
Scott R. Lambert, MD
E-Poster #25
Long-Term Outcomes of Anterior Chamber Intraocular Lens Placement in a Pediatric Cohort
Reid P. Turner, MD
Leah Owen, PhD, MD; Jennifer Davidson, MD; Rupal Trivedi, MD; M. Edward Wilson, MD
E-Poster #26
Benchmarks for Outcome Indicators in Pediatric Cataract Surgery
Deborah VanderVeen, MD
Bharti Nihalani-Gangwani, MD; Olumuyiwa Adebona, MBChB, MPH; Will Dean, MD
GLAUCOMA
E-Poster #27
Ocular Hypertension and Glaucoma Suspects in Pediatric Patient Population
Kara M. Cavuoto
Matthew Greenberg; Ta C Chang
E-Poster #28
Canaloplasty in Juvenile Glaucoma - A Case Report
Susan H. Senft, MD
Susie Y. Wong, MD; Kavita Surti, MD
E-Poster #29
Assessment of Intraocular Pressure with iCare Rebound Tonometry in a Pediatric Ophthalmology Clinic
Aman Sharma, MD
Desiree Albert, MS4; Matthew S. Pihlblad, MD; Megan Sheeley, COA; Nicholas Strauss; Diana Moya;
James D. Reynolds, MD
E-Poster #30
Survey of Health- and Vision-Related Quality of Life and Functional Vision in Children and Young People with
Childhood Glaucoma and Cataract
Vijay K. Tailor, Msc
Annegret Dahlmann-Noor; Gill G. Adams; Maria Papadopoulos
82
NEURO-OPHTHALMOLOGY AND ORBITAL DISEASE
E-Poster #31
Accommodation in Children with Cerebral Palsy
Claudia Avilés, MD
Juan Homar Páez, MD; Maria Teresa Rodriguez, CO
E-Poster #32
Pediatric Idiopathic Intracranial Hypertension: A Major Review
Rahul Bhola
Noura Estephane; Michael Sowell; Ian Mutchnick; Eric Downing; Pradeep Sharma
E-Poster #33
Strabismus in Patients with Cortical Visual Impairment: Observations of Spontaneous Resolution and Outcomes
of Surgery
Nicholas R. Binder
Jacqueline Kruglyakova; Mark S. Borchert
E-Poster #34
Outcome of Pediatric Patients Referred for Papilledema
Jessica J. Kovarik, MD
Poonam N. Doshi, MD; Janine E. Collinge, MD; David A. Plager, MD
E-Poster #35
Correlation of Optic Nerve Sheath Diameter Using B-Scan Ultrasound with MRI Anatomy in Pediatric Patients
Ellen R. Miller
David L. Rogers; Lisa Martin; April Logan
E-Poster #36
The Post-Concussion Syndrome: Influence on Binocular Function
Gill Roper-Hall, DBOT
Oscar A. Cruz, MD; Sophia M. Chung, MD
E-Poster #37
Ocular Long Term Effects of Airsoft Gun Pellet Injury, The Most Frequent Ocular Trauma Mechanism among
Danish Children. A 7-Year Follow-Up Study of 28 Cases
Jon Peiter Saunte, MD
E-Poster #38
Idiopathic Orbital Pseudotumor Preceding Systemic Inflammatory Disease in Children
Mai Tsukikawa
Sara E. Lally, MD; Carol L. Shields, MD; Ralph C. Eagle, MD; Barry N. Wasserman, MD
OCULAR MANIFESTATIONS OF SYSTEMIC DISEASES
E-Poster #39
Ophthalmic Pathology in Down Syndrome Patients: Characterization in Chilean Children
Bernardita Alamos, MD
Pablo Musa, MD; Macarena Lizama, MD; Pablo Altschwager, MD; Cristian Salgado, MD
E-Poster #40
Eye and Systemic Manifestations of Moebius Syndrome
Juan C. Juárez-Echenique
Ana M. Borbolla-Pertierra; Vanessa Bosch-Canto; Juan C. Ordaz-Favila; Pedro Acevedo-Gonzalez
E-Poster #41
Is It Usher Syndrome? Diagnosing Children with Hearing Loss and Ocular Findings
Ashley S. Ko, MD
Wanda L. Pfeifer, OC(C), COMT; Arlene V. Drack, MD
E-Poster #42
Prevalence and Clinical Characteristics of Ocular Disease in Children with HIV/AIDS
Taliva D. Martin, MD
Maya S. Ling, MD; Emmett T. Cunningham, MD, PhD, MPH; Ann Petru, MD; Susan H. Day, MD
E-Poster #43
Intraocular Pressure in Children with Down Syndrome
Maria Teresa Rodriguez, MD
Manuel A. de Alba, MD; Juan Homar Páez, MD; Mariya Kalashnikova, MD
OCULOPLASTICS
E-Poster #44
Novel Technique for the Repair of Large Upper Eyelid Colobomas
Alexandra T. Elliott, MD
E-Poster #45
Multi-Tool Instrument Decreases Complications with Nasolacrimal Intubation
Celia Haering
Robert W. Arnold
E-Poster #46
Retrieval of a Monoka Silicone Tube from the Pharynx During Silicone Intubation Procedure for Persistent
Congenital Nasolacrimal Duct Obstruction Assisted by the Anesthesiologist
Daphna Mezad-Koursh, MD
Noa Ela-Dalman, MD; Nina Gofman, MD; Gad Dotan, MD; Chaim Stolovitch, MD
83
E-Poster #47
Canalicular Laceration Repair with a Novel Viscoelastic Injection Technique to Locate and Dilate the Proximal
Torn Edge
Faruk H. Orge
PATIENT CARE DELIVERY - ELECTRONIC MEDICAL RECORDS
E-Poster #48
Analysis of the Readability of Patient Education Materials in Pediatric Ophthalmology
Ann M. John, BA
Elizabeth S. John, BA; David R. Hansberry, MD, PhD; Suqin Guo, MD
E-Poster #49
Evaluating Patient Satisfaction in the Pediatric Ophthalmology and Strabismus Clinic During the Transition to
Electronic Medical Records
Pedro F. Monsalve, MD
Ta C. Chang, MD; Kara M. Cavuoto, MD
E-Poster #50
Predicting Total Physician Time Per Patient Using Linguistic Features in an Electronic Health Record
Constance E. West, MD
Mary Anne Lenk, BS; Brandy L. Dearwater, RN; Christopher S. Byington, MHSA; Kelli Vieson, COT;
William W. Motley, MD
PUBLIC HEALTH
E-Poster #51
A Comparison of Food and Drug Administration (FDA) Status to Current Guidelines for Medications Used in
Pediatric Ophthalmology
Gerard P. Barry
Alyssa S. Hermann; John W. Simon
E-Poster #52
Establishing a Surgical Outreach Program in the Developing World: Pediatric Strabismus Surgery in Guatemala
City, Guatemala
Lauren C. Ditta
Emily T. Graves; Chantel Devould; Ebony Murchison; Natalie C. Kerr
E-Poster #53
Ophthalmologic Outcome of Extremely Preterm Infants at 6.5 Years of Age; Extremely Preterm Infants Study in
Sweden (EXPRESS)
Kerstin M. Hellgren
Ann Hellström; Kristina Tornqvist; Peter Jakobsson; Pia Lundgren; Birgitta Carlsson; Karin Stjernqvist;
Karin Källén; Fredrik Serenius; Gerd Holmström
E-Poster #54
A Comparison Between Pediatric and Adult Ophthalmology Consults in and Urban Academic Institution
Sunju Park, MD
Sejal H. Patel, BA; Jamie B. Rosenberg, MD
E-Poster #55
The Effectiveness of a Mobile Clinic in Improving Follow-Up Eye Care for At-Risk Children
Jinali Patel, MD
Wei Diao, BA; Melanie Snitzer, MSW, LSW; Michael Pond, BA; Rachel Weiner, BS;
Sarah Martinez-Helfman, BS; Kathleen Santa Maria, COT; Alex V. Levin, MD, MHSc
E-Poster #56
Epidemiology of Pediatric Ophthalmic Trauma
Joshua A. Schliesser
David Lyon; Anvesh Reddy; Amneet Hans; Faheem Mohomed; Ruby Parikh
E-Poster #57
The Impact of Insurance Status on Hospital Resource Utilization in Pediatric Ophthalmic Inpatients
Daniel C. Terveen
Benson S. Hsu, MD; Geoffrey T. Tufty, MD
E-Poster #58
Seizures Induced by Cycloplegic Eye Drops
Tamara Wygnanski-Jaffe, MD
Paolo Nucci, MD; Mauro Goldchmit, MD; Eedy Mezer, MD
RETINA
E-Poster #59
Evaluation of Optic Nerve Compression as a Potential Cause of Retinal Hemorrhage in Infants
Gil Binenbaum, MD, MSCE
Shaun M. Evans, MS; Vivian Lee, MD; Brittany Coats, PhD
E-Poster #60
Circumferential Macular Folds Associated with Reduced Macular Hemorrhages in Non-Accidental Trauma:
Implications for the Theory of Vitreous Traction
Alexander E. Pogrebniak, MD
84
E-Poster #61
Spectral Domain-Optical Coherence Tomography Findings in Pediatric Tilted Disc Syndrome
Massimiliano Serafino, MD
Francesco Pichi, MD; Simona Romano, MD; Paola Carrai, MD; Mariachiara Morara, MD;
Antonio P. Ciardella, MD; Kyoko-Ohno Matsui, MD; Paolo Nucci, MD
E-Poster #62
Pediatric Ophthalmologists’ Trends in Abusive Head Trauma
Evan C. Sussenbach, MD
R. Michael Siatkowski, MD; Kai Ding, PhD; Tammy L. Yanovitch, MD, MPH
RETINOPATHY OF PREMATURITY
E-Poster #63
UK National Survey of Treatment for Retinopathy of Prematurity (ROP)
Gillian G. Adams, FRCSEd
Catey Bunce, DSc; Annegret Dahlmann-Noor, MD
E-Poster #64
Ensuring Successful Enrollment of Premature Babies into NICU Based Clinical Studies: Lessons Learned from
the Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (ROP) - e-ROP Study
Agnieshka Baumritter
Akosua Nti; Graham E. Quinn, MD, MSCE; Karen Karp, RN, BSN
E-Poster #65
An Evaluation of Trainees’ Ability to Acquire Retinal Images of Premature Infants Using an Indirect
Ophthalmoscopy System
Jared E. Duncan, MD
Sharon F. Freedman, MD; David K. Wallace, MD, MPH; S. Grace Prakalapakorn, MD, MPH
E-Poster #66
Quantifying and Qualifying the Use of Topical Anesthetics in Retinopathy of Prematurity Examinations, A Survey
Blake D. Forcina, MD
Dean J. Bonsall, MD, MS, FACS, FACP
E-Poster #67
Program for Prevention on Blindness in Peru: An Update
Luz J. Gordillo, MD
Ana M. Villanueva, MD; Luz Dodobara, MD; Arminda Gil; Graham E. Quinn, MD
E-Poster #68
Accommodative Lag in Children with Retinopathy of Prematurity Treated with Intravitreal Injection of
Bevacizumab
Kathryn M. Haider
Heather A. Smith; Jingyun Wang
E-Poster #69
Severe Retinopathy of Prematurity (ROP) is Associated with Hypocarbia in Ventilated Preterm Infants
Hana Leiba, MD
Pesah Melnik, MD; Tali Bdolach; Eric S. Shinwell, MD
E-Poster #70
Babies at Risk for Retinopathy of Prematurity in Ghana
Akosua A. Nti, MD
Vera A. Essuman, MB ChB, FWACS; Christabel Enweronu-Laryea, MRCPCH, FGCP;
Asiedua Ofori-Darko, MB, ChB; Graham E. Quinn, MD, MSCE
E-Poster #71
Short and Intermediate-Term Clinical Outcomes in Infants Treated with 0.5 mg and 0.625 mg Intravitreal
Bevacizumab for Vision-Threatening Retinopathy of Prematurity
Leah A. Owen
Jennifer D. Davidson; Rupal H. Trivedi; Sarah K. Shirer; Edward W. Cheeseman; Richard A. Saunders
E-Poster #72
Characterization of Leukocyte Infiltration and Microglial Activation in Ischemia-Reperfusion Injury Induced
Retinal Neuroinflammation
Dolly Padovani-Claudio, MD, PhD
Sumathi Shanmugam, MS; Heather M. Lindner, MS; David Antonetti, PhD; Steven Abcouwer, PhD
E-Poster #73
Facilitated versus Self-Guided Training for Grading of Retinal Images for ROP
Nikolas N. Raufi, BA
Caleb K. Morris, MD; Sharon F. Freedman, MD; David K. Wallace, MD, MPH;
Sasapin G. Prakalapakorn, MD, MPH
E-Poster #74
Evaluating the Clinical Benefit of Earlier Retinopathy of Prematurity Screening
Dipal P. Shah, MD
Majida Gaffar, MD
E-Poster #75
Involution Patterns of Type 1 Retinopathy of Prematurity after Treatment with Intravitreal Bevacizumab
Nasrin Tehrani, FRCSC
Maram Isaac, MB BS; Kamiar Mireskandari, FRCOphth
85
E-Poster #76
ROPtool Analysis of Images from a Non-Contact Handheld Fundus Camera
Laura A. Vickers
Sharon F. Freedman; David K. Wallace; S. Grace Prakalapakorn
E-Poster #77
Racial Disparity in the Association of Average Day Length during Early Gestation with Treated Retinopathy of
Prematurity: A Multicenter Study
Michael B. Yang
Pia Lundgren; Patricia Cobb; Richard A. Lang; Lois E. Smith; Chatarina Lofqvist; Ann Hellstrom
STRABISMUS
E-Poster #78
The Spectrum of Diplopia Management in Ocular Motility Disorders
Shauna E. Berry, DO
Matthew D. Kay, MD; Garima Lal, MD; Kathryn E. Ireland, DO; Clint W. Kellogg, DO;
Hang M. Tran, MPH
E-Poster #79
Acquired Inverse Duane Retraction Syndrome Secondary to Medial Rectus Muscle Cysticercosis
Venkateshwar Bhoompally, MD
Ramesh Kekunnaya, DO, FRCS; Jyoti Matalia, DNB
E-Poster #80
Comparison of Objective and Subjective Techniques of Strabismus Measurement in Adults with Normal Retinal
Correspondence
Derek P. Bitner, MD
Ore-Ofe Adesina, MD; R. Michael Siatkowski, MD; Bradley K. Farris, MD
E-Poster #81
Correction of Binocular Diplopia with Novel Contact Lens Technology
Tara L. Bragg, CO
Christine Sindt, OD
E-Poster #82
Quality of Life in Strabismus
Melinda Chang, MD
Federico Velez, MD; Joseph Demer, MD, PhD; Sherwin Isenberg, MD; Anne Coleman, MD, PhD;
Stacy Pineles, MD
E-Poster #83
Functional Morphometry Using Magnetic Resonance Imaging (MRI) of Cyclovertical Extraocular Muscles
(EOMs) During Vertical Ductions
Robert A. Clark, MD
Joesph L. Demer, MD, PhD
E-Poster #84
“Knobby Eye Syndrome:” Irregular Posterior Staphyloma as a Factor Complicating Strabismus in High Myopia
Joseph L. Demer, MD, PhD
E-Poster #85
Dissociated Ocular Deviations in Adults
Sneh S. Dhannawat, MBBS
David A. Leske, MS; Jonathan M. Holmes, BM, BCh
E-Poster #86
Childhood Intermittent Exotropia from a Different Angle: Does Severity Affect Quality of Life?
Shin B. Lim
Wan L. Wong; Inez B. Wong, FRCSEd(Ophth)
E-Poster #87
A Twisted Tale of Ocular Torsion
Vaishali Lodhia
Louise Ramskold; Alistair Jones; Saurabh Jain
E-Poster #88
Stereoacuity in Children with Accommodative Esotropia versus Partially Accommodative Esotropia
Brian Mohney
Nancy N. Diehl
E-Poster #89
Superior Oblique Muscle Size in Brown Syndrome
Soh Youn Suh, MD
Joseph Demer, MD, PhD
E-Poster #90
What Does Convergence Insufficiency Look Like to the Strabismologist?
Naomie K. Warner, DO
Judith Lavrich, MD; Barry Wasserman, MD; Caroline Debenedictis, MD; Bruce Schnall, MD;
Donnelson Manley, MD; Kammi Gunton, MD
86
STRABISMUS SURGERY
E-Poster #91
Extraocular Muscles Abnormalities and Surgical Management of Strabismus Following Melanoma Plaque
Brachytherapy
Shatha H. Alfreihi, MD
Stacy Pineles, MD; Tara McCannel, MD, PhD; Colin McCannel, MD; Ben Glasgow, MD;
Federico Velez, MD
E-Poster #92
Successfully Managed Endophthalmitis Following Strabismus Surgery in Three Patients
Saba T. Alniemi, MD
Sophie J. Bakri, MD; Brian G. Mohney, MD
E-Poster #93
Defining Quality Standards in Primary Convergent Squint Surgery - A Prospective 5 Year Audit
Adam C. Bates, MBChB, FRCOphth
Phey Feng Lo, MBBS
E-Poster #94
Instructions to Patients and Families Following Strabismus Surgery
Gad Dotan
Hanya M. Qureshi; Leonard B. Nelson
E-Poster #95
Total Transposition Combined with Resection of Superior and Inferior Rectus Muscles in the Treatment of
Complete 6th Cranial Nerve Palsy
Marina A. Eisenberg
Steven M. Archer; Monte A. Del Monte
E-Poster #96
Accommodative Esotropia (AET) Treatment Utilizing Simultaneous Strabismus Surgery and Photorefractive
Keratoplasty
H. Sprague Eustis, MD
Pulin Shah D
E-Poster #97
Long-Term Outcomes of Strabismus Surgery in Mobius Syndrome
Marlo Galli, CO
Gregg Lueder, MD
E-Poster #98
Novel Technique for Surgical Correction of Small Angle Vertical Deviation
Larissa A. Habib, MD
Steven E. Brooks, MD
E-Poster #99
Immediate Postoperative Alignment Following Surgery for Esotropia in Children Compared to Adults
Mohamed B. Hassan
Nancy N. Diehl; Brian G. Mohney
E-Poster #100
The Newcastle Control Score - A Predictor of Surgical Outcome in Distance Intermittent Exotropia?
Hugh Jewsbury
Patrick Watts
E-Poster #101
Factors Affecting the Difference between Simultaneous Prism Cover Test (SPCT) and Alternate Prism Cover Test
(APCT): Monitoring Post-Operative Alignment after Surgery for Exotropia
Pavlina S. Kemp, MD
Yoon-Hee Chang, MD, PhD; Patrice Melvin, MPH; Linda R. Dagi, MD
E-Poster #102
Improved Maintenance of Binocularity in Ocular Neuromyotonia after Strabismus Surgery
Anna Kim, MD
Stacy Pineles, MD; Federico Velez, MD
E-Poster #103
Long-Term Surgical Outcome and Developmental Abnormalities in Infantile Exotropia
Gregg Lueder, MD
Marlo Galli, CO
E-Poster #104
A Comparison of Surgical Outcomes in Patients with Unilateral Cranial Nerve VI Palsy
Kimberly S. Merrill, CO
Laura Lenius, BS; Erick D. Bothun, MD; Stephen P. Christiansen, MD
E-Poster #105
A Modified Technique for Strabismus Surgery in the Presence of a Scleral Buckle
Mitra Nejad
Anna J. Kim; Stacy L. Pineles; Federico G. Velez
E-Poster #106
Surgical Success in Strabismus Surgery with Conventional vs Hang-Back Technique
Cristian M. Salgado, MD
Alvaro E. Morgado, MD: Bernardita M. Alamos, MD; Sylvia A. Araneda, MD; Pablo Altschwager, MD;
Felipe A. Sanhueza, MD
87
E-Poster #107
Adjustable Partial Vertical Rectus Transpositioning in Cases of Lateral Rectus Palsy
Pradeep I. Sharma, MD, FAMS
Nitesh Salunkhe, MBBS; Rohit Saxena, MD; Rahul Bhola, MD
E-Poster #108
Long-Term Stability of Postoperative Deviation in Sensory Strabismus: Surgery of the Dominant or
Non-Dominant Eye
Federica Solanes, MD
Bernardita Alamos, MD; Cristóbal Morales, MD; Cristián Salgado, MD
E-Poster #109
Divergence Insufficiency: Increasing Numbers of Surgeries and Changing Referral Pattern for a Common Type of
Adult Strabismus
David R. Stager, Sr, MD
Lori M. Dao, MD; David Stager Jr, MD; Joost Felius, PhD
E-Poster #110
Rectus Muscle Advancement for the Treatment of Ocular Misalignment Following Scleral Buckle
Kirstin L. Tawse
Mitchell B. Strominger; Shelley Klein
E-Poster #111
Poster Withdrawn
E-Poster #112
Surgical Treatment of Divergence Insufficiency Esotropia
Chris Y. Wu, BS
Monte A. Del Monte, MD
VISION
E-Poster #113
The Newly Sighted Match Seen with Felt - An Answer to Molyneux Question from 1688
Itay Ben-Zion, MD
E-Poster #114
New Trends in Childhood Vision Impairment in a Developed Country
Susan Carden, MBBS, FRANZCO, PhD
Shivanand J. Sheth, MS, DOMS, FICO, FAICO; Chengde Pham, MBBS, BMedSci; Jill Keeffe, OAM, PhD
E-Poster #115
Atropine 0.01% for the Treatment of Progressive Myopia Feasibility Study
Noha S. Ekdawi, MD
E-Poster #116
Prescribing Eye Glasses in Preverbal Children: Simplified Rules and Preferred Practice Patterns - AAPOS
Members Survey Results
Suqin Guo, MD
Rudolph Wagner, MD; Patrick DeRispinis, MD
E-Poster #117
Parent Experiences and Perspectives on Medical Services for their Children with Albinism: A Qualitative Study
Kelly E. Lusk, PhD, CLVT
Anne L. Corn, EdD; Terry L. Schwartz, MD
E-Poster #118
“It Does Matter, “ Outcomes of Prescribing Glasses in Students with Neuro-Developmental Disabilities
Ivonne M. Radinson Alvarado, BS
Nathan Schenkman, BA; Robert J. House, BA; Linda M. Lawrence, MD; Rosa Yemi Oyama Ganiko, MD;
Liliana Mayo Ortega, PhD
E-Poster #119
Functional Outcomes of Young Infants with and without Macular Edema
Adam L. Rothman, BS
Du Tran-Viet, BS; Vincent Tai, MS; Neeru Sarin, MBBS; Sandra Holgado, MD, CO;
C. Michael Cotten, MD, MHS; Sharon F. Freedman, MD; Cynthia A. Toth, MD
E-Poster #120
Outcomes of Optical Iridectomy in Peters Anomaly
Sirinya Suwannaraj
Oriel Spierer; Kara M. Cavuoto; Ta Chang Peter Chang; Craig McKeown
E-Poster #121
Visual Acutiy and Associations in Children with High Hypermetropia
Patrick Watts
Hugh Jewsbury; Marian Okeya; William John Watkins; Sailesh Kotecha
VISION SCREENING
E-Poster #122
Refractive Errors and Amblyopia in the UCLA Preschool Vision Program: First Year Results
Karen Hendler, MD
Shiva Mehravaran, MD; Fei Yu, PhD; Anne L. Coleman, MD
88
E-Poster #123
Bruckner Test, A Novel Technique for the Rapid Detection of Refractive Errors in Children by the Pediatricians
Piyush Jain
Vaibhav Gode; Mihir Kothari
E-Poster #124
High Specificity of the Pediatric Vision Scanner in a Private Pediatric Primary Care Setting
Reed M. Jost, MS
David Stager, Jr, MD; Lori Dao, MD; Scott Katz, MD; Russ McDonald, MD; Eileen E. Birch, PhD
E-Poster #125
BVAT Ordering of Letters: More than Visual Acuity?
Jill C. Rotruck
Susan Day
E-Poster #126
Do We Need to Directly Detect Astigmatism when Photoscreening for Amblyopia Risk Factors (ARFs)?
David I. Silbert, MD
Robert Arnold
E-Poster #127
Efficacy of a Vision-Screening Tool for Birth to 3 Early Intervention Programs
Roger Struble, Jr
Ryan R. House; Linda M. Lawrence, MD; Joyce E. Trower, PT
E-Poster #128
Oregon Elks Children’s Eye Clinic Vision Screening Results
Joannah M. Vaughan
Talitha Dale; Daniel Karr, MD
89
Notes
90
Lash ptosis as a complication of patching for treatment of amblyopia
Moustafa S Abdelhafez FRCS, MD
Electronic
Poster 1
Magrabi Eye Hospitals
Saudi Arabia
Introduction: The aim is to report cases developed lash ptosis during management of
amblyopia with patching.
Methods: Retrospective record of 10 cases, 2 to 10 years of age, who developed lash
ptosis on using patches during management of amblyopia. No one had previous history
of lid disorder or eye allergy. They patched 2 to 8 hours daily for one to 4 months. Eight
patients have continued visiting us 2 months after patch discontinuation.
Results: Lash ptosis had been noticed within one month of patching. Out of eight
patients, who discontinued patching, four (50%) showed improvement of lash ptosis.
Improvement showed direct relation to time of exposure to patching.
Discussion: I have not found papers talking about patching as a cause of lash tosis.
Conclusion: Lash ptosis should be considered as a possible complication of patching.
It is usually reversible. Shorter period of patching gives shorter period of recovery.
Amblyopia Occlusion Therapy Compliance: AmblyzTM Liquid Crystal Glasses
Versus Traditional Adhesive Patches
Tina Damarjian MD, Heather A. Smith MD, Daniel E. Neely MD, Jingyun Wang, PhD,
Jay Galli, Jessica Kovarik MD, James Bowsher MD, Joshua Schliesser MD, Kathryn M.
Haider MD, Gavin J. Roberts MD, Dana Donaldson OD,
Derek Sprunger MD, David A. Plager MD
Glick Eye Institute, Department of Ophthalmology, Indiana University School of Medicine
Indianapolis, Indiana
Introduction: Amblyopia treatment with adhesive occlusion patches is frequently inhibited by
poor compliance and complaints. Amblyz™ liquid crystal glasses utilize an intermittent occlusion
technique (at 30-second opaque/transparent intervals) and avoid adhesive, potentially improving
compliance. This study compares compliance with Amblyz™ glasses versus patching.
Methods: Sixteen children (3-8 YR) with untreated, moderate, unilateral amblyopia were enrolled.
All subjects wore optimal refractive correction for 12 weeks and were associated with strabismus,
anisometropia, or both. Subjects were randomized into two treatment groups: a 4-hour Amblyz™
glasses group, or a 2-hour patching group. Compliance was reported with a calendar log and an
Amblyopia Treatment Index (ATI) questionnaire characterizing the experience.
Results: At 12 weeks, compliance averaged at 82% in the patch group and 79% in the Amblyz™
group (no statistical difference). No adverse effects were reported. In the Amblyz™ group, some
parents reported that their child had trouble seeing outside at night secondary to the tint inherent to
the liquid crystal lenses; some parents complained that the glasses were easily subject to damage
by their child. The ATI demonstrated a high level of enthusiasm from parents and children with the
Amblyz™ glasses, commonly remarking that they were easier to wear and generated fewer complaints. Visual outcome measures are reported in a related abstract.
Discussion: These preliminary results are limited by the small sample size and short-term followup.
Conclusion: Compliance with Amblyz™ glasses is similar to patching, even when wearing time
was doubled in this trial. This promising device provides an alternative amblyopia treatment for
children.
91
Electronic
Poster 2
Electronic
Poster 3
Prevalence of Amblyopia in Children in Bulgaria
Stela P Dikova MD Violeta S Chernodrinska MD, PhD
Children`s Eye Hospital “Visus”
Sofia, Bulgaria
Introduction: The purpose of this study was to establish the prevalence of amblyopia
in children, aged 4 to 18, in Bulgaria, that presented a complaint or were consulted by
ophthalmologist because a parent noticed an abnormality.
Methods: A complete ophthalmology exam was performed on 285 children in the period
05.01.2014-05.31.2014 in Children’s Eye Hospital ‘Visus’ in Sofia, Bulgaria. All patients
who came in for a prophylactic exam in the period in question were excluded. Amblyopia
was defined as reduction of the best-corrected visual acuity for near and far under 40/60
on one or on both eyes. Squint, poor vision, difficulty in school, headache were the main
complaints presented.
Results: 59 out of 285 children had amblyopia (20,7%). 36 of them had amblyopia
resulting from strabismus (61%); 11 - anisometropia (18%); ten - high bilateral refractive
errors (16,9%), and two - cataract (3,4%). 43 children presented unilateral amblyopia
(73%), 16 - bilateral amblyopia (27%).
Discussion: High prevalence of amblyopia (20,7%) shows lack of screening program
involving children at an early age, poor compliance of the patient/parents and/or delay
in the treatment of the causes for amblyopia, in Bulgaria. A recent study conducted over
1861 ‘healthy’ school-aged children in northwest Bulgaria reports 4,3% prevalence of
amblyopia.
Conclusion: The lack of screening programs is the main reason for the higher prevalence of amblyopia in Bulgaria compared to North America and other developed countries. Other factors include: insufficient number of pediatric ophthalmologists in the
country and the lack of awareness among the parents.
References: A. Oscar, Cherninkova S, Haykin V, Aroyo A, Levy A, Marinov N, Kostova S, Elenkov Ch, Veleva N, Chernodrinska V, Spitzer J.
Amblyopia screening in Bulgaria. European Journal of Pediatric Ophthalmology and Strabismus 2014: Jun 25; 1-5
Electronic
Poster 4
False Positive Amblyopia Prediction During Fixation Preference Testing of
Strabismic Patients (“pseudoamblyopia”) Correlates with Ocular Dominance
Arif O. Khan MD; Dora H AlHarkan MD
King Khaled Eye Specialist Hospital
Riyadh, Saudi Arabia
Introduction: Binocular fixation preference testing (BFPT) is a commonly used clinical
method to predict Strabismic amblyopia in preverbal children. However, false positives
are a concern and can lead to inappropriate patching treatment. We explore potential
correlates for this phenomenon.
Methods: Prospective cohort study (2013-2014) of consecutive verbal Strabismic patients without incomitance or decreased vision other than strabismic amblyopia. BFPT
was graded from 1 (strong preference) to 4 (free alteration), with grade 1 or 2 considered predictive of amblyopia; this was later compared to the presence/absence of true
Strabismic amblyopia. Ocular dominance and hand dominance were assessed, and
previous patching history was documented.
Results: Of 114 enrolled subjects (mean 7.9 years old, range 3.4 to 22.4; 63 males and
51 females), 98 (86%) had esotropia and 16 (14%) had Exotropia (mean primary position horizontal strabismus 27.9 prism diopters [PD], range 8-70 with only one <10). For
false positives (39/114, 34.2%), fixating eye correlated with ipsilateral ocular dominance
(79.5%, chi square p value <0.0001) but not with hand dominance or recent patching
history. Positive predictive value was poor (45.8%, 95% confidence interval [CI] 34.058%) but negative predictive value was high (97.6%, 95% CI 87.4-99.6%). No subgroup (of type or degree of strabismus) differed.
Discussion: False positives are common during BFPT of strabismic patients and
preferred fixation in such cases correlates with ipsilateral ocular dominance, which is a
likely explanation for this phenomenon of “pseudoamblyopia.”
Conclusion: FBPT is more useful for predicting the absence rather than the presence
of strabismic amblyopia.
References: 1. Atilla H, Oral D, Coskun S, Erkam N. Poor correlation between “fix-follow-maintain” monocular/binocular fixation pattern evaluation
and presence of functional amblyopia. Binocul Vis Strabismus Q 2001; 16:85-90. 2. Hakim OM. Association between fixation preference testing
and strabismic pseudoamblyopia. J Pediatr Ophthalmol Strabismus 2007; 44:174-7.
92
Atropine penalisation in the management of amblyopia in children:
Survey of UK paediatric ophthalmologists
Neda Minakaran Saurabh Jain
The Royal Free Hospital NHS Foundation Trust
London, UK
Electronic
Poster 5
Introduction: Atropine penalisation has similar efficacy to conventional patching in the
PEDIG studies. The aim of our study was to explore its use amongst UK ophthalmologists.
Methods: We designed an electronic questionnaire that was sent to UK paediatric ophthalmologists (members of BIPOSA).
Results: There were 46 survey respondents: 42 (91.30%) used atropine penalization
always, often or sometimes. Only 1 (2.17%) always used it first line, whilst 22 (47.83%)
sometimes used it first-line, most commenting it was often parental choice. The most
common reason given for using atropine penalization was non-compliance with patching
(88.64%). Reverse amblyopia was reported by 13 respondents (28.26%). Just 16 ophthalmologists (34.78%) felt that in their practice atropine penalisation was as effective as
patching.
Discussion: Atropine penalization appears to be used most commonly as second-line
treatment in UK ophthalmology departments, and usually when there are compliance
issues with patching. Comments from respondents indicated that many felt unfamiliar
with it so tended to use it less than patching, and when used first-line it was more often
parental rather than clinician choice of treatment. Few raised concerns about sideeffects, and of those reporting reverse-amblyopia, all commented that it was one or two
cases in their paediatric experience.
Conclusion: Whilst clinicians are aware of the results of the PEDIG trials, and few have
major concerns that atropine penalization is a safe alternative to patching if carefully
monitored, there is still reluctance to use it first-line amongst UK paediatric ophthalmologists. Departmental audits should be encouraged and may increase clinician support for
this method of treatment.
Binocular dichoptic video content treatment for amblyopia - pilot study
Chaim Stolovitch MD Gad Dotan MD Noa Delman MD Daphna Mezad MD
Department of Ophthalmology,Tel Aviv Medical Center and Dana Children’s Hospital
Tel Aviv University, Tel Aviv, Israel
Introduction: Patching and Atropin penalization have been the main treatment for amblyopia overcoming the blocking or suppression of the amblyopic eye by the sound one. In recent years new
insights emerged for treatment of amblyopia using binocular stimulation dichoptically. Our objective was to assess a novel device for treatment of Amblyopia, using dynamically altered dichoptic
presentation of video contents without patching.
Methods: We used a dedicated software that alter dynamically video content presented dichoptically binocularly, using Reviview™ video goggles, in which reduced contrast of the video content is
presented to the good eye compared with enhanced contrast video content to the amblyopic eye.
Eighteen subjects, age 4-8 years, diagnosed with refractive or strabismic amblyopia, with VA worse
than 6/15 (20/50) in the amblyopic eye were enrolled. All the children were reluctant for further
patching or using atropine and their compliance was bad. All used the device for 30-60 min daily
while watching animated TV shows at home without patching. Visual Acuity and Randot stereoacity
were assessed at baseline and after 4,8 and 12 weeks of treatment.
Results: 16 patients completed 12 week of treatment.Two of our patients stopped treatment after
4 weeks. At the 4-week visit, visual acuity improved significantly (mean 0.1828 ± 0.1443 logMAR)
in the amblyopic eye, (T value=5.4175,P=0.001),at 8 weeks visit (N=16,mean 0.2475 ± 0.1267 logMAR) (Anova= F value=7.373,P=0.0017)and at 12 weeks (N=16,mean 0.2681 ± 0.1645 logMAR)
(Anova=F value=6.61211,P=0.0066 from base line Visual Acuity.
Discussion: New treatment modalities for amblyopia were introduced in recent years. Mainly by
Robert Hess and Elain Birch.They have used Ipad with Tetris and likewise games achieving mean
improvement of 0.08±0.01 logMar at 4 weeks with no improvement with further treatment to 8
weeks.
Our device and protocol of treatment achieved much better results at 4 weeks of treatment 0.1828
± 0.1443 logMAR with continuous improvement towards the 12 week visit 0.2681 ± 0.1645 logMAR.
Conclusion: The use of a dynamically altered dichoptic presentation of everyday video using Reviview™ video goggles without patching has the potential to be used as treatment for Amblyopia.
References: 1. Hess et al .An Ipod treatment of amblyopia:an updated binocular approach. Optometry 2012;83:87-94
binocular ipad treatment for amblyopic children. Eye 25 July 2014.165;1-8 advance publication
93
2. Birch EE et al. A
Electronic
Poster 6
Electronic
Poster 7
Measurement tool for assessing visual function in patients with amblyopia
Kathryn P Winkler, MD Sabin Dang, MD Rebecca Schwarzlose, PhD
Reecha S Bahl, MD
Kresge Eye Institute, Detroit, MI
Introduction: Amblyopia is the most common cause of visual impairment in children. In
both clinical and research settings, the degree of amblyopia is often measured solely with
the assessment of visual acuity. However, it is well known that the loss of visual function
is more complex than just loss of acuity. Our group presents a software tool that allows
for the quantitative measurement of amblyopia focusing on four factors: stereopsis, contrast sensitivity, acuity, and crowding.
Methods: We produced software that presented several stimuli. To assess visual acuity, standard letter stimuli of varying sizes were presented over a 50% gray background,
with the subject instructed to identify the letter presented. Contrast sensitivity was determined using gabor patch sinusolidal gratings of various luminance profiles. Crowding was
quantified in a two-dimensional fashion with flanking letters presented around a central
letter. The flanking stimuli were adjusted in both size and distance from the target stimuli.
Lastly, we asked subjects to perform a three-dimensional spatial discrimination task while
wearing red-green glasses. All tests were performed in an adaptive manner using the
QUEST algorithm to determine a threshold at which patients could accurately identify
each stimulus.
Results: Using our method, we are able to quantitatively define the visual function of a
given subject on several dimensions: acuity, contrast sensitivity, crowding, and stereopsis.
Discussion: Clinical studies involving amblyopia have relied on simple visual acuity as
an indicator of visual function. Using well characterized methods from visual psychophysics research, we are better able to quantify the visual function of a patient.
Conclusion: We believe using this tool in clinical studies can provide a more nuanced
assessment of visual function in patients with amblyopia.
Electronic
Poster 8
Alternate Occlusion for Bilateral Ametropic Amblyopia
Di Zou Lucy Stafford Saurabh Jain Mr
Royal Free London NHS Foundation Trust
The Royal Free Hospital, Pond Street, NW3 2QG
Introduction: Bilateral ametropic amblyopia occurs in the presence of high refractive
error and is attributed to pattern deprivation. Current treatment advocates full-time spectacle wear whilst the use of alternate occlusion and simple occlusion are supported by
anecdotal evidence and are implemented as a rare treatment option in some UK hospitals. This study looks at the effectiveness of alternate occlusion and simple occlusion in
comparison to spectacles with respect to bilateral ametropic amblyopia.
Methods: The study was a retrospective, case-note review. Twenty-eight case notes of
patients with bilateral ametropic amblyopia were reviewed in order to assess improvements in visual acuity. Patients were then divided into spectacles only (A), simple occlusion of the worse eye (B) or alternate eye occlusion (C) groups. Comparisons were then
made using spectacles only as the control.
Results: Change in monocular visual acuity for A was 0.19 and 0.01 for the right and left
eyes respectively; for B was 0.22; and for C was 0.26 and 0.24 for the right and left eyes
respectively. Comparison of alternate day or simple occlusion versus spectacles only
revealed no statistical significance.
Discussion: Alternate day occlusion and simple occlusion do not significantly affect the
outcome of monocular visual acuity after one year. Spectacle wear remains the most effective treatment for bilateral ametropic amblyopia.
Conclusion: Based on our results, we recommend the cessation of alternate occlusion
as a management option for patients with bilateral ametropic amblyopia.
94
Using Anterior Segment Imaging as a Guide for the Surgical Management of
Pediatric Corneal Opacities
Luxme Hariharan MD, MPH Dilshad Contractor MBS Julia Johnston MPAP Tova Mannis
MD Bibiana Jin Reiser MD, MS
Children’s Hospital of Los Angeles, USC Eye Institute
Los Angeles, CA
Electronic
Poster 9
Introduction: Pediatric corneal scarring and opacities often present a problem in the
visual development of children as the early obstruction of the visual axis can result in irreversible vision loss. The purpose of this study is to identify to role anterior segment OCT
can play a role in the surgical decision making of children with partial and full thickness
corneal opacities that are possible to transplant.
Methods: This is an ongoing IRB-approved prospective observational study of 41 patients at the Children’s Hospital of Los Angeles that underwent anterior segment imaging
for possible corneal surgery. Inclusion criteria included children age 1 month to 18 years
old with corneal opacities affecting the visual axis. Surgical options included: 1) Laser-assisted anterior keratoplasty (LALAK), 2) Penetrating keratoplasty (PKP) or 3) No surgery.
Using OCT findings and pacchymetry we determined whether PKP vs. DALK vs. LALAK
was best for each patient.
Results: Based on the anterior segment imaging a clinical exam, 4 were candidates for
anterior lamellar keratoplasty, 9 were for PKP, and 26 were not surgical candidates.
Discussion: The majority of children in our study had corneal opacities that were full
thickness on anterior segment OCT imaging and therefore needed surgical treatment via
PKP rather than DALK or LALAK. These deep opacities may be further examined with
dynamic Ultrasound Biomicroscopy (UBM) rather than anterior segment OCT and clinical
exam alone, for greater detail.
Conclusion: Anterior segment OCT imaging can be a useful tool in guiding a surgical
plan for pediatric corneal transplants as opposed to clinical exam alone for patients with
partial and full-thickness corneal opacities.
References: 1. Alward and Longmuir, “ Color Atlas of Gonioscopy”, American Academy of Ophthalmology.
Coherence Tomography Imaging of the Anterior Chamber Angle”, Ophthalmol Clin N Am, 2005; 18:375-381
2. Radhakrishnan, et al, “ Optical
Effect on blink rate during videogame related activities and reading
in school-aged children
Catherine O Jordan MD and David L Rogers MD
Nationwide Children’s Hospital, Columbus, OH
Introduction: This study compared blink rate per minute (B/m) during an interview, reading a book and playing a videogame.
Methods: Children aged 5 to 17 were recruited for a pilot study. Participants were individually videotaped for five minutes during each of these activities: being interviewed for
dry eye symptoms, reading a book and playing a handheld videogame. The videos were
reviewed and B/m was recorded. A two-tailed matched pairs t-test was used for statistical
analysis.
Results: 20 healthy subjects were recruited. Mean blink rates were: interview 11.91
B/m, reading 5.97 B/m and videogame 6.92 B/min. The mean blink rate during the
interview was statistically higher compared to reading (p <0.05) and videogame activities (p<0.05). Subjects found to have more dry eye symptoms (n=10) had lower mean
blink rates during reading (3.79 B/m) and videogame activities (3.97 B/m) than subjects
with low to no symptoms (n=10) during the reading (8.15 B/m) and videogame (9.86 B/m)
activities. This trend was not statistically significant.
Discussion: We showed a statistically significant decrease in blink rate during reading
and videogame use compared to an interview conversation. This decrease may be due
to increased visual demand of the near tasks. Although it wasn’t statistically significant,
decreased blink rates may be related to dry eye symptoms in children.
Conclusion: In children, blink rate decreases during activities such as reading and playing videogames compared to conversation. This may play a role in dry eye symptoms
that occur during these activities.
References: 1. Lavezzo MM, Schellini SA, Padavani CR, Hirai FE. Eye blink in newborn and preschool-aged children. Acta Ophthalmol. 2008;
86(3): 275-8. 2. Salman MS, Liu L. Spontaneous blink rates in children during different types of eye movements. Can J Neurol Sci. 2013; 40(5):
717-21.
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Electronic
Poster 10
Electronic
Poster 11
Episodic excessive blinking in children
Yasmin P Mali MD John W Simon MD Imran A Chaudhri Jitka Zobal-Ratner MD
Gerard P Barry MD
Albany Medical College/Lions Eye Institute
Albany, New York
Introduction: Many children present with excessive blinking. Categorization, associated
conditions, and prognosis are controversial.
Methods: All children with excessive blinking were reviewed, excluding those with
known uveitis, glaucoma, or obvious eyelid abnormalities. Parents were telephoned for
follow-up.
Results: A total of 74 children (54 boys), aged 1 to 10 years (mean 4.7), had excessive
blinking for 3 days to 1.5 years (mean 2.5 months). Parents were contacted in 55% of
cases. In 26, parents could not identify a cause. In 2, Tourette syndrome was diagnosed, 1 following presentation. In 2, dexmethylphenidate (a stimulant used for ADHD)
was suspected to be the cause. There was complete resolution in 29, some improvement in 8, and no improvement in 4 cases. No new ophthalmologic diagnoses were
uncovered.
Discussion: All children with excessive blinking should undergo ophthalmologic examination. Families should be encouraged to follow-up as needed for redness, light sensitivity, or other eye symptoms. If blinking persists, further evaluations can be coordinated
with the pediatrician.
Conclusion: Episodes of excessive blinking rarely indicate neurologic disorders and
frequently resolve spontaneously.
Electronic
Poster 12
Peters anomaly phenotypic spectrum - from mild to severe disease
Kamiar Mireskandari Uri Elbaz Hermina Strungaru Asim Ali
Department of Ophthalmology and Vision Sciences, Hospital for Sick Children
University of Toronto
Toronto, Ontario, Canada
Introduction: The phenotypic diversity of Peters anomaly leads to differences in management and outcomes for this condition. With improved imaging techniques we can
further understand the wide spectrum of Peters anomaly and potentially modify the grading scale for disease severity and provide a flowchart that simplifies the decision-making
process.
Methods: The charts and images of patients with Peters anomaly between January
2000 and December 2013 were reviewed retrospectively. Anterior segment imaging
including RetCam or slit lamp photographs, optical coherence tomography and ultrasound biomicroscopy images were utilized and served to assess anatomical features and
abnormalities in relation to visual outcome.
Results: Eighty-two eyes of 56 patients were included in the study. Seventy-one eyes
(86.6 %) had a centrally located opacity and 60 eyes (73.2%) had a dense opacity
obscuring iris details. Iridocorneal adhesions (90.2%), Corneal vascularization (37.8%),
posterior corneal thinning (35.4%), keratolenticular adhesions (21.9%), cataract (26.8%)
and aphakia (1.2%) were features associated with Peters anomaly. Also 20% of patients
with moderate Peters had very flat keratometry (36-38D) and high hyperopia. Natural
history of Peters involves mild resolution of corneal opacity; hence optical iridectomy
and pupil dilation were successfully utilized in third patients with a mean final corrected
distance visual acuity (CDVA) of 0.4 logMAR. In contrast severe opacity required corneal
transplantation with a mean final CDVA of 1.1 logMAR.
Discussion: Our study further describes phenotypic features in relation to management
and outcomes of Peters anomaly and will be compared to the literature.
Conclusion: Peters anomaly presents with variable phenotype requiring tailored management based on disease severity.
96
Lamellar Keratoplasty for Excision of Limbal Dermoids
Oriel Spierer MD Richard K Forster MD
Bascom Palmer Eye Institute, University of Miami Miller School of Medicine
Miami, Florida, USA
Electronic
Poster 13
Introduction: The purpose of this study is to assess the surgical outcomes of visual
acuity, refraction and cosmetic appearance in patients that underwent limbal dermoid
excision with lamellar keratoplasty.
Methods: The charts of 8 consecutive patients who underwent limbal dermoid excision
with lamellar corneoscleral graft transplantation, by one surgeon, were retrospectively
reviewed. Comparison of visual acuity, spherical equivalent and astigmatism before and
after the surgery was done. Vector analysis was used to evaluate the change in astigmatism after the surgery.
Results: Mean age of patients at day of surgery was 13.0 years old (62.5% female).
Mean dermoid size was 7.75 mm. Indications for surgery were cosmetic appearance,
high astigmatism and ocular irritation. Mean visual acuity (in LogMAR units) before and
after the surgery was 1.8 and 1.7, respectively (p=0.79). Spherical equivalent was 1.3 D
before the surgery and 0.7 D after the surgery (p=0.52). The mean astigmatism before
and after the surgery was 2.4 D and 1.5 D, respectively (p=0.37). Vector analysis revealed mild change in astigmatism with mean ‘d’ of 3.2 (0.56-6.89). None of the patients
had graft complications and patients had good cosmetic outcome.
Discussion: Surgical techniques for dermoid excision include simple excision, superficial keratectomy, penetrating keratoplasty and lamellar keratoplasty. Indications for excision include poor appearance and astigmatism. However, there is not enough support in
the literature that limbal dermoid excision reduces astigmatism.
Conclusion: Lamellar keratoplasty for limbal dermoid is safe and offers good appearance and tectonic stability. Significant improvement in the amount of astigmatism is not
expected following surgery.
References: 1. Lang SJ, Böhringer D, Reinhard T. Surgical management of corneal limbal dermoids: retrospective study of different techniques and
use of Mitomycin C. Eye (Lond). 2014 Jul;28(7):857-62. 2. Watts P, Michaeli-Cohen A, Abdolell M, Rootman D. Outcome of lamellar keratoplasty
for limbal dermoids in children. J AAPOS. 2002 Aug;6(4):209-15. 3. Scott JA, Tan DT. Therapeutic lamellar keratoplasty for limbal dermoids.
Ophthalmology. 2001 Oct;108(10):1858-67.
Endophthalmitis after cataract surgery in children
SUMITA AGARKAR MD ROSHNI DESAI MD
MEDICAL RESEARCH FOUNDATION , SANKARA NETHRALAYA
18 , COLLEGE ROAD , NUNGAMBAKKAM, CHENNAI , TAMILNADU, INDIA
Introduction: Endophthalmitis following cataract surgery is a rare and devastating complication. There is a
paucity of litreture regarding postoperative endophthalmitis following cataract surgery in children . We present a
retrospective case series of 9 cases of endophthalmitis following elective cataract surgery in children
Methods: Retrospective review of charts of all children with a diagnosis postoperative endophthalmitis following cataract surgery at a tertiary care hospital in India between year 2000 to 2012, by a single surgeon , was
done . All children who had a diagnosis of traumatic cataract were excluded. Diagnosis of endophthalmitis was
based on clinical signs and symptoms as well as diagnotic modalities like aqueous and vitreous culture , Gram
staining etc. Special note was made if patient had any symptoms suggestive of nasolacrimal duct obstruction
prior to the cataract surgery
Results: A total of 9 patients out of 1446 patients aged between 5 months to 14 years (mean - 5.9 years )developed symptoms and signs suggestive of post operative inflammation / infection following uneventful elective
cataract surgery. None of the patients in this series had nasolacrimal duct obstruction.All of them , barring one,
reported within 72 hours after an uneventful cataract surgery. All patients recieved intravitreal antibiotics and
steroid. Vitrectomy was required in 5 out of 9 cases. 6 patients tested positive for eubacterial genome on PCR
.Only 4 patients had positive vitreous culture. Organisms isolated on culture were Staphylococcus , Acinetobacter and Pseudomonas species. The mean follow up was 5.10 years (1.17 to 13 years). At the last follow up,
7 out of 9 eyes had visual acuity better than 6/24; one eye was amblyopic.Only one eye had nil perception of
light and was prepthysical. Three patients required additional surgery for retinal detachment
Discussion: There are few reports available on endophthalmitis following cataract surgery in children .Nasolacrimal duct block has been cited as a risk factor however none of children in this series , had any clinical
evidence of nasolacrimal duct obstruction.Visual outcome has been reported to be very poor. Wheeler et al
have reported 65%of patients devloping nil perception of light in contrast to our series. Good visual outcome in
our series could be attributed to either low virulence of organisms or early vitrectomy
Conclusion: Post operative endophthalmitis is a serious vision threatening condition .Clinicians should maintain a high index of suspicion in the event of any unexplained inflammation in immediate post operative period
that is first 72 hours . Aggressive intervention in form of intravitreal injections and early vitrectomy may help in
achieving good anatomic and visual outcomes
References: 1.Wheeler DT , StagerDR , Weakley DR jr. Endophthalmitis following pediatric intraocular surgery for qcongenital cataracts and
congenital glaucoma J Pediatr Ophthalmol Strabismus. 1992 May-Jun;29(3):139-41. 2. Good, William V, MD;Hing, Stephen;Irvine, Alexander R,
MD;Hoyt, Creig S, MD;Taylor, David S I, FR. Postoperative Endophthalmitis in Children Following Cataract Surgery. Journal of Pediatric Ophthalmology and Strabismus; Nov/Dec 1990; 27, 6; pg. 283
3 . Smith J, Poulose A, Olitsky SE. Endophthalmitis following pediatric cataract surgery with a
good outcome. J Pediatr Ophthalmol Strabismus. 2006 Jul-Aug;43(4):239-40.
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Electronic
Poster 14
Electronic
Poster 15
Manifest nystagmus in children with monocular congenital cataract
Luai T Eldweik Deborah Vanderveen
Children`s Hospital of Boaton
300 Longwood Avenue, Boston MA
Introduction: Little is known about associations between monocular congenital cataract
and bilateral manifest nystagmus.
Methods: Review of surgical logs(1993-2014) for unilateral cataract surgery in the first
year of life and minimum 1 year follow-up. Children with identifiable syndromes associated with nystagmus and posterior segment abnormalities were excluded. Variables studied included age at surgery, amount of prescribed patching and compliance, additional
surgical interventions, visual acuity measures and strabismus. Comparison of variables
between the groups with and without nystagmus was made.
Results: 12/101(11%) children with nystagmus were identified; 6 were excluded (Down
syndrome, metabolic disorder, encephalopathy). Of the 95 remaining patients, 81 had
contact lens correction of aphakia within one week of surgery, 14 had primary IOL implantation. Median age at surgery was lower for those with nystagmus 40 vs. 60 days
(mean, 96 vs. 107 days). No difference in patching recommendations or compliance was
associated with nystagmus except for one patient who developed reverse amblyopia and
nystagmus after compliance with almost full time patching. At age one year, mean logMar
visual acuity in the phakic eye was 0.64 in the nystagmus group compared to 0.71 in the
control group. Final recognition acuity of the operated eye was better than 20/200 in 3/12
children with nystagmus and 34/89 without nystagmus. Anomalous head posture was
observed in 8 children.
Conclusion: Bilateral manifest nystagmus is seen in a significant proportion of children
with monocular congenital cataract; no overall associations were noted. Over-rigorous
patching can lead to reverse amblyopia and nystagmus caused by early bilateral deprivation.
Electronic
Poster 16
Pentacam and OCT Imaging Techniques in Pseudophakic Eyes of Children
Catherine Gasper BS, M Edward Wilson MD, Rupal H. Trivedi MD
Storm Eye Institute, Medical University of SC
Charleston, SC, USA
Introduction: We sought to evaluate Pentacam and OCT imaging techniques in pseudophakic eyes of children. Our objective is twofold: to compare data from 1) randomly
selected pseudophakic eyes of bilateral cases to that of monocular pseudophakic eyes;
and 2) pseudophakic eyes of monocular cases to that of the fellow unoperated eyes.
Methods: Prospective ongoing study evaluating Pentacam and OCT. We excluded patients with traumatic cataract. Data were statistically analyzed using independent sample
and paired T-test.
Results: Of the twenty-one patients photographed, data from seven patients with
monocular cataract and ten patients with bilateral cataracts were further analyzed. The
mean age at time of cataract surgery was 4 years (SD=5). Twelve patients received primary IOL and five received secondary IOL. Corneal thickness (central, nasal, temporal,
superior, inferior, and thinnest), anterior chamber depth, and central macular thickness
was not significantly different between patients operated for bilateral cataract and those
with monocular cataract (P>0.05). However, corneal thickness (nasal, interior), anterior
chamber depth and central macular thickness was significantly different in patients operated for monocular cataract as compare to the fellow unoperated eyes (P = 0.001, 0.014,
<0.001 and 0.003 respectively). Corneal thickness in other areas did not reach statistical
difference (central, temporal, superior, thinnest).
Discussion: This is an early, exploratory study using Pentacam and OCT adult imaging
techniques for pseudophakic eyes of children. These non-contact imaging modalities will
likely see increased use in pediatric patients. Enrollment in our study is ongoing.
Conclusion: Pseudophakic eyes of children operated for bilateral cataract and monocular cataract appears to have similar results on Pentacam and OCT, while eyes operated
for monocular cataract were noted to have differences as compared to the fellow unoperated eyes.
98
Preferred Practice Patterns for Pediatric Cataract Surgery and Post-Operative
Management
Gennifer J Greebel1 Majida A Gaffar2
1
Electronic
Poster 17
Ophthalmology, Edward S. Harkness Eye Institute, Columbia Presbyterian, New York, NY
2
Ophthalmology, North Shore-Long Island Jewish Medical Center, Great Neck, NY
Introduction: To evaluate the practice patterns of pediatric cataract surgeons, summarize
new surgical techniques, and establish appropriate guidelines in this evolving field.
Methods: Invitations to participate in an internet-based survey were sent to 1330 physicians
of The American Academy of Pediatric Ophthalmology and Strabismus (AAPOS). A
35-question survey evaluated the surgeon’s experience, operative techniques, and long-term
management choices. Included physicians completed a pediatric ophthalmology fellowship,
and perform cataract surgery domestically.
Results: Seventy-six physicians of the 142 responses were included. The respondents were
subdivided into Group A, surgeons who perform < 20 surgeries yearly, and Group B, surgeons
who perform greater than 20 surgeries yearly. There were 60 surgeons in Group A and 16
surgeons in Group B. A Fisher’s exact test was performed for all questions on the survey,
comparing Groups A and B. Although there appeared to be many questions where practice
patterns differered between the two groups, the only question with statistically significant
results addressed the appropriate age in which to place a primary lens implant. Group A
mostly implants primary lenses between years 1-2, whereas Group B tends to place lenses
earlier between 8 months and 1 year (p-value < 0.032).
Discussion: Newly developed medications, innovative surgical techniques, improved
treatment of inflammatory conditions, and decreased mortality of prematurity, create more
challenges and management options for pediatric cataracts. While most surgeons adopted
new ways to treat their patients, some therapies are mostly utilized by more experienced
surgeons. A variety of surgical and post-operative situations exist, however, that lack
consensus regardless of expertise.
Conclusion: The diversity of therapy for pediatric cataracts reveals the need for further
investigation and continued education, in order to determine the best management protocols.
References: Mataftsi A et al. Postoperative glaucoma following infantile cataract surgery: an individual patient data meta-analysis. JAMA
Ophthalmol. 2014 Sep;132(9):1059-67 Robbins SL, Breidenstein B, Granet DB. Solutions in pediatric cataracts. Curr Opin Ophthalmol.
2014 Jan;25(1):12-8.
Ventura MCet al. Outcomes of congenital cataract surgery: intraoperative intracameral triamcinolone injection versus
postoperative oral prednisolone. J Cataract Refract Surg. 2014 Apr;40(4):601-8.
Traumatic Cataract In Children: A Long Term Follow-Up- A Retrospective
Observational Review
ASSAF HILELY MD HANA LEIBA MD REUT PARNESS-YOSSIFON MD
Department of Ophthalmology, Kaplan Medical Center
Rehovot, Israel
Introduction: To review long term results of operated unilateral traumatic cataract, due to either
blunt or penetrating traumas, in children.
Methods: A retrospective observational case series. Files of all children under the age of 18 years
who had unilateral traumatic cataract between the years 1983-2009 were reviewed. Exclusion criteria included trauma to posterior segment and follow up of less than 5 year. Main outcome measures
were final visual acuity and any complications.
Results: Of 18 children included, 83% were males. Mean follow-up time was 12.5 years (5-30)
Median age at injury was 7.5 years (range 2.6-17). Trauma was penetrating in 11 patients (61%)
and blunt in 7 (39%). 16 patients (89%) had cataract already on admission (10 had penetrating
trauma and 6 blunt trauma) and 14 of them needed operation. In 2 patients the cataract developed
along the follow up (1 blunt and 1 penetrating) and they were operated. Following lensectomy, an
intraocular lens implantation was performed in 14 (87.5%) of the patients, either in the first operation (43%) or as a secondary procedure (57%). Mean final visual acuity (VA) was 20/40 (Light
Perception-20/20) in the pseudophakic group and 20/2000 (Hand Movement-Counting Fingers) in
the aphakic group.In the pseudophakic group, intraocular lens dislocation was diagnosed in 36%
of the patients. No additional interventions for lens reposition were performed. Final mean VA was
20/63 in the dislocated group and 20/32 in the non dislocated group. Four (29%) of the pseudophakic patients (3 with penetrating and 1 with non penetrating trauma) developed glaucoma compared
to both (100%) of the aphakic group (all with penetrating trauma).
Posterior capsular opacity developed in 11 (79%) of the patients, Posterior capsule opening was
performed in 9 of them (7 YAG-laser and 2 surgical).
Discussion: Traumatic cataract was found to be more common among males. Penetrating trauma
was more frequent. Pseudophakic patients had better visual acuity and less glaucoma. Final VA
was good even with lens dislocation, better than aphakia albeit worse than without dislocation.
Conclusion: Children with traumatic cataract without initial damage to the posterior segment tend
to have favorable long term results. Glaucoma developed in all the aphakic patiens, probably due
to a severe initial injury.
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Electronic
Poster 18
Electronic
Poster 19
Visual Acuity and Refractive Outcome in Pediatric IOL Implantation
with Initial Low vs High Hyperopia
Dayane C Issaho Serena Wang Monica Bratton David Weakley
University of Texas Southwestern
Dallas
Introduction: Purpose: To compare the impact of initial post-operative refraction on
the visual acuity and refractive outcome in children after primary intraocular lens (IOL)
implantation following cataract extraction.
Methods: The records of all patients who underwent non-traumatic cataract extraction
with primary IOL implantation under 7 years of age were reviewed over a 12-year period.
Eyes were divided into 2 groups: (1) initial postoperative refraction < +3.00 D spherical
equivalent (SE) and (2) ≥ +3.00 D SE; and also analyzed according to the age at surgery: < 2, 2 to < 4 and, 4 to ≤ 7 years old.
Results: Sixty-four patients (88 eyes) were included; 55 eyes in the initial low hyperopia
group and 33 eyes in the high hyperopia group. The mean acuity at the most recent visit
was 0.5 logMar (SD 0.55) in group 1 (mean follow-up 65 months) and 0.58 logMar (SD
0.45) in group 2 (mean follow-up 49 months) (p = 0.75). Visual acuity outcome was not
affected by age at surgery. Mean SE at the last visit was -1.55 D in group 1 vs -0.21 D in
group 2 (p = 0.62). The age 0-2 subgroup had a greater myopic tendency when initially <
+3.00 D (-5.08 D SE vs -2.61 D SE, p=0.71).
Discussion:
Conclusion: More modest initial refractive undercorrection (<+3.00 D) after primary IOL
implantation does not improve visual outcome or later refractive status, especially in the
younger children who have a greater myopic shift.
Electronic
Poster 20
Structural Changes of the Anterior Chamber Following Cataract Surgery
During Infancy
Matthew Nguyen MD Scott Lambert MD Allen Beck MD Marla Shainberg CO
Emory Eye Center, Atlanta, GA
Introduction: Glaucoma occurs in up to 30% of children after cataract surgery during
infancy(1,2), possibly because of structural changes of the anterior segment causing the
trabecular meshwork to ‘collapse(3).’
Methods: After obtaining informed consent, the Heidelberg SPECTRALIS was used to
measure the angle opening distance (AOD) and trabecular iris angle (TIA) and the IOLMaster to measure the anterior chamber depth (ACD), corneal diameter and axial length
(AL) for 7 children, ages 6 to 12 years old, who underwent unilateral cataract extraction
with or without primary intraocular lens placement when <7 months of age. An ocular
examination was also performed.
Results: Unilateral cataract surgery was performed at a mean age of 2.2 (range, 0.9 to
4.2) months. Five treated eyes were aphakic and 2 were pseudophakic. Patients were
examined at a mean age of 9.2 (range, 6.6 to 12.5) years. No eyes had glaucoma. The
mean IOP was 17 mmHg in treated eyes and 16 mmHg in fellow eyes. Mean ACD was
greater in fellow (3.48 mm) than treated eyes (2.93 mm). ACD was deeper in pseudophakic eyes (IOL, 3.10 mm; aphakic, 2.85 mm) and AOD (IOL, 843 µm; aphakic, 767 µm)
and TIA (IOL, 42°; aphakic, 37°) were greater in pseudophakic eyes.
Discussion: Pseudophakic eyes had a shallower ACD than fellow eyes, but were
deeper than aphakic eyes.
Conclusion: Cataract surgery during infancy causes structural changes in the anterior
chamber. Primary implantation of an IOL was associated with a deeper anterior chamber
and greater TIA than eyes without IOL implantation.
References: 1. Lambert SR, Purohit A, Superak HM, Lynn MJ, Beck AD. Long-term Risk of Glaucoma After Congenital Cataract Surgery. Am J
Ophthalmol. Aug 2013;156(2):355-361 e352. 2. Mataftsi AH, Kikkali, S., Rabiah, P.K., Birch, E., Stager D.R., Cheong-Leen, R., Singh, V., Egbert,
J.E., Astle, W. F., Lambert, S.R., Amitabh, P., Khan, A.O., Grigg, J., Arvanitidou, M., Dimitrakos, S.A., Nishal, K.K. Postoperative gluacoma following
infantile glaucoma surgery: an individual patient data meta-analysis. JAMA Ophthalmology. In Press. 3. Asrani S, Freedman S, Hasselblad V, et
al. Does primary intraocular lens implantation prevent ‘aphakic’ glaucoma in children? J AAPOS. Feb 2000;4(1):33-39.
100
Refractive growth in pseudophakic children age 2-6 years
Bharti Nihalani-Gangwani,MD Deborah K VanderVeen,MD
Boston Children’s Hospital
Boston, MA
Electronic
Poster 21
Introduction: The purpose of this study is to report refractive changes in pseudophakic
children operated between 2-6 years age.
Methods: Retrospective chart review of pseudophakic children operated age 2-6 years
with minimum followup of 3 years. The refractive error was recorded at 1-2 months after
surgery and then yearly. Mean myopic shift was determined and refractive change per
year was calculated.
Results: 42 eyes of 27 children met the inclusion criteria. Mean age at the time of surgery: 3.9 years, mean followup: 7.5 years (range, 3-14). Patients operated between 2-3
years (n=12) had slightly greater mean myopic shift of -3.2 D compared to -2.6 D in 3-4
years (n=14) and -2.7 D in 4-6 years (n=16). Myopic shift per year was not significantly
different in these age groups (0.5 D/year, p=0.7, ANOVA). Myopic shift was somewhat
higher in unilateral than bilateral pseudophakia (-3.0 vs. -2.8 D; n=12 vs. 30; p=0.7, unpaired t test).
Discussion: While most axial growth and myopic shift occurs before 2 years, a variable
amount of refractive change can occur in the pre-school population, so most surgeons
aim for post-operative emmetropia around 6 years of age.
Conclusion: There is a myopic shift of 0.5 D/year in children operated between age 2-6
years. Myopic shift is somewhat greater in younger children and unilateral pseudophakia.
References: 1. Enyedi LB, Peterseim MW, Freedman SF, Buckley EG. Refractive changes after pediatric intraocular lens implantation. Am J Ophthalmol 1998;126:772-81 2. Crouch ER, Crouch ER Jr, Pressman SH. Prospective analysis of pediatric pseudophakia. Myopic shift and postoperative outcomes. J AAPOS 2002;6:277-82 3. Plager DA, Kipfer H, Sprunger DT, et al. Refractive change in pediatric pseudophakia. 6-year followup.
J Cataract Refract Surg 2002;28: 810-5
Bilateral pediatric cataracts: nystagmus, strabismus and visual outcome:
A 10-year data analysis
Judith R Sabah Nandini Gandhi Machelle Wilson Mary O’Hara
University of California Davis Health System
Sacramento, CA
Introduction: The purpose of this study was (a) to determine whether performing cataract
surgery on infants with bilateral cataracts before or after ten weeks of age affects visual acuity
outcome (VO) or nystagmus and (b) to determine whether pre-operative/post-operative nystagmus or strabismus affects VO.
Methods: This is a retrospective, non-randomized, single center, IRB approved study in
which the charts of all pediatric patients with bilateral cataracts between 2004 and 2013 were
reviewed. Children with CNS disease or other ocular abnormalities were excluded. A mixed
effects ANOVA or hierarchical logistic regression was performed for the variables analyzed.
Results: 29 subjects were included, 16 with nuclear cataracts and 13 with lamellar cataracts.
The median age at surgery for subjects with nuclear cataracts was 3 months (range: 3 weeks
to 30.5 months) and with lamellar cataracts was 58 months (range: 3.5-91 months). In the
nuclear cataract group, there was no statistically significant relationship between age at surgery and VO (p=0.3951), or age at surgery and post-operative nystagmus (p=0.8710). There
was also no evidence that pre-operative nystagmus affected the VO in that group (p=0.2836).
In the lamellar group, all patients had their surgery after our 10-weeks cut off. In both cataract morphology groups, post-op nystagmus was associated with poorer VO (p=0.0617 in the
nuclear group, p=0.0038 in the lamellar group). In contrast, irrespective of the type of cataract,
strabismus was not significantly associated with a worse VO (p= 0.7195).
Discussion: Our results are in agreement with those from VanderVeen et al. who recently
reported that pre-operative nystagmus did not portend a poor VO.
Conclusion: Age at surgery did not have a significant difference on VO in subjects with
nuclear cataracts. The presence of pre-operative nystagmus did not predict poor VO, but
post-operative nystagmus was associated with worse VO.
References: 1. Young PM, Heidary G, VanderVeen DK. Relationship between the timing of cataract surgery and development of nystagmus in patients with bilateral infantile cataracts. J AAPOS 2012;16:554-557.
2. Birch EE, Cheng CC, Stager DR Jr, Weakley DR, Stager DR Sr. The critical
period for surgical treatment of dense congenital bilateral cataracts. J AAPOS 2009;13:67-71.
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Ocular Axial Growth in Pseudophakic Eyes of Patients Operated for Monocular
Infantile Cataract: A Comparison of Operated and Fellow Eyes Measured at
Surgery and 5 or More Years Later
Dina Tadros, MD,(1-2) Rupal H Trivedi, MD,(2) M Edward Wilson, MD,(2) Jennifer Davidson,
MD,(2) Leah Owen, MD(2)
(1) Ophthalmology department, Faculty of Medicine, Tanta University, Egypt
(2) Storm Eye Institute, Medical University of South Carolina, Charleston, SC, USA
Introduction: To compare change in axial length (AL) and rate of AL growth of eyes
operated for monocular cataract surgery to that of the fellow unoperated eye.
Methods: Study population: Infants operated by one surgeon for monocular cataract
before seven months of age. Globe axial length was measured by immersion ultrasound
at surgery and 5 or more years later. Rate of AL growth was calculated as (postoperative
AL minus preoperative AL)/preoperative AL x 100.
Results: We identified 29 children fulfilling the inclusion criteria. Average age at cataract
surgery was 2.6 ±2.1 months, age at last follow-up was 7.7±2.7 years and duration of
follow-up was 7.5±2.6 years. 15 eyes received a primary IOL while 14 eyes received a
secondary IOL. Preoperatively, AL was significantly different between operative and fellow eye (18.1mm vs 18.8mm, P <0.001), however, at final follow-up it was not (22.4mm
vs 22.8mm, P =0.187). AL growth of operative eye and fellow eye was not significantly
different (4.2mm vs 4.0mm, P=0.451). Similarly, rate of growth of operative eye and fellow eye was also not significantly different (23.7 % vs 21.5%, P = 0.211).
Discussion: We report long-term axial growth in eyes operated for monocular cataract.
These eyes have shorter axial length at the time of surgery as compared to that of fellow
eye without cataract. Monocular pseudophakic eyes have similar axial growth to that of
fellow non-operated eyes.
Conclusion: Eyes operated for monocular cataract with primary or secondary IOL
implantation have similar axial growth to that of fellow non-operated eyes despite having
shorter axial length at the time of surgery.
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Poster 24
Associated Systemic and Ocular Disorders in Patients with Congenital Unilateral
Cataracts - The IATS Experience
Elias I Traboulsi MD, MEd Deborah Vanderveen MD David Morrison MD Carolyn D
Drews-Botsch MD Michael Lynn Scott R Lambert MD
Cole Eye Institute, Cleveland Clinic
Cleveland, OH
Introduction: Few reports provide prospectively collected information about ocular and
systemic disease in patients with a unilateral congenital cataract. Five year data collection for children enrolled in the IATS has provided an opportunity to explore these associations.
Methods: Infants < 7 months of age with a visually significant unilateral cataract were
eligible for IATS screening. Data pertaining to the exclusion of patients at screening, and
data collected on standardized study forms used at any time for documentation of ocular
or systemic disorders were reviewed.
Results: 227 infants were referred for possible enrollment. Of those excluded, 3 were
premature (<36 weeks), 28 had significant ocular disease (usually PFV or corneal diameter <9mm), and 4 had systemic disorders. 26 were excluded at the time of the 1st EUA,
most often because of PFV or variants thereof. During the follow up period for the 114
enrolled patients, the following disorders were diagnosed: Stickler syndrome (1), mitochondrial disease (1), autism (1), and presumed congenital rubella syndrome (1). No
patient developed a cataract in the fellow eye.
Discussion: While patients with unilateral cataracts may have significant associated abnormalities in the affected eye, the prevalence of associated significant systemic disease
is quite low.
Conclusion: Some conditions (e.g. Down syndrome) are diagnosed at birth or very
early in life, but others may become apparent long after cataract removal. It is extremely
unlikely that patients with a unilateral congenital cataract develop a cataract in the other
eye. PFV and its variants are the most common associated ocular findings.
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Long-term Outcomes of Anterior Chamber Intraocular Lens Placement
in a Pediatric Cohort
Reid P Turner MD Leah Owen PhD, MD Jennifer Davidson MD Rupal Trivedi MD M.
Edward Wilson MD
Storm Eye Institute - Medical University of South Carolina
Charleston, South Carolina
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Poster 25
Introduction: The use of intraocular lenses (IOL) in the pediatric population is an evolving paradigm.
A posterior chamber location remains the preferable lens position; however, in cases without sufficient
capsular support, use of alternate placement, including anterior chamber IOL (ACIOL), is necessary. We
report long-term outcomes of ACIOL placement in a pediatric cohort at one institution.
Methods: We report a retrospective analysis of 20 pediatric patients ranging in age from 2-23 years,
representing 33 eyes, with ACIOL placement at the Storm Eye Institute from 1992-2013. Primary
outcome measures included best corrected visual acuity (BCVA), ocular complications, and need for additional procedures. Patient outcomes were stratified by patient age at time of surgery, lens type, axial
length, and corneal diameter.
Results: Average age at ACIOL implantation was 11.41 years and average follow-up was 46.1 months.
The L122uv, U85JS, U85JS, UV65A MTA3UO model lenses were used in this cohort; pre-operative
and post-operative BCVA was not significantly different for these groups. Post-operative BCVA for all
eyes ranged from 20/20-20/80. The BCVA for all patients improved after receiving an ACIOL (p=0.025).
Patients in our cohort demonstrated a 6 % rate of glaucoma, 6% rate of macular edema and 3% rate
of vitreous hemorrhage. Ten of 33 eyes required additional procedures, 6 of which included ACIOL
explantation, 4 included repositioning. The primary indication for additional procedures was lens rotation
causing pupil distortion and photophobia. Age at implantation was an average of 9.6 years for the group
requiring explantation versus 12.2 years for those not requiring explantation (p=0.08). Average corneal
diameter, lens type and axial length were not significantly different for those requiring explantation compared who did not. BCVA did not significantly worsen after additional procedures (p=0.41).
Discussion: Long-term outcomes for ACIOL placement in the pediatric population are unclear. Overall,
our data show a good postoperative visual result after ACIOL placement. However, we demonstrate a
30% rate of re-operation among pediatric patients receiving ACIOLs. Our data show a trend for younger
age at time of ACIOL implantation as a risk factor for needing subsequent repositioning or explantation
surgery.
Conclusion: ACIOL use in the younger pediatric population may be associated with an increased rate
of explantation. Further work is needed to better characterize risk and identify patient risk factors.
Benchmarks for outcome indicators in pediatric cataract surgery
Deborah VanderVeen, MD; Bharti Nihalani-Gangwani,MD;Olumuyiwa
Adebona,MBChB,MPH; Will Dean,MD
Boston Children’s Hospital
Boston, MA
Introduction: Benchmark studies have been published for cataract surgery outcomes in
adult populations. The purpose of this study is to evaluate outcome indicators to ascertain
quality in pediatric cataract surgery.
Methods: Chart review of cataract surgeries performed for patients <18 years of age
from 2006-2013 at a single center by multiple surgeons. Patients with ocular co-morbidities were excluded. Outcome measures were: 1) Final best corrected Snellen visual acuity (BCVA) for bilateral cataract patients
2) Prediction error (PE): Expected refractionActual refraction, assessed 1 month postoperatively, irrespective of age or laterality.
Results: 1) BCVA was 20/40 or better in 94% (n=88 eyes, mean age: 8.4 + 4.6 years).
Remaining 5 eyes with BCVA < 20/40 had amblyopia. 2) PE was within + 0.5 D in
45.0%, +1.0 D in 68.2% and ± 2.0 D in 95.4% (n=172 eyes). Mean absolute PE was
0.9 + 0.7 in eyes with AL < 22 mm (n=79) and 0.7 + 0.5 in eyes with AL > 22 mm (n=93)
(p=0.06, unpaired t test).
Discussion: This is the first pediatric study that provides benchmark data for visual acuity and refractive error in pediatric eyes.
Conclusion: In children, cataract surgery should result in good vision in > 90% of uncomplicated cases; amblyopia is the most frequent cause of VA< 20/40. PE is somewhat
greater than benchmarks in adult population studies.
References: 1. Simon SS, Chee YE, Haddadin RI, Veldman PB, Borboli-Gerogiannis S, Brauner SC, Chang KK, Chen SH, Gardiner MF, Greenstein SH, Kloek CE, Chen TC. Achieving target refraction after cataract surgery. Ophthalmology. 2014 Feb;121(2):440-4. Epub 2013 Nov 26. 2.
Hahn U, Krummenauer F, Kölbl B, Neuhann T, Schayan-Araghi K, Schmickler S, von Wolff K, Weindler J, Will T, Neuhann I. Determination of valid
benchmarks for outcome indicators in cataract surgery: a multicenter, prospective cohort trial. Ophthalmology. 2011 Nov;118(11):2105-12. Epub 2011
Aug 19.
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Ocular hypertension and glaucoma suspects in pediatric patient population
Kara M Cavuoto Matthew Greenberg Ta C Chang
Bascom Palmer Eye Institute
Miami, Florida
Introduction: There exists no high quality evidence to guide the management of pediatric glaucoma suspect and ocular hypertension patients. The incidence of glaucomatous
progression in children is unknown. A retrospective chart review was performed to gauge
management trends of pediatric glaucoma suspects and ocular hypertension.
Methods: Records were identified using ICD-9 codes for glaucoma suspect and ocular hypertension. Patients older than 10-years of age at the time of search, with prior
ophthalmic surgery, diagnosed with glaucoma on initial visit and followed less than two
months were excluded. Glaucoma was declared when the patient met the World Glaucoma Association Consensus [1] diagnostic criteria based on their most recent visit.
Results: 73 records were included for analysis. Nine patients (12.3%) were diagnosed
with glaucoma after a follow up of 12.0 +/- 12.0 months (mean +/- SD), all of whom
presented with ocular hypertension. Glaucoma and ocular hypertension patients did not
differ significantly in age, average IOP, maximum IOP, corneal diameter, central corneal
thickness, cup/disc ratio, RNFL thickness, or axial length. 36.9% of OHTN received
IOP-lowering therapy. The treated group had insignificant trend toward having higher
maximum IOP (31.6 +/- 13.0 vs 26.3 +/- 5.7 mmHg, P = 0.09), and a significantly higher
central corneal thickness (655.1 +/- 97.6 vs 533.5 +/- 54.2 microns, P = 0.0081).
Discussion: No glaucoma suspect patient progressed to meet glaucoma diagnostic criteria without presenting with ocular hypertension. Initial biometric findings cannot predict
eventual glaucoma progression.
Conclusion: Pediatric ocular hypertension patients need to be monitored closely for the
development of glaucoma.
References: Beck A, Chang TC, Freedman S. World Glaucoma Association Consensus Series - 9: Childhood Glaucoma. Section 1: Definition,
classification, differential diagnosis. Amsterdam, The Netherlands: Kugler Publications; 2013. 3-10.
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Poster 28
Canaloplasty in Juvenile Glaucoma--A Case Report
Susan H Senft MD Susie Y Wong MD Kavita Surti MD
Island Eye Care, Inc.
Kailua-Kona, HI USA
Introduction: Juvenile glaucoma notoriously is challenging to control and surgical approaches have been limited to aqueous shunts with variable success rates. This case
report proposes an alternative approach utilizing canaloplasty.
Methods: A retrospective review of a male juvenile glaucoma patient age 13 was conducted. The patient was intolerant of maximal medical therapy. Pre-operative baseline
testing included visual acuity, visual fields, OCT, Cirrus anterior segment imaging, gonioscopy and fundus photography. He underwent bilateral sequential canaloplasty with
retentive stent and has been followed over 22 months.
Results: Intraocular pressures on presentation were 28 OD and 50 OS with cupping
of 0.7 and 0.9 respectively. Best-corrected visual acuity pre-op was 20/20 and visual
fields documented superior and inferior Bjerrum scotomas OD and profound constriction
with inferior nasal loss OS. Post-operative pressures maintained IOP of 14 OU on no
medication. Visual fields have normalized OD and improved OS, cupping has changed to
0.5 OD and 0.7 OS. Visual acuity has improved to 20/15 OU Anterior segment imaging
documented expansion of the Canal of Schlemm from its collapsed state pre-op.
Discussion: Problems with older techniques have high rates of failure in juvenile
glaucoma. Canaloplasty is minimally-invasive, maximally-effective and appears to work
through alterations in the Canal of Schlemm. This report documents improvement/control of the disease with reversal of damage.
Conclusion: Canaloplasty appears to present a viable option for juvenile glaucoma and
should be included in the treatment paradigm in this difficult and blinding disease.
References: 1. Lewis, R. A., et al. Canaloplasty: Three-year results of circumferential viscodilation and tensioning of Schlemm canal using a
microcatheter to treat open-angle glaucoma. J Cataract Refract Surg, 2011 Apr; 37(4):82-90.
2. Francis, B.A. et al. Novel glaucoma procedures:
a report by the American Academy of Ophthalmology, Ophthalmology, 2011 Jul;118(7):1466-80.
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Assessment of Intraocular Pressure with iCare Rebound Tonometry in a Pediatric
Ophthalmology Clinic
Aman Sharma MD Desiree Albert MS4 Matthew S Pihlblad MD Megan Sheeley COA
Nicholas Strauss Diana Moya James D Reynolds MD
Ross Eye Institute, University at Buffalo
Buffalo, NY
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Poster 29
Introduction: Intraocular pressure (IOP) is not routinely measured in the pediatric
population. We examined the utility and feasibility of routine IOP testing with the iCare
Rebound Tonometer (IRT) in a pediatric ophthalmology clinic.
Methods: All pediatric patients over several clinic days had IOP measurement performed on them using IRT, excluding post-operative and retinopathy of prematurity
screening examination patients. Several variables were recorded, including IOP with
reliability, length of time taken to measure, and patient comfort level.
Results: Our population consisted of a total of 97 patients with mean age of 8.5 years
(0.75-18). Mean time taken was 83 seconds (30-254), and mean comfort level was 0.7/10
on the Wong-Baker scale. Success rate at obtaining a reliable IOP was 57%. Mean
reliable IOP measured was 16.3±3.7 mmHg (range 8-29), with 6% of the reliable IOP
measurements >21 mmHg.
Discussion: Our data indicate that IRT is a well-tolerated and relatively quick method
to test IOP in children, and can be performed reliably in the majority of pediatric patients.
However, the success rate of 57% and documented ocular hypertension in 6% with no
suspicion of glaucoma other than the pressure, may not justify routine testing.
Conclusion: Routine IOP testing in a pediatric clinic using IRT is easy, quick, and
comfortable to the patient, but success rates are less than optimal. IRT is a very useful
device for recording IOP in children when other methods are not possible, but it may be
best utilized on an as needed basis.
References: 1. Lundvall A, Svedberg H, Chen E. Application of the ICare rebound tonometer in healthy infants. J Glaucoma. Jan 2011;20(1):7-9.
2. Kageyama M, Hirooka K, Baba T, Shiraga F. Comparison of ICare rebound tonometer with noncontact tonometer in healthy children. J Glaucoma.
Jan 2011;20(1):63-66. 3. Sahin A, Basmak H, Niyaz L, Yildirim N. Reproducibility and tolerability of the ICare rebound tonometer in school children. J Glaucoma. Mar 2007;16(2):185-188.
Survey of health- and vision-related quality of life and functional vision in children
and young people with childhood glaucoma and cataract
Vijay K Tailor Msc Annegret Dahlmann-Noor Dr Gill G Adams Dr Maria Papadopoulos Dr
NIHR Biomedical Research Centre at Moorfields Eye Hospital
and UCL Institute of Ophthalmology, London
Introduction: Impaired vision, repeated surgical interventions, topical eye medications
and frequent hospital appointments affect daily life of children with childhood glaucoma,
cataract, aphakia and pseudophakia and their families. We aim to explore the health- and
vision-related quality of life (QoL) and functional vision (FV) of these children and families.
Methods: Recruitment is ongoing: 180 children aged 2-16 years with unilateral or bilateral congenital or secondary glaucoma; cataract, aphakia or pseudophakia and their parents/carers. Parents complete PedsQL™ family report and PedsQL™ about their child;
children complete an age-appropriate PedsQL™, Cardiff Visual Ability Questionnaire for
Children (CVAQC) and Impact of Vision Impairment for Children (IVI-C).
Results: Preliminary results: Parents report that their child’s eye condition has a significant impact on their child’s QoL, as reflected in a total PedsQL™ parental report score of
69 (19) (healthy peers normal QoL – score: 100). Children’s self-report scores are higher
than parental reports (all ages: 78 (15)), indicating that children may be less aware or
concerned than their parents. Scores increase with children’s age (5-7 years: 65 (21),
8-12 years: 79 (14), 13-16 years: 83 (14)). Parents report they are affected by their child’s
condition (41 (38)).
Discussion: FV ability measured by CVAQC is reduced ((mean)-1.65 log units (SD
1.038), (-3.00 = normal sight; +2.80 severe visual disability) and related to best-corrected
visual acuity in the better eye.
Conclusion: Childhood cataract and glaucoma, particularly if resulting in low vision, can
affect all dimensions of Qol, i.e. physical, emotional, social, physical and educational.
Parents’ QoL can be affected by the child’s condition.
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Accommodation in Children with Cerebral Palsy
Claudia Avilés MD Juan Homar Páez MD María Teresa Rodríguez CO
Tec Salud
Batallon San Patricio 112 Colonia Real de San Agustin, San Pedro Garza García, Nuevo
León 66278
Introduction: The purpose of this study is to compare the accommodative response of
children with cerebral palsy (CP) to that of a group of healthy children. Clinical evaluation
of accommodation is an essential part of assessing visual dysfunction. Having an accommodation deficiency is known to hinder learning abilities and development due to its
causing the inability to see nearby objects clearly.
Methods: Patients aged between 3 and 18 years diagnosed with CP were analyzed.
Two dynamic retinoscopy techniques were used: the Monocular Estimate Method (MEM)
and the Merchán Method.
Results: 41 patients with CP aged between 3 and 18 (average age 7.61 years +/- 4.777
SD) were analyzed. Twenty were male and twenty-one were female. Thirty-nine patients
(95%) had spastic CP, two patients (5%) had mixed CP (athetoid and spastic). Analyses of variance were carried out in order to compare dioptre measurements for patients
with CP to those of patients without CP, finding an average in lag of accommodation of
>1.50D (p < 0.0001) for children with CP in both techniques.
Discussion: A decrease in accommodative response was observed in children with
CP compared to the results of the group of healthy children in both dynamic retinoscopy
techniques.
Conclusion: We could interpret the deficiency in accommodation as a limitation in the
capacity of learning. It would be interesting to analyze whether or not there is an improvement in the development and advancement of their intellectual capacity based on
the fact that the majority of activities carried out by children with CP are close work.
References: 1. Leat SJ. Reduced accommodation in children with cerebral palsy. Ophthal Physiol. 1996;16:385- 390.
2. Jones MH, Dayton
GO. Assesement of visual disorders on cerebral palsy. Arch Ital Pedr. 1968;25:251-264.
3. McClelland JF, Parkes J, Hill N,et al. Accommodative
dysfunction in children with cerebral palsy: a population-based study. Invest Ophthalmol Vis Sci. 2006;47: 1824-1830.
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Poster 32
Pediatric Idiopathic Intracranial Hypertension: A major Review
Rahul Bhola Noura Estephane Michael Sowell Ian Mutchnick Eric Downing
Pradeep Sharma
University of Louisville, Louisville, Kentucky
Introduction: Idiopathic Intracranial Hypertension (IIH) is characterized by signssymptoms of increased intracranial pressure in absence of space-occupying lesion. Even
though it is recognized among pediatric population the clinical characteristics in this
population are not well described. We performed a multi-team approach to better understand this disease in pediatric population.
Methods: We performed a retrospective chart review of pediatric patients diagnosed
with IIH over an eight-year period. Of 110 identified patients in our database, 78 meeting
the eligibility criteria were included. Main outcome variables included demographic characteristics, presenting symptoms, medical/ surgical treatment, long-term visual outcomes
and recurrences.
Results: The mean age of onset was 11.92 ± 4.09. Of the 78 patients 70.5% were
females with a strong female preponderance in adolescents (92.5%) but no gender
preference in patients younger than 12 years. Ninety-percent of adolescent patients
were overweight, moderately or severely obese with majority of younger patients having
normal weight. Presenting symptoms included headaches (83.3%), blurry vision (48.7%),
nausea (41.02%), and photophobia (38.46%). Papilledema was noted on presentation
in 91% patients. Nine percent had cranial nerve VI palsy. All patients attempted medical
management and 14 patients (18.0%) subsequently underwent surgical interventions.
Seven (10.9%) of 64 patients who did not undergo surgical intervention experienced
recurrence. Permanent visual-field changes were seen in 25% patients.
Discussion: Prepubertal children with IIH have lower incidence of obesity with no gender predilection. Children with IIH usually complain of headaches and blurred vision and
are at risk for permanent visual loss.
Conclusion: Early diagnosis and prompt management is essential in preventing permanent vision changes in patients with pediatric IIH.
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Strabismus in patients with cortical visual impairment: observations of
spontaneous resolution and outcomes of surgery
Nicholas R Binder Jacqueline Kruglyakova Mark S Borchert
University of Southern California / Children’s Hospital Los Angeles
Los Angeles, CA
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Poster 33
Introduction: Cortical visual impairment (CVI) is the leading cause of bilateral visual impairment in children in developed countries and has a high rate of concurrent strabismus
(1). This study set forth to examine the rate of spontaneous resolution of strabismus in
CVI patients, success rates of strabismus surgery, and present data on baseline characteristics.
Methods: Retrospective chart review was performed on patients with CVI and strabismus for 10 years between 10/2003 and 10/2013. Statistical analysis was performed via
Fisher’s exact and chi-squared testing.
Results: 70 patients with CVI and strabismus were included for review. Four outcome
groups were analyzed. 27 patients (38%) had persistent strabismus and were observed
without receiving surgery (group 1). 11 patients (16%) experienced spontaneous resolution of their strabismus (group 2). 32 patients (46%) underwent strabismus surgery; 18
(56%) achieved post-operative alignments of 10 prism diopters (PD) or less (group 3), 9
(28%) were 11-25PD (group 4), and 5 (16%) were >25PD (also group 4). A trend towards
better vision at the final clinic visit in groups 2 and 3 as compared to 1 and 4 was observed but did not quite reach statistical significance (p=0.08).
Discussion: Patients with CVI and strabismus can be observed to have spontaneous
resolution of their strabismus. Only 16% of patients undergoing surgery had poor final
alignments of >25 PD. Improving vision may be a guideline as to which patients will have
acceptable outcomes.
Conclusion: Patients with CVI and strabismus show considerable rates of resolution of
their strabismus, either spontaneously or through surgery.
References: 1. Huo R, Burden S, Hoyt CS, Good WV. Chronic cortical visual impairment in children: aetiology, prognosis, and associated neurological deficits. 1999 British Journal of Opthamology 83:670-5.
Outcome of Pediatric Patients Referred for Papilledema
Jessica J Kovarik MD Poonam N Doshi MD Janine E Collinge MD David A Plager MD
Indiana University, Indianapolis, Indiana
Introduction: Referrals for suspected papilledema are common in pediatric ophthalmology practice, though few patients are found to have true papilledema. The purpose of this
study is to determine the prevalence of papilledema versus pseudopapilledema among
children referred for suspected papilledema and to identify factors differentiating the two
diagnoses clinically.
Methods: This is a prospective, cross-sectional analysis of patients <18 years old
referred to a pediatric ophthalmology clinic by other physicians or optometrists for suspected papilledema by ophthalmoscopic exam between April 2012 and February 2014.
Patients underwent detailed ophthalmologic and, when indicated, neurologic evaluation
to determine the presence or absence of papilledema.
Results: A total of 34 patients were identified. 26/34 patients were diagnosed with pseudopapilledema or normal variant. 2/34 patients were diagnosed with papilledema. 6/34
were diagnosed with unrelated or indeterminate etiology. Headache was a presenting
symptom in 25/34 patients. 5/34 patients complained of additional symptoms suggestive
of increased intracranial pressure (ICP); two of those five were the patients diagnosed
with papilledema.
Discussion: The majority of patients referred had pseudopapilledema or a normal variant. Among our population, headache was a common, nonspecific symptom in most patients, whether they had papilledema or not. However, symptoms suggestive of increased
ICP were rarely seen in patients without papilledema.
Conclusion: This study suggests that in asymptomatic children, a diagnosis of papilledema is unlikely. A detailed history and examination coupled with non-invasive testing,
such as ultrasonography, is usually sufficient to diagnose papilledema from other abnormal appearing optic nerves.
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Correlation of Optic Nerve Sheath Diameter Using B-scan Ultrasound with MRI
Anatomy in Pediatric Patients
Ellen R Miller, David L Rogers, Lisa Martin, April Logan
Nationwide Children’s Hospital
Columbus, Ohio
Introduction: The purpose of this study is to determine the correlation of B-scan ultrasound optic nerve sheath diameter (ONSD) measurements with high resolution orbital
MRI in pediatric patients.
Methods: This is a prospective study on pediatric patients scheduled to have an MRI.
A supine B-scan was performed on both eyes within 30 minutes of MRI. Independent
measurements of the vertical ONSD were then performed by the ophthalmologist on the
B-scan image at 3, 6, and 9 mm posterior to the papilla. A radiologist performed similar
measurements of the ONSD on MRI.
Results: Ten patients, ages 5 to 17 are included. A measures model with compound
symmetry was used to determine if the two modalities correlate. The difference between
the average ONSD measurement in the right eye by ultrasound and MRI is 1.13 mm at 3
mm (p=0.0085). MRI is larger at this point. Ultrasound measurements then progressively
increase, with a difference of 1.28 mm and 2.71 mm at 6 and 9 mm (p<0.0001). Left eye
results have larger MRI measurements at 3mm, a difference of 0.71 mm (p=0.0778), with
increasing ultrasound measurements by 1.22 mm (p=0.0001) and 2.39 mm (p<0.0001)
at 6 and 9mm. The differences between the modalities at all three points are statistically
significant, except for left eye at 3mm.
Discussion: As the distance from the globe increases, the ultrasound ONSD measurements increase relative to MRI measurements.
Conclusion: B-scan ultrasound is a useful in-office tool for obtaining various ophthalmic
images, but is unreliable in providing anatomically accurate measurements of the ONSD.
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Poster 36
The Post-Concussion Syndrome: Influence on Binocular Function
Gill Roper-Hall DBOT Oscar A Cruz MD Sophia M Chung MD
Saint Louis University
1755 S. Grand Blvd, St. Louis. MO 63104
Introduction: The post-concussion syndrome encompasses a constellation of findings
including convergence paresis, disequilibrium and cognitive changes. Ocular symptoms
may be exacerbated by head movement or motion. Associated findings include memory
loss, difficulty concentrating, and depression. There has been recent media interest in the
long term effects of sports-related concussion, particularly repeated concussions. 1-3
Methods: A retrospective study was conducted at our institution of adult patients evaluated and treated between 2002 and 2012 for binocular symptoms occurring after concussion. Exclusion criteria were previous strabismus, concurrent ocular injury, facial or orbital
fracture, or vision loss.
Results: Eight patients met the inclusion criteria; 5 females and 3 males aged 22 to 51
(mean 35.1). Convergence near point and amplitudes were decreased in all patients.
Accommodation was decreased in 5. Pupils were normal. Initial symptoms included
blurred vision, asthenopia and headache (8), diplopia (7), cognitive difficulty (7), nausea,
dizziness or disequilibrium (6), photophobia or hyperacusis (5). Initial response to convergence therapy was slow despite a modified approach, especially in the motion-intolerant
group, necessitating deferred treatment for several months.
Full recovery following therapy (1); normal convergence function but persistent concussion-related symptoms (3); partial improvement with no further recovery (4).
Discussion: Concussions or ‘mild’ traumatic brain injuries, while not life-threatening, can
have lasting effects on a patient’s ability to function at work or in daily life. Convergence
paresis is common and should be differentiated from convergence insufficiency.
Conclusion: Binocular management techniques after concussion should be modified
and simplified in face of associated cognitive and otoneurological signs. Rest is an important adjunct to therapy.
References: 1. Harmon KG, Drezner JA et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports
Med 2013; 47: 15-26. 2. Sahler CS, Greenwald BD. Traumatic brain injury in sports: A review. Rehabil Res Pract 2012. 1-14. 3. www.cdc.gov/
traumaticbraininjury
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Ocular long term effects of airsoft gun pellet injury, the most frequent ocular
trauma mechanism among Danish children. A 7-year follow-up study of 28 cases.
Jon Peiter Saunte MD
Department of Ophthalmology, Copenhagen University Hospital Glostrup
Copenhagen, Denmark
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Poster 37
Introduction: Pediatric ocular trauma caused by airsoft gun (ASG) pellets often result in
serious ocular injury(1,2,3), but sparse data on persisting ocular damage are available. We
wanted to evaluate long-term ocular effects of this trauma mechanism.
Methods: A follow-up ophthalmological evaluation of 28 patients with prior ASG ocular
trauma. The fellow eye served as control.
Results: Of 33 patients with prior documented ASG ocular injury at mean 13 years-of-age(2),
28 (26 male, mean age 20 years, range 8-31 years) were able to participate in a follow-up
study at mean 7 years (range 4-9 years) later. 9 suffered from reading problems(CI:0.16-0.52),
11 of photophobia(CI:0.22-0.59), 3 of blurred vision(CI:0.02-0.28), 3 of decreased monocular color vision(CI:0.02-0.28), 2 of ocular discomfort(CI:0.001-0.24), and 2 of cosmetic
disturbing anisocoria(CI:0.001-0.24). Automated visual field perimetry was possible in
26 patients, and was abnormal in 8 trauma eyes(CI:0.14-0.52). Accomodation deficit of
more than 2 cm compared to the fellow eye was found in 8 patients measured by the RAF
ruler(CI:0.13-0.49). Gonioscopy was possible in 24 patients, and angle recession was present
in 18 trauma eyes(CI:0.53-0.90). Slitlamp examination revealed traumatic anterior capsular
cataract in 5 eyes(CI:0.06-0.37), and retinal exam revealed 5 trauma eyes with focal retinal
atrophy(CI:0.06-0.37).
Discussion: Former studies have documented acute ocular morbidity in ASG pellet injuries(1,2). This study reveals serious ocular long-term pathology in eyes with serious damage
to the trabecular meshwork, lens or retina.
Conclusion: ASG pellets frequently cause persisting ocular injury in the pediatric population,
with an increased long term risk of developing glaucoma, cataract or retinal pathology.
References: 1) Shazly TA, Al-Hussaini AK. Pediatric ocular injuries from airsoft toy guns. J Pediatr Ophthalmol Strabismus 2012;49:54-7 2)
Saunte JP, Saunte ME. 33 cases of airsoft gun pellet ocular injuries in Copenhagen, Denmark, 1998-2002. Acta Ophthalmol Scand 2006;84:7558 3) Saunte JP, Saunte ME. Childhood ocular trauma in the Copenhagen area from 1998 to 2003: eye injuries caused by airsoft guns are twice as
common as firework-related injuries. Acta Ophthalmol Scand 2008;86:345-7
Idiopathic orbital pseudotumor preceding systemic inflammatory disease
in children.
Mai Tsukikawa Sara E Lally MD Carol L Shields MD Ralph C Eagle MD
Barry N Wasserman MD
Wills Eye Hospital, Philadelphia, Pennsylvania
Introduction: Idiopathic orbital pseudotumor is a noninfectious and non-neoplastic clinical syndrome characterized by the presence of an inflammatory mass within the orbit.
Orbital pseudotumor has been observed in association with systemic inflammatory diseases. We present three cases of orbital pseudotumor occurring months to years before
the systemic disease.
Methods: Clinical records of patients with orbital pseudotumor seen at the Ocular Oncology Service were reviewed retrospectively, and those associated with systemic inflammatory disease were selected for further analysis.
Results: We describe three pediatric cases in which isolated orbital pseudotumor preceded the diagnosis of a systemic inflammatory disease. Our first case was 2-year-old
white female who presented with right upper eyelid (RUL) swelling secondary to orbital
pseudotumor. One year later, the patient developed pauciarticular juvenile idiopathic
arthritis (JIA) with anterior uveitis. Our second case was an 11-year-old Hispanic female
who presented with RUL swelling and was subsequently diagnosed with orbital pseudotumor. Nine months later, the patient developed a right-sided renal mass, and was
diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA). Our third case was
a 12-year-old white female who presented with right orbital pseudotumor. Four months
later, the patient was diagnosed with granulomatosis with polyangiitis (GPA).
Discussion: Orbital pseudotumor may be the initial presentation of systemic inflammatory disease in some children. Earlier diagnosis of systemic inflammatory disease might
be possible if suspicion is raised after presentation of pediatric orbital pseudotumor.
Conclusion: Closer observation and suspicion may be warranted in children with idiopathic orbital pseudotumor.
References: 1. Kitei, D. and DiMario, F.J.,Jr. Childhood orbital pseudotumor: case report and literature review. J Child Neurol. 2008; 23: 425-30 2.
Yuen, S.J. and Rubin, P.A. Idiopathic orbital inflammation: distribution, clinical features, and treatment outcome. Arch Ophthalmol. 2003; 121: 491-9
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Poster 39
Ophthalmic Pathology in Down Syndrome patients:
characterization in chilean children
Bernardita Alamos MD, Pablo Musa MD, Macarena Lizama MD, Pablo Altschwager MD,
Cristián Salgado MD
Pontificia Universidad Catolica de Chile
Santiago, Chile
Introduction: The aim of this study is to describe the prevalence of different ophthalmic pathologies in chilean pediatric patients with Down Syndrome (DS) and to evaluate
whether those figures are comparable to internationally reported standards.
Methods: Retrospective descriptive study. Pediatric patients with DS were selected out
of all patients attending their pediatric health supervision at a local hospital which underwent at least one ophthalmological evaluation between 2009 and 2013.
Patients who were examined during hospitalization, had incomplete ophthalmological
evaluations or were older than 17 years at the time of evaluation, were excluded.
Patient records were examined in order to obtain the frequency of different ophthalmic
pathologies.
Results: 202 met the inclusion criteria. Median patient age was 2 years and 6 months
(range, 1 month to 17 years), 48,1% were male. 20,2% of patients presented myopia
(>/= -0.50D), 58,9% had hyperopia (= 1,00D) and 63,3% suffered from astigmatism (>/=
0,75D). 30,1% of patients were prescribed glasses. 19,8% presented horizontal strabismus and 0,9% presented vertical strabismus. 2,9% of patients underwent surgery for
their strabismus, for which successful results were attained in 100% of cases. 15,3% of
patients had nystagmus. 2,5% of patients had cataracts, 21,2% showed nasolacrimal
duct obstruction. Overall 94,5% of subjects presented ophthalmic pathology.
Discussion: Our research demonstrated a high prevalence of ophthalmic pathologies
for this group, showing comparable figures to what has been previously reported in international literature.
Conclusion: These results confirm the importance of designing structured ophthalmological evaluation protocols for these patients.
References: J Pediatr Ophthalmol Strabismus 2009: Ophthalmic Abnormalities in Children with Down Syndrome; 46:76-82.
Electronic
Poster 40
Eye and systemic manifestations of Moebius syndrome
Juan C Juárez-Echenique Ana M Borbolla-Pertierra Vanessa Bosch-Canto
Juan C Ordaz-Favila Pedro Acevedo-González
National Institute of Pediatrics
Insurgentes sur 3700, Letra C, Delegación Coyoacán. Distrito Federal 04530
Introduction: Moebius syndrome is characterized by damage in the nucleus of the sixth
and seventh cranial nerves, with subsequent facial palsy and abduction limitation of the
eyes. The aim of this article is to describe the ophthalmological findings of the Moebius
syndrome in Mexican children.
Methods: A cross-sectional, retrospective, observational and descriptive study was
conducted. A review was made of the clinical charts of patients with Mobius syndrome
who were seen in the National Institute of Pediatrics in Mexico, between the years 2000
and 2010.
Results: A total of 64 charts were reviewed. The most important findings were eye
abduction limitation (100%), facial palsy (100%), esotropia (54%), epicanthus (51.5%),
entropion (22%), and history of use of abortion inducers in the mother in the first trimester of pregnancy (28%). We also found exotropia and hypertropia in some cases.
Discussion: Moebius syndrome is a rare cranial nerve disease associated with other
systemic anomalies.In Mexico the most frequent findings are 6th and 7th cranial nerve
palsy, and therefore esotropia. Almost 30% of the patients were products of mothers that
attempted to abort them. Entropion was not reported in previous series.
Conclusion: Moebius syndrome has a wide spectrum of ophthalmological manifestations that are important to detect early in order to improve function and esthetics.
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Is it Usher Syndrome? Diagnosing children with hearing loss and ocular findings.
Ashley S Ko MD Wanda L Pfeifer OC(C), COMT Arlene V Drack MD
Department of Ophthalmology and Visual Sciences, University of Iowa
Iowa City, Iowa USA
Electronic
Poster 41
Introduction: Because approximately 10% of children with hearing loss have Usher
syndrome, hearing impaired children are often referred for ocular evaluation. We studied
referring and final diagnoses in children with hearing loss to determine the most effective
work up.
Methods: IRB-approved retrospective chart review of patients presenting between 20082014 was performed. Data collected included referring and final diagnoses, ophthalmic
examination, hearing loss correction, work-up tests and results.
Results: 17 patients were identified;11 male, 6 female. Age at referral averaged 5.9
years (8/12 -30 years). Visual acuity averaged 20/58 Snellen, (LogMAR 0.46). 4/17
patients had nystagmus. 5/17 had cochlear implants, 9/17 had hearing aids. Referring diagnoses included Usher(9), nystagmus(3), dominant optic atrophy (DOA)(1),
optic nerve atrophy(1), cone dystrophy(1), fourth nerve palsy(1), and ocular apraxia (1).
Work-ups included ERG, MRI, and molecular genetic testing. 15/17 had OtoScope
testing for hearing-loss genes. 12/15 had at least one Usher mutation found; 7/15 had
2 mutations found, confirming Usher. Final diagnoses were Usher(7), Waardenburg(3),
DOA(1),Baraitser-Winter, Harboyan, and Cowshock syndromes(1 each), LCA(1), deletion/
duplication(1), unknown(1).
Discussion: Multiple polymorphic genes cause Usher syndrome, and many unaffected
people are carriers but do not have Usher. Waardenburg syndrome may present like
Usher with decreased vision and hearing loss, but is autosomal dominant rather than
recessive and stable rather than progressive.
Conclusion: Usher syndrome is the most common eye-ear genetic disorder, but others
must be considered. ERG is helpful but not diagnostic. Molecular genetic testing is vital
and requires family blood samples and detailed analysis of DNA variants.
Prevalence and Clinical Characteristics of Ocular Disease
in Children with HIV/AIDS
Taliva D Martin MD Maya S Ling MD Emmett T Cunningham MD, PhD, MPH
Ann Petru MD Susan H Day MD
California Pacific Medical Center
San Francisco, CA, USA
UCSF Benioff/Children’s Hospital Oakland, Oakland, CA, USA
Introduction: Describe the prevalence and clinical characteristics of ocular disease in children with HIV/ AIDS.
Methods: Charts of patients less than 18 years old followed at the HIV/AIDS clinic at UCSF
Benioff/ Children’s Hospital Oakland between March 2012 and May 2014 were reviewed.
Patients who consented for the study underwent an eye examination by a pediatric ophthalmologist.
Results: Charts of fifty patients were reviewed. Thirty-six (72%) underwent an eye examination, including 19 (52.8%) girls and 17 (47.2%) boys. Age at the time of examination ranged
from 3 to 17 years, with a mean and median of 11.4 years and 11.0 years, respectively. Mean
and median CD4 count were 814.4 cells/microliter and 772.5 cells/microliter, respectively. 31
(86.1%) patients had a visual acuity at last visit of 20/20. Four (11.1%) patients had interpalpebral conjunctival injection, and 1 each (2.8%) had an accommodative esotropia, an intermittent exotropia, congenital ptosis, peripheral lattice degeneration, retinal scars from previous
treatment of retinopathy of prematurity, hypopigmented retinal lesions, hyperpigmented retinal
lesion, and HIV-associated retinal vasculitis and optic neuropathy. Six of the 12 patients with
ocular findings (50.0%) were born outside of the United States.
Discussion: Ocular complications of HIV/AIDS are less common in children compared to
adults. The prevalence of ocular disease in our referral cohort (33.3%) was consistent with
other studies.
Conclusion: Ocular complications of HIV/AIDS are uncommon in children infected with HIV.
References: 1. Cunningham ET Jr, Kestelyn P, Pavesio CE. Ocular manifestations of HIV/AIDS in children. In: Hoyt C and Taylor D, eds. Pediatric
Ophthalmology and Strabismus, 4th ed. London, UK: Elsevier, 2012:132-138.
2. Shukla D, Rathinam SR, Cunningham ET Jr. Contribution of HIV/
AIDS to global blindness. Int Ophthalmol Clin. 2007;47:27-43.
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Poster 43
Intraocular pressure in children with Down syndrome
María Teresa Rodríguez MD Manuel A de Alba MD Juan Homar Páez MD
Mariya Kalashnikova MD
Tec Salud
Batallon San Patricio 112 Colonia Real de San Agustin, San Pedro Garza García,
Nuevo León 66278
Introduction: A cross-sectional, prospective, case-control study to determine whether
intraocular pressure is affected in children with Down syndrome (DS) compared with
general population.
Methods: Ninety-one children with DS aged 0 to 11 years and 91 age-matched and
gender-matched healthy control subjects (HCS) from same ethnic backgrounds were enrolled in the study. Intraocular pressure (IOP) was measured by induction/impact rebound
tonometry and expressed in mmHg. Both eyes of each child were analyzed. Repeated
measures using two-sample unpooled t-test with unequal variances were used and a Pvalue <0.05 was considered statistically significant.
Results: Patients from each comparative group were divided into 3 subgroups according to their age. Sixty-two patients in group A and B (0-3 years old) and (4-7) respectively
and 54 in group C (8-11). Mean IOP for group A was 10.58 in right eye (RE) and 10.65 in
left eye (LE) in DS children, compared to 12.68 RE and 13.28 LE in HCS. Mean IOP for
group B was 13.28 RE and 11.65 LE in DS children, compared to 14.28 RE and 15.12 LE
in HCS. Mean IOP for group C was 11.70 RE and 11.88 LE in DS children, compared to
15.66 RE and 15.70 LE in HCS.
Discussion: Mean IOP in DS children of all groups (11.68±4.06) was significantly lower
(p<0.05) than the HCS (14.48±4.39).
Conclusion: Children with DS had decreased IOP compared with HCS. No previous
studies have reported IOP measurements in children with DS. Rebound tonometry provides useful ophthalmological information in these patients in which standard tonometry
is difficult to perform.
References: 1)Evereklioglu C, Yilmaz K, Bekir N. Decreased Central Corneal Thickness in Children With Down Syndrome. J Pediatr Ophthalmol
Strabismus. 2002; 39:274-277. 2)Pakrou N, et al. Clinical comparison of the Icare Tonometer and Goldmann Applanation Tonometry. J Glaucoma.
2008; 17(1). 3)Catalano R. Down Syndrome. Survey of Ophthalmology.1990; 34(5).
Electronic
Poster 44
Novel Technique for the Repair of Large Upper Eyelid Colobomas
Alexandra T Elliott MD
Children’s Hospital Boston
Boston, Massachusetts
Introduction: Large eyelid colobomas that affect between 50%-75% of the upper eyelid
present a management challenge due to lack of sufficient tissue for repair. A novel approach to its repair resulting in excellent cosmesis and absence of induced astigmatism
will be presented.
Methods: A case series of three infants who underwent this proceedure were reviewed.
Results: All three had superior cosmetic results and absence of induced astigmatism.
All skin grafts were healthy and indestinguishable from surrounding tissues.
Discussion: Full thickness skin grafting in children is notorious for poor healing and tissue mismatch. In this technique where the graft is harvested from the resected colobomatous tissue there is no tissue mismatch. By dividing anterior and posterior lamella but
leaving middle lamella intact, graft is well perfused and astigmatism secondary to tight
postoperative eyelid is avoided.
Conclusion: Autogenous skin graft from colobomatous tissue when comined with
middle lamella preservation offers superior cosmetic and functional results to children
with large upper lid colobomas. This technique is an improvement over traditional rotational flaps.
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Multi-tool instrument decreases complications with nasolacrimal intubation
Celia Haering Robert W Arnold
Alaska Blind Child Discovery
Anchorage, Alaska
Electronic
Poster 45
Introduction: Silicone stenting is a recognized method for treatment of nasolacrimal
obstruction (NLD) and canalicular laceration. Despite several variations in surgical
techniques, complications including wire-stripping of the stent, premature dislocation, and
re-operation persist. A combined surgical instrument was designed in hopes of simplifying
Farson bilateral-monocanalicular Crawford intubation.
Methods: In an ongoing IRB study with >12 months follow-up, 716 cases of tear duct
care by one surgeon over two decades were evaluated for complications before and after
use of a new surgical instrument- the nasolacrimal dilator-rasp.
Results: 493 cases of NLD had Farson modified Crawford tube- 356 with the new dilator
rasp. 146 had conventional Crawford tube, 53 had probing (21 dacryocystoceles), 18
had canalicular lacerations, 2 DCR, 3 fistula excision and 1 Lacricath. Of Farson cases
comparing 137 past to 356 new instrumentation, absent puncta treated 1:10 times, wirestripping 2:2 times, re-operation 4:6 cases.
Discussion: For cases of NLD, the nasolacrimal dilator-rasp and the Farson Crawford
tube can achieve 98% success (no re-op) despite no in fracture of the turbinates. Parents easily remove the stent at home.
Conclusion: The nasolacrimal dilator-rasp can simplify tear duct surgery.
References: Arnold RW: Bilateral monocanilicular silicone loop: Predictable home removal of nasolacrimal stents. J Pediatr Ophthalmol Strabismus.
32:200-201, 1995
Retrieval of a Monoka Silicone Tube from the Pharynx During Silicone Intubation Procedure for Persistent Congenital Nasolacrimal Duct Obstruction Assisted
by the Anesthesiologist
Daphna Mezad-Koursh MD Noa Ela-Dalman MD Nina Gofman MD Gad Dotan MD
Chaim Stolovitch MD
Tel Aviv Sourasky Medical center, Sackler Faculty of Medicine, Tel Aviv University
Tel Aviv, Israel
Introduction: Persistent nasolacrimal duct obstruction is often treated with silicone intubation. At times hooking the silicone tube from under the inferior conchae can be difficult,
time consuming and traumatic. Occasionally silicone tubes can be found in and rescued
from the pharynx. We describe herein our method of tube retrieval from the pharynx.
Methods: Surgical technique description
Results: Our new suggested technique is to be used in cases in which the self-threading
Monoka is easily pushed through the Ritleng probe into the nasal cavity but cannot be
hooked from under the inferior conchae. After unsuccessful hooking of the silicone tube
we ask the anesthesiologist to look into the Pharynx with a laryngoscope searching for
a wire. If the wire is visualized, the Anesthesiologist uses Magill forceps to pull the wire
through the patient’s mouth. We then use a funneled suction catheter, which is transferred through the nose into the pharynx and then pulled out of the mouth. The edges of
the suction catheter and the Monoka silicone tube are tied together and then the suction
catheter is pulled back through the nose with the edge of the silicone tube. The silicone
tube is then cut short and is left to pull back into the nose.
Discussion: The technique we described is simple, inexpensive and time saving at
those cases in which hooking of the silicone tube from under the inferior conchae is difficult and the edge of the silicone tube is observed in the pharynx.
Conclusion: see discussion
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Canalicular laceration repair with a novel viscoelastic injection technique to locate
and dilate the proximal torn edge
Faruk H Orge
University Hospitals of Case Medical Center, Department of Ophthalmology
Cleveland, Ohio
Introduction: Canalicular lacerations are common complications of eyelid trauma in
the pediatric population. Irrigating air, water, colored or viscous agents through the intact
canaliculus have been suggested to make locating the torn proximal edge easier. We report our experience in repairing canalicular lacerations using a novel viscoelastic injection
technique with a Monoka monocanalicular stent.
Methods: Patients under the age of 18 who underwent repair of a canalicular laceration
with a monocanalicular stent using a novel viscoelastic injection technique at our institution were retrospectively reviewed. Demographics, cause of eyelid injury, surgical management using our novel viscoelastic injection technique, and its outcome were analyzed.
Results: After reviewing 38 children with lid lacerations, 17 children (mean age = 6.27
years) who had canalicular injury due to dog bites (9 patients) and shearing trauma (8
patients) were included the study. Locations of injury included 11 lower lids, 4 upper lids,
and 2 combined upper and lower lids. All patients had good anatomic repair and on follow
up had negative dye disappearance tests and were free of tearing.
Discussion: In our institution’s experience deploying viscoelastic in the vicinity of and
injecting into the injured canaliculus has proven a useful technique.
Conclusion: The technique improves visualization of the operative field by retracting the
anatomy and tamponading any bleeding, aids in location and dilation of the torn canaliculus initially and in subsequent steps, eases intubation into the lubricated torn canaliculus
and nasolacrimal duct, and avoids iatrogenic injury to an uninjured canaliculus.
Electronic
Poster 48
Analysis of the Readability of Patient Education Materials
in Pediatric Ophthalmology
Ann M John BA Elizabeth S John BA David R Hansberry MD, PhD Suqin Guo MD
The Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School
Newark, NJ
Introduction: Patients increasingly utilize online resources for healthcare information. Studies
show that over eight in ten caregivers have Internet access, and 84% of them search online for
health information(1). The American Medical Association (AMA) and National Institute of Health
(NIH) recommend that online patient resources be written between a 3rd and 7th grade-level for
sufficient patient comprehension(2,3). This study assesses whether online health information in
pediatric ophthalmology abides by these guidelines.
Methods: Ten pediatric ophthalmology conditions were entered into a commonly used search
engine, Google.com(1). Conditions included amblyopia, cataract, conjunctivitis, corneal abrasion,
nystagmus, retinoblastoma, retinopathy of prematurity, sty, and glaucoma. The first ten patient
information articles for each condition were assessed using 10 validated readability scales: FleschReading Ease, Flesch-Kincaid Grade-Level, SMOG Grading, Coleman-Liau Index, Gunning-Fog
Index, New Dale-Chall, FORCAST, Fry graph, Raygor-Estimate, and New Fog-Count. Scientific
articles and articles written on patient forums were excluded. Common sources of articles were
aapos.org, aoa.org, kidshealth.org, and geteyesmart.org.
Results: The majority of articles were written above recommended guidelines. Across all scales,
the 100 articles were written at a mean grade-level of 12.1±1.8. Only 12% of articles were written
below a 9th grade-level and only 2% met recommended criteria.
Discussion: The readability of online patient education material exceeds NIH and AMA guidelines. This can adversely affect caregiver comprehension of such resources, contributing to poor
decision-making.
Conclusion: Pediatric ophthalmology online articles are generally written at a level too high for
caregiver comprehension. Revision of the level of articles may increase patient education, improve
health outcomes, and facilitate the patient-physician relationship.
References: 1. Fox S, Duggan M, Purcell K. Family Caregivers are Wired for Health. Pew Research Internet Project. http://www.pewinternet.
org/2013/06/20/part-1-health-information-specialists. Published June 20, 2013. Accessed September 4, 2014.
2. Weiss BD. Health Literacy: A
Manual for Clinicians. Chicago, IL: American Medical Association, American Medical Foundation. 2003. 3. National Institutes of Health. How to
Write Easy to Read Health Materials. National Library of Medicine Website. http://www.nlm.nih.gov/medlineplus/etr.html. Updated February 13, 2013.
Accessed September 5, 2014.
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Evaluating Patient Satisfaction in the Pediatric Ophthalmology and Strabismus
Clinic During the Transition to Electronic Medical Records
Pedro F Monsalve MD Ta C Chang MD Kara M Cavuoto MD
Bascom Palmer Eye Institute, Miami, Florida
Electronic
Poster 49
Introduction: As of January 2014, the use of electronic medical records (EMR) is federally mandated. We assessed the impact of the transition from paper charts to EMR in a pediatric ophthalmology practice at a tertiary care center.
Methods: Prospective, cross-sectional survey. Patients/guardians completed a questionnaire
consisting of ten Likert-type scaled questions and two free response questions at three time points:
two weeks prior to (phase 1), two weeks after (phase 2), and three months after (phase 3) the EMR
transition.
Results: A total of 382 surveys were collected: 158 from phase 1, 68 from phase 2 and 156 from
phase 3. The survey response rate was 92%, 85% and 93% for phase 1, 2 and 3 respectively.
Overall, patient satisfaction was high at all three time points. Of significance, the patients’ preference for the EMR over paper charts increased in phase 3 compared to phase 2 (p=0.022). The
time between check-in and physician entering the room was significantly longer in phase 1 and
phase 3 when compared to phase 2 (133 versus 102 minutes, p=0.0019; 139 versus 102 minutes,
p=0.0004). Physicians spent significantly more time with the patient in phase 2 as compared to
phase 3 (31 vs 18 minutes, p=0.001). Patients’ estimates of waiting time compared to actual waiting time were not significantly different at any phase; however, patients’ estimates of time spent
with the physician were significantly underestimated in phase 1 (20 versus 25 minutes, p=0.04) and
overestimated in phase 3 (24 versus 18 minutes, p=0.0002).
Discussion: Most patients were satisfied with the service regardless of use of paper chart or
EMR. The EMR does not seem to improve patient’s waiting time, but seems to have a significant
impact in the perception of time spent with physician.
Conclusion: Transition to EMR does not seem to impact patient wait time. Time spent with the
patient increased during transition and normalized after mastery of the system, although patients
continued to perceive longer time spent with the physician long after transition to EMR.
References: 1.Wylie MC, Baier RR, Gardner RL, Perceptions of Electronic Health Record Implementation: a Statewide Survey of Physicians in
Rhode Island, The American Journal of Medicine (2014), doi: 10.1016/j.amjmed.2014.06.011 2. Karishma G. Reddy, BS, and Jack C. Yu, MD,
DMD, MS Ed, The Impact of Electronic Medical Record Implementation on the Outpatient Volumes of a Midsize Academic Center. Annals of Plastic
Surgery (2014), doi: 10.1097/SAP.0000000000000314
Predicting Total Physician Time per Patient Using Linguistic Features
in an Electronic Health Record
Constance E. West, MD, Mary Anne Lenk, BS, Brandy L. Dearwater, RN,
Christopher S. Byington, MHSA, Kelli Vieson, COT, William W. Motley, MD
Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of
Medicine Department of Ophthalmology, Cincinnati, Ohio
Introduction: Differences in inter-patient complexity lead to variability of total physician time
per patient, with adverse effects on both patients’ and physician’s experience and flow. We
sought to improve scheduling accuracy by determining if simple linguistic features contained
in an electronic health record (EHR) could predict total physician time per patient.
Methods: The Davis Observation Code(1) and the methods of Fiks et al(2) were adapted to
measure and characterize time spent by a pediatric ophthalmologist at various tasks, including documentation in an EHR, in a hospital-based pediatric ophthalmology practice. A Delphi
approach was utilized to achieve consensus about which linguistic features in a patient’s
EHR record signal increased physician time. Physician time per patient was recorded by an
observer masked to presence/absence of identified linguistic features during two clinic days.
Results: Linguistic features identified that signaled above-average (“Extended”) physician
time included: ‘glaucoma’, ‘cataract’/’aphakia’/’pseudophakia’, ‘nystagmus’, ‘Trisomy 21’, ‘second opinion’, and ‘surgical consult’. Mean total physician time for ‘Extended’ patients (n=11)
was 1165 sec (SD 388 sec), while mean physician time for patients lacking identified linguistic
features (n=34) was 764 sec (SD 277 sec); p-value <0.0001. Our results enabled us to derive
a mathematical model to optimize appointment schedule templates that account for varied
patient complexity.
Discussion: Simple linguistic features in an EHR can be utilized to accurately predict and
account for physician time per patient based on anticipated patient complexity.
Conclusion: This work provides proof-of-concept for inclusion of decision support approaches involving textual data, such as natural language processing, in an EHR.
References: 1. Callahan EJ, Bertakis KD. Development and validation of the Davis Observation Code. Fam Med. 1991; 23:19-24. 2. Fiks AG,
Alessandrini EA, Forrest CB, Khan S, Localio AR, Gerber A. Electronic medical record use in pediatric primary care. J Am Med Inform Assoc 2011;
18:38-44.
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Poster 51
A comparison of Food and Drug Administration (FDA) status to current guidelines
for medications used in pediatric ophthalmology
Gerard P Barry Alyssa S Herrmann John W Simon
Albany Medical College
47 New Scotland Ave, Albany, NY 12208
Introduction: A comparison of the Food and Drug Association (FDA) status of medications used in pediatric ophthalmology to current medical guidelines.
Methods: Medications used to treat visually threatening disorders were selected. They
include: amblyopia (atropine), juvenile idiopathic arthritis (prednisolone, difluprednate,
loteprednol, rimexolone), bacterial keratitis (moxifloxacin, gatifloxacin, ofloxacin, levofloxacin, ciprofloxacin, besifloxacin), herpetic keratitis (acyclovir), pediatric glaucoma (oral
acetazolamide, latanoprost, dorzolamide-timolol, dorzolamide, brinzolamide), infantile
hemangioma (oral propranolol), ophthalmia neonatorum prophylaxis (erythromycin), and
ROP (intravitreal bevicizaumab). We reviewed the FDA status of each medication and
compared this to the guidelines found in AAO, AAPOS, AAP and Cochrane.
Results: 3/20 medications were FDA-approved for the indication in children of any age.
3/20 medications were FDA-approved for the indications but not proven safe in children
under 1 or 2 years of age. 14/20 medications were not FDA-approved for the indication
and/or not recommended for pediatric use. Current guidelines supported, to some extent,
the use of all 20/20 medications for the selected indication and specifically mentioned use
in children for 8/20 medication.
Discussion: A divergence exists between FDA status and current guidelines for medications used in pediatric ophthalmology. Guidelines support a broader range of medications
used for pediatric ophthalmologic conditions than FDA status would suggest.
Conclusion: The FDA status of several medications used in pediatric ophthalmology is
more restrictive than what is suggested by current medical guidelines. Medical guidelines
should be considered when treating pediatric ophthalmic conditions. Future FDA classification may consider current medical guidelines in pediatric ophthalmology and other
fields of medicine.
Electronic
Poster 52
Establishing a surgical outreach program in the developing world: pediatric strabismus surgery in Guatemala City, Guatemala
Lauren C Ditta Emily T Graves Chantel Devould Ebony Murchison Natalie C Kerr
University of Tennessee, Hamilton Eye Institute
Memphis, TN
Introduction: Organizing a sustainable pediatric surgical outreach mission to an underserved
population in a foreign country presents unique challenges for the pediatric ophthalmologist.
Methods: During Fall of 2013 and 2014, we organized a pediatric ophthalmic surgical
outreach mission for strabismic disorders in Guatemala. In year one, patients were referred
by local healthcare providers. In year two, greater than 60% were pre-screened by a local
pediatric ophthalmologist prior to referral. Children were evaluated for surgical intervention by
three pediatric ophthalmologists and an orthoptist. Surgical care was provided at the Moore
Outpatient Surgical Care Facility in Guatemala City, Guatemala over four days.
Results: We screened 47% more patients in year two (90 vs. 132). Patient age range (1-17
years). Diagnoses included congenital and acquired esotropia, consecutive and acquired
exotropia, congenital nystagmus, Duane’s syndrome, and oblique muscle dysfunction. We
performed 18 more surgeries in our second year (40 vs. 58), a 45% increase. Three patients
from year one returned for additional treatment. Of these, one was over-corrected. There were
three additional immediate post-operative over-corrections. There were no significant complications during anesthesia, surgery, or in the immediate post-operative period.
Discussion: Each year, 44% of screened patients underwent surgery, suggesting that
despite screening a larger volume of patients, a similar incidence of surgical pathology was
identified.
Conclusion: International cooperation, a multidisciplinary team of healthcare providers, and
equipment allocations provide a safe and effective surgical outreach program for children with
strabismus in the developing world. Coordinating pre and post-operative care with a local
pediatric ophthalmologist facilitates best practice management and sustainability.
References: 1. ‘Peace, Hope, Health, Safety, Completeness...’ The Shalom Foundation RSS. N.p., n.d. Web. http://www.theshalomfoundation.
org. 10 Oct. 2013. 2. ‘The Moore Pediatric Surgery Center.’ The Shalom Foundation RSS. N.p., n.d. Web. http://www.theshalomfoundation.org/
programs/medical-program/mp/. 10 Oct. 2013.
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Ophthalmologic outcome of extremely preterm infants at 6.5 years of age;
Extremely Preterm Infants Study in Sweden (EXPRESS)
Kerstin M Hellgren1, Ann Hellström2, Kristina Tornqvist3, Peter Jakobsson4,
Pia Lundgren2, Birgitta Carlsson5,
6
Karin Stjernqvist , Karin Källén7, Fredrik Serenius8, Gerd Holmström9
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Department of Clinical Neuroscience, Karolinska Institutet, Stockholm. 2 Section of Pediatric Ophthalmology,
Sahlgrenska Academy, University of Gothenburg, Gothenburg. 3 Department of Ophthalmology, Lund University
Hospital, Lund. 4 Department of Clinical and Experimental Medicine, Linköping University, Linköping. 5 Department of Ophthalmology, Örebro University,Örebro. 6 Department of Psychology, Lund University, Lund. 7 Centre of
Reproductive Epidemiology, Lund University, Lund. 8 Department of Women’s and Children’s Health, Section for
Pediatrics, Uppsala University, Uppsala.9 Department of Neuroscience, Ophthalmology, University Hospital, Uppsala.
1
Introduction: There are concerns that improved survival rates of extremely preterm infants
might increase the rate of long-term eye and visual problems. The purpose was to investigate
the ophthalmologic outcome of extremely preterm children (EPT, <27 weeks) at 6.5 years
Methods: A population-based cohort of all EPT children (n=496) born in Sweden 2004 - 2007
was assessed and compared with a term-born control group, as part of a prospective national
follow-up study.1 Visual and stereo acuity, refraction and manifest strabismus were evaluated.
Results: At a median age of 79 months 430 of 496 eligible EPT children (87%) were assessed (73 by chart review) and 296 controls. In the EPT group subnormal visual acuity was
found in 15.0%, visual impairment in 2.6% and blindness in 2.1% versus 0.7%, 0.3% and 0%
in the control group. Hyperopia (> 3D), myopia (</= -3D), astigmatism (< -2D) and anisometropia (>/= 2D) were found in 17.6%, 5.2%, 8.4% and 8.8% respectively in the EPT group
as compared to 4.2%, 0%, 1.8% and 0.4% in the control group, and manifest strabismus in
14.1% versus 0% in the controls. Stereo acuity was deficient in 43.8% of EPT children and in
4.7% of controls and was negative in 22.6% vs 1.0%. All group differences were highly significant with p-values <0.001 (Mann-Whitney U test).
Discussion: Ophthalmologic outcome will be discussed in relation to ROP, GA, BW and
cognition.
Conclusion: A Swedish population based three years cohort of extremely preterm children at
school-age have significantly affected ophthalmologic outcomes as compared to age-matched
controls.
References: 1.EXPRESS Group. One-year survival of extremely preterm infants after active perinatal care in Sweden. JAMA. 2009;301:2225-33
2.Austeng D et al. Incidence of retinopathy of prematurity in infants born before 27 weeks’ gestation in Sweden. Arch Ophthalmol. 2009;127:1315-9
A Comparison Between Pediatric and Adult Ophthalmology Consults in an Urban
Academic Institution
Sunju Park MD Sejal H Patel BA Jamie B Rosenberg MD
Albert Einstein College of Medicine/Montefiore Medical Center
Bronx, NY
Introduction: The purpose of this study is to compare pediatric and adult ophthalmology
consults in an urban academic center.
Methods: Retrospective chart review was conducted of patients evaluated by the ophthalmology consultation service from January-March 2014. Patient charts were abstracted
for data related to reasons for consult and findings/recommendations made.
Results: 379 patients were evaluated, 72 (19.0%) children and 307 (81.0%) adults. More
children (38.9%) than adults (7.5%) were seen with an attending (p<0.001). More adults
(81.1%) than children (61.1%) had an eye complaint (p<0.001). More adults (92.2%) than
children (76.4%) had abnormal findings on exam (p<0.001). The other variables were not
significantly different: an alteration in management was recommended for 50% of patients; outpatient follow up was recommended for 70% of patients.
Discussion: There are several differences between pediatric and adult consults in our
institution. More adult patients had a chief complaint, because many pediatric exams
were done to screen for systemic diseases or non-accidental trauma. Many of these
screens result in negative examinations, which explains why more of the adult patients
had abnormal findings. Despite the higher rate of abnormal findings in adults, patient
management was changed at similar rates among children and adults.
Conclusion: Comparing pediatric and adult consults allows for the identification of patterns among both providers and patients. These patterns can be used to help educate
primary care physicians and ophthalmology residents on the best management of inpatient consults.
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The Effectiveness of a Mobile Clinic in Improving Follow-up Eye Care
for At-Risk Children
Jinali Patel MD Wei Diao BA Melanie Snitzer MSW, LSW Michael Pond BA
Rachel Weiner BS Sarah Martinez-Helfman BS Kathleen Santa Maria COT
Alex V Levin MD, MHSc
Wills Eye Hospital
840 Walnut Street, Philadelphia PA 19107
Introduction: Every year over 22,000 Philadelphia public school students fail a school
vision screen but only approximately 4,000 see an ophthalmologist. While mobile optometric care units have had success in delivering primary eye care, only 53% of patients
referred to pediatric ophthalmologists complete this consultation. This study investigates
whether a mobile eye unit with the same equipment as a pediatric ophthalmologist’s office could improve the rate of successful consultation.
Methods: Cohort study of students from schools in socioeconomically disadvantaged
communities, referred to a mobile ophthalmic unit after failing an in-school optometric
exam and obtained consent to be seen by a mobile unit instead of at a local hospital.
Results: 132 students were referred by the optometric program to the mobile unit. 101
students had signed consent forms of which 82 (81%, CI 74%-89%) were seen by the
mobile ophthalmic unit, which represents a follow-up rate of 62% (CI 54-70%). The rate
of successful completions of ophthalmology consultation increased compared with the
historical rate of 53% (p=0.036). School nurses responded favorably to this program citing improved convenience, simpler logistics, and more effective use of personnel time.
Discussion: Our data suggest that a mobile eye unit can increase the ability to successfully provide ophthalmic care to high risk children.
Conclusion: As screening without follow-up does not adequately address the needs of
pediatric patients, the use of mobile eye clinics in schools may allow consultation completion to be more successful.
References: 1. Public Citizens for Children and Youth, A Problem We Don’t See: The Status of Children’s Vision Health in Philadelphia. 2008.
https://www.pccy.org/userfiles/file/ChildHealthWatch/VisionReport2008.pdf. Accessed August 26, 2014.
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Epidemiology of Pediatric Ophthalmic Trauma
Joshua A Schliesser David Lyon Anvesh Reddy Amneet Hans Faheem Mahomed
Ruby Parikh
University of Missouri - Kansas City
Kansas City, Missouri
Introduction: Pediatric ocular trauma is recognized as a leading cause of preventable
unilateral blindness.1 Anecdotal evidence suggests pediatric ocular trauma increases
during summer months. Our study aim is to determine if pediatric ocular trauma occurs
more frequently during the summer season and determine how visual outcome varies by
seasonality, gender, age, mechanisms of injury, and surgical management.
Methods: Pediatric ophthalmology consults for ocular trauma occurring between January 2003 and November 2012 were reviewed retrospectively.
Results: 374 patients with eye injuries were evaluated. 255 patients were male and
119 were female (p<0.001). Eye injuries occurred most during the spring and summer
months (58.8%, p=0.007). Blunt trauma occurred more frequent than penetrating (78.34
vs 21.66%; p<0.001), with an average age of 10.49±4.48 years and 8.26±4.36 years, respectively (p<0.001), and resulted in better visual acuity (0.16 logMAR vs 0.73 logMAR;
p<0.001). Projectile injuries resulted in worse vision (0.68 logMAR vs 0.21 logMAR;
p<0.001).
Discussion: Eye injuries were observed most in the spring and summer months. Risk
factors for poor visual outcome included penetrating trauma, projectile mechanism, and
trauma requiring multiple surgeries.
Conclusion: Pediatric ocular trauma outcomes vary greatly. By understanding these
outcome variables there is potential for improving patient safety and the management of
pediatric ophthalmic trauma.
References: 1. Brophy M, Sinclair SA, Hostetler SG, Xiang H. Pediatric eye injury-related hospitalizations in the United States. Pediatrics. 2006
Jun;117(6):e1263-71.
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The Impact of Insurance Status on Hospital Resource Utilization
in Pediatric Ophthalmic Inpatients.
Daniel C Terveen Benson S Hsu MD Geoffrey T Tufty MD
University of South Dakota Sanford School of Medicine
1400 W 22nd St, Sioux Falls, SD 57105
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Introduction: To determine the impact of insurance status on hospital resource utilization for pediatric ophthalmic inpatients in the United States.
Methods: We conducted a retrospective cohort study using 2009 hospital discharge
data from the Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database
(KID). Pediatric ophthalmic inpatients (n=7,796) age 0-20 were stratified by primary payer
status. To assess resource utilization, we used hospital charges as well as assessed
length of stay, time to initial procedure, and number of procedures.
Results: Pediatric ophthalmic inpatients with Medicaid (n=3,932) had higher total
charges than patients with private insurance (n=3,864). Total charges were $20,773 for
all Medicaid patients compared to $20,586 for those with private insurance (p<0.001).
When comparing Medicaid to privately insured patients we found differences in Length of
Stay (3.43 to 3.11 days, p<0.001), Time to Initial Procedure (1.10 to 0.79 days, p<0.01),
and Number of Procedures (1.01 to 1.14, p<0.001). There was no difference in Number
of Chronic Conditions (0.91 to 0.93, p=0.49).
Discussion: Medicaid pediatric ophthalmic inpatients had longer length of stay, longer
time to initial procedure, less procedures performed, and higher total charges compared
to private insurance patients.
Conclusion: Among pediatric ophthalmic inpatients there is a significant difference in
resource utilization between the payer types. Patients with Medicaid had the longest
lengths of stay and highest total charges even when controlling for patient comorbidities. Our findings suggest that shifting privately insured patients to Medicaid as proposed
through the Affordable Care Act could increase costs and resource utilization in this
population.
Seizures induced by cycloplegic eye drops
Tamara Wygnanski-Jaffe MD Paolo Nucci MD Mauro Goldchmit MD Eedy Mezer MD
Goldschleger Eye Institute, University Eye Clinic San Giuseppe, Cema Hospital,
Rambam Health Center
Tel Hashomer, Israel, Milan, Italy, Sao Paulo, Brazil, Haifa, Israel
Introduction: The Most dreaded effect of cycloplegic eye drops have been their effect
on the central nervous system. The puprose of this study was to assess the incidence of
seizures induced by cycloplegic drops.
Methods: A survey among members of the American Association for Pediatric Ophthalmology and Strabismus yielded five patients who received cycloplegic eye drops between
1998 and 2010 and who consequently developed a seizure.
Results: The median age of the patients was 5 years (range 3 months to 12years).
Cyclopentolate hydrochloride 1% was the only causative agent. The seizure occured on
average 12 minutes after the instillation of dilating eye drops. Three were generalized
convulsions, and two patients had a focal seizure. Past medical history was unremarkable in four cases. Sixteen previous cases of seizures induced by cycloplegic drugs
were identified in reports published between 1890 and 2004, implicating atropine in 9
reports,tropicamide and phenylephrine eye drops in 1, and cyclopentolate in 6.
Discussion: A small amount of cyclopentolate drops could induce convulsions in young
children after only minutes to less than an hour, while a larger dosage of atropine over the
span of several hours could cause this rare and unpredictable complication. Predisposing
factors were rare and those developing the seizures were healthy subjects. Generalized
seizures were much more frequent than focal seizures.
Conclusion: Fatel side effects due to cylopentolate drops are extremely rare, they occur
shortly after instillation and have no predilection to unhealthy children;therefore there is
no reason to fear using cyclopentolate drops.
References: 1. Adcock EW, 3rd. Cyclopentolate (Cyclogyl) toxicity in pediatric patients. J Pediatr 1971;79(1):127-9. 2. Bauer CR, Trottier MC,
Stern L. Systemic cyclopentolate (Cyclogyl)toxicity in the newborn infant. J Pediatr 1973;82(3):501-5. 3. Brunner GA, Fleck S, Pieber TR, et al.
Near fatal anticholinergic intoxication after routine fundoscopy. Intensive Care Med 1998;24(7):730-1
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Evaluation of optic nerve compression as a potential cause of retinal hemorrhage
in infants
Gil Binenbaum MD MSCE Shaun M Evans MS Vivian Lee MD Brittany Coats PhD
The Children’s Hospital of Philadelphia
Philadelphia, PA
Introduction: Pathophysiological mechanisms underlying retinal hemorrhage (RH) in
pediatric abusive head trauma/shaken baby syndrome are not clearly established. We
used an animal model to evaluate the potential for optic nerve compression (ONC) to
cause RH and determine the effects of increased cerebral blood volume (CBV) and intracranial pressure (ICP).
Methods: Anesthetized piglets were used as surrogates for 1 month old infants. A custom clamp with transducers to measure force applied ONC sufficient to achieve retinal
vascular occlusion, confirmed ophthalmoscopically. Group 1, n=2 eyes, received static
ONC alone; group 2, n=3, received static ONC with thoracoabdominal compression
(TAC); group 3, n=2, received static and cyclic ONC, with TAC. Indirect ophthalmoscopy
and histopathology were performed.
Results: Group 1: 1/2 eyes had 3 small blot RH. Group 2: 2/3 eyes had extensive RH,
including large nerve-fiber-layer hemorrhagic-schisis/cyst, deeper intra-RH, sub-RH/fluid,
ON and disc hemorrhages. Group 3: 1/2 eyes had ON and disc hemorrhages. Clamping
force and application rate were not clearly related to RH.
Discussion: ONC with TAC presumably caused retinal venous occlusion and extensive
RH. ONC may result from traumatic kinking during shaking. TAC has been shown experimentally to simulate known physiological changes (raised CBV/ICP) of crying, which is a
primary trigger of infant shaking. Perhaps this combination, along with other physiological
or mechanical factors, contributes to RH seen clinically.
Conclusion: Multilayered RH can develop in an animal model from ONC combined with
TAC. ONC from shaking, raised CBV/ICP, and their thresholds for RH when combined
with traumatic retinal venous occlusion or vitreoretinal traction, require further study.
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Circumferential Macular Folds Associated with Reduced Macular Hemorrhages in
Non-accidental Trauma: Implications for the Theory of Vitreous Traction
Alexander E Pogrebniak MD
The Nemours Children’s Clinic
Jacksonville, Florida
Introduction: The direct intraocular mechanisms and forces required to create retinal
hemorrhages in non-accidental head injury remain a matter of controversy and conjecture. The predominant theory implicates vitreous traction on retinal vessels; however,
retinal hemorrhages occur in other settings without history of rapid acceleration-deceleration injury, such as in healthy newborns. Circumferential macular folds are seen
almost exclusively in severe non-accidental trauma. We sought to document the pattern
of retinal hemorrhages relative to macular folds to determine if the altered vitreoretinal
interface may influence the formation of retinal hemorrhages.
Methods: We present a report of two cases of non-accidental trauma with circumferential macular folds to examine the location of hemorrhages related to the macular schisis
cavities.
Results: As seen in the analysis of photographs, in both cases retinal hemorrhage was
almost confluent peripheral to the circumferential macular folds, was prominent on the
apex and sides of the folds, but almost absent central to the folds (ratio area hemorrhage
peripheral to fold: central to fold > 5:1).
Discussion: The pattern of retinal hemorrhages post severe non-accidental trauma appears altered by the presence of retinal folds, with decreased hemorrhage central to the
folds where macular schisis has occurred, in contrast to the typical finding of widespread
macular hemorrhages when non-accidental trauma occurs without macular folds.
Conclusion: The findings may support the theory of vitreous traction causing retinal
hemorrhages whereby retinal hemorrhage is prominent on and peripheral to the retinal
folds where vitreous attachments persist and minimized central to the folds where schisis
has occurred.
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SPECTRAL DOMAIN-OPTICAL COHERENCE TOMOGRAPHY FINDINGS
IN PEDIATRIC TILTED DISC SYNDROME
Massimiliano Serafino MD Francesco Pichi MD Simona Romano MD Paola Carrai MD
Mariachiara Morara MD
Antonio P Ciardella MD Kyoko-Ohno Matsui MD Paolo Nucci MD
University Eye Clinic, San Giuseppe Hospital, University of Milan, Milan, italy
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Introduction: To report a novel spectral domain-optical coherence tomography (SDOCT) finding in children affected by tilted disc syndrome (TDS), and to correlate it with
early visual field defects.
Methods: Patients between 5 and 17 years old with TDS were enrolled in this study.
The diagnosis of TDS was made by stereoscopic fundus photography. All eyes were examined with 12 radial SD-OCT B-scans of 12 mm centered on the optic disc; the fundus
area encompassing the optic nerve was additionally scanned using several vertical and
horizontal scans. C-scan SD-OCT were acquired using the Macular Cube 512 x128 to
create the en face image. Standard automated perimetry 24-2 tests were performed on
all patients.
Results: Thirty-eight eyes of 20 pediatric patients with TDS syndrome were enrolled
during this 24-months clinical trial. Their mean age was 10.9±2.7 years (range 7-15
years), 12 (60%) were male and 8 (40%) were female. The OCT images of the optic
discs showed a protrusion of the upper edge of Bruch’s membrane and choroid at the
nasal edge of the optic disc in 39.5% of the eyes. The retinal nerve fiber tissue appeared
to be herniated into this protrusion and bent superiorly in 15 eyes. This severe bending
corresponded to early visual field anomalies that were not reduced by corrective lenses
in 46.7% of the eyes.
Discussion: Visual field defects that do not improve by increased myopic correction
in TDS may be due to the severe bending of the retinal nerve fiber tissue, which would
impair axonal flow.
Conclusion: Better understanding of correlation among myopia, optic disc, and visual
field defects.
Pediatric Ophthalmologists’ Trends in Abusive Head Trauma
Evan C Sussenbach MD R Michael Siatkowski MD Kai Ding PhD
Tammy L Yanovitch MD, MPH
Dean McGee Eye Institute, Oklahoma University Health Sciences Center
Oklahoma City, Oklahoma
Introduction: To estimate the number of abusive head trauma (AHT) cases seen by
pediatric ophthalmologists and analyze factors associated with physician subpoenas and
court testimony.
Methods: Pediatric ophthalmologists were surveyed about their experience with AHT.
The survey was sent to 875 active members of the American Association for Pediatric
Ophthalmology and Strabismus (AAPOS).
Results: The response rate was 15% (132 surveys). The median pediatric ophthalmologist was consulted 10.0 (interquartile range [IQR] = 4.0-19.0) times per year to evaluate
patients for AHT and saw 2.5 (IQR = 1.0-6.0) patients with probable AHT annually. Pediatric ophthalmologists were equally likely to be subpoenaed (4.6% vs. 4.8%, p=0.84) or
to testify (1.9% vs. 1.7%, p=0.79) whether they did or did not perform retinal photography.
Physicians were equally likely to be subpoenaed (4.8% vs. 7.1%, p=0.92) or to testify
(2.2% vs. 0.0%, p=0.17) whether a child abuse team was involved in patient care or not.
Geographic location had no statistical significance on how frequently pediatric ophthalmologists were subpoenaed (p=0.17) or testified in court (p=0.12).
Discussion: Obtaining retinal imaging, having a child abuse team, and geographic
location had no significant relationship to how frequently pediatric ophthalmologists were
subpoenaed or testified in court.
Conclusion: It is likely that a pediatric ophthalmologist will be subpoenaed and testify
in a case of AHT in his or her career. Although the use of retinal photography and child
abuse teams assist in documenting and reporting AHT, these factors do not supersede
the role of the pediatric ophthalmologist in medico-legal proceedings.
References: Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for
prevention. Child Abuse Neglect. 2012: 36(2); 156-65. US Department of Health and Human Services, Administration for Children and Families,
Administration on Children, Youth and Families, Children’s Bureau. (2013). Child Maltreatment 2012. Available from http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment Epley, KD. Ocular signs lead to recognition of non-accidental trauma in
children. Epub July 10, 2012. Ocular Surgery News.
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UK National survey of treatment for retinopathy of prematurity (ROP)
Gillian G Adams FRCSEd Catey Bunce DSc Annegret Dahlmann-Noor MD
Moorfields Eye Hospital
162, City Road, London, EC1V 2PD, UK
Introduction: ROP remains a leading cause of childhood blindness. Most countries
have screening guidelines but there is little national data on ROP requiring treatment.
Collecting epidemiological data on the incidence of treatable ROP, the treatment methods used and facilities for treatment allows for effective planning of resources and manpower.
Methods: A prospective epidemiological study of ROP treatment in the UK was started
on 1 December 2013. Cases are identified through existing reporting systems by the
British Ophthalmic Surveillance Unit BOSU, which sends out a monthly report card to
every consultant ophthalmologist in the UK. A special interest collaborative study group
(ROP SIG) was set up to facilitate information gathering. A questionnaire identifies ROP
stage at time of treatment, treatment method, location, and time to treatment from making the decision to treat.
Results: 174 cases were identified in the first 38 weeks: 94 male, 79 female. Mean
gestational age was 24.9 weeks (range 23-30 weeks), mean birthweight 728.4g (range
360-1375g). Primary treatment was laser in 160 babies, antiVEGF in 11, cryotherapy in
1 baby. 15/142 were IVF babies. 120 were singletons.
Discussion: A previous UK ROP treatment study (1) in 1997-1999 reported on 131
treatments over 15 months. At that time 76% were treated with laser, and 22% with cryo.
This study demonstrates an increase in babies undergoing ROP treatment and a significant move away from cryotherapy.
Conclusion: This study demonstrates the increased workload from using early treatment guidelines and shows the adoption of newer treatments in ROP management.
References: 1. L Haines, A R Fielder, H Baker, A R Wilkinson UK population based study of severe retinopathy of prematurity: screening, treatment, and outcome. Arch Dis Child Fetal Neonatal Ed 2005;90:F240-F244.
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Ensuring Successful Enrollment of Premature Babies into NICU based Clinical
Studies: Lessons learned from the ‘Telemedicine Approaches to Evaluating
Acute-phase retinopathy of prematurity (ROP) - e-ROP’ Study
Agnieshka Baumritter Akosua Nti Graham E Quinn MD, MSCE Karen Karp RN, BSN
Children’s Hospital of Philadelphia, Philadelphia
Introduction: Conducting research on very low birth weight (VLBW) premature infants is challenging. Parents, NICU nurses and physicians are concerned about procedures not deemed essential
or directly beneficial. We report enrollment from a multi-center, NEI-funded e-ROP study undertaken in infants with birth weight (BW)<1251g to identify those who need ophthalmological examinations.
Methods: Study Certified Coordinators (SCC) at 13 Level 3 NICUs in the US/Canada sought
consent to enroll 2,000 preterm babies in a minimal risk study in which babies undergo serial ROP
imaging by non-physicians using a wide-field camera, and diagnostic examinations by ophthalmologists. All e-ROP investigators received training in the protocol and consenting techniques,
including verbal consent. Accrual monitoring, feedback and incentives were provided to improve
enrollment.
Results: 1284 babies (mean BW 864g, mean GA 27 wks.) out of 2351 eligible (59.8%) were
enrolled with 71.5% at 4 high enrolling (HE) centers compared to 50.4% at other centers. SCC
background and time commitment varied across sites, but SCCs at HE centers were more likely to
have NICU/ROP experience and be full-time research coordinators with established relationships
with neonatology and nursing.
Discussion: The e-ROP enrollment rate (59.8%) was higher than most research studies in VLBW
infants primarily due to: SCC’s relevant experience (research training, knowledge of preemie status, ROP), time/flexibility (screening for eligibility, direct contact with parents), getting NICU’s buy-in
, coordination/sequencing of competing NICU studies.
Conclusion: e-ROP study demonstrated the feasibility of enrolling VLBW infants into clinical
research and provided lessons for building resonant context for other clinical studies working with
high risk populations.
References: 1.Early CPAP versus Surfactant in Extremely Preterm Infants. SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network. N Engl J Med. 2010;362 (21):1970-1979. 2.Telemedicine Approaches to Evaluating Acute-phase Retinopathy of Prematurity Cooperative Group. Telemedicine Approaches to Evaluating Acute-phase Retinopathy of Prematurity: Study Design. Ophthalmic Epidemiology
2014; 21:256-67. 3.Telemedicine Approaches to Evaluating Acute-phase Retinopathy of Prematurity Cooperative Group. Validity of a telemedicine
system for the evaluation of acute-phase ROP. JAMA Ophthalmology 2014 (published online June 26, 2014).
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An evaluation of trainees’ ability to acquire retinal images of premature infants using an indirect ophthalmoscopy system
Jared E Duncan, MD Sharon F Freedman, MD David K Wallace, MD, MPH
S. Grace Prakalapakorn, MD, MPH
Duke Eye Center, Durham, North Carolina
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Introduction: Current U.S. guidelines for retinopathy of prematurity (ROP) screening
require retinal examinations for at-risk infants be performed by an ophthalmologist with
sufficient knowledge and experience to identify serial changes of ROP.1 The insufficient
supply of experienced examiners able and willing to screen for ROP necessitates strategies for effective screening by less-experienced examiners. Purpose: 1) to evaluate
the ability of non-ROP experts (ophthalmology residents/fellows) to use video indirect
ophthalmoscopy (Keeler) to acquire retinal images, and 2) to determine whether these
images can be accurately graded for ROP.
Methods: We reviewed all videos (with visible optic nerves) acquired by fellows/residents during ROP examinations (7/2013-6/2014). Still images (≤3) captured from each
video examination were presented to one junior and one senior attending, masked to all
clinical data, who graded them for quality and normal/pre-plus/plus disease. Grades were
then compared to clinical examination results (as reference standard).
Results: 258 images (107 infants) were presented to the graders; 248/258(96%) were
considered good or fair quality by the senior grader. The junior and senior grader had
71% vs. 88% agreement with the clinical exam, respectively. Of those infants with plus
disease on clinical examination, the senior vs. junior grader had a sensitivity of grading
pre-plus or plus disease of 100% vs. 90% and specificity of 65% vs. 89%, respectively.
Discussion: Trainees can obtain high quality retinal images using video indirect ophthalmoscopy of infants requiring ROP screening, which can be graded with high sensitivity to
detect plus disease.
Conclusion: Less-experienced examiners may play an integral role in future ROP
screening guidelines.
References: 1. Policy statement: Screening examination of premature infants for Retinpathy of Prematurity. Pediatrics 2013; 131: 189-195.
Quantifying and Qualifying the Use of Topical Anesthetics in Retinopathy of Prematurity Examinations, a Survey
Blake D Forcina MD Dean J Bonsall MD, MS, FACS, FACP
West Virginia University
Morgantown, WV
Introduction: Use of topical anesthetic eye drops during retinopathy of prematurity
examinations is a common practice, but many ophthalmologists believe it is unnecessary.
No data exists to quantify the practice of topical anesthetic use or physicians’ reasons for
using or not using anesthetics.
Methods: IRB approval was obtained. An online survey was distributed to all active
United States and international members of AAPOS.
Results: Two hundred and thirty-eight responses were collected. Of the 225 respondents who are active members and screen for ROP, 185 (82.2%) use topical anesthetics,
and 40 (17.8%) do not. Of those using anesthetics, proparacaine was the most common
at 61%, followed by tetracaine at 34%. Common reasons cited in favor of topical anesthetic use were 1) decreased pain from the speculum insertion and overall comfort, 2)
habit, practice pattern, or hospital policy, and 3) decreased pain from scleral depression.
Reasons for not using anesthetics included 1) no noticeable difference or unnecessary,
2) no speculum use, and 3) equal efficacy of alternative methods of soothing.
Discussion: Although topical anesthetic use during ROP examinations is common, it is
far from universal practice. While some believe it decreases ocular pain and its sequelae, others hold that alternative methods are equally effective or that speculum use is
unnecessary.
Conclusion: This survey is the first of its kind to quantify and qualify use of topical anesthetics during ROP examinations and will guide further research of anesthetic use in ROP
screening and development of preferred practice patterns.
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Program for prevention on blindness in Peru: an update
Luz J Gordillo MD Ana M Villanueva MD Luz Dodobara MD Arminda Gil
Graham E Quinn MD
Instituto Damos Vision
Avenida Brasil 1129 Lima 11 - Peru
Introduction: Retinopathy of prematurity is a common cause of blindness in countries with
rapidly developing systems of neonatal care. At present, detection and treatment programs
are not widely available in many regions of middle and low income countries. Purpose: Determine the effect of an evidence-based approach to decreasing ROP blindness in Peru by
workshops emphasizing neonatal care, especially oxygen administration
Methods: Identify where ROP blind babies had been cared for. Concentrating on those
teaching hospitals with >1000 births/year, we assessed conditions of oxygen delivery in the
neonatal service. We provided interventional workshops, attended by all NICU personnel, offering training and equipment designed to improve neonatal care. A training program for ophthalmologists in detection and treatment of ROP was also provided. Since 2007, 24 NICUs in
Lima (2007-July 2013) and 15 NICUs outside Lima (Jan 2012 to present) have participated
Results: Only 8 NICUs had sufficient pre-workshop data to assess efficacy, but in those
NICUs there are more babies being screened. In 4 of the NICUs, before and after the intervention data were available for treatment. In these, 28 infants were treated among 260 examined before intervention (11%) and 21 of 397 (5%) were treated after intervention (P <0.01),
suggesting decreasing severity of ROP associated with the intervention. At present, no new
ROP blind children have been found from those NICUs that have participated in the project.
Discussion: These results show a positive effect from training of NICU personnel in systems
with scarce resources.
Conclusion: Though time intensive, intervention workshops to improve neonatal care can
reduce the burden of ROP blindness in a country.
Sponsored by CBM, SCB and ORBIS
References: 1) Sola A, Chow L, Rogido M. Retinopathy of prematurity and oxygen therapy: a changing relationship. An Pediatr (Barc.) 2005;62:48
- 63. 2) Gilbert C, Fielder A, Gordillo L, Quinn G, Semiglia R, Visintin P, et al. Characteristics of infants with severe retinopathy of prematurity in
countries with low, moderate, and high levels of development: implications for screening programs. Pediatrics.2005;115:e518 - 25.
Electronic
Poster 68
Accommodative Lag in Children with Retinopathy of Prematurity treated with
Intravitreal Injection of Bevacizumab
Kathryn M Haider Heather A Smith Jingyun Wang
Glick Eye Institute, Department of Ophthalmology, Indiana University School of Medicine
1160 W Michigan St. Indianapolis, IN
Introduction: Intravitreal bevacizumab (IVB) has been reported to be effective as the
standard laser ablation for treating severe ROP. However, little is known about the accommodation in individuals treated with IVB or laser. This study is to compare accommodative lag in infants treated with bevacizumab and infants treated with laser ablation.
Methods: Infants treated with IVB (N=9; gestational age (GA)=24.2±1.3WK) and with laser ablation (N=11, GA=24.4±1.3WK) were enrolled. Infants treated with IVB had severe
zone 1 ROP or posterior zone 2 disease. Between 9 and 24 months, cycloplegic refraction and Teller cards visual acuity were measured; accommodative lag was measured
with “monocular estimation method” retinoscopy in binocular viewing a near target at a
50cm distance. Results from the right eye were reported.
Results: Spherical equivalent is -0.11±2.63D in the IVB group and 1.20±2.54D in
the laser group (P=0.55). Accommodative lag was 0.34±0.47D in the IVB group and
0.69±0.63D in the laser group (P=0.42). Visual acuity was 1.05±0.19logMAR in the IVB
group and 0.81±0.22logMAR, in the laser group (P=0.20). The correlation coefficient of
accommodative lag and spherical equivalent is 0.81 (P=0.001), suggesting accommodative lag are highly correlated with uncorrected refractive error.
Discussion: In this pilot study, although patients in the IVB group often had more severe ROP than in the laser group, our results are promising.
Conclusion: There is no significant difference in refraction, visual acuity and accommodation between IVB and laser groups. With the increasing use of IVB, further study with a
larger sample is required to understand its effect on refractive development.
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Severe Retinopathy of Prematurity (ROP) is associated with hypocarbia in
ventilated preterm infants
Hana Leiba MD Pesah Melnik MD Tali Bdolach Eric Shinwell MD
Kaplan Medical Center, Rehovot Israel
Electronic
Poster 69
Introduction: Retinopathy of Prematurity (ROP) is a leading cause of blindness in children. While excessive Oxygen administration has been implicated in the pathogenesis,
the potential role of high or low levels of CO2, a highly vasoactive compound, is unclear.
Mechanical ventilation may contribute to both hypercarbia (vasodilatation) and hypocarbia (vasoconstriction). We report a case-control study of the relationship between CO2
levels during the first 3 days of life in ventilated preterm infants and the development of
ROP.
Methods: The study included ventilated infants born at less than 34 weeks gestational
age (GA) at Kaplan Medical Center, Rehovot during 2010-2013. 300 infants met criteria
and of these 15 developed ROP of all grades. 16 healthy birth weight and GA-matched
controls were identified. The first 72 hours of life were split into18 epochs of 4 hours and
in each hypercarbia was defined as above 50 or above 60 and hypocarbia as less than
30 or 35. ROP was assessed as all grades and also as mild (Grades 1-2) and severe
(Grades 3+).
Results: No difference was found in the occurrence of both hypercarbia and hypocarbia
between the ROP and non-ROP groups. However, hypocarbia below 30 mmHg was
found in 71% (5/7) infants with severe ROP and in no infants with mild ROP and 19%
(3/16) non-ROP infants (p=0.005). Similarly, hypocarbia below 35 was more common
in the severe ROP group (86%) vs. 13% in mild ROP and 50% in the non-ROP group
(p=0.021).
Discussion: Hypocarbia is a risk factor for severe ROP in ventilated preterm infants and
should be avoided whenever possible.
Conclusion: Hypocarbia is a risk factor for severe ROP in ventilated preterm infants and
should be avoided whenever possible. This finding should be confirmed in a larger study.
Babies at Risk for Retinopathy of Prematurity in Ghana
Akosua A Nti M.D.,1 Vera A Essuman MB.ChB., F.W.A.C.S,2
Christabel Enweronu-Laryea M.R.C.P.C.H., F.G.C.P., 2
Asiedua Ofori-Darko MB.ChB., 2 Graham E Quinn M.D., M.S.C.E. 1
1
Children’s Hospital of Philadelphia, Philadelphia, USA
2
Korle Bu Teaching Hospital, University of Ghana, Accra, Ghana
Introduction: Developing Retinopathy of Prematurity (ROP) detection and treatment
programs in a region with emerging expertise in care of premature infants is a complex
and multifaceted task. We sought to determine the need for such a program in Accra,
Ghana.
Methods: We undertook a retrospective survey of neonatal care and infants born from
6/2011 to 12/2013 in a single neonatal intensive care unit (NICU) in Korle Bu Teaching
Hospital in Accra, Ghana. We collected birth weight (BW), gestational age (GA), survival
to discharge, oxygen treatment, and pulse oximeter monitoring status for neonates.
Results: The records of 647 premature infants with a GA </= 34 weeks and BW </=
1800g were available for review. Of these, 88% survived to discharge. Mean BW= 1612g
(+/- 439g), and GA= 33.4 weeks (+/-2.9 weeks). Of the 37 infants with GA </= 28 weeks,
and 63 babies with GA >28-30 weeks, 51% and 68%, respectively, survived to discharge.
Among the 62 infants with BW </= 1000g, 45% survived to discharge. Fifty-one percent of
infants received oxygen therapy, however only 22% were on pulse oximeter. The nurse to
patient ratio in the NICU was 1: 15.
Discussion: There are infants at risk of developing ROP in this NICU. Thirteen percent
of the infants reviewed fell within the US screening criteria, and 49% fell within the criteria
established in Brazil.1-2
Conclusion: There is an urgent need for an ROP screening program in Ghana. Next
steps include presenting these data to administrators/Ministry of Health, and a survey of
blind schools for ROP blind children in Ghana.
References: 1. Gilbert C, Fielder A, Gordillo L, Quinn G, Semiglia R, Visintin P, Zin A. Characteristics of Infants with Severe Retinopathy of Prematurity in Countries With Low, Moderate, and High Levels of Development: Implications for Screening Programs. Pediatrics Vol. 115 (5): May 2005.
2. Zin AA1, Moreira ME, Bunce C, Darlow BA, Gilbert CE. Retinopathy of prematurity in 7 neonatal units in Rio de Janeiro: screening criteria and
workload implications. Pediatrics. 2010 Aug;126(2):e410-7.
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Poster 70
Electronic
Poster 71
Short and Intermediate-term Clinical Outcomes in Infants Treated with 0.5 mg and 0.625
mg Intravitreal Bevacizumab for Vision-Threatening Retinopathy of Prematurity
Leah A Owen Jennifer D Davidson Rupal H Trivedi Sarah K Shirer
Edward W Cheeseman Richard A Saunders
Medical University of South Carolina; Storm Eye Institute, Charleston, South Carolina
Introduction: Retinopathy of prematurity (ROP), a sight threatening morbidity faced by very low birth-weight infants, is characterized by avascular retina and aberrant retinal neovascularization. While laser photocoagulation remains the ‘gold standard’
treatment, ablative therapy leads to permanent loss of peripheral retinal tissue, may require general anesthesia, is problematic
in posterior disease, and may result in greater amounts of myopia later in life. The use of biologic therapies, including bevacizumab, is an evolving treatment paradigm which has short term effectiveness, but has not been systematically studied.
Methods: We retrospectively analyzed short- and intermediate-term clinical outcomes for infants treated with either 0.5mg
or 0.625mg of intravitreal bevacizumab between February 2011 and August 2014. Outcome measures include recurrence of
disease, need for additional procedures, refractive error, and ocular alignment. These data were analyzed both in aggregate as
well as via random selection to control for correlation effect.
Results: We report clinical outcomes for 27 preterm infants representing 48 eyes treated with intravitreal bevacizumab for
vision threatening ROP with follow-up ranging from 3 months to 3.5 years. We identified 13 eyes treated with 0.5mg and 35
eyes treated with 0.625 mg of bevacizumab. There was no statistically significant difference between the gestational age, birth
weight, or stage of ROP at treatment between the two groups. When taken in aggregate, we found a 15% (odds ratio 0.2149
95% CI 0.0390 to 1.1848) recurrence rate in those treated with 0.5mg of bevacizumab vs a 9% (odds ratio of 0.1315; 95% CI
0.0264 to 0.6543) rate of recurrence in the 0.625 mg treatment group. Using random eye selection analysis, the 0.5 mg treatment group demonstrated a 12.5% recurrence rate; the 0.625 mg group demonstrated a 5% recurrence rate.
|Recurrence in the 0.625mg treatment group occurred at 4.5 weeks post-treatment on average and 14 weeks post-treatment in
the 0.5mg treatment group. One-third of treated eyes (16 of 48) demonstrated anatomically full vascularization without evidence
of functional impairment by indirect ophthalmoscopy. Laser photocoagulation was performed in the 4 eyes demonstrating
recurrent disease; infants not displaying recurrent disease required no additional ocular procedures. The remaining 27 eyes
demonstrated stable regression of ROP. When analyzed in aggregate, the average spherical equivalent was -0.98 D. There
was no statistically significant difference in refractive outcome between the two treatment groups. Two patients demonstrated a
small angle esotropia not requiring surgical intervention; no others displayed strabismus.
Discussion: Short and intermediate-term clinical outcomes after treatment of ROP with intravitreal bevacizumab are not well
understood. Further, the optimum bevacizumab dose has not been determined. We demonstrate a slightly increased rate of
recurrence in the 0.5 mg treatement group; however, no statistical difference was found between groups. Importantly, when
taken in aggregate, our data show that a significant proportion of bevacizumab treated eyes, regardless of dose, achieved full
vascularization, and no cases of late recurrence were observed in infants followed as long as 3.5 years. All patients showed
appropriate visual behavior and no more than minimal myopia.
Conclusion: 0.625mg or 0.5 mg of intravitreal bevacizumab are effective for treatment of vision-threatening ROP and appear
to produce good intermediate-term visual outcomes. Recurrence of ROP, though uncommon, occurred as late as 15 weeks
post-treatment and timing may correlate with bevacizumab dose.
References: 1. Blair M and Shapiro MJ. Bevacizumab for ROP. Ophthalmology. 2012; 119(2): 421-32
2. Mintz-Hittner HA, Kennedy KA, Chuang AZ et al. Efficacy of intravitreal bevacizumab for stage 3+ retinopathy of prematurity. N Engl J Med. 2011; 364(7): 603-15.
3. Mintz-Hittner
HA. Avastin as monotherapy for retinopathy of prematurity. J AAPOS. 2010; 14(1): 2-3.
Electronic
Poster 72
Characterization of leukocyte infiltration and microglial activation in
ischemia-reperfusion injury induced retinal neuroinflammation
Dolly Padovani-Claudio, M.D., Ph.D, Sumathi Shanmugam, M.S., Heather M. Lindner,
M.S., David Antonetti, Ph.D., Steven Abcouwer, Ph.D.
Univerity of Michigan Kellogg Eye Center
Ann Arbor, MI
Introduction: Retinal ischemia is common in retinopathy of prematurity and diabetic
retinopathy. The retinal ischemia-reperfusion (IR) model exhibits neurodegeneration,
blood-retina-barrier (BRB) disruption and neuroinflammation, coinciding with increased
CCL2 chemokine expression. CCL2 is known to alter endothelial tight junction function,
attract monocytes, and modulate microglial activation in the central nervous system. This
study examined leukocyte infiltration and the role of CCL2 in retinal microglia reaction to
IR injury.
Methods: Immunofluorescence (IF) analysis of flat-mounted retinas was used to identify
microglia, leukocytes, blood vessels, and endothelial tight junctions. The effects of IR
injury on microglia numbers and soma volume increase (a measure of activation) were
compared in wild-type (Ccl2+/+) and Ccl2 knock-out (Ccl2-/-) mice.
Results: After IR, CD45+ leukocytes appeared in regions with disrupted vascular tight
junctions suggesting a possible route of extravasation. Iba1+ microglia exhibited decreased ramification and increased soma size after IR. The number and soma size of
microglia were increased after IR in both Ccl2-/- and Ccl2+/+ retinas, with a significantly
larger increase in soma size for Ccl2-/- compared to Ccl2+/+ retinas.
Discussion: Neroinflammation following retinal IR injury included microglial activation,
disruption of endothelial tight junctions, and leukocyte infiltration. Future studies using
bone marrow chimeras may help elucidate whether additional Iba1+ cells are derived
from resident microglia or from infiltrating monocytes.
Conclusion: CCL2 appears to modulate the activation of microglia after IR.
126
Facilitated versus self-guided training for grading of retinal images for ROP
Nikolas N Raufi, BA; Caleb K Morris, MD; Sharon F Freedman, MD; David K Wallace,
MD, MPH; Sasapin G Prakalapakorn, MD, MPH
Duke University Eye Center
2351 Erwin Rd. Durham, NC 27705
Electronic
Poster 73
Introduction: Retinopathy of prematurity (ROP) remains an important cause of preventable
blindness; screening barriers necessitate novel approaches. While trained non-physicians
can accurately grade wide-field retinal images for ROP,i effective training protocols have not
been determined. This study compares the effectiveness of facilitated versus self-guided
training for grading retinal images for ROP.
Methods: Thirty undergraduate and graduate students were trained to analyze narrow-field
(i.e. from indirect ophthalmoscopy) still retinal imagesii for the presence of pre-plus or plus
disease. Students were randomized into one of two training protocols. Both utilized identical electronic slideshows, but one was guided by an in-person facilitator, and the other was
self-guided. After completing their respective training, students showing proficiency in grading
pre-plus and plus disease graded a 107-retinal-image screening scenario. Accuracy of grading for ROP was compared to a reference standard (i.e. clinical examination).
Results: 80% (24/30) of trained students (89% in the facilitated versus 76% in the self-guided group, p=0.6) qualified to grade the ROP screening scenario. Median accuracy for grading
normal, pre-plus or plus disease was 71% (71% in the facilitated vs. 70% in the self-guided
group). When considering the designation of plus or pre-plus disease by graders as a screening test for detecting plus disease (confirmed on clinical exam), the median sensitivity of both
groups was 97% and the median specificity 63%.
Discussion: Both facilitated- and self-guided teaching protocols yielded similar performance
in ROP image grading.
Conclusion: Self-guided training protocols may be adequate to train non-ophthalmologists to
appreciate retinal blood vessel changes and detect plus disease with high sensitivity.
References: i. Quinn GE, Ying GS, Daniel E, et al. Validity of a Telemedicine System for the Evaluation of Acute-Phase Retinopathy of Prematurity.
JAMA Ophthalmol 2014. ii. Prakalapakorn SG, Freedman SF, Wallace DK. Evaluation of an indirect ophthalmoscopy digital photographic system
as a retinopathy of prematurity screening tool. J Aapos 2014;18:36-41.
Evaluating the Clinical Benefit of Earlier Retinopathy of Prematurity Screening
Dipal P Shah, MD Majida Gaffar, MD
North Shore - Long Island Jewish Health Center
Great Neck, NY
Introduction: To determine if screening of infants born between 22-24 weeks gestational age (GA) prior to 31 weeks is beneficial to the neonate in diagnosing and treating their
retinopathy.(1)
Methods: Retrospective chart review of 275 infants (550 eyes) screened between July
2013 - August 2014 at a XXX NICU was conducted. Infants included were 22-24 weeks
GA. Outcome measures were presence of ROP prior to 31 weeks, ROP at initial examination, and treatment initiated prior to 31 weeks.
Results: Twenty patients met criteria; 1 died prior to first examination. Average GA 23.65
weeks (SD=0.49); average BW 692.45 grams. Average age on initial examination 29.95
weeks (SD=1.22). Ten babies screened prior to 31 weeks GA, 3 had ROP (30%) on
initial examination. Nine subjects first evaluated at 31 weeks, 6 (66%) had ROP on initial
presentation. No infants had type I ROP prior to 31 weeks. Nine infants required treatment (47%) with average GA 34.9 weeks. Average number of examinations prior to 31
weeks 0.95 (range=0-3).
Discussion: ROP examinations on neonates can be psychologically harmful for both
infant and parents. Although rare, dilating drops can cause episodes of apnea and bradycardia in neonates, further warranting the need to elucidate the efficacy of earlier ROP
exams.(2)
Conclusion: Although more data is needed, based on this small subset of infants, we
can conclude that starting the screening process at 31 weeks may be adequate in identifying at risk infants.
References: 1. Screening Examination of Premature Infants for Retinopathy of Prematurity. Pediatrics. 2013; 131(1):189-195. 2. Lee, JM, Kodsi
SR, Gaffar MA, Rubin SE. Cardiopulmonary Arrest following Cyclomydril eyedrops for outpatient retinopathy of prematurity screening. J AAPOS.
2014.18(2)183-184.
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Poster 74
Electronic
Poster 75
Involution patterns of type 1 retinopathy of prematurity after treatment with
intravitreal bevacizumab
Nasrin Tehrani FRCSC Maram Isaac MB BS Kamiar Mireskandari FRCOphth
The Hospital for Sick Children
Toronto, Ontario, Canada
Introduction: To describe regression patterns following monotherapy with intravitreal
bevacizumab for type 1 ROP in zone I or zone II posterior.
Methods: A retrospective chart review was done for all infants with minimum of 72
weeks of postmenstrual age at last follow up. Main outcomes included timing of involution of type 1 ROP for the first 12 weeks post treatment and structural outcomes at last
follow up. Data was collected on demographics, retinal examination results at each visit
and development of recurrence and/or retinal detachment (RD). Findings are described
in cumulative frequency tables.
Results: Seventeen infants (28 eyes) were included. The average follow up period
post treatment was 22 ±11.25 months (range 8.9-55.1). Regression of plus disease was
seen in 71%, 88%, and 100% by days 3, 5, and 8 cumulatively. Regression of both stage
3 and plus/preplus ROP was observed cumulatively in 29%, 82%, 88%, and 100% by
weeks 1, 2, 3, and 4 post treatment. None developed a recurrence or RD at last follow
up.
Discussion: Regression of plus disease occurred earlier than regression of stage 3 and
was seen in all by eight days. Regression of stage 3 was observed in 100% of eyes by
week four. We did not observe any unfavorable structural outcomes at last follow up.
Conclusion: Based on this data, routine laser treatment soon after bevacizumab injection may not be indicated. Our experience suggests that disease recurrence and retinal
detachment are not common. None of our patients required further laser treatment.
Electronic
Poster 76
ROPtool Analysis of Images from a Non-contact Handheld Fundus Camera
Laura A Vickers Sharon F Freedman David K Wallace S. Grace Prakalapakorn
Duke University Eye Center
Durham, North Carolina, 27710
Introduction: While the diagnosis of plus disease in retinopathy of prematurity (ROP)
largely determines the need for treatment, it is subjective and prone to error. ROPtool is a
semi-automated computer program that quantifies vascular tortuosity and dilation. Pictor
is an FDA-approved, non-contact, handheld fundus camera that can simultaneously take
a color and red-free digital retinal photograph. We evaluated ROPtool’s ability to analyze
digital retinal images of prematurely born infants taken with Pictor.
Methods: We analyzed Pictor images that were previously acquired coinciding with
routine ROP screening of infants.[1] For this study, we included only images that were
considered to have fair or good quality and four quadrants that could be graded by experts. We used ROPtool to analyze a color and corresponding red-free image from one
eye of each infant. An image was ‘traceable’ if ROPtool could trace 2 major blood vessels
>/=1 disc diameter from the optic nerve in each of the 4 quadrants. We evaluated ROPtool’s ability to analyze Pictor images and generated ROC curves to assess ROPtool’s
accuracy relative to bedside clinical examination.
Results: Of the 48 infants with Pictor images, 40(83%) fulfilled inclusion criteria. Of
these, ROPtool could trace 35(88%) color and 37(92%) red-free images. Areas under
ROC curves for the diagnosis of plus disease were 0.83 for color versus 0.89 for red-free
images (p=0.2).
Discussion: ROPtool can trace most fair or good quality Pictor fundus images and can
diagnose plus disease with very good accuracy.
Conclusion: ROPtool analysis of Pictor images shows promise for ROP screening.
References: [1] Prakalapakorn SG, Wallace DK, Freedman SF. Retinal imaging in premature infants using the Pictor noncontact digital camera. J
AAPOS 2014;18(4):321-6.
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Racial Disparity in the Association of Average Day Length during Early Gestation
with Treated Retinopathy of Prematurity: A Multicenter Study
Michael B Yang, Pia Lundgren, Patricia Cobb, Richard A Lang, Lois E Smith,
Chatarina Lofqvist, Ann Hellstrom
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
Electronic
Poster 77
Introduction: To analyze a multicenter cohort of premature infants for an association
between average day length (ADL) during early gestation and treated retinopathy of
prematurity (TROP).
Methods: In 2090 premature infants (11 centers), multiple logistic regression analysis
(MLRA) of predictive variables for an outcome of TROP included ADL during days 61-90
after conception (ADL61-90).
Results: Increasing birth weight & gestational age and black race were associated with
a lower, while male gender was associated with a higher, likelihood of TROP. Multiple
birth status was not predictive of outcome. While ADL61-90 was not significantly associated with TROP in the overall population (p=0.104), subgroup analysis for 530 black
infants showed that each additional hour of ADL61-90 (range: 8.98 to 15.4 h) was associated with a 31.5 % lower likelihood of developing TROP (Odds Ratio: 0.685, p = 0.003).
The addition of WINROP alarm status, a marker of “illness severity”, to the MLRA did not
eliminate ADL61-90 as a significant predictor.
Discussion: The association of ADL with TROP occurred only in black infants and may
be due to greater attenuation of light to a critical threshold of response by the mother’s
darker skin pigment and/or involvement of a different pathway for light-induced vascular
development. Current treatment at the less severe type 1 prethreshold ROP may have
masked the previously reported association of ADL with more severe ROP, i.e. classic
threshold, in a different cohort of infants.
Conclusion: There may be a role for light therapy in early gestation to reduce the risk of
TROP among black premature infants.
References: 1. Rao S, Chun C, Fan J, Kofron JM, Yang MB, Hegde RS, Ferrara N, Copenhagen DR, Lang RA. A direct and melanopsin-dependent
fetal light response regulates mouse eye development. Nature 2013;494:243-6. 2. Yang MB, Rao S, Copenhagen DR, Lang RA. Length of day
during early gestation as a predictor of risk for severe retinopathy of prematurity. Ophthalmology 2013;120:2706-13.
The spectrum of diplopia management in ocular motility disorders
Shauna E Berry DO Matthew D Kay MD Garima Lal MD Kathryn E Ireland DO
Clint W Kellogg DO Hang M Tran MPH
Larkin Community Hospital
Miami, FL
Introduction: We retrospectively evaluated the percentage of patients with an ocular
motility disorder that opted for strabismus surgery versus prismatic correction.
Methods: All new patients billed between March- June 2013 with a 378 ICD9 code were
selected for chart review. We assessed whether the diplopia was managed with observation, occlusion, prism glasses, or strabismus surgery. Patients with the diagnosis of ocular
myasthenia gravis were excluded. Other factors taken into consideration were patient
satisfaction with prism glasses, previous strabismus surgery, if surgery was discussed as
an option, and if pathology was evident on radiologic or laboratory studies.
Results: 122 patients with a total of 135 independent diplopic events were reviewed in
regards to management. Of these diplopic events, surgery was discussed with 15 % of
patients of which 47% selected surgical management. Prism glasses were prescribed to
51.9% of patients which yielded 67% patient satisfaction with prismatic correction alone.
Discussion: A large volume of patients present to neuro-ophthalmology practices with
ocular motility disorders. In this setting it is important that the neuro-ophthalmologist and
strabismologist work together to manage the diplopia. Strabismus surgery was discussed
as an option with the patient when deemed appropriate, typically after stabilization of the
motility dysfunction. Patients included in this study presented with a cranial nerve palsy,
divergence insufficiency, thyroid eye disease, convergence insufficiency, hypertropias,
exotropias, and esotropias. Spontaneous resolution occurred in approximately 25% of
cases, generally in the setting of a microvascular nerve palsy.
Conclusion: The majority of patients presenting with diplopia were satisfied with conservative non-surgical management.
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Electronic
Poster 78
Electronic
Poster 79
Acquired Inverse Duane Retraction Syndrome Secondary to Medial Rectus Muscle
Cysticercosis
Venkateshwar Bhoompally MD Ramesh Kekunnaya DO, FRCS Jyoti Matalia DNB
Shreya Eye Care Center
Hyderabad India
Introduction: Inverse Duane retraction syndrome is an uncommon condition with
reverse clinical features of classic Duane syndrome. It is most often seen due to entrapment of medial rectus muscle in the medial orbital wall after trauma.
Purpose - To report 2 cases of acquired inverse Duane retraction syndrome caused by
infestation of the medial rectus muscle by cysticercosis cellulosae.
Methods: Two cases presented with 5-10 days history of pain, redness with diplopia.
Clinical examination of ocular motility established a diagnosis of inverse Duane retraction
syndrome.Imaging(CT/MRI) and ultrasonography of the orbit established the diagnosis of
cysticercosis of the medial rectus muscle. Oral albendazole (15 mg/kg) and corticosteroid
(1mg/kg) were given for a month and followed up for one year
Results: Clinical recovery with improvement of ocular motility and regression of imaging
features was noted at the end of treatment
Discussion: The treatment of cysticercosis of extraocular muscles has shifted from
surgical to medical therapy following successful results using oral albendazole.Oral
corticosteroids are recommended along with cysticidal drugs to control the inflammation
produced from the dying cyst, thereby preventing chronic fibrosis in the involved extraocular muscle.
Conclusion: Acquired inverse Duane retraction syndrome secondary to medial rectus
muscle cysticercosis is a new entity. Awareness of this condition and institution of appropriate medical treatment results in successful clinical outcome
References: 1.Chatterjee PK, Bhunia J, Bhattacharyya I. Bilateral Inverse Duane Retraction syndrome - A case report. Indian J Ophthalmol
1991;39:183-5 2.Lew H, Lee JB, Kim HS, Han SH. A case of congenital inverse Duane retraction syndrome. Yonsei Med J 2000 Feb; 41 (1) : 1558 3.Venkateshwar B Rao, Prashant Sahare, Vidyullata Varada. Acquired Brown syndrome secondary to superior oblique cysticercosis. J AAPOS
2003; 7:23-34
Electronic
Poster 80
Comparison of objective and subjective techniques of strabismus measurement in
adults with normal retinal correspondence
Derek P Bitner MD Ore-Ofe Adesina MD R. Michael Siatkowski MD Bradley K Farris MD
Dean McGee Eye Institute
Oklahoma City, Oklahoma
Introduction: Accurate measurement of strabismus is vital to diagnosis and treatment.
We hypothesized that subjective measurement techniques would measure larger deviations than objective ones.
Methods: Adults with strabismus, visual acuity > 20/40 in each eye and normal retinal
correspondence had deviations measured at distance and near using alternate prism
cover (ACPT) and red glass tests (RGT).
Results: Forty-two subjects have been enrolled to date. Median data points were
compared using the signed rank test. McNemar’s test was used to compare categorical
data points. The RGT tended to measure a larger distance horizontal deviation (6 vs 4
PD, p=0.03), and detected a vertical deviation more frequently at both distance (5 vs 0,
p=0.025) and near (9 vs 1, p=0.011). Of 158 measurement sets, 136 (86%) were within 4
PD of each other. In 5% of cases, the discrepancy was > 10 PD.
Discussion: While in the majority of cases both tests measured similar deviations, the
RGT was more likely to measure a larger distance horizontal deviation and to detect
vertical deviations. Deviation discrepancy of > 10 PD occurred rarely and there was no
obvious trend for either technique to measure a larger deviation in these cases.
Conclusion: In patients with NRC, both subjective and objective measurement techniques generally yield similar results. The differences we noted were most likely to be
clinically important when prescribing small amounts of vertical prism. Inter-test discrepancy that would likely influence surgical planning occurred in only 5% of cases, with
neither technique being clearly superior.
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Correction of binocular diplopia with novel contact lens technology
Tara L Bragg CO Christine Sindt OD
University of Iowa Department of Ophthalmology & Visual Sciences
Iowa City, Iowa
Electronic
Poster 81
Introduction: Small angle strabismic deviations with binocular diplopia can be difficult to
treat satisfactorily in contact lens wearers who are often not happy wearing glasses. This
is a case study examining the clinical success of new prismatic contact lens technology in
the correction of binocular diplopia.
Methods: We present a 48 year old woman with a history of keratoconus, high myopia
and a 4 prism diopter comitant right hypertropia with binocular diplopia. Her refractive
needs had previously been met by scleral contact lens wear; however she needed the
addition of spectacles with vertical prismatic correction for the maintenance of binocular
single vision. She was fit with an EyePrintPROTM custom scleral device, made from an
impression of the ocular surface, in each eye for correction of her irregular astigmatism.
3.5 prism diopters base up prism was incorporated into the device design for the left eye.
Results: Wearing these contact lenses, her acuity is 20/20 in each eye and she reports
no vertical diplopia. She measures 1 to 2 prism diopters of right hyperphoria in primary.
Discussion: To our knowledge, stable base up prismatic correction has not been reported in a contact lens device. It is the manufacturers’ hope to incorporate up to 8 prism
diopters of optical prism per lens in any direction; approximately equivalent to the maximum amount of prism that can be comfortably ground into spectacle lenses.
Conclusion: This case study introduces and examines the successful use of new
custom scleral contact lens technology for stable base up prismatic correction of vertical
binocular diplopia.
Quality of Life in Strabismus
Melinda Chang MD Federico Velez MD Joseph Demer MD, PhD Sherwin Isenberg MD
Anne Coleman MD, PhD Stacy Pineles MD
Jules Stein Eye Institute, University of California, Los Angeles
Los Angeles, CA
Introduction: Strabismus can detrimentally influence quality of life by affecting both
vision and appearance. Little is known about how quality of life in strabismus patients
compares to quality of life in patients with other ocular diseases. We aim to assess the
relative impact of strabismus on quality of life.
Methods: Forty-two adults over the age of 50 with strabismus were recruited from four
pediatric ophthalmology clinics at a single institution. All subjects completed the 25-item
National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25). NEI VFQ-25
subscale score means and standard deviations were compared between strabismus patients and patients with other ocular diseases, including diabetic retinopathy, age-related
macular degeneration (AMD), glaucoma, cataract, cytomegalovirus (CMV) retinitis, and
low vision, as reported in the National Eye Institute Visual Functioning Questionnaire field
test study.
Results: Patients with strabismus performed the same or worse on nearly all vision-related subscales compared to patients with diabetic retinopathy, age-related macular degeneration, glaucoma, cataract, and CMV retinitis. Additionally, strabismic patients reported
significantly worse ocular pain than patients with all other ocular diseases studied (p <
0.0001 in all cases).
Discussion: Strabismus may have a greater impact on quality of life than other common
ocular diseases. Both functional and psychosocial factors may contribute to diminished
quality of life in strabismic patients.
Conclusion: Physicians treating patients with strabismus should be aware of the quality
of life issues unique to these patients and address them accordingly.
References: 1. McBain HB, Au CK, Hancox J, et al. The impact of strabismus on quality of life in adults with and without diplopia: a systematic review. Survey of ophthalmology 2014;59:185-91. 2. Durnian JM, Noonan CP, Marsh IB. The psychosocial effects of adult strabismus: a review. The
British journal of ophthalmology 2011;95:450-3. 3. Pineles SL, Velez FG, Isenberg SJ, et al. Functional burden of strabismus: decreased binocular
summation and binocular inhibition. JAMA ophthalmology 2013;131:1413-9.
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Poster 83
Functional Morphometry Using Magnetic Resonance Imaging (MRI) of
Cyclovertical Extraocular Muscles (EOMs) During Vertical Ductions
Robert A Clark MD Joseph L Demer MD/PhD
Jules Stein Eye Institute
Los Angeles, CA
Introduction: To optimize an MRI indicator of EOM function, we explored multiple
single-plane and partial volume multi-plane quantitative measures of cyclovertical EOMs
to determine the morphometric parameters that correlated best with degrees of vertical
duction and thus contractility.
Methods: Surface coil MRI was obtained at 312 micron resolution in quasi-coronal
planes in 13 subjects (25 orbits) in target-controlled central gaze, plus a wide range of
supraduction and infraduction. Ductions were quantified by change in position of the
globe-optic nerve junction. EOM cross-sections were manually outlined in contigous
2-mm thick image planes spanning the orbit, then areas, partial volumes, and locations of
peak cross sections were computed.
Results: All single plane and posterior multi-plane measures correlated significantly
with degrees of duction for all cyclovertical EOMs (p < 0.01). For the inferior rectus (IR)
and superior oblique (SO), anterior multi-plane measures had a significant negative
correlation. The best measure observable in a single plane was the percentage change
in maximum cross-section (R2 = 0.76 for superior rectus (SR), 0.53 for IR, and 0.46 for
SO). The best measure observable from multiple planes was the percentage change in
partial volumes (PPV) in the region 8-14 mm posterior to the globe-optic nerve junction
(R2 = 0.84 for SR, 0.90 for IR, 0.56 for SO).
Discussion: Like horizontal EOMs, the percentage change in PPV correlates best with
degrees of vertical duction.
Conclusion: Change in cyclovertical EOM morphology correlates well with degrees
of duction, providing a reliable estimate of contractility useful for quantifying over- and
underaction.
References: Clark, R. A. and J. L. Demer (2012). ‘Functional morphometry of horizontal rectus extraocular muscles during ocular duction.’ Invest
Ophthalmol Vis Sci 53(11): 7375-7379.
Electronic
Poster 84
‘Knobby Eye Syndrome:’ Irregular Posterior Staphyloma As A Factor Complicating
Strabismus In High Myopia
Joseph L Demer MD, PhD
Stein Eye Institute and Department of Neurology, University of California, Los Angeles
Los Angeles, California
Introduction: Traditional concepts of strabismus assume a spherical globe. This study
employed magnetic resonance imaging (MRI) to demonstrate complex effects of irregular
posterior staphylomata in axial high myopes with strabismus.
Methods: High resolution (2 mm planes, 312 micron resolution), surface coil axial MRI
was obtained in central gaze in 18 highly myopic subjects with strabismus. Scans were
repeated in dextro- and levoversion in most subjects. Images were analyzed for scleral
shape and deflection of muscle paths.
Results: While myopic globes were generally spherical in 6 subjects, one or both globes
of the other 12 subjects exhibited prominent irregular nasal posterior, temporal posterior,
nasal and temporal posterior, or equatorial (1 case) staphylomata. These scleral ectasias were positioned to contact and elongate the paths of the horizontal rectus muscles
in some gaze positions. Axial length averaged 30.3±3.3 (SD) mm for eyes with irregular
staphylomata, not significantly different from 28.2±0.8 mm in spherical eyes (P>0.15).
While subjects with irregular staphylomata were older at 57±11 years than spherical eye
subjects at 24±8 years (P<0.0005), other clinical features were similar.
Discussion: Irregular equatorial or posterior staphylomata are common in strabismic axial high myopes. Staphylomata act like ‘cams’ affixed to the normally spherical
globe; thus staphylomata have no mechanical effect until they ecentrically rotate against
muscles. After rotational contact, staphylomata would add tension to the muscle that increases non-linearly with further duction. This phenomenon, detectable only by imaging,
might be confused with myopathic or neurogenic pathology.
Conclusion: Concepts of strabismus in axial high myopes should be expanded to include nonlinear changes in muscle tension produced by irregular posterior staphylomata;
imaging may be clinically informative about this “knobby eye syndrome.”
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Dissociated ocular deviations in adults
Sneh S Dhannawat MBBS David A Leske MS Jonathan M Holmes BM, BCh
Mayo Clinic
Rochester, Minnesota
Electronic
Poster 85
Introduction: To describe clinical characteristics, symptoms and quality of life in adults
with dissociated vertical deviation (DVD) and dissociated horizontal deviation (DHD).
Methods: We retrospectively identified adults with dissociated ocular deviations, defined
as a difference in deviation between fixing right and fixing left eyes (violating Hering’s
law) of >2pd vertically (DVD) and/ or >5pd horizontally (DHD). We used a standardized
10 seconds prism under cover test. We excluded paretic and restrictive strabismus. All
patients completed the Adult Strabismus-20 (AS-20) HRQOL questionnaire, the diplopia
questionnaire, and rated strain on a 5-point frequency scale.
Results: Of 35 adults, all had DVD and 6 also had DHD. Associated current distance
horizontal deviations were esotropia (17) and exotropia (18). 14 (40%) were microtropic
at distance and near. 31 (89%) patients had childhood strabismus surgery. Regarding
original strabismus, 28 (80%) had infantile ET, 2 (6%) had infantile XT, 1 (3%) had childhood ET, and 4 (11%) had childhood XT. 20 (57%) rated strain as often or sometimes.
Subnormal AS-20 scores were found in 25 (71%) in self-perception, 25 (71%) in interactions, 21 (60%) in reading function, and 26 (74%) in general function. 5 (14%) reported
more than rare diplopia in distance straight ahead and 4 (11%) reported more than rare
diplopia for reading.
Discussion: DVD and DHD in adults may be associated with strain, diplopia, and
HRQOL concerns.
Conclusion: DVD and DHD may be symptomatic in adults and treatment should be
considered.
Childhood intermittent exotropia from a different angle:
does severity affect quality of life?
Shin B Lim Miss Wan L Wong Miss Inez B Wong FRCSEd(Ophth)
National University Hospital
1E Kent Ridge Road, NUHS Tower Block 7, Singapore 119288, Republic of Singapore
Introduction: Few studies have explored the relationship between heath-related quality
of life (HRQOL) and clinical severity of childhood intermittent exotropia (IXT).
Methods: Sixty-eight consecutive children aged 5-17 with IXT attending the pediatric
eye clinic were recruited, together with 1 accompanying parent. HRQOL was measured
using the intermittent exotropia questionnaire (IXTQ)[1]. Clinical measures of IXT (angle
of deviation, control, stereoacuity and visual acuity) were correlated with IXTQ scores using Student’s t-test and Pearson’s correlation coefficient.
Results: 62 children and 68 parents were included in the analysis. There was no correlation between child HRQOL and clinical measures of IXT. Poorer parent HRQOL was
correlated with poorer distance control (surgery subscale, r = -0.24 p = 0.049), poorer
near control (surgery subscale, r = -0.30, p = 0.013), poorer office control (mean, r =
-0.24, p = 0.047; psychological subscale, r = -0.27, p = 0.025; surgery subscale, r = -0.28,
p = 0.020) and larger angle of deviation (psychological subscale, r = -0.30, p = 0.013).
Poorer proxy HRQOL was correlated with poorer home control (r = -0.28, p = 0.022) and
larger angle of deviation (r = 0.33, p = 0.0061).
Discussion: It is difficult to predict child HRQOL based on clinical measurements. However, parent HRQOL is likely to be worse if the child’s IXT is more severe.
Conclusion: Parents’ views have a major influence on treatment decisions in this pediatric condition. HRQOL can be routinely assessed in clinic to ensure the views of both
children and parents are represented, so as to tailor management appropriately.
References: 1. Hatt SR, Leske DA, Yamada T, Bradley EA, Cole SR, Holmes JM. Development and initial validation of quality of life questionnaires
for intermittent exotropia. Ophthalmology 2010;117:163-8.
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Poster 87
A twisted tale of ocular torsion
Vaishali Lodhia Dr Louise Ramskold Dr Alistair Jones Mr Saurabh Jain Mr
Royal Free Hospital NHS Foundation Trust
London, UK
Introduction: Toric intraocular lenses (IOLs) are being increasingly used to correct corneal astigmatism in cataract surgery. We describe the first documented case of excyclotorsion causing diplopia following toric IOL implantation.
Methods: Retrospective case note review and literature search.
Results: A 78 year-old woman presented with one week’s history of diplopia. She had
undergone bilateral cataract surgery, the right with a toric IOL. On examination, visual
acuity was 20/40 OD and 20/30 OS. She exhibited right hyperphoria (3 ^ R/L), exophoria
(15 ^ BI) and excyclotorsion measuring 5° in primary gaze, worsening to 8° in downgaze.
Anterior segment examination demonstrated rotation of the right toric IOL with its axis at
85° - 20° away from the intended position. The patient underwent urgent repositioning
of the toric IOL. Post-operatively, her visual acuity improved to 20/20, excyclotorsion reduced to 2° in primary gaze and hyperphoria to 2 ^ R/L, which she could fuse. At 3-month
follow-up, the patient was asymptomatic.
Discussion: Post-operative rotation of toric IOLs has clinically significant consequences. Rayner T-flex IOLs (as used in this case) have a reported 3.4-5.0° mean rotational
stability and 9-21% of these patients have >10° post-operative misalignment (Entabi et
al 2011, Stewart & McAlister 2010). In this case, toric IOL implantation exacerbated a
pre-existing asymptomatic torsion, resulting in visual decompensation and subsequent
diplopia.
Conclusion: The case described is a rare complication following toric IOL implantation
and ophthalmologists need to examine for torsion carefully and be aware of the possibility of inducing torsional symptoms following surgery.
References: Stewart CM, McAlister JC. Comparison of grafted and non-grafted patients with corneal astigmatism undergoing cataract extraction with a toric intraocular lens implant. Clin Experiment Ophthalmol [serial online]. 2010;38(8):747-57. Available at: http://www.ncbi.nlm.nih.gov/
pubmed/20497428. Accessed September 9, 2014.
Entabi M, Harman F, Lee N, Bloom P a. Injectable 1-piece hydrophilic acrylic toric intraocular
lens for cataract surgery: efficacy and stability. J Cataract Refract Surg [serial online]. 2011;37(2):235-40. Available at: http://www.ncbi.nlm.nih.gov/
pubmed/21241904. Accessed September 9, 2014.
Electronic
Poster 88
Stereoacuity in Children with Accommodative Esotropia
versus Partially Accommodative Esotropia
Brian Mohney Nancy N Diehl
Mayo Clinic
Rochester, Minnesota
Introduction: High grade stereoacuity is an essential characteristic of ocular alignment
and long-term motor stability. The purpose of this study was to assess population-based
stereoacuity outcomes in children with fully accommodative esotropia compared to partially accommodative esotropia.
Methods: All children (< 19 years) diagnosed with accommodative esotropia in XXX
from January 1, 1975 through December 31, 1994, were retrospectively reviewed for
their final stereoacuity.
Results: A total of 306 children with accommodative esotropia were diagnosed during
the study years; 244 (80%) were fully accommodative and 62 (20%) were partially accommodative. After a mean follow-up of 9.8 years, the median final stereoacuity was 100
arc seconds (range, 40-nil) among children with fully accommodative esotropia compared to 800 arc seconds (range, 40-nil) for those with partially accommodative esotropia
(p=<0.001). High-grade stereoacuity (> 60 arc seconds) was found in 81/230 (35.2%)
of the 244 children with accommodative esotropia compared to 8/58 (13.8%) of 62 with
partially accommodative esotropia at final follow-up (p=0.002).
Discussion: Children with fully accommodative esotropia are significantly more likely to
achieve high-grade stereoacuity than are those with partially accommodative esotropia.
Further investigation is warranted to explain these differences and the factors associated
with the development of high-grade stereoacuity.
Conclusion: In this population-based cohort of 306 children, fully accommodative esotropia was associated with significantly better stereoacuity outcomes compared to those
with partially accommodative esotropia.
134
Superior oblique muscle size in Brown syndrome
Soh Youn Suh MD Joseph Demer MD,PhD
Stein Eye Institute, UCLA
Los Angeles, California
Introduction: Isometric exercise has been promoted for skeletal muscle growth. The
restrictive limitation to supraduction in adduction in Brown syndrome can cause isometric contraction of the superior oblique (SO) muscle that might potentially contribute to
muscle hypertrophy. We thus asked if there are size changes in SO muscles in Brown
syndrome.
Methods: High resolution, quasi-coronal orbital MRI were obtained in 20 patients with
Brown syndrome and 59 normal control subjects. Maximum cross-section area of the SO
muscle belly in central gaze was determined by digital image analysis in both eyes of
patients with Brown syndrome, and compared with controls.
Results: Eight congenital and 12 acquired Brown syndrome patients were included.
Seventeen patients had unilateral and 3 had bilateral Brown syndrome. Mean maximum
SO cross-section area was 16.3 ± 3.8 mm2 in the ipsilesional eye, and 16.6 ± 3.4 mm2
in contralesional eye in unilateral cases, and 17.8 ± 2.2 mm2 in bilateral cases. Differences in SO muscle size between ipsilesional and contralesional eyes were not significant (P=.356). Mean SO cross-section area was 17.8 ± 2.8 mm2 in normal subjects, not
significantly different from Brown syndrome (P=.122).
Discussion: Isometric SO contraction in attempted supraduction in adduction in Brown
syndrome does not produce compensatory change in SO muscle size. This may be
because isometric contraction does not induce hypertrophy in extraocular muscles, or
because patients compensate by avoiding the problematic gaze position.
Conclusion: Despite restriction that requires the unusual situation of isometric contraction, affected SO muscles in Brown syndrome have normal size, reflecting absence of
compensatory hypertrophy.
Electronic
Poster 89
References: 1. Bhola R, Rosenbaum AL, Ortube MC, Demer JL. High-resolution magnetic resonance imaging demonstrates varied anatomic abnormalities in Brown syndrome. J AAPOS 2005;9:438-48. 2. Kono R, Okanobu H, Ohtsuki H, Demer JL. Absence of relationship between oblique
muscle size and bielschowsky head tilt phenomenon in clinically diagnosed superior oblique palsy. Invest Ophthalmol Vis Sci 2009 Jan;50:1759.
3. Kaeser PF, Brodsky MC. Fourth cranial nerve palsy and Brown syndrome: two interrelated congenital cranial dysinnervation disorders? Curr
Neurol Neurosci Rep 2013;13:352.
What does convergence insufficiency look like to the strabismologist?
Naomie K Warner DO Judith Lavrich MD Barry Wasserman MD
Caroline Debenedictis MD Bruce Schnall MD
Donnelson Manley MD Kammi Gunton MD
Wills Eye Hospital
840 Walnut St, Suite 1210, Philadelphia, PA 19107
Introduction: Convergence insufficiency (CI) is commonly described as the inability to
bring both eyes together on a near target. Patients with CI often have symptoms such as
headaches, asthenopia, difficulty reading or doing tasks at near, or diplopia. The clinical findings of abnormal near points of convergence, decreased fusional amplitudes and
phorias or tropias can help to make a diagnosis, however not all patients will have all
findings.
Methods: We have conducted a retrospective chart review of over 800 patients with the
diagnosis of convergence insufficiency to examine exactly what this disease looks like to
the strabismologist on initial diagnosis. We reviewed 260 patient charts to date and collected data on 145 patients. Data was analyzed using positive regression.
Results: Our results showed a significant correlation between an older age of diagnosis
and manifest refraction, strabismus and symptoms such as diplopia, difficulty focusing
and pain. Individuals who are orthophoric were more likely to be diagnosed at a younger
age than those who are exotrophic or exophoric. Myopic and emmetropic individuals
were also more likely to be diagnosed at an older age.
Discussion: The current literature discusses patients who have been diagnosed with
convergence insufficiency while not having any of the above findings. Controversy also
exists regarding fusional amplitudes, tropias and phorias. Typically CI has manifested as
an exotropia greater at near than distance, however in up to 3% of diagnoses there may
actually be an esotropia reported.
Conclusion: Definitive criteria are needed to better classify convergence insufficiency.
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Electronic
Poster 91
Extraocular Muscles Abnormalities and Surgical Management of Strabismus Following Melanoma Plaque Brachytherapy
Shatha H Alfreihi MD Stacy Pineles MD Tara McCannel M.D. , Ph.D
Colin McCannel M.D. Ben Glasgow MD Federico Velez MD
UCLA
Los Angeles, CA
Introduction: Strabismus following plaque brachytherapy for ocular melanoma is a rare
complication. Management is complex due to factors affecting the muscles and periocular tissues that may have resulted from the plaque implantation and the radiation exposure. The mechanism of strabismus is not well described.
Methods: Patients who developed strabismus following melanoma plaque brachytherapy that underwent strabismus surgery were retrospectively studied. Pre-operative and
post-operative orthotropic examination findings, intraoperative and MRI findings were
reviewed.
Results: A total of 6 patients were included. Preoperatively, 5 patients had a horizontal
and vertical deviation in primary gaze, 1 had vertical deviation only, and 2 had excycolotorsion. Mean preoperative horizontal deviation was 22.6 PD, and mean vertical deviation
was 10 PD. At final follow-up examination mean horizontal deviation was 4.4 PD and vertical 5.83 PD. In a patient with large exotropia, pathology showed mild myofiibrillar disarry
and endomesial fibrosis of the medial rectus muscle, and MRI showed enlarged muscle.
Intraoperative photos of another patient showed enlarged muscle.
Discussion: Strabismus post plaque brachytherapy for ocular melanoma is associated
with a unique form of extraocular muscle fibrosis, thickening and weakening. Antagonist
muscle contracture and radiation could also contribute to the etiology.
Conclusion: Strabismus following brachytherapy plaque for melanoma is challenging
due to incomitance caused by muscle fibrosis and weakness. Ocular motility assessment
and Imaging studies may help guide surgical planning.
Electronic
Poster 92
Successfully Managed Endophthalmitis following Strabismus Surgery
in Three Patients
Saba T Alniemi MD Sophie J Bakri MD Brian G Mohney MD
Mayo Clinic Department of Ophthalmology
Rochester, Minnesota, USA
Introduction: Endophthalmitis generally results in very poor outcomes. The purpose of
this study was to report a series of 3 consecutive patients with severe endophthalmitis
following apparently uneventful strabismus surgery in which all 3 returned to their preoperative vision.
Methods: The medical records of 3 consecutive cases of post-operative endophthalmitis following strabismus surgery at a single institution were retrospectively reviewed.
Results: Three male patients (age 20 months, 6 years, and 57 years) each underwent
uneventful bilateral strabismus surgery. Unilateral endophthalmitis with an associated
scleral or choroidal abscess adjacent to a recessed muscle was diagnosed a mean of 11
days (range, 3-18 days) following surgery. All 3 were treated with >/= 1 dose of intravitreal antibiotics as well as intravitreal dexamethasone in 2, while one patient required
cataract surgery. The vision returned to the preoperative level by 11 weeks in the adult
and to normal vision after 18 months of follow-up in the 2 children.
Discussion: Traditional treatment of endophthalmitis consists of a vitreal tap and intravitreal antibiotics, often also accompanied by vitrectomy, and subconjunctival, topical,
and systemic antibiotics. All 3 of the study cases were treated with intravitreal, topical,
and systemic antibiotics at the first suspicion of infection. Intravitreal steroids were utilized in 2 of the patients to decrease ocular inflammation.
Conclusion: Endophthalmitis following strabismus surgery is not always associated
with poor outcomes. The use of intravitreal dexamethasone in 2 of the study patients,
although controversial, may have played an advantageous role in the outcome of these
patients.
136
Defining Quality Standards in Primary Convergent Squint SurgeryA Prospective 5 year Audit
Electronic
Poster 93
Adam C Bates MBChB, FRCOphth Phey Feng Lo MBBS
Eye, Ear and Mouth Unit, Maidstone and Tunbridge Wells NHS Trust
Maidstone, Kent, United Kingdom
Introduction: To measure consistency of the Consultant team’s performance in performing primary convergent squint surgery over 5 years.
Methods: Data was collected prospectively on 107 children undergoing unilateral or
bilateral convergent squint surgery for primary esotropia over a 5-year period. Age of children ranged from 1 to 13 years old. The target distance angle on prism cover testing was
determined pre-operatively and the outcome 3 months post-operatively was compared to
the target angle.
Results: Validity of surgical dosage tables was confirmed by the average deviation from
aim being -0.29 prism dioptres (indicating a slight tendency to undercorrection). The
mean absolute deviation as a measure of variability in performance was 6.78 prism dioptres over the 5-year period. To assess a trend in performance the period was split into
4 equal sections and the mean absolute deviation showed a reduction with time. 58.9%
of cases were within 5 prism dioptres from the aim whilst 79.4% were within 10 prism
dioptres from the aim.
Discussion: Most published papers on horizontal strabismus show outcomes of surgery with patients achieving an outcome within 10PD of orthotropia. We believe that an
individualised target angle should be determined for each patient based primarily on the
probability of a patient obtaining motor with or without sensory control post-operatively
and/or the probable long-term tendency to exotropic shift in non-binocular patients.
Conclusion: Our results show both consistencies in outcomes over time and continued
accuracy of the team’s surgical tables.
Instructions to patients and families following strabismus surgery
Gad Dotan Hanya M Qureshi Leonard B Nelson
Department of Ophthalmology, Tel Aviv Medical Center and Pediatric Ophthalmology and
Ocular Genetics, Wills Eye Hospital
Tel Aviv, Israel and Philadelphia, PA
Introduction: Instructions to patients following strabismus surgery often differ between
surgeons, and are usually based on personal experience and prior training. The purpose
of this study was to identify common post-operative practice policies.
Methods: In April 2012 a 12 question electronic survey was sent to all AAPOS members
questioning their instructions to patients undergoing strabismus surgery. The questions
specifically addressed patients’ daily activities, such as their resumption of school and
work, sports, swimming, normal showering and bathing, and contact lens use.
Results: One hundred and two responses were completed. Participation was greater by
North-American members (86%) and respondents with more than 10 years of experience
(75%). Fifty percent of the respondents advised patients to resume normal showering
and bathing 24 hours after surgery. Conversely, respondents recommended that children
wait 3-4 days before resuming schoolwork (52%) and at least 2 weeks before playing in
a sandbox (47%). Furthermore, respondents indicated that patients should refrain from
participating in sports-related activities for at least a week (43%) and should not go swimming for at least 2 weeks (56%). Finally, 47% percent advised their patients not to wear
contact lenses for 2 weeks after surgery.
Discussion: Overall, the responses indicated a high regard amongst AAPOS members
for promoting normal healing and prevention of infection and other post-operative complications.
Conclusion: This survey identified that following strabismus surgery, normal showering
is commonly resumed after 1 day, schooling after 3-4 days, sports-related activities after
1 week, and sandbox play, swimming, and contact lens wear after 2 weeks.
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Poster 94
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Poster 95
Electronic
Poster 96
Total Transposition Combined with Resection of Superior and Inferior Rectus
Muscles in the Treatment of Complete 6th Cranial Nerve Palsy.
Marina A Eisenberg Steven M Archer Monte A Del Monte
University of Michigan, Kellogg Eye Center
Ann Arbor, Michigan
Introduction: Complete 6th cranial nerve palsy results in large angle incomitant esotropia, often with diplopia. Current surgical techniques are often technically difficult and
associated with complications. This study compares outcomes of combining small resections of superior and inferior rectus muscles with total transposition adjacent to the lateral
rectus insertion to outcomes of Foster-Augmented Transpositions.
Methods: Records of patients undergoing transpositions for complete 6th cranial nerve
palsies between 1/1/1985 and 8/1/2014 done by MDM and SMA were reviewed. A t-test
was employed for statistical analysis.
Results: Relative changes in horizontal deviation in primary gaze were not statistically
significant between procedures(p=0.2). Nevertheless, horizontal and vertical post-operative deviations were smaller (p=0.016 and p=0.006) after Foster-Augmented Transpositions. Post-operative abduction improvement measured 1.9 with Foster-Augmented
Transpositions and 1.6 with transpotision with resection, making the two procedures
equivalent to within one unit (TOST, p=0.04). Multivariate analysis showed that preoperative deviation carried highest statistical correlation with final outcomes (p=0.018).
Discussion: Foster-Augmented Transpositions appeared to have better post-operative
horizontal and vertical alignment than transpositions with resections, possibly due to the
larger preoperative deviations in the resection group. When compared to Foster-Augmented Transpositions, the simplicity of transposition with resection and its amenability to
reoperation should be considered when a selecting a procedure for patients with complete 6th nerve palsies.
Conclusion: Foster-Augmented Transpositions appear more effective at reducing primary esotropia and unwanted vertical deviations in patients with total 6th nerve palsies, but
the differences are small and the simplicity of the transposition and resection procedure
may make it the procedure of choice in many patients.
Accommodative Esotropia (AET) Treatment Utilizing Simultaneous Strabismus
Surgery and Photorefractive Keratoplasty
H Sprague Eustis MD Pulin Shah D
Ochsner Clinic Foundation
New Orleans, La
Introduction: Accommodative esotropia (AET) is a common cause of acquired esotropia. Pathogenesis varies among patients but usually includes excessive hyperopia and
a high AC/A ratio or tight medial recti. The present study reviews an individualized treatment plan combining refractive surgery (PRK) and strabismus surgery to correct these
problems.
Methods: 14 patients with AET treated were retrospectively reviewed. Patient ages
ranged from 11 to 19 yrs. PRK and strabismus surgery were performed on 11 patients
and PRK only in 3 patients. The goal was to create a physiologic refractive error, good
visual acuity (VA), and straight eyes without correction.
Results: All patients were spectacle free at 6 mos. follow up. 26/28 eyes had VA equal
to preoperative VA without correction. Two eyes had a 2 line reduction in VA. Alignment
results: plus or minus 10 PD: 13/14. Spherical refractive outcomes: 20 of 28 eyes within
1 D of target: 8 eyes within 2 D of target. Astigmatism refractive outcomes: 21/28 eyes
<1 D: 3 eyes: 1- 2 D: 4 eyes > 2 D. Two patients complained of halos at night, and one
patient had peripheral corneal haze. Additional patients may be added.
Discussion: Simultaneous PRK and strabismus surgery is safe and effective in treating
AET. Outcomes are skewed for under corrections at 6 mos. and present algorithms need
to be revisited. Residual uncorrected astigmatism was seen in 2 patients, yet visual acuity was unaffected.
Conclusion: An individualized treatment plan in AET, addressing the causes can result
in a physiologic refractive error, good visual acuity, and a spectacle free existence.
138
Long-term Outcomes of Strabismus Surgery in Mobius Syndrome
Marlo Galli CO Gregg Lueder MD
St. Louis Children’s Hospital, Washington University School of Medicine
Saint Louis, MO
Electronic
Poster 97
Introduction: Mobius syndrome is a rare disorder characterized by presumed congenital sixth and seventh nerve palsies. Approximately half of affected patients have esotropia with limitation of extraocular movements. This study reviewed the long-term outcome
of strabismus surgery for such patients.
Methods: Retrospective review of five children with Mobius syndrome and congenital
esotropia who underwent bilateral medial rectus muscle recessions.
Results: All patients had limitation of abduction in both eyes. The age at surgery
ranged from 4.5 to 14 months. The preoperative esotropia ranged from 20 to 30 prism
diopters (mean 27). The medial rectus muscles were recessed from 4.0 to 6.5 mm. Inferior transposition of the medial rectus muscles was performed in two patients for treatment of associated V-pattern, and two patients also had surgery for vertical strabismus.
The final horizontal alignment was < 8 prism diopters in all patients, and all demonstrated
some binocularity. Follow-up ranged from 1.5 to 17 years (mean 13 years).
Discussion: The presence of relatively moderate angles of esotropia despite marked
limitation of abduction and the good response to medial rectus muscle recessions alone
suggests that the strabismus in Mobius syndrome is more like that seen in Duane retraction syndrome, rather than congenital sixth nerve palsy.
Conclusion: Bilateral medial rectus muscle recession alone is an effective treatment for
esotropia associated with Mobius syndrome, with good long-term stability.
Novel Technique for Surgical Correction of Small Angle Vertical Deviation
Larissa A Habib MD Steven E Brooks MD
Columbia University Medical Center - Harkness Eye Institute
New York, NY
Introduction: Surgical options for adult patients with small angle (<5PD) vertical strabismus and fusion potential are limited, as standard recess/resect procedures are not well
suited for such small angles. We describe a novel surgical technique designed to address
this subset of patients, and its results in three patients.
Methods: The surgery consisted of disinserting the medial and lateral thirds of the superior rectus from the globe, and recessing each pole a pre-determined amount using 6-0
vicryl suture. It was assumed that full muscle recession corrects 3PD/mm. Because only
2/3 of the muscle is recessed this is reduced to 2PD/mm. Furthermore, the recession
increases in a linear fashion from the intact central third out to each pole, reducing the
weakening effect by 50%, yielding a final expected effect of 1PD/mm.
Results:
Patient
Age (yrs)
Preop (PD)
Recession (mm)
Postop (PD)
Length F/U
1
53
2 RHT
2.5
ortho
3 yrs
2
38
3-4 RHT
3
ortho
2 yrs
3
59
4 RHT
4
ortho
2 weeks
Discussion: In each case the dose-response matched the predicted effect, and appeared to demonstrate long term stability. There were no complications. The procedure is
potentially revisable in the case of over or under-correction, and does not exclude the use
of adjustable sutures, features which are not available with marginal or central tenotomy.
Conclusion: Our procedure appears to be a safe, effective, titratable technique for correcting very small angle vertical strabismus in adults who cannot, or do not wish to, wear
prisms.
References: Wright KW. Mini-tenotomy procedure to correct diplopia associated with small-angle strabismus. Trans Am Ophthalmol Soc.
2009;107:97-102. Yim HB, Biglan AW, Cronin TH. Graded partial tenotomy of vertical rectus muscles for treatment of hypertropia. Trans Am
Ophthalmol Soc. 2004;102:169-75.
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Immediate postoperative alignment following surgery for esotropia in children
compared to adults
Mohamed B Hassan Nancy N Diehl Brian G Mohney
Introduction: The purpose of this study was to determine if the immediate postoperative alignment among patients undergoing successful surgery for esotropia is different in
children compared to adults.
Methods: The medical records of all patients undergoing bilateral weakening surgery for
esotropia by a single surgeon between January 1, 2002, and July 1, 2014 (n=544) were
reviewed. Exclusion criteria included those with prior strabismus surgery, unilateral surgery, strengthening procedures, vertical or superior oblique surgery, and those wearing
hyperopic spectacles for accommodative esotropia. Additionally, all patients had to have
a 1 week and 6 week postoperative exam, and have </=8 PD of deviation at their 6 week
examination.
Results: Ninety-five (17.5%) of the 544 met inclusion criteria. Surgery was performed at
a median age of 3.7 years (range, 7 months to 86 years) for a median esodeviation of 35
(range, 12 to 70) prism diopters. Among the 73 patients under 11 years, the immediate
mean postoperative alignment was 9 PD of exotropia (range, 14 ET to 30 XT) compared
to a mean of 2 PD of exotropia (range 9 ET to 30 XT) in the 22 patients 11 years or older
(p=0.001).
Discussion: Esotropic children who undergo successful strabismus surgery have a
greater immediate postoperative overcorrection compared to adults. Recognizing these
differences is useful in predicting and anticipating motor outcomes for strabismic patients
of various ages.
Conclusion: Successful bilateral strabismus surgery for esotropic children results in a
significantly greater overcorrection in the immediate postoperative period compared to
adult patients.
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Poster 100
The Newcastle Control Score A Predictor Of Surgical Outcome In Distance Intermittent Exotropia?
Mr Hugh Jewsbury, Mr Patrick Watts
Cardiff Eye Unit, Cardiff, UK
Introduction: The Newcastle Control Score (NCS) is used to quantify observed control of distance intermittent exotropia(1). It has been demonstrated as a valuable tool in
predicting those likely to require surgical intervention when compared to historical criteria
for listing(2). However, whether the NCS predicts actual surgical outcome is unclear. This
study aims to investigate if a relationship exists.
Methods: Retrospective analysis of patients’ notes undergoing strabismus surgery for
distance intermittent exotropia at a UK teaching hospital between February 2002 and
February 2014. The primary end point was the magnitude of deviation for near and distance at 3 months post operatively.
Results: 67 patients included with 35 of them male. Mean age 12.3 ± 5.19yrs. The differences in pre-operative NCS for distance, near, home and total control were compared
between patients achieving an excellent result (within 10D of orthophoria) and those
achieving a poor outcome (>10D of orthophoria). There was no statistical difference between any groups (p = >0.3). There was no statistical difference in the number of patients
achieving an excellent result (within 10D of orthophoria) when divided into those with
a low pre-operative NCS (≤5) and a high pre-operative score (≥6), Chi-square statistic
0.042, p = 0.84.
Discussion: Whilst the NCS may predict those that are likely to undergo surgery, it does
not appear to predict successful outcomes.
Conclusion: Additional tools need to be developed to help predict surgical outcomes in
patients with intermittent exotropia in order to better inform surgeons, patients and families of the need for surgery and likely success.
References: 1. Haggerty H, Richardson S. Br J Ophthalmol 2004;88:233-23
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2. Buck D, Hutt SR. Br J Ophthalmol 2007;91:215-218
Factors Affecting the Difference between Simultaneous Prism Cover Test (SPCT)
and Alternate Prism Cover Test (APCT): Monitoring Post-operative Alignment after
Surgery for Exotropia
Pavlina S Kemp MD Yoon-Hee Chang MD PhD Patrice Melvin MPH Linda R Dagi MD
Boston Children’s Hospital
Boston, MA, USA
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Poster 101
Introduction: Motor outcomes for surgical treatment of exotropia differ significantly when monitored and reported by SPCT versus APCT. We investigated factors potentially augmenting this
difference.
Methods: Review of our database of outcomes after surgical remediation of exotropia (years 2007
- 2013) identified those with alignment documented both by SPCT and APCT at the same examination. Patients were divided into those demonstrating no difference, and those with signficant
difference(1) between SPCT and APCT. Age, visual acuity, fusion, size of pre-operative deviation,
intermittency versus non-intermittency, type of deviation, alphabet patterns, inclusion of resection
during repair, and post-operative exotropia versus esotropia were among factors analyzed.
Results: 273 patients had available SPCT and APCT measures at distance, and 318 at near. We
found an increased difference between SPCT and APCT at distance for those with intermittent
exotropia (p=0.028), larger pre-operative angle (p=0.003), surgery without resection (p=0.015),
and post-operative exotropia rather than esotropia (p<0.001). Post-operative exotropia rather than
esotropia increased this difference at near (p=0.005). Performance of a resection had a similar
impact on those with intermittent versus non-intermittent exotropia. Post-operative alignment within
10 prism diopters of orthophoria by SPCT was associated with much greater difference between
SPCT and APCT than those with greater post-operative misalignment.
Discussion: Although surgeon’s choice to resect narrows the range between SPCT and APCT
at distance effectively improving control of residual misalignment, independent risk factors may
remain including presence of intermittent exotropia, larger pre-operative deviation and undercorrection.
Conclusion: Surgical approach can impact the SPCT versus APCT difference. Outcomes based
on SPCT versus APCT are not readily comparable.
References: (1) Hatt SR, Leske DA, Liebermann L, Mohney BG, and Holmes JM. Variability of angle of deviation measurements in children with
intermittent exotropia. J AAPOS Apr 2012;16(2):120-124.
Improved maintenance of binocularity in ocular neuromyotonia
after strabismus surgery
Anna Kim MD Stacy Pineles MD Federico Velez MD
University of California Los Angeles; Stein Eye Institute
Los Angeles, California
Introduction: Surgical treatment for ocular neuromyotonia has not yet been described.
Variable baseline deviation and episodic spasms make correction challenging in these
patients. We report the strategies and outcomes of surgery in patients with ocular neuromyotonia.
Methods: Three patients with ipsilateral cranial sixth nerve palsy and ipsilateral lateral
rectus muscle ocular neuromyotonia who underwent strabismus surgery were included.
All patients had a history of radiation therapy for tumors, including a pituitary tumor invading the cavernous sinus, an invasive nasophargyngeal carcinoma and a clival chordoma.
Preoperative and postoperative data are described and analyzed.
Results: All patients were female with a mean age of 61±14 years. The delay in onset
of neuromyotonia post-radiation was 10.3 years (range 6-13). Preoperative ocular alignment during the resting phase measured 41±30 PD of esotropia (range 18-75 PD) at
distance and 37.6±41 PD (range 12-85 PD) at near. All patients developed a large angle
exotropia with limited adduction during the spasmodic phase. Postoperative follow-up
ranged from 8 months to 2 years. Postoperative ocular alignment ranged from 0-8 PD of
esotropia in all gaze positions. Neuromyotonic paroxysms were significantly reduced in
two patients. Two patients demonstrated stereopsis post-operatively.
Discussion: Strabismus surgery is a safe and effective procedure to achieve single vision, fusion and ocular alignment in patients with ocular neuromyotonia. Surgery did not
result in worsening of neuromyotonic spasms.
Conclusion: Surgical management is a safe alternative in patients who do not respond
to medical treatment.
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Long-Term Surgical Outcome and Developmental Abnormalities
in Infantile Exotropia
Gregg Lueder MD Marlo Galli CO
St. Louis Children’s Hospital, Washington University School of Medicine
Saint Louis, MO
Introduction: Because infantile exotropia may be associated with developmental delay,
some have recommended neurologic evaluations for all such patients. We evaluated a
group of patients with infantile exotropia with regard to associated developmental problems and surgical outcomes.
Methods: Retrospective review of children who had surgery for exotropia that presented
within the first year of life, including patients with developmental delay. Patients with <1
year postoperative follow-up were excluded. Surgery was considered successful if the
horizontal deviation was less than 10 prism diopters (PD).
Results: Twenty-six patients were included. Age at presentation ranged from 2-10
months. The range of exotropia was 20-95 PD. Ten patients (38%) had developmental
delay. Nine of these had systemic conditions that were recognized at the time of their initial evaluation. Age at surgery ranged from 4-18 months. Successful outcomes occurred
in 10/26 (38%) patients after one surgery and an additional 13 (50%) patients after two
surgeries. Three patients underwent 3 or more surgeries. Follow-up ranged from 1-16
years (mean 7 years).
Discussion: Developmental delay is common in patients with infantile exotropia, but
the cause of delay is usually recognized at the time of the initial evaluation. The need
for more than one surgery is higher in infantile exotropia than in other forms of childhood
strabismus.
Conclusion: Routine neurologic screening of otherwise normal infants with infantile
exotropia is not indicated. Most children achieve good long-term alignment with one or
two surgeries.
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A Comparison of Surgical Outcomes in Patients
with Unilateral Cranial Nerve VI Palsy.
Kimberly S Merrill CO Laura Lenius BS Erick D Bothun MD Stephen P Christiansen MD
University of Minnesota Department of Ophthalmology and Visual Neuroscience and
Boston University School of Medicine Department of Ophthalmology
Minneapolis, MN and Boston, MA
Introduction: A significant abduction deficit complicates surgical management of patients with CN VI palsy. We compared the outcomes of four surgical interventions in
patients with unilateral CN VI palsy who had a -3 or greater abduction deficit: botulinum
toxin (BTX-A) alone, horizontal surgery alone, vertical transposition alone, and vertical
transposition plus BTX-A.
Methods: With IRB approval, we performed a retrospective chart review for patients with
unilateral CN VI palsy who had surgery between 1998 and 2013. Inclusion criteria were
-3 or greater abduction deficit, stable preoperative alignment > 6 months, and > 6 months
postoperative follow-up.
Results: Of 82 patients with CN VI palsy, 26 met inclusion criteria. Mean duration of
follow-up was 18 months (6-51 mo). There was a trend towards better alignment at
distance in patients treated with vertical transposition with or without BTX-A, although
these patients were more likely to develop a consecutive exodeviation at distance or near
(11/19, 58% vs. 1/7, 14%). Residual esotropia was most common in patients treated with
BTX-A alone.
Discussion: In this study, horizontal transposition of the vertical rectus muscles with
or without BTX-A resulted in better alignment than horizontal muscle surgery or BTX-A
alone.
Conclusion: A significant abduction deficit is an indication for transposition in patients
with CN VI palsy but this procedure may result in a consecutive exodeviation.
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A modified technique for strabismus surgery in the presence of a scleral buckle
Mitra Nejad Anna J Kim Stacy L Pineles Federico G Velez
Jules Stein Eye Institute
Los Angeles
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Poster 105
Introduction: Scleral exoplant implantation for retinal detachment can cause strabismus. Removing the exoplant has minimal effect in ocular alignment, while increasing the
risk of scar tissue formation and retinal re-detachment. Scleral exoplants may interfere
with EOM reattachment during strabismus surgery especially during recessions and
adjustable suture techniques where the final position of the muscle insertion after adjustment is not always clear to the surgeon. We describe a surgical technique to perform
strabismus surgery including adjustable sutures in patients with scleral exoplant without
removing or modifying the exoplant.
Methods: All patients with scleral exoplant who underwent strabismus surgery preserving the integrity of the scleral exoplant were included in the study. Recessed muscles
and those operated on adjustable sutures were repositioned between the scleral exoplant
and the sclera leaving the exoplant intact. Analysis included motor and sensory results,
easiness of adjustment and postoperative complications.
Results: Six patients were included. Mean age was 45+/-2 years. Time between scleral
exoplant implantation and strabismus surgery ranged between 0.5-38 years. Six rectus
EOM were recessed and 2 were resected, all on adjustable suture. All rectus EOM
excluding the inferior rectus were operated on. Postoperative follow up ranged between
6-24 months.
Discussion: No patient developed retinal re-detachment, exoplant extrusion, EOM slippage or significant ocular alignment shift following the postoperative course. If needed,
EOM adjustments were performed without difficulties.
Conclusion: Strabismus surgery, including adjustable sutures, can be performed without
affecting the integrity of the scleral exoplant in patients with previous retinal detachment
surgery.
Surgical success in strabismus surgery with conventional vs Hang-back technique
Cristian M Salgado MD Alvaro E Morgado MD Bernardita M Alamos MD
Sylvia A Araneda MD Pablo Altschwager MD Felipe A Sanhueza MD
Pontificia Universidad Catolica de Chile, Santiago, Chile
Introduction: Muscle recession using the suspension technique (hang-back) is an alternative
to conventional (scleral) surgery with some advantages. We compare the surgical outcomes
of both techniques in Chilean patients.
Methods: We conducted a prospective, randomized, comparative study of patients undergoing scleral or hang-back surgery between June 2011 and December 2013. Patients had horizontal strabismus, full motility and visual acuity greater than or equal to 20/80. Patients with
neurological disorders or genetic syndromes, previous eye surgery, vertical strabismus and A
or V anisotropia were excluded. The main outcome was motor successful surgery established
as a residual deviation of 10 or fewer prism diopters. For the comparison of groups, Fischer’s
exact test was used and p values < 0.05 were considered significant.
Results: Thirty-nine patients were studied. Twenty-three patients underwent scleral surgery
and sixteen underwent hang-back surgery. The average age of the patients was 94 months,
and 20 patients were male (51.3%) and 23 patients had esotropia (59.0%). There were no
significant differences between the groups. The average follow-up period was 11.6 months.
The surgical success rate was 76.9% in the whole group at the last follow up: 69.6% in the
conventional group and 87.5% in the hang-back group (p = 0.26). No severe complications
occurred in any group.
Discussion: Although there was a tendency of better long-term stability with the hang-back
technique, both techniques produced similar surgical success rates that were not statistically
different.
Conclusion: Hang-back surgery is a safe and effective alternative to strabismus surgery with
several advantages.
References: 1. Rajavi Z, Ghadim HM, Nikkhoo M, Dehsarvi B. Comparison of hang-back and conventional recession surgery for horizontal
strabismus.J Pediatr Ophthalmol Strabismus. 2001;38:273-7 2. Orlin A, Mills M, Ying GS, Liu C. A comparison of hang-back with conventional
recession surgery for exotropia. J AAPOS. 2008 Apr;12(2):215; author reply 215-6. Epub 2008 Feb 7. 3. Spierer O, Spierer A. Comparison of
hang-back and convenional bimedial rectus recession in infantil esotropia. Graefes Arch Clin Exp Ophthalmol. 2010 Jun;248(6):901-5
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Adjustable partial Vertical Rectus Transpositioning in cases of Lateral rectus palsy
Pradeep I Sharma MD, FAMS Nitesh Salunkhe MBBS Rohit Saxena MD
Rahul Bhola MD
RP Center for Ophthalmic Sciences, All India Institute of Medical Sciences
New Delhi, India
Introduction: To evaluate adjustable partial Vertical Rectus Transpositioning (pVRT) as
a treatment modality in non-recovering cases of Lateral rectus palsy
Methods: Prospective trial of 20 patients of LR palsy randomized into two groups:
Conventional partial VRT and Adjustable partial VRT as groups 1 & 2. Medial rectus
recession was done as indicated by passive ductions. Adjustment done after 5 hours of
surgery.
Results: Mean change of esodeviation was from 49.4+13.62 prism diopter (PD) to 1.3±
2.66 PD in group 1 and from 45.8 ± 9.56 PD to 4.3± 4.47 PD in group 2.The inter group
difference was significant, p value=0.016. Orthotropia (<8pd) was achieved in 9/10cases
in group 1 vs 5/10 in group 2(p=0.04). Percentage improvement in BSV was 560 ±381.22
vs 246 ±131.04 in group 1 and 2 (p value=0.047). The grade of abduction improved to
3.3+1.41 vs 2.1+.87 respectively from the preoperative 0.9+.56 in each group. The difference between the two groups was significant (p=0.015). No vertical deviations and
evidence of anterior segment ischemia noted
Discussion: Postoperative diplopia can be intriguing and is better controlled by the
adjustable technique.
Conclusion: In management of lateral rectus palsy adjustable partial VRT holds statistically significant advantage over conventional partial VRT giving better improvement in
abduction, total binocular single visual fields and achieving orthotropia.
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Long-term stability of postoperative deviation in sensory strabismus: surgery of
the dominant or non-dominant eye.
Federica Solanes MD, Bernardita Alamos MD, Cristóbal Morales MD,
Cristián Salgado MD Pontificia Universidad Catolica de Chile
Santiago, Chile
Introduction: The non-fixing eye (NFE) is typically operated to improve sensory strabismus (SS). It is believed that surgery on the fixing eye (FE) would provide more longterm stability. To evaluate the surgical success, stability and complications of monocular
surgery in FE versus NFE in SS.
Methods: Descriptive prospective study which included patients with SS, with deviations
from 15 to 70 with modified Krimsky (MK), visual acuity logMAR >0,3 in FE and <0,7 in
NFE. Secondary strabismus and previously operated were excluded. Monocular surgery
was performed according to tables of Wright (endotropia and exotropia <50) and Rosenbaum (exotropia >50). Surgery was based on the inability to operate on the NFE or the
decision of the patient providing informed consent prior to the procedure. We assessed
postoperative surgical success (MK for endotropia +10 to -5 and -10 to +5 for exotropia),
complications and stability at 1 week and 1, 6 and 12 months.
Results: We operated 9 patients: in 5 the NFE and in 4 the FE. The rate of success on
the FE was 100% in all controls. On the NFE, the rate of success at 1 week was 60%,
50% at 1 month, 40% at 6 and 12 months (p0.119). No patients had complications that
threatened their vision.
Discussion: Although the number of patients in our series is small, those who underwent surgery on their FE tended to improve surgical success and stability for 12 months
without complications that threatened their vision.
Conclusion: Surgery on FE shows tendency to be better in success and stability.
References: 1. Dotan G. Nelson L, Surgical outcomes of strabismus surgery in patients with unilateral vision loss and horizontal Strabismus. J Pediatr Ophthalmol Strabismus 2014, (51)5, 294-298
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Divergence Insufficiency: Increasing Numbers of Surgeries and Changing Referral
Pattern for a Common Type of Adult Strabismus
David R Stager Sr MD,1 Lori M Dao MD,2 David Stager Jr MD,2 Joost Felius PhD3
1
Center for Misaligned Eyes, Dallas, TX, USA;
2
Pediatric Ophthalmology and Adult Strabismus, Plano, TX, USA;
3
Retina Foundation of the Southwest, Dallas, TX, USA
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Poster 109
Introduction: Divergence insufficiency (DI) is a common type of strabismus in older individuals [1]. The number of diagnosed cases has risen over recent years [2]. We investigated
whether this increase is reflected in the number of surgeries performed for DI, and if rising
numbers are associated with a possible increased awareness among eye care professionals
that strabismus in adults is treatable.
Methods: Medical records from 2006 to 2013 were searched for surgical DI cases in a
private practice specializing in adult strabismus. For each patient, the referral source was
categorized as specialist, general ophthalmologist, optometrist, or primary care practitioner.
Results: A total of 120 patients with DI received surgery (recession of one lateral rectus
muscle [3].) The annualized number of DI surgeries increased from 12 to 26 (P=0.02), representing a change from 4% to 12% of all adult surgeries. The proportion of DI patients referred
by general ophthalmologists increased from 23% to 53% (P=0.02), the proportion referred by
specialists (neuro-ophthalmology; neurology; oculoplastics; cataract or retinal surgeons) decreased from 60% to 27% (P=0.01), while the proportion of referrals from optometrists (18%)
and primary care practitioners (8%) remained approximately constant.
Discussion: We found an increase in the relative and absolute annual number of surgeries
for adults with DI and a shift in the referral pattern, with more patients being referred by general ophthalmologists. Referrals from optometrists remain constant and comparatively low.
Conclusion: The increased number of DI surgeries mirrors the reported increased incidence
of DI. Attention in the general ophthalmic literature may have led to an increase in referrals to
the strabismus surgeon by general ophthalmologists.
References: 1. Martinez-Thompson JM, Diehl NN, Holmes JM, Mohney BG. Incidence, types, and lifetime risk of adult-onset strabismus. Ophthalmology 2014;121:877-82. 2. Repka MX, Downing E. Characteristics and surgical results in patients with age-related divergence insufficiency
esotropia. J AAPOS 2014;18:370-3. 3. Stager DR, Sr., Black T, Felius J. Unilateral lateral rectus resection for horizontal diplopia in adults with
divergence insufficiency. Graefes Arch Clin Exp Ophthalmol 2013;251:1641-4.
Rectus muscle advancement for the treatment of ocular misalignment following
scleral buckle
Kirstin L Tawse Mitchell B Strominger Shelley Klein
Tufts Medical Center
Boston, Massachusetts
Introduction: Reestablishment of ocular alignment following scleral buckle is fraught
with difficulty and limited literature. The primary etiology of the deviation is thought to be
secondary to scarring of the extraocular muscles and restrictive in nature. We report our
experience in the surgical management of these patients.
Methods: We present a retrospective chart review of 10 patients who underwent eye
muscle surgery since 2010 for the reestablishment of ocular alignment following scleral
buckle. Preoperatively, there were five patients with exotropia, three with esotropia and
two with hypotropia.
Results: All patients were discovered intraoperative to have a rectus muscle scarred
posterior to the buckle and in the direction away from the deviation, causing posterior
fixation of the muscle with underaction. In all cases the posterior fixated muscle was
advanced to the original insertion using an adjustable suture. Four of these cases were
combined with a resection of the advanced muscle. In our cases prior to June 2012,
exploration of the opposing muscle also demonstrated posterior scarring allowing further
recession to be impossible.
Discussion: Posterior scarring of the rectus muscle behind the scleral buckle with underaction in the direction away from the deviation appears to play a significant role in the
ocular misalignment following scleral buckle placement.
Conclusion: Surgical advancement with possible additional resection of these posterior
scarred muscles is critical in reestablishing ocular alignment. In many cases, exploration
of the opposing muscle is unnecessary because they too are found scarred posterior,
thus prohibiting further recession.
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Surgical Treatment of Divergence Insufficiency Esotropia
Chris Y. Wu, B.S., Monte A. Del Monte, M.D.
Department of Ophthalmology and Visual Sciences, WK Kellogg Eye Center
University of Michigan, Ann Arbor, Michigan 48105, USA
Introduction: Several surgical protocols for divergence insufficiency pattern of esotropia
(DPE) have been reported. We aim to compare the effectiveness of isolated unilateral
medial rectus (MR) recession with unilateral MR recession-lateral rectus (LR) resection.
Methods: We analyzed 33 patients who underwent surgery for DPE by one surgeon at
our institution between 1996 and 2014; most recessions were performed on adjustable
sutures. DPE was defined by exam findings of diplopia at distance with distance esodeviation >/= 5 PD more than at near deviation. Patients with distance esodeviation </= 20
PD underwent isolated MR recession, while those with esodeviation > 20 PD underwent
combined recess-resection.
Results: Eighteen patients underwent MR recession while 15 underwent recess-resection. Mean preoperative distance/near esodeviations were 12.83/2.44 PD for recessions
and 25.47/15.26 PD for recess-resections (P < 0.001). For recessions, final dosages
were 1.96 ± 1.02 mm greater than that recommended by Park’s Surgical Tables for
esotropia, while recess-resections required 1.18 ± 1.64 mm more recession and 0.37 ±
1.36 mm more resection. Post-operatively, recession patients needed prisms more often
(38.9% vs. 6.7%; P = 0.046) though reoperation rates did not differ (11.1% vs. 0%; P =
0.489). Recess-resections were more likely to cause early lateral incomitant exotropia (P
= 0.033).
Discussion: Unilateral MR recession for ET </= 20 PD and unilateral recess-resection
for ET > 20 PD effectively treats DPE with a 6% cumulative reoperation rate. Larger dosages were needed for MR recessions than recommended, affirming the utility of adjustable sutures. Adding ipsilateral resection to solitary MR recession may be beneficial
given the high rate of post-operative diplopia requiring prism correction.
Conclusion: Several effective surgical protocols exist for DPE though better-powered
comparative studies are still needed.
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The newly sighted match seen with feltan answer to Molyneux question from 1688
Electronic
Poster 113
Itay Ben-Zion MD
Goldschlager eye insitiute, Sheba medical center
Sackler Faculty of Medicine. Tel-Aviv, Israel
Introduction: William Molyneux raised a question that was only philosophical until recently : Imagine, Molyneux wrote, that a man blind from birth that has learned to identify
objects only through his sense of touch is suddenly able to see. The puzzle is: whether
he could by his sight only know and name the objects? The answer to Molyneux question
will resolve a fundamental uncertainty about the human mind: Do we recognize identities
between seen shapes and felt ones by associative learning or by using intrinsic connections between these modalities
Methods: In Ethiopia we conduct a study of kids with bilateral Congenital Cataract who
present late for medicl treatment (age>6 years old) with sensory nystagmus and positive
family history
Vision preoperative is LP OU, under general anaesthesia we perform cataract extraction
and foldable P/C IOL bilateral. Vision and object recognition is performed immediately
after bandages removal the next day
Results: we demonstrate (with video recording) visual performance, recognition and
naming of objects by one child of the cohort preop and immediately following sight
restoration, the child is able postop with sight only to name objects he has named preop
by touch only, Visual acuity was 2 meter finger count (tested immediately following the
recognition task)
Discussion: This child demonstrates tactile-visual transformation thus answering positively to the question Molyneux raised nearly 250 years ago
Conclusion: Revealing how we learn to see is crucial for our understanding of the entire
visual processing possibly enabling us in the future with better treatment modalities
New trends in childhood vision impairment in a developed country
Susan Carden MBBS, FRANZCO, FRACS, PhD
Shivanand J Sheth MS, DOMS, FICO, FAICO
Chengde Pham MBBS, B.Med.Sci Jill Keeffe OAM, PhD
The Royal Victorian Eye and Ear Hospital, Melbourne, Australia
Introduction: The Educational Vision Assessment Clinic (EVAC) reviews school children aged 4 to 18 years with vision impairment, in the State of Victoria, Australia, to
determine their eligibility for educational support. The clinic is conducted at the Royal
Victorian Eye and Ear Hospital, Melbourne, and is staffed by a pediatric ophthalmologist,
an education officer and an educational psychologist.
Methods: A retrospective chart review was undertaken of all students (n=543) attending EVAC during the period from 2003 - 2012 (10 years). Demographic data analyzed
included: age, gender, visual acuity, diagnosis, and eligibility for educational support.
Results: 355 (65%) students were eligible for educational assistance (best corrected
visual acuity <20/60 in the better eye and/or a field of vision constricted to <20 degrees).
Of those, 106 had a VA <20/200 and/or field of vision < 10 degrees. The commonest
causes of visual impairment amongst the children eligible for educational assistance
were: retinal dystrophies (16%), optic nerve pathology (15%), ocular albinism (13%), congenital nystagmus (8%), cortical visual impairment (5%), retinopathy of prematurity (5%),
and congenital cataract-related low vision (4%).
Discussion: EVAC is instrumental in ensuring that students with low vision, from any
socioeconomic background, benefit from specialist services. It is likely that most students
with significant vision impairment, including those with multiple disabilities, in the State of
Victoria, attend this free clinic.
Conclusion: The treatable and potentially preventable causes of vision loss such as
retinopathy of prematurity and cataract now make up <10% of cases of significant vision
loss in school children in Victoria, Australia.
References: 1. Gilbert C, Muhit M. Twenty years of childhood blindness: what have we learnt? Community Eye Health. 2008 Sep;21(67):46-7 2.
Parikshit Gogate, Clare Gilbert, Andrea Zin. Severe Visual Impairment and Blindness in Infants: Causes and Opportunities for Control. Middle East
Afr. J Ophthalmol. 2011 Apr-Jun;18(2):109-114
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Atropine 0.01% for the treatment of Progressive Myopia Feasibility Study
Noha S Ekdawi MD
Wheaton Eye Clinic, Wheaton, Illinois
Introduction: Recent studies have shown atropine 0.01% reduces progression of
myopia after two years of treatment (1) with continued effect after discontinuation(2). This
study evaluates the feasibility of using atropine 0.01% in a private practice, documents
side-effects, and reports on myopic progression.
Methods: Patient charts treated by the author with atropine 0.01% for greater than one
year from February 2012 to present were retrospectively reviewed. These patients were
compared to a control set who were offered atropine, but deferred, and had two cycloplegic refractions.
Results: Seven patients were treated with atropine 0.01% and 5 in the control group.
Both groups had one female. One of the 7 atropine patients was Asian, 1 Hispanic
and 5 Caucasian. In the control group, 3 were Asian, 1 Hispanic and 1 Caucasian.
The average age at the beginning of treatment was 10 years versus 9 in the control
group(p=0.03). The treatment group had progressed by 1.20 diopters in the previous
year versus 1.79 diopters in the controls(p=0.10). Prior to treatment, the range of spherical equivalent myopia was -3.00 to -12.00 diopters in the atropine group and -1.00 to
-7.00 diopters in the controls. After an average of 20 months on atropine, the treatment
group progressed by 0.40 diopters versus 0.81 diopters after an average of 11.5 months
in the control group(p=0.005). Patients in the atropine group had mild difficulty reading
for less than 4 weeks; one had headaches.
Discussion: Most patients in this study tolerated the use of atropine 0.01% well without
side effects and instilled the drops for one year. The treatment group showed a significant decrease in myopic progression.
Conclusion: The use of atropine 0.01% is well tolerated and effective in a private practice with a variety of racial backgrounds.
References: 1. Chia A, Chua WH, Cheung YB, Wong WL, Lingham A, Fong A, Tan D. Atropine for the treatment of childhood myopia: safety and
efficacy of 0.5%, 0.1%, and 0.01% doses (Atropine for the Treatment of Myopia 2). Ophthalmology. 2012 Feb;119(2):347-54 2. Chia A, Chua
WH, Wen L, Fong A, Goon YY, Tan D. Atropine for the treatment of childhood myopia: changes after stopping atropine 0.01%, 0.1% and 0.5%.
American Journal of Ophthalmology. 2014 Feb;157(2):451-457
Electronic
Poster 116
Prescribing Eye Glasses in Preverbal Children: Simplified Rules and Preferred
Practice Patterns- AAPOS Members Survey Results
Suqin Guo MD Rudolph Wagner MD Patrick DeRispinis MD
The Institute of Ophthalmology and Visual Science, New Jersey Medical School,
Rutgers University
Newark, New Jersey
Introduction: Prescribing eyeglasses in preverbal children can be challenging for both
comprehensive ophthalmologists and pediatric ophthalmology specialists.
Methods: This study will demonstrate and discuss survey results from over 400 pediatric ophthalmologists in the United States. The Survey included 21 commonly encountered clinical situations.
Results: Each clinical situation will be analyzed and presented with percentage of
responses in bar figure fashion. We will also provide a case-based approach to analyze
the most commonly encountered clinical situations in prescribing glasses in preverbal
children.
Discussion: The results will provide: (1) better understanding of when and how to prescribe eyeglasses in commonly encountered clinical situations (2) learning the simplified
rules for prescribing eye glasses in preverbal children.
Conclusion: The survey reveals valuable data to explain how and why these decisions in prescribing eye glasses in preverbal children are made by experienced pediatric
ophthalmologists. The survey analysis reveals useful guidelines to help maximize vision,
promote fusion and prevent the development of amblyopia in preverbal children.
148
Parent Experiences and Perspectives on Medical Services for their Children with
Albinism: A qualitative study
Kelly E Lusk PhD, CLVT Anne L Corn EdD Terry L Schwartz MD
Cincinnati Children’s Hospital Medical Center/University of Cincinnati College of Medicine
Cincinnati, OH
Electronic
Poster 117
Introduction: For parents of children with visual impairments, including albinism, it is often
difficult to navigate the array of medical services. The purpose of this study was to investigate
experiences and perspectives of parents regarding their children’s medical care (specifically,
but not limited to, pediatric ophthalmologists and primary eye care physicians) via guided
focus groups.
Methods: Parents of children with albinism were recruited through participation at the National Organization of Albinism and Hypopigmentation Conference in July 2014. Focus groups
were conducted on four separate occasions during the conference.
Results: Thirty-seven parents from across the U.S. and Canada participated in focus groups.
Overall themes from the focus groups included knowledge level of albinism, coordination of
services/interdisciplinary approach to services, referral practices regarding pediatric low vision services and local school systems, and expectations for future visual and independent
functioning.
Discussion: Parents had both positive and negative experiences/perspectives regarding
medical services. Many parents were not aware of some medical services/resources that
other parents discussed. There are wide differences in parents’ statements about how medical
services are provided to children with albinism.
Conclusion: These data give insight into how families perceive experiences with medical
professionals, including pediatric ophthalmologists. This information can aid pediatric ophthalmologists and their staff, in understanding how and why parents may be satisfied or dissatisfied with the care their children receive. A quantitative study is currently underway on this
same topic to further investigate and provide additional guidance to pediatric ophthalmologists
and other medical professionals regarding the care of patients with albinism.
References: 1. Gold M. The effects of the physical features associated with albinism on the self-esteem of African-American youth with albinism.
J Vis Imp Blindness 2002;96:234-242. 2. Gorman J. Raising a Child with Albinism: A Guide to the School Years. East Hampstead (NJ): National
Organization for Albinism and Hypopigmentation; 2014. 3. Killebrew B, Corn AL. An initial study of ophthalmologist-parent communication during
first office visits. RE:view 2002;34:135-142.
‘It Does Matter’, Outcomes of Prescribing Glasses in Students
with Neuro-developmental Disabilities
Ivonne M Radinson Alvarado B.S. Nathan Schenkman B.A. Robert J House B.A.
Linda M Lawrence M.D. Rosa Yemi OyamaGaniko M.A. Liliana Mayo Ortega PhD
Centro Ann Sullivan del Peru-CASP
Calle Petronila Alvarez 180 Urb. Pando 5 Etapa San Miguel, Lima 32 - Peru
Introduction: The purpose of this study is to determine if students with neurodevelopmental
disorders and significant refractive errors, can demonstrate behavioral and communication
improvements by adapting to wearing glasses.
Methods: Sixty students with neurodevelopmental disorders at an educational center in Lima,
Peru were identified by a pediatric ophthalmologist as needing glasses to improve functional
vision, and prescribed accordingly. Ten months later the parents completed a survey regarding the use of glasses. Parents reported on the frequency of use, the activities and locations
when glasses were used and any changes in behavior when wearing the glasses.
Results: Fifty-one (85%) students were using the glasses 10 months after they were prescribed. Thirty-three (55%) used glasses at home, at school and in the street, with the
remaining students using glasses in on or two of these environments. Fourteen (23%) of the
students reportedly cleaned and cared for their own glasses. Forty-three (72%) of the parents
surveyed reported seeing positive behaviors ranging from increased help around the house to
more interest in books and improved general behavior and communication when glasses were
worn.
Discussion: Ten months after glasses prescription a vast majority of the students had obtained glasses and were using them.
Conclusion: Visual impairment in students with neurodevelopmental disorders is under
diagnosed. The results collected from the current study demonstrate that students with developmental disorders and vision problems can adapt to wearing glasses when given proper
diagnosis, intervention, and support leading to an increase in quality of life.
References: 1. Banda, D.R., Griffin-Shirley, N., Okungu, P.A., Ogot, O.P., Meeks, M.K. A review of intervention studies conducted with individuals
with autism and sensory impairments. Journal of Visual Impairment & Blindness. Jul/Aug2014; 108: 299-309 2. DeLeon, I.G., Hagopian, L.P., Rodriguez-Catter, V., Bowman, L. G., Long, E.S., Boelter, E.W. Increasing wearing of prescription glasses in individuals with mental retardation. Journal
of Applied Behavior Analysis. 2008; 41: 137-142 3. Gogate, P., Soneji, F.R., Kharat, K., Dulera, H., Deshpande, M., Gilbert, C., Ocular disorders in
children with learning disabilities in special education schools of Pune, India. Indian Journal of Ophthalmology. 2011; 59: 223-228
149
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Electronic
Poster 119
Functional Outcomes of Young Infants with and without Macular Edema
Adam L Rothman BS Du Tran-Viet BS Vincent Tai MS Neeru Sarin MBBS
Sandra Holgado MD, CO C. Michael Cotten MD, MHS Sharon F Freedman MD
Cynthia A Toth MD
Duke University School of Medicine
Durham, NC
Introduction: We relate posterior segment microanatomy from perinatal spectral-domain optical coherence tomography (SDOCT) to visual acuity (VA), brain abnormalities,
and neurodevelopment.
Methods: Twelve infants (10 preterm, 2 term birth), imaged in the nursery with portable
SDOCT, had VA and sensorimotor testing at age 9-15 months (grating acuity) or 4-5
years (optotype), and medical records reviewed for brain magnetic resonance imaging
(MRI) reports and Bayley Scales testing at age 18-24 months. Two children with retinal
detachments or dense vitreous hemorrhages and suboptimal acuity were excluded from
analysis.
Results: Five children with age-appropriate macular microanatomy without edema on
perinatal SDOCT had optimal (> 20/40) or within normal limits (grating acuity) VA. Five
children with perinatal macular edema and some with additional OCT anomalies had
suboptimal VA (in 9/10 eyes) and either sensorimotor deficits, MRI abnormalities or poor
neurodevelopment. Macular edema persisted in one infant through 9 months corrected
age.
Discussion: Maturation of the visual system and evolution of retinal anomalies can be
monitored with posterior segment SDOCT. Macular edema on perinatal SDOCT appears
as a potential indicator of retinal or visual pathway function and potentially of global problems in early brain development.
Conclusion: Retinal microanatomy might predict acuity and relate to other central nervous system events, but additional studies are needed to determine the range of normal
microanatomy in infants and how this relates to vision and neurodevelopment.
Electronic
Poster 120
Outcome of Optical Iridectomy in Peters anomaly
Sirinya Suwannaraj, Oriel Spierer, Kara M. Cavuoto, Ta Chang Peter Chang,
Craig McKeown
Bascom Palmer Eye Institute
Miami
Introduction: Peters anomaly is a rare congenital corneal opacity. It may result in
profound amblyopia if the opacity involves the visual axis. The purpose of this study is to
evaluate the outcomes of optical sector iridectomy in children with Peters anomaly.
Methods: The medical records of all patients diagnosed with Peters anomaly who
underwent optical iridectomy during the years 2002-2014 were reviewed. Data collection
included visual outcome and surgical complications.
Results: Twelve eyes (8 patients) were included in the study. Mean age at the time of
surgery was 17.0 ± 28.8 months (range 1.5-92). Mean follow-up time was 38.5 ± 29.9
months (range 4-94). A red reflex was obtained in all of the patients after surgery. Mean
visual acuity improved from 2.4 to 2.0 logMAR at last follow-up visit (p=0.04). No intraoperative or postoperative complications occurred. Mean intraocular pressure at last followup was 17.8 ± 3.2 mm Hg (range 12-24) with none of the patients requiring treatment for
ocular hypertension.
Discussion: The conventional treatment for potentially amblyogenic Peters anomaly
is early penetrating keratoplasty. However, corneal transplantation in young children is
associated with a high graft failure rate and other post-operative complications, including glaucoma. Optical sector iridectomy is an alternative in cases where there is a clear
peripheral corneal zone. Our study found that children who underwent optical iridectomy
had improvement in visual acuity and a low complication rate.
Conclusion: Optical sector iridectomy is a safe and effective alternative for penetrating
keratoplasty in certain patients with Peters anomaly.
References: 1. Sundaresh K, Jethani J, Vijayalakshmi P. Optical iridectomy in children with corneal opacities. J AAPOS. 2008 Apr;12(2):163-5
2.
Zaidman GW, Rabinowitz Y, Forstot SL. Optical iridectomy for corneal opacities in Peter’s anomaly. J Cataract Refract Surg. 1998 May;24(5):71922
3. Jünemann A, Gusek GC, Naumann GO. Optical sector iridectomy: an alternative to perforating keratoplasty in Peters’ anomaly. Klin Monbl
Augenheilkd.1996 Aug-Sep;209(2-3):117-24
150
Visual Acuity And Associations In Children With High Hypermetropia
Patrick Watts Mr Hugh Jewsbury Mr Marian Okeya Mrs William John Watkins Dr
Sailesh Kotecha Prof
Cardiff Eye Unit, Cardiff, UK
Electronic
Poster 121
Introduction: To report the visual results and the ocular and systemic associations of
children with high hypermetropia.
Methods: Children with hypermetropia > 5 dioptres were identified from a paediatric
ophthalmology database. The age, gender, visual acuity, refraction, presence of strabismus, duration of follow up and the systemic associations were recorded. Children with <
6 months follow up or where a crowded acuity could not be recorded were excluded.
Results: 103 children were included with 57 of them boys. The mean age at presentation and final follow up was 3.6 ±1.9 years and 6.3±1.8 years respectively with a mean
follow up of 33±21 months (range 6 -124 months). Mean hypermetropia was 7.07 ±1.5
dioptres. 50% of children had an esotropia. The mean presenting and final visual acuity
was 0.46± 0.28 LogMAR and 0.21±0.15 LogMAR respectively. There was a significant
association between the degree of hypermetropia and the final visual acuity (P<0.05).
There was no association between the age of presentation and the final visual acuity.
Residual amblyopia was present in 34%. 11 children had developmental delay or a syndromic condition.
Discussion: The prevalence of residual amblyopia in this study reinforces reports of
suboptimal visual outcomes in high hyperopes1,2 and refutes previous studies suggesting excellent visual outcomes in these patients3. Carers of high hyperopes can be better
informed at the outset of treatment regarding the possible visual outcomes and associations of high hypermetropia.
Conclusion: A third of children with high hypermetropia have residual amblyopia. A
significant number of children have strabismus.
References: 1. Klimek DL, Cruz OA. Isoametropic Amblyopia Due to High Hyperopia in Children J AAPOS. 2004 Aug;8(4):310-3. 2. Wallace DK,
Chandler DL. Treatment of bilateral refractive amblyopia in children three to less than 10 years of age Am J Ophthalmol. 2007 Oct;144(4):487-96.
Epub 2007 Aug 20. 3. Edelman PM, Borchert MS. Visual outcome in high hypermetropia
|J AAPOS. 1997 Sep;1(3):147-50
Refractive Errors and Amblyopia in the UCLA Preschool Vision Program;
First Year Results
Karen Hendler, MD1, Shiva Mehravaran, MD1, Fei Yu, PhD2, Anne L Coleman, MD1,3
Stein Eye Institute, UCLA
Los Angeles, CA
Introduction: Early diagnosis and treatment of refractive errors in children can greatly
improve their quality of life, their academic achievements, and can reduce the prevalence
of refractive amblyopia.
Methods: The University of California Los Angeles (UCLA) preschool vision program
(UPVP) screened low income children aged 3-5 years with the Retinomax autorefractor.
Children who failed screening were fully examined on the UCLA Mobile Eye Clinic. Amblyopia was defined as unilateral if there was a >/=2 line difference in the best corrected
visual acuity (BCVA), and bilateral if BCVA was <20/50 for children <4 years old, and
<20/40 for children >/=4 years old.
Results: Between August 2012 and May 2013, 11,260 children were screened by the
UPVP. Of those, 1007 failed and were examined by an ophthalmologist. Glasses were
prescribed for 73.5%. Uncorrected visual acuity was 0.4±0.2 (logMAR mean±SD), and
BCVA was 0.2±0.1. Of the 85% cyclopleged, 57.4% had hyperopia (spherical equivalent (SE)>/=+0.50D) with a mean of +2.50D, and 20.8% had myopia (SE</=-0.50D)
with a mean of -1.40D. A total of 71.3% had astigmatism >/=1.50D. Mean astigmatism
was 1.50D (range 0-5.75D). Most children (76%) were corrected to ≥20/30. Refractive
amblyopia was found in 9% of those examined, or 0.8% of the original population. Of the
amblyopes, 76% were unilateral.
Discussion: Screening by the UPVP led to diagnosis and early treatment of uncorrected
refractive errors. By treating children early, amblyopia can be prevented.
Conclusion: Vision screening has been recommended for children aged 3-5 years.
Preschool vision screening should become an important part of child care and preventive
health.
151
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Electronic
Poster 123
Brückner test, a novel technique for the rapid detection of refractive errors
in children by the paediatricians
Piyush Jain Vaibhav Gode Mihir Kothari
Jyotirmay Eye Clinic, Thane, India
Introduction: Purpose: To present the efficiency of Brückner test in detection of ametropia
when used by a pediatrician.
Methods: In this prospective double masked cohort study, a paediatrician performed the
Brückner test in class room of a school in dark lighting condition using a direct ophthalmoscope followed by the same test being performed by a masked ophthalmologist. Findings of
the test were noted as emmetropia, hyperopia or myopia. For the purpose of the analysis, the
data of hyperopia and myopia was clubbed into a single category - ametropia. The sensitivity,
specificity, predictive value and clinical agreement were calculated from 2x2 Bayesian table.
The findings of the paediatric ophthalmologists were considered gold standard. The technique
of Brückner test used in this study has been already validated against the cycloplegic refraction and vision assessment and published previously.1
Results: 236 eyes of 118 subjects were examined.. The time taken to complete this test was
< 10 seconds per subject. Ophthalmologist identified 59 eyes as ametropic (12 hyperopic and
47 myopic eyes) and 177 as emmetropic compared to 61 eyes as ametropic and 175 emmetropic by paediatrician. At prevalence of 25.9%, the sensitivity of the Brückner test by paediatrician was 90.2%, specificity was 97.7%,predictive value of the positive test was 93.2%
and predictive value of the negative test was 96.6%. Clinical agreement (kappa) between the
ophthalmologist and the paediatrician was 0.9.
Discussion:
Conclusion: Brückner test is an excellent tool for the detection of significant refractive errors
in the hands of paediatrician to rapidly screen the children for ametropia.
References: 1. Kothari M, Turakhia J, Vijayalakshmi P. Can Brü ckner test be used as a Rapid Screening Test for the detection of amblyogenic
factors in developing countries? Am Orthop J 2003;23:112-6. 2. Simons K. Preschool vision screening: Rationale, methodology and outcome.
Surv Ophthalmol 1996;41:3-30. 3. Brückner R. Exakte strabismus diagnostik bei1/2-3 jhrigen klindern miteinem einfachem verfahren, dem “Durchieeuch tungtest”. Ophthalmologica 1962;144:184-98. 4. Paysse EA, Williams GC, Coats DK, Williams EA. Detection of red reflex asymmetry by
pediatric residents using Brückner reflex versus the MTI Photoscreener. Pediatric.2001;108:1-7. [PubMed] 5. Seema S, Vashisht B, Meenakshi K
and Manish G (2009) Magnitude of refractive errors among school children in a rural block of Haryana. The Internet J. Epidemiol. 2(6), 21-24. 6.
N. Prema Prevalence of refractive error in school children Indian Journal of Science and Technology Vol. 4 No. 9 (Sep 2011) 7. Roe LD, Guyton
DL. The light that leaks: Brü ckner and the red reflex. Surv Ophthalmol 1984;28:665-70. 8. Watts P, Walker K, Beck L. Photoscreening for refractive errors in children and young adults with severe learning disabilities using the MTI photo-screener. Eye 1999;13:363-8.
Electronic
Poster 124
High Specificity of the Pediatric Vision Scanner
in a Private Pediatric Primary Care Setting
Reed M Jost MS David Stager, Jr MD Lori Dao MD Scott Katz MD Russ McDonald MD
Eileen E Birch PhD
Retina Foundation of the Southwest, Dallas, TX
Introduction: The Pediatric Vision Scanner (PVS) directly detects strabismus and amblyopia by
analyzing binocular scans for birefringence that, due to the organization of the radially arranged
Henle fibers, is characteristic of steady, bifoveal fixation. In a pediatric ophthalmology office setting,1 we found that the PVS had 97% sensitivity and 87% specificity for detection of strabismus
and amblyopia. However, this study did not directly assess performance of the PVS in a primary
care screening setting, where it is designed to be used. Here we report PVS specificity and positive
likelihood ratio for a cohort of children screened in a pediatric primary care setting.
Methods: 95 children (2-6y) were screened with the PVS and SureSight™ Autorefractor in a
pediatric primary care setting. Each test yielded a recommendation of ‘pass’ or ‘refer.’ All children
received a gold-standard comprehensive ophthalmic exam by a pediatric ophthalmologist who was
masked to the screening results.
Results: Screening success rates were 93% for PVS and 92% for SureSight™. At the goldstandard exam, one child was identified as having anisometropic amblyopia; 94 had normal
exams. Both the PVS and SureSight™ referred the amblyopic child. The PVS passed 78 of 88
children with no strabismus or amblyopia (90% specificity; 95%CI: 82-98%). In comparison, the
SureSight™ passed 73 of 87 children with no strabismus or amblyopia (85% specificity; 95%CI:
75-95%). Positive likelihood ratios were 9.7 (95%CI: 4.4-21.3) for PVS and 6.6 (95%CI: 3.5-12.5)
for SureSight™.
Discussion: In this ongoing study of the PVS in a pediatric primary care setting, results were
comparable to the 87% specificity reported previously for an large cohort (n=300) tested in an ophthalmology practice with high prevalence of strabismus and amblyopia.1 In a pediatric primary care
setting, the PVS had higher specificity and positive likelihood ratio compared to the SureSight™,
resulting in fewer over-referrals of children with no strabismus or amblyopia.
Conclusion: Preschool vision screening appears to be more efficient with a device that directly
detects strabismus and/or amblyopia.
References: 1. Jost RM; Yanni SE; Beauchamp CL; Stager DR; Stager DR; Dao L; Birch EE. ‘Beyond Screening for Risk Factors: Objective
Detection of Strabismus and Amblyopia.’ JAMA Ophthalmol. 132.7 (2014): 814-20.
152
BVAT Ordering of Letters: more than visual acuity?
Jill C Rotruck Susan Day
California Pacific Medical Center
2340 Clay Street San Francisco, CA 94115
Electronic
Poster 125
Introduction: The Baylor Visual Acuity Tester (BVAT) is a common computer software
program that presents randomized sequences of optotypes for visual acuity testing.
Based on anecdotal concerns of multiple pediatric ophthalmologists, the purpose of this
study was to evaluate if the sequence ‘F followed by U’ occurs more frequently than
would be expected by chance.
Methods: A single individual (JR) blinded to the purpose of the study obtained 6,750
serial samples of two-letter sequences from a single computer with BVAT software. The
number of occurrences of each two-letter sequence were then totaled and analyzed.
Results: The mean number of occurrences of each two-letter sequence was 18.2 with
a SD of 5.5. The occurrence of the sequence ‘F followed by U’ was 18, which was not
significantly different from the mean number of occurrences for all two-letter sequences.
Two-letter sequences of repeat letters (i.e. AA, BB, etc.) were found to occur at significantly lower frequencies than average (Mean 4.2 with SD of 3.2 with P-value <0.001).
Discussion: The number of occurrences of two-letter sequences randomly generated
by BVAT software follows a normal distribution. Despite impressions of multiple pediatric ophthalmologists, the sequence ‘F followed by U’ was not found to occur more than
would be expected by programming of other sequences. Significantly lower rates of
repeat letter sequences suggest that it is possible to alter the BVAT algorithm to decrease
the number of occurrences of unwanted sequences.
Conclusion: While the sequence ‘F followed by U’ does not occur at a greater rate than
chance, the BVAT algorithm could be altered to decrease its occurrence, thereby avoiding
awkward moments during pediatric exams.
Do we need to directly detect astigmatism when photoscreening for Amblyopia
Risk Factors (ARFs)?
David I Silbert MD Robert Arnold
Family Eye Group
Lancaster, Pennsylvania USA
Introduction: The cost of smart phone platforms makes them highly desirable for use
as vision-screening devices. Traditional vision screening uses two off-axis flashes in
sequential photographs. We hypothesize that the vast majority of astigmatic eyes could
be appropriately detected with a single flash and only one photograph simplifying image
acquisition.
Methods: 174 patients at 2 sites were enrolled prospectively. Children aged 12-72
months of age were consented and tested. The GoCheck Kids (Gobiquity Mobile Health,
Inc) smartphone photorefraction measurements were compared to cycloplegic (gold standard) refraction using AAPOS ARF guidelines. Two photos were taken on each patient at
90 and 180 degrees. Analyses were performed for single-axis and double-axis photorefraction and compared.
Results: 55/348 eyes of 30 patients identified with a cycloplegic astigmatism component
above AAPOS ARF guidelines. 14/30 patients referred for cylinder only with the remaining
16 with refractive anomalies. Overall Single-axis sensitivity/specificity for AAPOS ARFs
were 59%/83% respectively, while dual axis was 74%/82% respectively.
Discussion: A single flash photoscreening system is effective for the detection of hypermetropia, myopia, and anisometropia. Although it will not directly detect astigmatism,
astigmatism is indirectly detected and referred due to its association to other refractive
anomalies. Elimination of need for a second photograph simplifies the use of a smartphone to detect ARFs.
Conclusion: A single flash photoscreening system such as the Gobiquity mobile photoscreening device can be substituted for traditional two flash systems without sacrificing
much sensitivity and specificity in astigmatism detection.
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Electronic
Poster 127
Efficacy of a vision-screening tool for birth to 3 early intervention programs.
Roger Struble Jr. Ryan R House Linda M Lawrence MD Joyce E Trower PT
University Of Kansas School of Medicine
Kansas City, Kansas, ASA
Introduction: This study aims to validate a screening tool to detect unsuspected ocular
pathology in developmentally disabled children under age 3. There is a lack of a nationwide standardized vision-screening tool for children in birth to 3 in early intervention
programs(1), and this inherently difficult-to-screen population is known to have a high risk
for ocular pathology(2).
Methods: 300 consecutive charts were reviewed from the health records at a birth to 3
early intervention program. Inclusion criteria were documented Kansas Department of
Health and Environment vision screening exams performed by trained early interventionist, and full ophthalmologic evaluations. The patients were considered a passed exam if
it was recorded on the chart and did not have any of the 23 risk factors listed by KDHE
automatic referral guidelines(3). The ocular pathology status was determined after comprehensive ophthalmic examination, with the ophthalmologist blinded to the vision screen
results. 216 met inclusion criteria.
Results: The vision screen referred 85 of 216 children. The sensitivity, specificity,
positive predictive value, negative predictive value, and negative likelihood ratio were
respectively: 95.3% (90.8, 99.8), 57.25%, 59.1%, 94.9%, and 0.082. A Yates-Corrected
Chi-Square test for goodness of fit gave an approximate p value of <0.001.
Discussion: Information bias present with 65 incomplete charts and 19 children did not
show for ophthalmologic exam.
Conclusion: This inexpensive screening tool is effective as a standardized vision
screen in early intervention programs for developmentally disabled children under age 3.
References: 1. American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern® Guidelines.
Amblyopia. San Francisco, CA: American Academy of Ophthalmology; 2012. Available at: www.aao.org/ppp. 2. Ikeda J, Bradley VD, Ultmann M,
et al. Brief report: incidence of ophthalmologic disorders in children with autism. J Autism Dev Disord 2013;43:1447-51.
3. Kansas Department
of Health and Environment. Bureau for Children, Youth, and Families. Vision Screening Guidelines: For Infants, Toddlers, Children and Youth. June
2004, Fifth Edition.
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Poster 128
Oregon Elks Children’s Eye Clinic Vision Screening Results
Joannah M Vaughan Talitha Dale Daniel Karr MD
Elks Children’s Eye Clinic at the Casey Eye Institute
Portland, Oregon
Introduction: The Oregon Elks Preschool Vision Screening program screens Head
Start children ages 3 to 5-years old to identify children at risk for amblyopia and referral
warranted refractive error. The main goal of this study is to determine the accuracy of the
plusoptiX referrals during 2013.
Methods: In Oregon, 4077 vision screenings were completed by Head Start teachers
and Elks Children’s Eye Clinic vision screening staff. Children were screened using a
plusoptiX S12 with option 5 settings. IRB consent was obtained to follow up on referrals
and to review exam chart notes.
Results: Dilated eye exams were recommended for 1067 (26%) who were referred by
the screening. A chart note review of 618 exams indicates that 54% of those referred
received treatment, usually glasses. The primary treatment was glasses for 327 referrals.
Of those treated with glasses, 225 received glasses after a dilated exam, 72 received
glasses without the benefit of dilation, and 30 received glasses and it was unclear if they
were dilated. Amblyopia was diagnosed by eye exam in 51 cases. The most common
diagnosis was refractive error.
Discussion: The program goal is to achieve high quality referrals. Astigmatism was the
most common reason for over referrals. 42.4% of the plusoptiX astigmatism referrals did
not require treatment.
Conclusion: The plusoptiX S12 settings should be modified to minimize over referrals.
In order to improve the quality of the referrals, the plusoptiX settings for astigmatism will
be changed from 1.50D to 2.50D.
154
Notes
155
Notes
156
Workshop Schedule
Thursday, March 26, 2015
2:45 PM - 4:00 PM
Workshop #1
OMIC Workshop - The Risks and Benefits of Malpractice Litigation
Paul Weber, JD; Denise R. Chamblee, MD;
Elyssa P. Rosenthal, MD; James R. Broening, JD
Celestin Ballroom
Friday, March 27, 2015
7:00 AM - 8:15 AM
Workshop Session A
Workshop #2
Telemedicine for the Detection of Serious Acute Phase ROP: Time for a
Paradigm Shift?
Graham E. Quinn, MD, MSCE; P. Lloyd Hildebrand, MD;
Karen A. Karp, BSN; Ebenezer Daniel, MBBS, MS, MPH, PhD;
Kelly Wade, MD, PhD; Alex R. Kemper, MD, MPH, MS;
Daniel T. Weaver, MD
Celestin F-H
Workshop #3
AOC/AACO Workshop: Sensory Evaluation and Surgical Success. Is the
Worth 4-Dot Test Really Worth-Less?
Lisa Rovick, CO; Natalie Kerr, MD; Anna Schweigert, CO;
Raymond Areaux, MD; Jorie Jackson, CO; Aaron Miller, MD;
Cindy Pritchard, CO; George Ellis, MD; Erika Acera, CO;
David Granet, MD; David Silbert, MD
Celestin D
Workshop #4
The Tools of Data Analysis: Matching the Hammer to the Nail
Kristina Tarczy-Hornoch; Gil Binenbaum; Mays A. El-Dairi;
Joost Felius; Jing Jin; Iris S. Kassem; Sudha Nallasamy;
Stacy L. Pineles; Jingyun Wang
Celestin A-C
Workshop #5
Oops What Happened? Presentation and Discussion of Cases in Pediatric
Ophthalmology and Strabismus When the Unexpected Happened. What
Happened and Why? How Can I Treat It? Prevent It? What I Learned From It?
Tamara Wygnanski-Jaffe, MD; Alex V. Levin, MD;
Sharon F. Freedman, MD; Joseph L. Demer, MD;
Itay Ben-Zion, MD; Gregg T. Lueder, MD
Celestin E
8:30 AM - 9:45 AM
Workshop Session B
Workshop #6
What Pediatric Ophthalmologists Need to Know about Clinical Quality
Measurement, Registries, PQRS, and Measure Development
Michael F. Chiang; Michael X. Repka; Christie Morse;
Robert Wiggins; Kristina Tarczy-Hornoch
Celestin A-C
Workshop #7
Dyslexia: What Pediatric Ophthalmologists and Families Need to Know
Sheryl M. Handler, MD; Walter M. Fierson, MD;
A. Melinda Rainey, MD; William O. Young, MD
Celestin D
Workshop #8
The Impact of Brain Tumors on Vision and Ocular Motility
Gena Heidary, MD, PhD; Robert Avery, DO; Stacy Pineles, MD;
Jane Edmond, MD
Celestin F-H
Workshop #9
Secrets to Solve Pediatric Ophthlamology Case Mysteries
Aparna Ramasubramanian; Carol L. Shields; Alex V. Levin;
Bruce Schnall; Jerry A. Shields
Celestin E
157
10:30 AM - 11:45 AM
Workshop Session C
Workshop #10
Neuro-Ophthalmic Manifestations of Systemic Disease, Part 2
Jane C. Edmond, MD; R. Michael Siatkowski, MD
Celestin E
Workshop #11
Kids are NOT a Line of Vision: Pediatric Low Vision
Linda M. Lawrence, MD; Melinda Rainey, MD;
Amanda Lueck, PhD; Kelly Lusk, PhD; William Daugherty
Celestin A-C
Workshop #12
Apt Lecture Workshop: Science, Pseudoscience, and the Law in AHT
Celestin F-H
Alex V. Levin, MD, MHSc, FRCSC; Brian J. Forbes; Gil Binenbaum;
Steve E. Rubin
Workshop #13
Pediatric Ocular Tumors and Pseudotumors. Quick Cases and Clinical Pearls
Jerry A. Shields, MD; Carol L. Shields, MD
Celestin D
Workshop #14
Symposium: Phenotype-Genotype Correlations in Pediatric Cataract,
Including Conditions You Don’t Want to Miss
Arif O. Khan, MD; Elias I. Traboulsi, MD
Celestin E
Workshop #15
Symposium: Meaningful Use of Physician Extenders in the Pediatric Ophthlamology Practice
Jorie Jackson; Kyle Arnoldi; Karl Henson; Traci Fritz;
Aaron M. Miller; Richard S. Freeman; Laurie Hahn-Parrott
Celestin D
1:15 PM - 2:30 PM
Workshop Session D
Workshop #16
RPE65 Related Inherited Retinal Degeneration Gene Therapy Trials:
Background and Current Status, Need for Genetic Testing, and Future Gene
Therapies for Other Retinal Dystrophies
Daniel C. Chung, DO, MA; Arlene V. Drack, MD
Celestin A-C
Workshop #17
Does This Child Have Glaucoma or Something Else? Applying Newer
Technologies to the Diagnosis and Management of Pediatric Glaucoma
Sharon F. Freedman, MD; Allen D. Beck, MD; Alex V. Levin, MD
Celestin F-H
Workshop #18
Adult Strabismus Workshop
David B. Granet, MD; David L. Guyton, MD;
Edward G. Buckley, MD; Steven M. Archer, MD;
David Stager, Sr., MD; Forrest J. Ellis, MD; Lionel Kowal, MD;
David Hunter, MD
Celestin E
Workshop #19
Global Challenges in the Management of Childhood Cataracts
Phoebe D. Lenhart; Ana Paula Rodrigues; M. Edward Wilson;
Ramesh Kekunnaya; Arif Khan; Lee Woodward; Scott R. Lambert
Celestin D
2:45 PM - 4:00 PM
Workshop Session E
Workshop #20
Just Do It...Better: Tips for Efficiency in Clinical Practice
Rebecca Leenheer, MD; Kara Cavuoto, MD; Janine Collinge, MD;
S. Grace Prakalapakorn, MD; Theodore Curtis, MD;
Michael Chiang, MD; Daivd Silbert, MD; Kenneth Wright, MD
Celestin F-H
Workshop #21
Low Vision Rehabilitation Update: New and Innovative 2015
Terry L. Schwartz, MD; Kelly Lusk, PhD, CLVT;
Rebecca Coakley, MA, CLVT
Celestin A-C
Workshop #22
AAP/AAPOS Difficult Conversations in Pediatric Ophthalmology and
Strabismus
R. Michael Siatkowski, MD; Sharon F. Freedman, MD;
David B. Granet, MD; George S. Ellis, MD;
Cindy Pritchard, CO, COT; Robert E. Wiggins, Jr, MD;
Christie L. Morse, MD
Celestin D
Workshop #23
What’s New and Important in Pediatric Ophthalmology and Strabismus 2015
Jitka L. Zobal-Ratner, MD; Nisha Krishan-Dave, MD;
William W. Motley, MD; Jason H. Peragallo, MD;
Rebecca S. Braverman, MD; Hilda Capo, MD;
Leemor Rotberg, MD; Tina Rutar, MD; Melanie Schmitt, MD
Celestin E
12:00 PM - 1:00 PM
158
4:30 PM - 6:00 PM
Workshop #24
Symposium: Taking Care of Our Patients in a Changing Healthcare System; A
Call to Include Social Media and Patient Advocacy Activities in Our
Professional Life
Jean E. Ramsey, MD, MPH; Ken Cheng, MD; Brad Black, MD;
Luxme Hariharan, MD, MPH; Stacey J. Kruger, MD;
Daniel Briceland, MD; Pamela E. Williams, MD; Patrick Hynes
Celestin E
7:00 AM - 8:15 AM
Workshop #25
Symposium: Use of Digital Photoscreeners to Detect Amblyopia Risk Factors
(ARFs), A Multidisciplinary Evidence Based Approach; Care and Cost
Implications
David I. Silbert, MD; Sean P. Donahue, MD, PhD;
Alan Greene, MD; Deborah Alcorn, MD; Robert Arnold, MD
Celestin Ballroom
2:00 PM - 3:15 PM
Workshop #26
Fiscal Benchmarking Workshop - Data from CY 2013, AAPOS Socioeconomic
Committee
Deborah S. Lenahan, MD; Nils Mungan, MD;
Eric Lichtenstein, MD; Robert Wiggins, MD; John Bishop, MD;
Mike Bartiss, MD, OD
Celestin Ballroom
3:30 PM - 5:30 PM
Workshop #27
The Ups, Downs, Ins and Out of Strabismus and Pediatric Ophthalmology
Coding
Sue Vicchrilli, COT, OCS
Celestin Ballroom
Saturday, March 28, 2015
Sunday, March 29, 2015
7:30 AM - 8:30 AM
Workshop #28
Video Demonstrations of Signs, Diseases, and Complex Surgical Procedures in
Pediatric Ophthalmology and Strabismus
Federico G. Velez, MD; Evelyn A. Paysse, MD;
Jonathan M. Holmes, MD; Michael X. Repka, MD;
Bibiana Jin Reiser, MD; Ramesh Kekunnaya, MD
Celestin Ballroom
9:00 AM - 10:00 AM
Workshop #29
Difficult Non-Strabismus Problems In Pediatric Ophthalmology
Elias I. Traboulsi, MD, MEd; Arlene V. Drack, MD;
F. James Ellis, MD; Mohamad S. Jaafar, MD; Virginia Utz, MD
Deborah VanderVeen, MD
Celestin Ballroom
10:10 AM - 11:10 AM
Workshop #30
Difficult Problems Strabismus Workshop
Sean P. Donahue, MD, PhD; Edward G. Buckley, MD;
Stacy Pineles, MD; Oscar Cruz, MD; Linda Dagi, MD;
Marc Greenberg, MD
Celestin Ballroom
159
Notes
160
The Risks and Benefits of Malpractice Litigation
Paul Weber JD Denise R Chamblee MD Elyssa P Rosenthal MD
James R Broening JD
Workshop 1
Thursday
2:45 - 4:00 pm
Purpose/Relevance: No matter how careful and skilful, an ophthalmologist is at risk
of being sued for medical malpractice. In order to successfully defend the lawsuit, ophthalmologists need to understand the legal process and the emotional challenges they
will face. They also need to understand good risk management practices (documentation, informed consent) that will help them prevail in litigation.
Target Audience: Ophthalmologists who specialize in pediatric ophthalmology and
treat strabismus
Current Practice: Ophthalmologists often experience shock and anger when sued
for malpractice. While these emotions are natural they tend to be counterproductive in
understanding the legal process and preparing an effective defense.
Best Practice: This review of an actual lawsuit against an ophthalmologist that went
to jury trial will describe specific steps to channel the strong emotions that arise in
litigation into effectively working with the defense team to defend the lawsuit.
Expected Outcomes: When faced with a malpractice claim, ophthalmologists will
be able to identify positive steps they can take to successfully weather this stressful
event.
Format: Didactic and panel discussion
Summary: This workshop will explore the personal, professional and legal issues
that arise in malpractice litigation. Specifically, the faculty will discuss the importance
of positive collaboration between the ophthalmologist, the defense attorney and the
insurance company, and how this essential teamwork helps minimize the stress of
litigation and increase the potential for a favorable outcome.
References: Weber, P. The Risks and Benefits of Malpractice Litigation http://www.omic.com/the-risks-and-benefits-of-malpractice-litigation/
Cibis, G. How To Survive a Malpractice Lawsuit and Emerge Stronger http://www.omic.com/how-to-survive-a-malpractice-lawsuit-and-emergestronger/
Telemedicine for the detection of serious acute phase ROP:
time for a paradigm shift?
Graham E Quinn MD, MSCE, P Lloyd Hildebrand MD, Karen A Karp BSN,
Ebenezer Daniel MBBS, MS, MPH, PhD,
Kelly Wade MD, PhD, Alex R Kemper MD, MPH, MS, Daniel T. Weaver, MD
Purpose/Relevance: To describe a telemedicine system for the detection of serious
acute-phase ROP (e-ROP) and the implications of the study results.
Target Audience: Ophthalmologists providing ROP detection and/or treatment
Current Practice: The present strategy to identify infants needing treatment for retinopathy of prematurity (ROP) relies on repeated eye examinations of at-risk infants,
few of whom require treatment.
Best Practice: The best practice is to identify all premature infants at risk for serious
ROP using non-physician personnel and targeting only those infants for examination
by an ophthalmologist.
Expected Outcomes: Retinal imaging by non-physicians with remote image interpretation by non-physicians may provide a more effective, accessible and efficient strategy than that currently in place.
Format: Presentations, panel discussion with audience questions
Summary: There is an urgent need to develop programs for detection of serious ROP
that efficiently and effectively identify at-risk infants worldwide and that reduce the
reliance on serial examinations by ophthalmologists. The results of the e-ROP study
provide important information about the value of an ROP telemedicine system. Using
a systematic approach with trained imagers and graders with quality management can
decrease the burden of examinations on infants with sufficient identification of those
infants that require more intensive eye care.
References: 1. Quinn GE on behalf of the e-ROP Cooperative Group. Telemedicine Approaches to Evaluating Acute-phase Retinopathy of
Prematurity: Study Design. Ophthalmic Epidemiology 2014; 21(4): 256-267. 2. Quinn GE, Ying GS, Daniel E, Hildebrand PH, Ells A, Baumritter A, Kemper AR, Schron E, Wade K, for the e-ROP Cooperative Group. Validity of a Telemedicine System for the Evaluation of Acute-Phase
Retinopathy of Prematurity. JAMA Ophthalmol. Published online June 26, 2014. 3. Chiang M, Melia M, Buffenn AN, Lambert SR, Recchia FM,
Simpson JL, Yang MB. Detection of Clinically Significant Retinopathy of Prematurity
Using Wide-angle Digital Retinal Photography.Ophthalmology 2012;119:1272-1280.
161
Workshop 2
Friday
7:00 - 8:15 am
Workshop 3
Friday
7:00 - 8:15 am
AOC/AACO Workshop: Sensory Evaluation and Surgical Success.
Is the Worth 4-dot Test Really Worth-Less?
Lisa Rovick CO Natalie Kerr MD Anna Schweigert CO Raymond Areaux MD
Jorie Jackson CO Aaron Miller MD Cindy Pritchard CO George Ellis MD
Erika Acera CO David Granet MD David Silbert MD
Purpose/Relevance: Sensory evaluation is an essential element in the preoperative
evaluation of strabismic patients. The accurate selection, administration, and interpretation of sensory tests is crucial for optimizing the surgical plan. This workshop
will illustrate how to effectively utilize preoperative sensory testing to improve surgical
outcomes, including Lancaster red-green, synoptophore, Worth 4-Dot, stereo, and
fusional/accommodative amplitudes.. Alternative means of testing will be presented
for situations when the desired instrument or test is not available.
Target Audience: Pediatric Ophthalmologists, Orthoptists, Researchers
Current Practice: Surgeons do not always develop a surgical plan based on the
knowledge of a patient’s sensory status.
Best Practice: Practitioners will recognize the best sensory test for each clinical situation, and will administer and interpret the results correctly to help patients develop
the best post- surgical alignment and binocularity.
Expected Outcomes: Preoperative sensory testing allows the orthoptist and ophthalmologist to develop an appropriate surgical plan which optimizes patient binocularity
and increases post-operative patient satisfaction.
Format: Case-based illustrations with MD/CO co-presenters
Summary: The best surgical plans incorporate accurate and effective preoperative sensory testing. This workshop will illustrate how and when these tests are best
employed.
References: Etezad Razavi M1, Najaran M, Moravvej R, Ansari Astaneh MR, Azimi A. Correlation between Worth Four Dot Test Results and
Fusional Control in Intermittent Exotropia. J Ophthalmic Vis Res. 2012 Apr ;7(2):134-8. Singh A, Sharma P, Singh D, Saxena R, Sharma A,
Menon V. Evaluation of FD2 (Frisby Davis distance) stereotest in surgical management of intermittent exotropia. Br J Ophthalmol. 2013 Oct;
97(10):1318-21. Epub 2013 Jul 31.
Workshop 4
Friday
7:00 - 8:15 am
The tools of data analysis: matching the hammer to the nail
Kristina Tarczy-Hornoch Gil Binenbaum Mays A El-Dairi Joost Felius Jing Jin
Iris S Kassem Sudha Nallasamy Stacy L Pineles Jingyun Wang
Purpose/Relevance: In this workshop, a panel of research committee members will
present a friendly overview of the tools of data analysis, with the aim of helping the
audience become more comfortable with approaching analysis of their own data, or
understanding the data analysis in papers they read.
Target Audience: Pediatric ophthalmologists who are not normally enamored of
statistics.
Current Practice: Clinicians do not always feel comfortable with statistical concepts
and statistical jargon; yet reading or contributing to the evidence that forms the basis
for our clinical practice requires a basic understanding of statistical analysis.
Best Practice: Clinicians should feel at ease, not mystified, when reading the clinical
research literature, and should be empowered to attempt straightforward data analysis
of their own.
Expected Outcomes: At the conclusion of this workshop, attendees will not be statisticians; they will be able to suggest appropriate statistical tools for different types of
data analysis, and have a basic understanding of common analysis tools used in the
clinical research literature.
Format: Panel presentation, with didactic lectures and question/answer period.
Summary: Components covered in this workshop include: a practical approach to
basic statistics with a focus on the analysis tools commonly used in clinical trials and
other clinical research; what tools are appropriate for what types of data; comparison
of mean values; comparison of proportions; correlations; multivariate analysis; repeatability; sensitivity, specificity, and predictive values; power vector analysis of refractive
error; numerical examples to promote empirical understanding (minimizing mathematical theory); common analysis pitfalls to avoid; a glossary of common and important
statistical terms and concepts.
References: Walsh M, Srinathan SK, McAuley DF, Mrkobrada M, Levine O, Ribic C, Molnar AO, Dattani ND, Burke A, Guyatt G, Thabane L,
Walter SD, Pogue J, Devereaux PJ. The statistical significance of randomized controlled trial results is frequently fragile: a case for a Fragility
Index. J Clin Epidemiol. 2014 Jun;67(6):622-8.
162
Oops What Happened? Presentation and Discussion of Cases in Pediatric
Ophthalmology and Strabismus When the Unexpected Happened. What
Happened and Why? How Can I Treat It? Prevent It? What I Learned From It?
Workshop 5
Friday
7:00 - 8:15 am
Tamara Wygnanski-Jaffe MD Alex V Levin MD Sharon F Freedman MD
Joseph L Demer MD Itay Ben-Zion MD Gregg T Lueder MD
Purpose/Relevance: The workshop is designed to share mistakes, unpredicted findings and outcomes with a discussion on preventive measures and management.
Target Audience: Pediatric ophthalmologists, general ophthalmologists, and trainees.
Current Practice: It’s much more difficult to present and discuss mistakes in history
taking, diagnosis, imaging, surgical techniques, and unexpected surgical findings and
complications than it is to present treatment successes. Sharing others experiences
can teach us to expect, be aware, avoid and plan for the unexpected, if/when it should
occur.
Best Practice: This workshop allows participants to observe cases with unexpected
outcomes with an explanation and discussion by the presenting clinician and discussion with the panel and the audience.
Expected Outcomes: At the conclusion of the workshop the audience and the panel
will have shared their experience with unexpected findings in common and rare clinical scenarios. It encourages the participants to expect the unexpected, seek and plan
for it appropriately.
Format: Members of the panel will present clinical and surgical cases in which they
experienced an unusual finding due to a clinical anomaly or a clinical, imaging, or
surgical mistake.
Summary: Clinical and surgical cases with appropriate audio and visual material will
be presented for discussion. These presentations will attempt to give the participants
something to think about and take back to their respective practices.
What Pediatric Ophthalmologists Need to Know about Clinical Quality Measurement, Registries, PQRS, and Measure Development
Michael F Chiang Michael X Repka Christie Morse Robert Wiggins
Kristina Tarczy-Hornoch
Purpose/Relevance: We are rapidly moving from a reimbursement system that pays
for volume (fee-for-service) to one that pays for value. This means that physicians are
increasingly rated according to the costs and quality of their care. The Physician Quality
Reporting System (PQRS) is expanding with the move to value-based purchasing. Meanwhile, large-scale registries (such as the AAO IRIS Registry) are providing unprecedented
opportunities for access to clinical data that may be used for quality measurement. These
trends are critical for pediatric ophthalmologists to understand. The purpose of this workshop is to discuss these topics, including ongoing work by AAO and AAPOS on developing
quality measures for pediatric ophthalmology and strabismus.
Target Audience: Pediatric ophthalmologists, administrators, researchers
Current Practice: There are currently no PQRS quality measures directly related to pediatric ophthalmology. Lack of good quality measures may have negative financial implications for pediatric ophthalmologists under value-based payment models.
Best Practice: AAPOS and AAO are working to develop quality measures relevant to
pediatric ophthalmology practice.
Expected Outcomes: Participants will understand the implications of these issues for
quality improvement, how clinical documentation must be performed to support these
outcome measures, and how this will affect reimbursement under value-based payment
models.
Format: 1) Panel presentations (45 minutes) 2) Open question and answer forum (30
minutes)
Summary: This workshop will discuss: 1) Big data and registries for quality improvement.
2) Value-based purchasing and financial implications of PQRS and Meaningful Use for
pediatric ophthalmologists. 3) Past and future work by AAO and AAPOS in these areas.
References: 1) AAO IRIS Registry website. Available at: http://www.aao.org/iris-registry/index.cfm. 2) Physician Quality Reporting System
website. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/.
3) Mistry KB, et al. Advancing children’s health care and outcomes through the pediatric quality measures program. Acad Pediatr 2014;
14(5S):S19-S26.
163
Workshop 6
Friday
8:30 - 9:45 am
Workshop 7
Friday
8:30 - 9:45 am
Dyslexia: What Pediatric Ophthalmologists and Families Need to Know
Sheryl M Handler M.D. Walter M Fierson M.D. A. Melinda Rainey M.D.
William O Young M.D.
Purpose/Relevance: Initial difficulty in learning to read occurs in nearly 40% of students in the
U.S. A number of different factors can cause difficulties in early reading including a true reading
disability called dyslexia. Dyslexia is the most common learning disability, representing 80%
of all learning disabilities and nearly 1 in 5 people in the U.S. have some degree of a learning
disability. Most parents are unfamiliar with dyslexia and may believe that it is a vision-based
disorder. Pediatric ophthalmologists need to be thoroughly informed about dyslexia, its controversial treatments, evidence-based educational treatments and resources available to be able
to provide information and guidance to families of struggling readers.
Target Audience: Pediatric Ophthalmologists and Certified Orthoptists
Current Practice: Pediatric Ophthalmologists are often asked to evaluate children with reading or learning problems early in the process but may not have enough information to guide
families.
Best Practice: Pediatric ophthalmologists will be able to evaluate and manage children with
reading and learning problems, become familiar with the AAPOS Learning Disabilities Package
and guide families to resources and local educational experts.
Expected Outcomes: The participant will gain a thorough understanding of the issues, controversies, evidence and resources on dyslexia to be better equipped to evaluate the patient who
is experiencing reading difficulties, discuss dyslexia and provide guidance to our patients and
their families.
Format: Lecture format with question and answer session
Summary: This workshop will give a comprehensive summary of the latest information on
language acquisition, reading, dyslexia, the educational process, evidence-based educational
treatments, the eye functions necessary to read and how to test for them in the ophthalmic
exam. We will explore the controversial topics of vision therapy and colored lenses and filters.
We will also provide information and guidance on what to tell parents using the AAPOS Learning Disabilities Package as an aid so that we can assist our patients in receiving the correct
diagnoses and beneficial evidence-based therapies and accommodations.
References: 1. Learning disabilities, dyslexia, and vision. Technical Report 2. Handler SM, Fierson WM, Section on Ophthalmology;
Council on Children with Disabilities; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus;
American Association of Certified Orthoptists. 3. Pediatrics. 2011 Mar;127(3):e818-56. doi: 10.1542/peds.2010-3670. Epub 2011 Feb 28.
Review.
Workshop 8
Friday
8:30 - 9:45 am
The Impact of Brain Tumors on Vision and Ocular Motility
Gena Heidary MD, PhD, Robert Avery, DO, Stacy Pineles, MD, Jane Edmond, MD
Purpose/Relevance: Central nervous system (CNS) neoplasms comprise the most common
solid tumors in childhood accounting for 27% of childhood cancer.1, 2 As the survival rate from
childhood tumors continues to improve, visual morbidity from childhood cancer is significant.
The direct effects of the tumor itself and tumor therapy including surgical resection, chemotherapy, and radiation therapy may impact visual function. The purpose of this workshop is
to highlight important considerations regarding visual and ocular motility outcomes in those
children suffering from CNS tumors.
Target Audience: Pediatric ophthalmologists and pediatric neuro-ophthalmologists
Current Practice: Ophthalmologists may not be familiar with the ophthalmic symptoms/signs
suggestive of a CNS tumor, advances in our ability to screen for tumors of the visual pathways,
and the role of the ophthalmologist in long term management of brain tumors that impact the
visual system.
Best Practice: Ophthalmologists should recognize the clinical signs that warrant urgent neuroimaging and be familiar with the natural history of tumors that affect the visual pathways in order
to optimize clinical management.
Expected Outcomes: The attendee will be empowered to recognize clinical signs suggestive
of a CNS tumor and be familiar with the diagnostic evaluation. The clinician will become aware
of evidence based visual and ocular motility outcomes for these patients thereby enhancing
clinical management.
Format: Panel with case presentations, didactic lectures and question/answer period
Summary: The workshop will be divided into four topics: optic pathway gliomas (OPGs),
craniopharyngiomas, dorsal midbrain tumors, and posterior fossa tumors. Each topic will be
led by one of the authors with a case presentation followed by a didactic talk. The OPG section
will provide insight into the natural history and treatment outcomes of these tumors as well as
utility of handheld OCT. The craniopharyngioma and posterior fossa sections will provide data
regarding visual outcomes and ocular motility outcomes. The dorsal midbrain tumors section
will be focused on the tumor types that affect the dorsal midbrain and the afferent and efferent
dysfunction associated with these tumors.
References: 1. NCI SEER Program Pediatric Monograph.
164
2. American Cancer Society Facts and Figures 2012.
Secrets to Solve Pediatric Ophthalmology Case Mysteries
Aparna Ramasubramanian Carol L Shields Alex V Levin Bruce Schnall
Jerry A Shields
Workshop 9
Friday
8:30 - 9:45 am
Purpose/Relevance: The specialty of pediatric ophthalmology poses a unique challenge in that there are a multitude of diseases. Some can masquerade and have
atypical presentations. The exam is often limited and the diagnosis may need to be
determined with few clinical signs. This workshop will provide rapid diagnostic and
management tips to crack some of the mysteries of pediatric ophthalmology.
Target Audience: Pediatric Ophthalmologists & General Ophthalmologists
Current Practice: Pediatric ophthalmologists often encounter diagnostic dilemmas in
the setting of atypical clinical presentations or rare clinical diseases. Clinical acumen
is essential and there are several ancillary tests that can add critical information in
each particular scenario.
Best Practice: Recognition of key clinical features and ordering the right diagnostic
test that can clinche the diagnosis. Appropriate treatment decisions can make an immense difference in the final outcome of the child.
Expected Outcomes: At the conclusion of this presentation, attendees would be
able to recognize key clinical features of various pediatric ophthalmology conditions.
The workshop would aid in ordering the appropriate diagnostic test and would give
management tips to the audience.
Format: Case Presentation
Summary: With the use of multiple split second cases an overview of important diagnostic pearls in pediatric ophthalmology will be provided. The range of the workshop
would be from external diseases to glaucoma, systemic syndromes and tumors.
References: Shields CL, Schoenfeld E, Kocher K, Shukla SY, Kaliki S, Shields JA. Lesions simulating retinoblastoma (pseudoretinoblastoma)
in 604 cases. Ophthalmology 2013;120:311-6.
Neuro-ophthalmic Manifestations of Systemic Disease, Part 2
Jane C Edmond MD R Michael Siatkowski MD
Purpose/Relevance: The afferent and efferent visual systems may be affected by a
wide range of systemic diseases: neurologic, hematologic, inflammatory, infectious,
toxic/adverse drug reactions, paraneoplastic and genetic. In a case presentation style,
specific conditions will be presented and discussed. Examples are neuro-degenerative
and demyelinating diesases, acquired Horner syndrome, nystagmus and cranial nerve
palsies.
Target Audience: Comprehensive pediatric ophthalmologists
Current Practice: Pediatric ophthalmologists, especially those who are performing hospital consultations or who practice in tertiary care facilities, often encounter
children with multi-system disease. A wide variety of systemic disorders cause neuroophthalmic complications, some that may be sight threatening if not recognized and
treated. This symposium with present some of the more common systemic diseases
that lead to neuro-ophthalmic complications in the pediatric population
Best Practice: Pediatric ophthalmologists may not be aware of the ophthalmic
complications of common systemic disease states, especially when they are neuroophthalmic in nature.
Expected Outcomes: Participants will be better able to identify neuro-ophthalmic
complications of certain systemic diseases and provide a prompt diagnosis and treatment, with may impact the visual and overall outcome of the patient.
Format: Case presentations with panel discussion, with open question and answer
forum for the audience.
Summary: Summarize material to be presented at the workshop : neuro-degenerative and demyelinating diesases, acquired Horner syndrome, nystagmus and cranial
nerve palsies.
References: Ophthalmology CLinics of North America. Volume 19, issue 4, Dec 2006 Neuro-Ophthalmology Manifestations of Systemic
Disease
165
Workshop 10
Friday
10:30 - 11:45 am
Workshop 11
Friday
10:30 - 11:45 am
“Kids are NOT a line of vision” : Pediatric Low Vision
Linda M Lawrence MD Melinda Rainey MD Amanda Lueck PhD Kelly Lusk PhD
William Daugherty
Purpose/Relevance: The aim is better understanding of appropriate referrals and evidence-based
interventions for children with low vision and blindness between rehabilitation, education, and medical professionals that serve children with low vision and blindness and their families, including those
with multiple disabilities.
Target Audience: Pediatric Ophthalmologist, Pediatricians, Orthoptists, and others involved in the
treatment of children.
Current Practice: Pediatric ophthalmologists need information about what exists in the real world
for their patients with low vision and/or blindness. They may not understand the importance of their
“eye report” for the individual education plan (IEP) that legally governs the child’s education. Communication with the educational specialist at home and school is not commonplace from the medical
profession.
Best Practice: Referrals to vision rehabilitation and intervention services should be made within
30 days of diagnosis. Accurate and understandable documentation and communication is crucial to
ensure the educational team can provide the proper resources in the home or classroom for the child
with visual impairment. Pediatric ophthalmologists and their eye care teams need better understanding of how their evaluations and recommendations translate into the educational setting.
Expected Outcomes: Expected outcomes are earlier referrals from medical to educational resources, better understanding of educational interventions that exist for children with low vision and
blindness, including those with multiple disabilities, and the importance of the IFSP (Individual Family
Service plan (for birth to 3) or IEP (Individual Educational Plan for 3-22yo), documents that direct the
child’s educational interventions.
Format: Presenting ophthalmologists will team with educational experts. Case presentation will
demonstrate proper assessments and interventions with interactive discussion between the ophthalmologist and educators: 1. Introduction of the history of pediatric low vision interventions 2. Early
intervention 3. School age 4. Teenage and transition to work 5. Open questions and answers
Summary: Low vision and blindness needs a continuum of care between medical and educational
professionals.
References: 1. American Academy of Ophthalmology, Preferred Practice Pattern® Guidelines. Pediatric Eye Evaluations. San Francisco,
CA: American Academy of Ophthalmology; 2012, pp 18-22. 2. Wilson ME, Lawrence LM, Pediatric Low Vision, In: Wilson ME, Saunders
RA,Trivedi RH, eds. Pediatric Ophthalmology: Current Thought and a Practical Guide. Berlin, Germany: Springer-Verlag; 2009:461-70.
Workshop 12
Friday
10:30 - 11:45 am
Apt Lecture Workshop
Science, Pseudoscience, and the law in AHT
Alex V Levin MD, MHSc, FRCSC Brian J Forbes Sr Gil Binenbaum Steve E Rubin
Purpose/Relevance: Ophthalmologic examination is an important component in the evaluation of the young child
whose injuries are suspicious for child abuse. Abusive head trauma (AHT) refers to the repetitive violent acceleration-deceleration head and neck movements with resultant injuries in children typically younger than 3 years
of age. It is generally characterized by fractures, intracranial hemorrhages, and/or intraocular hemorrhages, with
retinal hemorrhages being the most characteristic ocular finding.
Target Audience: All doctors, although focusing on ophthalmologists, evaluating children in the setting of possible
abuse and those expected to appear in court or be deposed to report their medical findings.
Current Practice: Recent publications have disputed some of the long held beliefs associated with AHT, and
pediatric ophthalmologists are increasingly encountering questionable proposed alternative diagnoses and a controversy over the diagnosis of AHT. We will present and discuss these theories and evaluate examples of recent
literature consistent with or challenging previous beliefs about the interpretation of retinal findings.
Best Practice: It is the hope of all health care providers to do what is best for both the child and the family in
cases of AHT but navigating the medical, legal and judicial systems can be out of our comfort zone as physicians.
This workshop is designed to help participants gain comfort with the process.
Expected Outcomes: This workshop is designed to help participants gain comfort in navigating the medical, legal
and judicial systems in cases of AHT by familarizing them with the current AHT literature and means by which to
navigate the legal system.
Format: A didactic presentation of characteristic ophthalmic aspects of AHT, ‘new science’ and ‘new pseudoscience’, followed by a talk on the legal aspects of AHT within the contexts of medical certainty, reasonableness and
practical advice for the legal area will be presented. Finally, time will be reserved for the audience to submit cases
for discussion.
Summary: Recent publications have disputed some of the long held beliefs associated with Shaken Baby Syndrome/Abusive Head Trauma, and pediatric ophthalmologists are increasingly encountering questionable proposed
alternative diagnoses and a controversy over the diagnosis of abusive head trauma. We will present and discuss
these theories and evaluate examples of recent literature consistent with or challenging previous beliefs about the
interpretation of retinal findings.
References: 1. Duhaime A.C., Christian C.W., Rorke L.B., Zimmerman R.A. Nonaccidental head injury in infants--the ‘shaken-baby syndrome’. N Engl J Med 1998;338(25):1822-9. 2. Keenan H.T., Runyan D.K., Marshall S.W., Nocera M.A., Merten D.F., Sinal S.H. A populationbased study of inflicted traumatic brain injury in young children. JAMA 2003;290(5):621-6. 3. Levin A.V. Retinal hemorrhage in abusive head
trauma. Pediatrics 2010;126(5):961-70. 4. Bhardwaj G., Jacobs M.B., Moran K.T., Tan K. Terson syndrome with ipsilateral severe hemorrhagic retinopathy in a 7-month-old child. J AAPOS 2010;14(5):441-3.
5. Binenbaum G., Mirza-George N., Christian C.W., Forbes B.J. Odds
of abuse associated with retinal hemorrhages in children suspected of child abuse. J AAPOS 2009;13(3):268-72. 6. Gardner H.B. Immunizations, retinal and subdural hemorrhages: are they related? Med Hypotheses 2005;64(3):663. 7. Clemetson C.A. Elevated blood histamine
caused by vaccinations and Vitamin C deficiency may mimic the shaken baby syndrome. Med Hypotheses 2004;62(4):533-6. 8. Rosen E.
A postvaccinial ocular syndrome. Am J Ophthalmol 1948;31(11):1443-53. 9. Berkman N. [A case of segmentary unilateral occlusion of the
central retinal vein following hepatitis B vaccination]. Presse Med 1997;26(14):670. 10. Devin F., Roques G., Disdier P., Rodor F., Weiller
P.J. Occlusion of central retinal vein after hepatitis B vaccination. Lancet 1996;347(9015):1626.
11. Granel B., Disdier P., Devin F., Swiader
L., Riss J.M., Coupier L., Harle J.R., Jouglard J., Weiller P.J. [Occlusion of the central retinal vein after vaccination against viral hepatitis B with
recombinant vaccines. 4 cases]. Presse Med 1997;26(2):62-5.
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Pediatric ocular tumors and pseudotumors. Quick cases and clinical pearls
Jerry A Shields MD Carol L Shields MD
Workshop 13
Friday
10:30 - 11:45 am
Purpose/Relevance: To familarize the pediatric ophthalmologist with a variety of
pediatric ocular tumors.
Target Audience: Pediatric ophthalmologists
Current Practice: To recognize unusual, but serious ocular tumors and pseudotumors.
Best Practice: Be cognizant of potenially serious eye cancers.
Expected Outcomes: They will be able to recognize and know when to refer ocular
tumors.
Format: Open question and answer forum
Summary:
1. quick case presentations
2. audience discussion
3. answering questions
References: 1. Shields JA, Shields CL, Intraocular Tumors and Atlas and Textbook, Philadelphia, PA. Lippincott, Ed 2 2008
Shields CL, Atlas of Eyelid, Conjunctival and Orbital Tumors, Philadelphia, PA. Lippincott, Ed 2 2008
2. Shields JA,
Phenotype-genotype correlations in pediatric cataract, including conditions you
don’t want to miss
Arif O. Khan MD; Elias I Traboulsi MD
Purpose/Relevance: The phenotype of bilateral congenital or juvenile cataract is
generally non-specific. However, there are exceptions. These include treatable disease which the pediatric ophthalmologist is uniquely able to recognize early.
Target Audience: Pediatric ophthalmologists.
Current Practice: Pediatric ophthalmologists often manage pediatric cataracts with
minimal or no diagnostic evaluation.
Best Practice: Certain types of cataract (phenotypes) should raise suspicion for particular underlying genetic/metabolic conditions, the early diagnosis of which is optimal
for the child.
Expected Outcomes: Improved diagnosis and decreased patient morbidity.
Format: Didactic lecture, case presentation, open question and answer forum, panel
discussion.
Summary: Certain forms of bilateral pediatric cataracts are characteristic of specific
underlying gene mutations and metabolic disorders, some of which are amenable to
early treatment. The pediatric ophthalmologist is uniquely able to recognize these
conditions early. Several recognizable phenotype-genotype correlations for pediatric
cataracts will be discussed, with emphasis on treatable conditions.
References: 1. Trumler AA. Evaluation of pediatric cataracts and systemic disorders. Curr Opin Ophthalmol. 2011 Sep;22(5):365-79. 2.
Khan AO, Aldahmesh MA, Mohamed JY, Alkuraya FS. Juvenile cataract morphology in 3 siblings not yet diagnosed with cerebrotendinous
xanthomatosis. Ophthalmology. 2013 May;120(5):956-60.
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Workshop 14
Friday
12:00 - 1:00 pm
Workshop 15
Friday
12:00 - 1:00 pm
Meaningful Use of Physician Extenders in the Pediatric Ophthalmology Practice
Jorie Jackson Kyle Arnoldi Karl Henson Traci Fritz Aaron M Miller
Richard S Freeman Laurie Hahn-Parrott
Purpose/Relevance: Two important goals of any business are to maximize income
and minimize overhead. Simultaneously attaining these goals for a business that is
heavily regulated, such as medicine, can be challenging. One way to improve efficiency and productivity is to hire a physician extender, such as an orthoptist. But for
this to be effective, revenue generated by the hiring of additional personnel must well
outweigh the increased overhead.
Target Audience: This workshop is directed to pediatric ophthalmologists and administrators with an interest in incorporating an orthoptist into their practice, or for those
who already employ orthoptists, and are seeking to boost productivity and practice
income.
Current Practice: Currently in many areas of the country, there is limited access to a
pediatric ophthalmologist. Pediatric ophthalmologists may find themselves sacrificing
quality of care in order to meet the high demand for their services.
Best Practice: When physician extenders, such as an orthoptist, are utilized appropriately one can increase access of care to the pediatric ophthalmologist without
compromising quality of care.
Expected Outcomes: Panelists will present data on the value of an orthoptist as an
income generator, and as a skilled, well-educated provider, as well as how to hire an
orthoptist and create a thriving orthoptic clinic within a practice.
Format: Panel discussion that will feature the Chair of the AACO Practice Management Committee, practice managers for both a private group practice and an academic institution, pediatric ophthalmologists who successfully employ orthoptists and other
technical personnel, and an Orthoptist Program Director and past Chair of the AACO
Education Committee.
Summary: An orthoptist can be a valuable asset to both academic and private practices, who will stimulate growth, enhance the quality of care, and increase profits.
References: 2013 AACO Practice Management Salary Survey
Workshop 16
Friday
1:15 - 2:30 pm
RPE65 Related Inherited Retinal Degeneration Gene Therapy Trials:
Background and Current Status, Need for Genetic Testing,
and Future Gene Therapies for Other Retinal Dystrophies
Daniel C Chung DO, MA Arlene V Drack MD
Purpose/Relevance: RPE65 gene mutations lead to an early onset form of an inherited childhood retinal disorder, referred to as Leber Congenital Amaurosis (LCA2), and a later onset
retinitis pigmentosa (RP20). Currently there are no approved pharmacologic treatments, but
current phase III subretinal gene replacement clinical trials show potential for treatment availability in the near future. There are potentially many patients in the U.S. with RPE65 mutations
that do not have genetic testing confirmation. Pediatric ophthalmologists are often the first to
make a diagnosis of LCA or RP, and are therefore in a unique position to educate patients and
parents about current clinical trials and potential future treatments.
Target Audience: Pediatric ophthalmologists, orthoptists and inherited retinal degeneration
specialists
Current Practice: Genetic testing for inherited retinal degeneration (IRD) has not always been
viewed as a necessary component of patient care. Since historically these conditions were untreatable, eye care professionals may not have been trained to educate patients about genetic
testing, clinical trials and possible future treatments.
Best Practice: Gene replacement strategies have made major advances toward a treatment of
RPE65 related disease as well as other retinal disorders. The standard of care should include
molecular genetic testing, genetic counseling and education about clinical trials and future treatment options, enabling identification of patients who may benefit from gene-based therapies.
Expected Outcomes: 1. To be knowledgeable about ordering appropriate genetic tests. 2.
Be able to discuss current gene therapy trials, the impact for patients and future availability of
treatment.
Format: Didactic lecture, open question and answer forum
Summary: 1. Overview of RPE65 gene therapy trials, and update on which disorders have
treatment trials underway. 2. Outline of the procedures for obtaining genetic testing. 3. Summary of gene therapy and pharmacologic therapy clinical trials for other IRDs. 4. Summary of
what animal models are teaching us about subretinal gene therapy.
References: 1. Zanolli, Mario T., et al, Curr Opin Ophthalmol., 2014
Lancet. 2009
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2. Bennett, J., et al., Sci Transl Med. 2012
3. Maguire, AM., et al.,
Does this child have glaucoma or something else? Applying newer technologies to the diagnosis and management of pediatric glaucoma.
Sharon F Freedman MD Allen D Beck MD Alex V Levin MD
Workshop 17
Friday
1:15 - 2:30 pm
Purpose/Relevance: The workshop is designed to highlight the sometimes challenging clinical entity of the ‘glaucoma
suspect’, with emphasis on newer ophthalmic technologies and how they may assist in our diagnostic evaluation of these
cases. Medication update and pearls for use in children will be included.
Target Audience: Pediatric ophthalmologists, pediatric-interested comprehensive ophthalmologists, and trainees.
Current Practice: Although childhood glaucoma cases often present with clear objective signs that make its diagnosis
(though not necessarily its successful treatment!) rather straightforward, there are other cases where optic nerve or other
features raise the specter of ‘glaucoma suspect’. The stakes are high, since missing true glaucoma may lead to irreversible optic nerve/vision damage. On the other hand, labeling a child with glaucoma who has ‘something else’ may involve
needless worry, unnecessary testing, and even long-term interventions that have risks. Discussing challenging cases
where glaucoma suspicion arises, and examining the selective use of newer technologies and other clinical clues, may assist the clinician in dealing with cases of possible childhood glaucoma. New glaucoma medications and combinations keep
‘popping up’, often without clear guidelines for their optimal use/warnings in children.
Best Practice: Ideally, the practicing pediatric ophthalmologist and pediatric-oriented comprehensive ophthalmologist, should employ clinical and family history, clinical examination of the child’s ocular features (anterior segment and
angle, intraocular pressure, refraction, and optic nerve), together with technology (when appropriate to include tonometry,
pachymetry, visual fields, and retinal nerve fiber layer analysis, optic nerve head photography), to assess the likelihood
that a particular child’s eye has true or suspected glaucoma, or ‘something else’ (concerning or reassuring). A management plan should follow based upon the level of risk. The clinician should be able to devise a medication regimen (when
indicated) that maximizes effect and minimizes risk to the child.
Expected Outcomes: At the conclusion of this workshop, the audience will have seen examples of children suspected
of glaucoma based upon optic nerve head abnormalities, elevated intraocular pressure, and other ocular features. They
will also have seen cases presenting as possible glaucoma that turned out to be ‘non-glaucoma’ entities. They should
have gained an understanding of when to use newer tonometers, how to interpret corneal pachymetry findings, as well as
imaging such as optical coherence tomography as tools in the diagnosis of these ‘glaucoma suspects’. They should have
gleaned several strategies for managing ‘suspects’ at various degrees of “suspicion” for true glaucoma in their practices, as
well as criteria that might prompt referral or treatment. They should be familiar with current medications for glaucoma and
tips for their safe use in children who need them.
Format: Members of the panel will present cases where glaucoma was suspected, and highlight their diagnostic strategy,
highlighting technology when appropriate to the case diagnosis or management. Attendee questions and comments will be
encouraged.
Summary: This workshop will examine the features that bring children in as ‘glaucoma suspects’, and will include cases
of ‘real’ glaucoma, legitimate ‘suspects’, as well as those who turned out to have “something else” that was either benign or
worrisome. We will emphasis newer ophthalmic technologies (including tonometry, optical coherence tomography, visual
fields and ultrasound), as well as good old clinical acumen, and how they may assist in our diagnostic evaluation of these
cases. We will include a medication update and pearls for medication use in children.
References: World Glaucoma Association, Childhood Glaucoma, Consensus series 9, 2013. Edited by: Weinreb et al, Kugler Publications.
Adult Strabismus Workshop
David B Granet MD, David L Guyton MD, Edward G Buckley MD,
Steven M Archer MD, David Stager, Sr MD,
Forrest J Ellis MD, Lionel Kowal MD, David Hunter MD
Purpose/Relevance: The surgical treatment of the adult with strabismus comprises
a significant portion of the clinical and surgical volume of many pediatric ophthalmologists. This workshop is designed to educate attendees regarding surgical treatment of
adults with strabismus.
Target Audience: Pediatric ophthalmologists & orthoptists interested in evaluating
and treating adults with strabismus.
Current Practice: Pediatric ophthalmologists are often intimidated by adults with
complicated forms of strabismus. A variety of challenges often deter surgical intervention including fear of post-operative diplopia and a lack of confidence in managing
torsion and re-operations.
Best Practice: Clinicians will gain a more thorough understanding of the surgical approaches and techniques which yield better outcomes in adults with strabismus.
Expected Outcomes: At the conclusion of the workshop, attendees will have a better
understanding of effective strategies for managing adults with complicated forms of
strabismus.
Format: The workshop will include discussions and presentations by a panel of
experts. In addition, time for audience participation with questions of the panelists is
planned. Use of video for teaching will be included. Throughout the discussions, pertinent scientific literature will be presented and reviewed.
Summary: Topics will include challenging cases of adults with complicated forms of
strabismus; including re-operation strategies, management of torsion and incomitant
deviations, and correction after other ocular surgery or disease, as well as tips, pearls,
and advice from surgeons with years of experience.
References: 1. Stager D Jr., J AAPOS. 2014 Apr;18(2):103-4. Adult Strabismus: It’s never too late. Improvement in specific function-related
quality-of-life concerns after strabismus surgery in non-diplopic adults. 2. Robbins SL, Granet DB, Burns C, Freeman RS, Eustis HS, Yafai
S, Cruz F, Danylyshyn-Adams K, Langham K. Br J Ophthalmol. 2010 Sept;94(9):1169-73. Delayed adjustable sutures: a multicentered clinical
review.
3. Deschler EK, Irsch K, Guyton KL, Guyton DL., J AAPOS. 2013 Oct;17(5):524-7. A new, removable, sliding noose for adjustablesuture strabismus surgery.
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Workshop 18
Friday
1:15 - 2:30 pm
Workshop 19
Friday
1:15 - 2:30 pm
Global Challenges in the Management of Childhood Cataracts
Phoebe D Lenhart Ana Paula Rodrigues M. Edward Wilson Ramesh Kekunnaya
Arif Khan Lee Woodward Scott R Lambert
Purpose/Relevance: Childhood cataracts have become a leading cause of preventable
blindness worldwide.1 This workshop will address how pediatric cataracts are managed in
different parts of the world and what needs to be done to improve the present situation in
each region. The focus of the discussion will be public health approaches as opposed to
surgical techniques.
Target Audience: Pediatric Ophthalmologists
Current Practice: The workshop will begin with a summary of the current situation and
recommendations for managing pediatric cataracts in different regions of the world derived
from small group discussions during the 4th International Congenital Cataract Symposium
held in March 2014 in New York City. Next, pediatric ophthalmologists representing various
regions of the world will share their perspective on how pediatric cataracts are managed in
the country or region they are representing: Dr. Ana Paula Rodrigues (Brazil), Dr. M. Edward Wilson (Guatemala, Costa Rica); Dr. Ramesh Kekunnaya (India); Dr. Lee Woodward
(Tanzania); Dr. Arif Khan (Saudi Arabia); and Dr. Phoebe Lenhart (United States).
Best Practice: The panel will then discuss potential ways to improve the management of
cataracts in these different regions. Audience participation will be encouraged.
Expected Outcomes: Our goal is to provide an opportunity for an international group of
experts to engage in meaningful dialogue to improve the management of pediatric cataracts on a global basis.
Format: Panel discussion, audience participation
Summary: Childhood cataracts are a leading cause of preventable blindness in the developing world. Panel members will highlight key aspects of the current situation, challenges,
and recommendations in their region of the world. The audience will have an opportunity
to discuss strategies for improving the management of pediatric cataracts with regional
experts.
References: Kong L, Fry M, Al-Samarraie M, Gilbert C, Steinkuller PG. An update on progress and the changing epidemiology of causes of
childhood blindness worldwide. J AAPOS 2012;16:501-507.
Workshop 20
Friday
2:45 - 4:00 pm
Just Do It...Better: Tips for Efficiency in Clinical Practice
Rebecca Leenheer MD Kara Cavuoto MD Janine Collinge MD
S. Grace Prakalapakorn MD Theodore Curtis MD
Michael Chiang MD David Silbert MD Kenneth Wright MD
Purpose/Relevance: After training in pediatric ophthalmology, Young Ophthalmologists (YOs) have the skills to provide excellent medical and surgical care. However,
developing efficiency in and balancing clinical and research responsibilities in the era
of electronic health records (EHRs) can be challenging. This workshop provides solutions to these and other challenges for both budding and seasoned pediatric ophthalmologists.
Target Audience: Pediatric ophthalmologists in their first ten years of practice, fellows and residents pursuing a career in pediatric ophthalmology; and established
pediatric ophthalmologists seeking ideas to maximize their efficiency.
Current Practice: New pediatric ophthalmologists frequently rely on residency and
fellowship mentors for guidance in clinical, surgical, and research practices. Endeavors to maximize efficiency are often addressed using trial and error.
Best Practice: Preparing YOs for maximizing efficiency in clinic and the operating
room in the era of EHRs, along with incorporating research into their practices will
help them better navigate their first decade of practice.
Expected Outcomes: The attendee will learn skills to help successfully navigate
challenges in the modern day practice of pediatric ophthalmology, with particular
emphasis on efficiency. These solutions will be of use in both private practice and academic settings, by both young and more experienced pediatric ophthalmologists.
Format: Presentation by discussants followed by panel discussion and question and
answer forum.
Summary: This workshop will highlight how to maximize efficiency in the clinic,
research, charting, and the operating room for pediatric ophthalmologists in any stage
of practice.
References: Submitted and officially sponsored by the AAPOS Young Ophthalmologist Committee.
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Low Vision Rehabilitation Update: New and Innovative 2015
Terry L Schwartz MD Kelly Lusk PhD, CLVT Rebecca Coakley MA, CLVT
Workshop 21
Friday
2:45 - 4:00 pm
Purpose/Relevance: Technology and classroom innovations have revolutionized
access to printed materials and the visual environment for children with visual impairment. Knowledge of available technology, accessibility options in the modern classroom, the continuum of literacy choices, and the spectrum of spectacle choices will be
presented to aid the ophthalmologist who is caring for the child with permanent vision
loss.
Target Audience: Pediatric Ophthalmologist
Current Practice: Awareness of rehabilitation options and changes in the field of
education are often outside the training and continuing education for physicians.
Best Practice: A broad knowledge of innovations in the field of low vision rehabilitation and education of patients with visual impairment will help the ophthalmologist
advocate for their patients as they transition from medical and surgical treatment to
rehabilitation.
Expected Outcomes: The attendee will gain the following; knowledge of new low
vision technologies, advances in the classroom, advantages of using spectacles and
contact lenses to enhance the use of magnification, and tips for using the electronic
medical record.
Format: Panel presentation
Summary: This workshop will introduce new and innovative options for maximizing
functional vision in children with visual impairment. The physician will be able to mentor patients and families as they navigate issues of accessibility, literacy, education,
technology, and transition toward independence as older teens and young adults.
References: Raising a Child with Albinism: A Guide to the School Years. 2014 East Hampstead, NJ: National Organization for Albinism and
Hypopigmentation.
Difficult Conversations in Pediatric Ophthalmology and Strabismus
R. Michael Siatkowski MD, Sharon F Freedman MD, David B Granet MD,
George S Ellis MD, Cindy Pritchard CO, COT, Robert E Wiggins Jr MD,
Christie L Morse MD
Purpose/Relevance: To improve physicians’ skills in handling difficult situations in
clinical practice.
Target Audience: Pediatric ophthalmologists, orthoptists.
Current Practice: Interpersonal/communication skills is the competency most associated with negative physician-patient experiences.
Best Practice: Physicians will respond to difficult situations in an honest, ethical,
compassionate manner.
Expected Outcomes: Physicians will learn 2 new techniques in communication and
interpersonal skills and apply principles endorsed by the AAO Ethics Committee to difficult situations in their practice.
Format: Brief didactic presentations,panel discussion, audience Q & A.
Summary: Circumstances addressed are: the poorly behaved child, inappropriate
parental treatment of the child, dismissing a patient, non-compliance and treatment
refusal, and functional visual disorders will be addressed. Application of ethical principles endorsed by the AAO will be reviewed.
References: 1. Teutsch C. Patient-doctor communication. Med Clinic NA. 2003;87:1115-45.
ethics
2. AAO Code of Ethics. www.aao.org/about/
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Workshop 22
Friday
2:45 - 4:00 pm
Workshop 23
Friday
2:45 - 4:00 pm
What’s New and Important in Pediatric Ophthalmology and Strabismus in 2015
Jitka L Zobal-Ratner MD Nisha Krishan-Dave MD William W Motley MD
Jason H Peragallo MD Rebecca S Braverman MD Hilda Capo MD
Leemor Rotberg MD Tina Rutar MD Melanie Schmitt MD
Other Contributors from the AAPOS Professional Education Committee:
Darron A. Bacal MD Linda R Dagi MD Patrick J Droste MD Sergul A Erzurum MD
Christopher M Fercarotta MD Douglas Fredrick MD C. Corina Gerontis MD
Melanie A Kazlas MD Ramesh Kekunnaya MD, FRCS Jennifer A Kozak MD
Stacy L Pineles MD Graham E Quinn MD Terri L Young MD
Purpose/Relevance: The authors will investigate the literature for articles of interest to
the sub-specialty of Pediatric Ophthalmology and Strabismus for the time period March
2014-February 2015. Ophthalmic journals are stressed but journals from other specialties
such as pediatrics, neurology and comprehensive medicine will be included. The authors
will summarize the key findings in the major topics including, but not limited to, vision
screening, amblyopia, neuro-ophthalmology, retinopathy of prematurity, strabismus, cataract, glaucoma, genetics, retina, orbit, uveitis and practice management. The presentations
in these topic areas will summarize and emphasize second-order analyses of the material.
Target Audience: Pediatric and Comprehensive Ophthalmologists, Orthoptists
Current Practice: Pediatric Ophthalmology is a rapidly evolving sub-specialty. It is difficult
to remain current with all of the literature in this field.
Best Practice: The authors will summarize, analyze and present the most current and
important information from more than 20 medical journals
Expected Outcomes: The audience will understand the most current published information in this sub-specialty.
Format: Didactic lecture
Summary: More than 20 medical journals will be reviewed for relevant new findings in
the sub-specialty of Pediatric Ophthalmology and Strabismus from March 2014-February
2015. The material presented will educate the Ophthalmologists and Orthoptists in new
research.
References: Journal of AAPOS, Ophthalmology, Pediatrics
Workshop 24
Friday
4:30 - 6:00 pm
Taking Care of Our Patients in a Changing Healthcare System
A Call to Include Social Media and Patient Advocacy Activities
in Our Professional Life
Jean E Ramsey MD, MPH, Ken Cheng MD, Brad Black MD,
Luxme Harlharan MD MPH, Stacey J Kruger MD,
Daniel Briceland MD, Pamela E. Williams MD, Patrick Hynes
Purpose/Relevance: This symposium will (1) present information about the myriad of external forces
that may negatively impact the eye health of our patients, (2) provide attendees with social media tools for
communication with patients and (3) motivate attendees to integrate patient advocacy activities into our
professional life.
Target Audience: This symposium is targeted to pediatric and general ophthalmologists, orthoptists, and
others engaged in the work of improving eye care for our patients.
Current Practice: Legislative and regulatory policies can negatively impact the eye health of our patients.
Ophthalmologists historically have received little formal education about such external forces and know little
of the tools, including social media and advocacy, that can be utilized to improve eyecare for our patients.
Best Practice: Ophthalmologists spend years of training to develop a strong knowledge base and excellent clinical skills. Personal professional attention must also be directed at system-wide issues that impact
the eye health of our patients and consumer perception of eye health options.
Expected Outcomes: It is hoped that with an increase in knowledge and awareness of the many different types of advocacy activities available, in addition to increased skills in social media communication,
attendees will become personally engaged in social media communication and advocacy on behalf of our
patients.
Format: The format for the symposium will be panel discussion, highlighted entertaining presentation, with
open Q&A
Summary: Our ability to take care of our patients is influenced by many forces outside of medicine on the
national, state and local level. Techniques for effective social media communication, applicable to many
types of relationships, will be discussed. Through education, with a focus on social media, and humorous
entertainment, the AAPOS Legislative Committee hopes to inspire attendees to include advocacy activity
as an integral part of his/her professional life.
References: 1. American Academy of Ophthalmology. The Profession of Ophthalmology: Practice Management, Ethics, and Advocacy, 2nd
Edition. David A Durfee, ed. 2010 2. Scheufele DA. Medical professionalism in the age of online social networking. http://www.ncbi.nlm.nih.
gov/pubmed/19717700
3. Thompson LA, Dawson K, Ferdig R, Black EW, Boyer J, Coutts J, Black NP. The intersection of online social networking with medical professionalism. http://www.ncbi.nlm.nih.gov/pubmed/18612723
4. Scheufele DA. Science communication as political
communication. http://www.ncbi.nlm.nih.gov/pubmed/25225389
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Use of digital photoscreeners to detect Amblyopia Risk Factors (ARFs),
a multidisciplinary evidence based approach; care and cost implications.
David I Silbert MD (Moderator); Sean Donahue MD; Alan Greene MD;
Deborah Alcorn MD; Robert Arnold MD
Workshop 25
Saturday
7:00 - 8:15 am
Purpose/Relevance: Traditional vision screening utilizes visual acuity charts, requiring a subjective
response from a child. This can be especially challenging for non-verbal, preverbal, and early verbal
children and can lead to over-referral of young children for confirmatory examinations with significant
cost implications. This has led to the wide use of photoscreeners.
Target Audience: Pediatric Ophthalmologists, Orthoptists and Ophthalmic Technicians
Current Practice: Screening for ARF’s are performed in the medical home, as well as the school
setting utilizing both objective and subjective tests including acuity testing and photoscreening.
Best Practice: This seminar will provide evidence-based data and will familiarize participants with
the various commercially available photoscreeners. The literature will be reviewed looking at the sensitivity and specificity of the devices for detection of AAPOS ARF’s and comparing this to subjective
acuity testing, specifically looking at the detection of AAPOS Amblyopia Referral Criteria (ARF’s) and
comparing as compared to subjective acuity testing.
Expected Outcomes: Improvement in detection of ARF’s and effective treatment of target population
Format: The seminar will address: 1) AAPOS, AAO, and AAP positions on photoscreening, AAPOS
guidelines, USPF task force recommendations and the recent National Expert Panel recommendations 2) Positive Predictive Value of acuity testing and photoscreening 3) Evidence-based look at
sensitivity and specificity of photoscreeners 4) A pediatrician’s perspective on acuity testing and
photoscreening including, challenges of vision screening in the primary care setting, understanding
impact of sensitivity and specificity, and impact of over-referral to ophthalmology 5) Evidence of
benefit of early detection and treatment of amblyopia and communication with referring pediatricians
to improve outcomes 6) Partnership between primary care and pediatric ophthalmology, to enhance
outcomes, the Alaska experience.
Summary: Recent advances in photoscreening, have made photoscreeners a useful option for nonverbal, preverbal and early verbal children.
References 1. Preschool vision screening: what should we be detecting and how should we report it? Uniform guidelines for reporting results
of preschool vision screening studies. Donahue SP, Arnold RW, Ruben JB; AAPOS Vision Screening Committee. J AAPOS. 2003 Oct;7(5):3146. 2. Guidelines for automated preschool vision screening: a 10-year, evidence-based update. Donahue SP, Arthur B, Neely DE, Arnold
RW, Silbert D, Ruben JB; POS Vision Screening Committee. J AAPOS. 2013 Feb;17(1):4-8
3. Nine-year results of a volunteer lay network
photoscreening program of 147 809 children using a photoscreener in Iowa. Longmuir SQ1, Pfeifer W, Leon A, Olson RJ, Short L, Scott WE.
Ophthalmology. 2010 Oct;117(10):1869-75. 4. Vision screening among children aged 6 years--Medical Expenditure Panel Survey, United
States, 2009-2010. Kemper AR, Crews JE, Strickland B, Saaddine JB; Centers for Disease Control and Prevention (CDC). MMWR Surveill
Summ. 2014 Sep 12;63 Suppl 2:43-6.
Fiscal Benchmarking Workshop- Data From CY 2013,
AAPOS Socioeconomic Committee
Deborah S Lenahan MD Nils Mungan MD Eric Lichtenstein MD Bob Wiggins MD
John Bishop MD Mike Bartiss MD, OD
Purpose/Relevance: The purpose of this presentation is to present financial data
gathered by a survey of AAPOS members. This will be the fifth consecutive year that
key metrics for a successful pediatric ophthalmology practice have been evaluated
and discussed. Each year, the survey continues to be refined. This year will debut a
new survey platform intended to minimize unreliable responses and diminish loss of
data due to incomplete surveys.
Target Audience: The target audience is pediatric ophthalmologists and their practices.
Current Practice: Financial benchmarks have not been available for pediatric ophthalmology until the advent of the SEC Fiscal Benchmarks Project in 2010.
Best Practice: The ongoing survey discussed at this workshop allows AAPOS members to establish norms specific to pediatric ophthalmology, thus enabling participants
to identify potential problem areas in their practice, whether private or academic.
Expected Outcomes: At the conclusion of the session, the attendees will be able to
understand key financial metrics in their practices and have norms available for comparison. Additionally, they will gain a better understanding of how practice patterns
can be modified to enhance practice profitability.
Format: Panel discussion/open question and answer forum.
Summary: The data from the just completed CY 2013 survey will be presented. This
information will be discussed, with a panel discussion of each of the benchmarks and
questions from the audience.
References: AAPOS Benchmarking Presentations, 2011, 2012, 2013, and 2014 meetings.
173
Workshop 26
Saturday
2:00 - 3:15 pm
Workshop 27
Saturday
3:30 - 5:30 pm
The Ups, Downs, Ins and Out of Strabismus and Pediatric Ophthalmology
Coding
Sue Vicchrilli COT, OCS
Purpose/Relevance: Medical record documentation requirements vary by state and
by payer. In order to be compliant physicians must keep up-to-date with the ever
changing rules.
Target Audience: Pediatric ophthalmologists, general ophthalmologists and their staff.
Current Practice: How to document and code for E/M services vs. Eye code services.
How to document vision exams.
Which tests are bundled with other tests, or surgeries.
Appropriate modifier application in the office, in the facility and during global period.
Best Practice: Internal compliance controls
Subscribe to all payer listservs,
Liaison with provider representative, and
Conduct quarterly internal audits, to identify deficiencies and implement corrective action plan.
Expected Outcomes: Improved awareness of variation in payer policies and apply
knowledge to exam, test, and surgical coding documentation. Identification of ICD-9
and correct ICD-10 code linkage.
Format: Didactic lecture and case presentation
Summary: Identification of 5 types of payers including the impact of Affordable care
act, and the nuances of each.
Appropriate modifier application
Coding cases from the routine to the complex.
Attendees are encouraged to submit questions to coding@aao.org prior to the course.
References: 1. AAO Health Policy Committee
Strabismus coding module.
Workshop 28
Sunday
7:30 - 8:30 am
2. Listserve ecode@aao.org,
3. Ophthalmic Coding Series Essential Topics and Pediatric/
Video Demonstrations of Signs, Diseases, and Complex Surgical Procedures in
Pediatric Ophthalmology and Strabismus
Federico G Velez MD Evelyn A Paysse MD Jonathan M Holmes MD Michael X Repka
MD Bibiana Jin Reiser MD Ramesh Kekunnaya MD
Purpose/Relevance: Video demonstration of unusual and complex signs, diseases,
and surgical procedures in pediatric ophthalmology and strabismus
Target Audience: Pediatric Ophthalmologist and Strabismologist, Orthoptists, and
Training Ophthalmologist.
Current Practice: Some signs and surgical procedures described in textbooks represent a challenge because some conditions are rarely seen in clinics and some surgical
procedures are almost exclusively performed at tertiary referring centers.
Best Practice: This workshop allows to see videos of rare signs and surgical procedures, with an explanation by the ophthalmologist who recorded it and a discussion
with the panelist and the audience.
Expected Outcomes: Increase the level of awareness and confidence when performing an examination, making a diagnosis and planning treatment.
Format: Six experienced pediatric ophthalmologist and strabismologist will present
and discuss videos of signs, diseases, and surgical procedures. Panelist will discuss
differential diagnosis and potential treatment options. Audience participation is encouraged.
Summary: Demonstration of classical or rare signs, diseases, surgical procedures using high quality video presentations.
174
Difficult Non-Strabismus Problems in Pediatric Ophthalmology
Elias I Traboulsi MD, MEd Arlene V Drack MD F. James Ellis MD
Mohamad S Jaafar MD Virginia Utz, MD Deborah Vanderveen MD
Workshop 29
Sunday
9:00 - 10:00 am
Purpose/Relevance: Sharing the difficulties in making the diagnosis and managing rare
and atypical cases allows practitioners to benefit from each other’s experience and to
discuss alternative evaluation and treatment plans. The presentation of several such cases
to a broad audience of interested individuals allows the appropriate ditribution of such
teaching cases.
Target Audience: Pediatric ophthalmologists , orthoptists, vision scientists and trainees
Current Practice: While many pediatric ophthalmologists elect to manage difficult cases,
others refer such cases to other pediatric ophthalmologists or subspecialists with advanced or more extensive experience in the particular area of disease or management that
the patient needs.
Best Practice: While many difficult diagnostic cases can be addressed via telephone or
email communications between the primary treating physician and the expert, others need
to visit one or more subspecialists before a final diagnosis is reached and a treatment plan
is firmly established. Group presentation of cases in some instances is necessary with
the participation of several advanced practitioners, sometimes from specialities outside of
ophthalmology.
Expected Outcomes: At the conclusion of the workshop the audience and the panel will
have shared their experiences and strategies for the diagnosis and management of a few
challenging cases. The practitioner in the audience is expected to gain new insights into
the clinical reasoning behind each diagnosis and the purpose of any intervention.
Format: Each panelist will present one case and invite the other panelists to discuss their
approaches to diagnosis and treatment. The audience will participate by asking questions
or providing personal insights.
Summary: Case-based learning experience involving 5 challenging pediatric ophthlalmology non-strabismus cases
Difficult Problems: Strabismus
Sean P Donahue MD, PhD Ed Buckley MD Stacy Pineles MD Oscar Cruz MD
Linda Dagi MD Marc Greenberg MD
Purpose/Relevance: The most common ICD-9 codes used by pediatric ophthalmologists
concerned strabismus. Patients that present with straight-forward unoperated strabismus do
not present a challenge to most pediatric ophthalmologists. However, patients may also present with very complex strabismus that pose diagnostic and therapeutic challenges: strabismus
secondary to brain injury, brain tumors, cranial nerve palsies, orbital disease or anomalies, and
status post multiple extraocular muscle surgeries. This workshop will specifically deal with rarer
and more atypical presentations of strabismus that present a knowledge gap to the practicing
pediatric ophthalmologist.
Target Audience: Pediatric ophthalmologists in practice and fellowship training, Orthoptists,
Opthalmology Residents
Current Practice: They are reading medical journals, attending CME meetings, talking among
their colleagues.
Best Practice: Participants will gain new perspective from the review of cases by pediatric
ophthalmologist experts who deal with complex strabismus. New insights will inform clinical and
surgical approach when confronted complex strabismus.
Expected Outcomes: At the conclusion of the symposium the attendees will have been taught
new skills and refine previous skills in the diagnosis of complex and diverse strabismus conditions, the salient exam features to perform, tests to order, and new surgical skills in the treatment of complicated strabismus
Format: The symposium will consist of expert panel discussion and subsequent open question
and answer forum with the audience’s participation. Actual patient vignettes will be presented.
The presenter will provide a differential diagnosis, a treatment plan, shedding insight on the disease process, the etiology of the strabismus, and the rationale behind the treatment, and treatment outcome. Also discussed will be the potential reasons for the treatment success or failure
Summary: The panel participants are all internationally recognized experts in the field of
strabismus and strabismus surgery. They will each present a difficult case that will be discussed
by the other experts, and the results of the treatment will be presented and discussed. Approximately 6 cases will be presented.
References: Strabismus Surgery - Basic and Advanced Strategies, Ophthalmology Monographs 17. The American Academy of Ophthalmology,
Oxford University Press, 2004
175
Workshop 30
Sunday
10:10 - 11:10 am
Notes
176
Notes
177
Notes
178
AAPOS Committees – 2014-15
Audit
Eric A. Lichtenstein, MD, Chair
William P. Madigan, Jr, MD, FACS, Vice Chair
Laurie Hahn-Parrot, CO, COT, MBA
Barry N. Wasserman, MD
Allan M. Eisenbaum, MD
Bylaws and Rules
Steven C. Thornquist, MD, Chair
Richard Alan Lewis, MD, MS, Vice Chair
Constance E. West, MD
Christopher Gappy, MD
Robert D. Gross, MBA, MD
Edward L. Raab, MD
Steven E. Rubin, MD
David G. Hunter, MD, PhD, Consultant
Corporate Relations
David I. Silbert, MD, Chair
Gregory I. Ostrow, MD
Phoebe D. Lenhart, MD
Meghan S. Flemmons, MD
Jamie L. Ikeda, MD
Cybil Bean Cassady, MD
Cindy J. Cline, CO, COMT
Brian N. Campolattaro, MD
Erin D. Stahl, MD
Constance E. West, MD
Kamiar Mireskandari, MBChB, FRCSEd, FRCOphth, PhD
A. Melinda Rainey, MD
John W. Simon, MD
Gennifer J. Greebel, MD
M. Edward Wilson, Jr., MD, Consultant
Costenbader Lecture
Benjamin H. Ticho, MD, Chair
David Stager, Jr, MD, Vice Chair
Willaim P. Madigan, Jr., MD, FACS
Scott E. Olitsky, MD
Stephanie L. Davidson, MD
Susan H. Day, MD, Consultant
Fellowship Training Compliance
Daniel J. Karr, MD, Chair
Alex V. Levin, MD, Vice Chair
Erin P. Herlihy, MD
Joseph C. Paviglianiti, MD
Marijean M. Miller, MD
Mohamad S. Jaafar, MD
David R. Weakley, MD
Hee-Jung Park, MD, MPH
Leah Reznick, MD
Ilana B. Friedman, MD
Denise A. Hug, MD, Membership Representative
Brian J. Forbes, MD, PhD, Consultant
Finance
Robert E. Wiggins, Jr., MD, Chair
Mary O’Hara, MD, Vice Chair
David A. Plager, MD
David G. Hunter, MD, PhD
Andrea Molinari, MD
Robert S. Gold, MD
Eric A. Lichtenstein, MD
Katherine A. Lee, MD, PhD
M. Edward Wilson, Jr., MD
Sherwin J. Isenberg, MD
Sharon F. Freedman, MD
Christie L. Morse, MD, EVP
International Affairs
David Robbins Tien, MD, Chair
Erick Bothun, MD, Vice Chair
Miguel Paciuc, MD
Iason S. Mantagos, MD
Alejandra G. de Alba Campomanes, MD
David R. Weakley, Jr, MD
Serena X. Wang, MD
Lee M. Woodward, MD
Michelle T. Cabrera, MD
Robert O. Hoffman, MD
Federico G. Velez, MD
Daniel T. Weaver, MD
Edward L. Raab, MD
Daniel E. Neely, MD
Cheryl L. McCarus, CO, COMT, OSA
Rudolph S. Wagner, MD
Hana Leiba, MD
Igor E. Aznauryan, MD, PhD
Michael G. Hunt, MD
Eugene M. Helveston, MD, Consultant
Sobi Pandey, MD, Consultant
Monte Del Monte, MD, Consultant
Andrea Molinari, MD, Consultant
Marilyn T. Miller, MD, Consultant
Mohamad S. Jaafar, MD, Consultant
Michael X. Repka, MD, International Meeting Coordinator
International Program Committee (India, 2016)
Sean P. Donahue, MD, PhD, Chair
Derek T. Spunger, MD
Mary Louise Z. Collins, MD
Sonal Farzavandi, FRCS
Frank J. Martin, MD
Scott A. Larson, MD
Yogesh Shukla, MD
Albert W. Biglan, MD
Interorganizational Relations
Mary Louise Z. Collins, MD, Chair
David A. Plager, MD, Vice Chair
Sharon F. Freedman, MD, Past President
Christie L. Morse, MD, EVP
Sherwin J. Isenberg, MD, President
David Rogers, MD, Public Information Chair
Jitka L. Zobal-Ratner, MD, Professional Education Chair
Kartik S. Kumar, MD, Young Ophthalmologist Chair
Faruk H. Orge, MD, Online Media Chair
Sharon S. Lehman, MD, AAO-SOOP Member
179
Denise R. Chamblee, MD, CEF Representative
Daniel J. Briceland, MD, AAO Secretariat
Bob Palmer, AAO, State Affairs
Cheryl L. McCarus, CO, COMT, OSA, AACO
Jean E. Ramsey, MD, Legislative Committee Chair
Linda M. Lawrence, MD, Member at Large
Sheryl M. Handler, MD, Member at Large
Jennifer Hull, SF-AMS
Brandan Marr, AAO, State Affairs
Jane C. Edmond, MD, Member at Large
Derek T. Sprunger, MD, Board Liaison
Legislative Committee
Jean E. Ramsey, MD, MPH, Chair
Kenneth P. Cheng, MD, Vice Chair
Jeffery S. Hunter, MD
Ronald GW Teed, MD
Evelyn A. Paysse, MD
Iris S. Kassem, MD, PhD
Stacey J. Kruger, MD
Jill Thalacker Clark, CO
Steven Awner, MD
Donald P. Sauberan, MD
Robert W. Arnold, MD
Vicki M. Chen, MD
Danielle M. Ledoux, MD
Carl Bernard Guterman, MD
Bradley C. Black, MD
Luxme Hariharan, MD, MPH
Geoffrey E. Bradford, MD
Brendan Marr, AAO-State Affairs
Bob Palmer, AAO - State Affairs
Michael X. Repka, MD, Consultant
Membership
Denise A. Hug, MD, Chair
Kathryn M. Haider, MD, Vice Chair
Christian Carter, MD
Erin D. Stahl, MD
Dean J. Bonsall, MD, MS, FACS
Stephanie L. Davidson, MD
Michael C. Struck, MD
Lindsay Horan, CO, Orthoptist Consultant
Bradley V. Davitt, MD, Consultant
Nominating
Sharon F. Freedman, MD, Chair
Denise R. Chamblee, MD
Oscar A. Cruz, MD
Deborah S. Lenahan, MD
David Robbins Tien, MD
Online Media
Faruk Orge, MD, Chair
Scott A. Larson, MD, Vice Chair
Sonal Farzavandi, FRCS
Inna Marcus, MD
Wendy W. Huang, MD
Jennifer A. Galvin, MD
Tara G. Missoi, MD
Mitchell B. Strominger, MD
N. Marie Koederitz, MD
Noha Stephanie Ekdawi, MD
Mays A. El Dairi, MD
Eric D. Weber, MD
Eric A. Pennock, MD
Professional Education
Jitka Zobal-Ratner, MD, Chair
Darron A. Bacal, MD, Vice Chair
Tina Rutar, MD
Nisha Krishan Dave, MD
Stacy L. Pineles, MD
Graham E. Quinn, MD
William Walker Motley, MD
Leemor Rotberg, MD
Rebecca S. Braverman, MD
Patrick J. Droste, MD
Ramesh Kekunnaya, MD
Melanie A. Kazlas, MD
Terry L. Young, MD
Hilda Capo, MD
Linda R. Dagi, MD
Jennifer A. Kozak, MD
Sergul Erzurum, MD
C. Corina Gerontis, MD
Melanie Schmitt, MD
Christopher M. Fecarotta, MD
Douglas R. Fredrick, MD
Jason H. Peragallo, MD
Program
Sean P. Donahue, MD, PhD, Chair
Katherine A. Lee, MD
Graham E. Quinn, MD
Oscar A. Cruz, MD
K. David Epley, MD
Scott A. Larson, MD
Tina Rutar, MD
Nancy A. Hamming, MD
Subday Program
Sean P. Donahue, MD, PhD, Chair
Daniel E. Neely, MD, Program Director
R. Michael Siatkowski, MD, Program Director
David A. Plager, MD
Jane C. Edmond, MD
Daniel J. Karr, MD
Laura B. Enyedi, MD
Public Information
David Rogers, MD, Chair
Richard P. Golden, MD, Vice Chair
Marlet G. Bazemore, MD, MPH
Katheryn S. Klein, MD, MPH
Faruk H. Orge, MD
Alexander J. Khammar, MD
Leah Reznick, MD
Amr A. ElKamshoushy, MD
Robert S. Lowery, MD
Pamela H. Berg, CO
Scott W. Yeates, MD
Adam J. Rovit, MD
Kathryn Camille Dimicelli, MD
Amber A. Sturges, MD
Omondi Nyong’o, MD
Alejandro Leon, MD
Rick Whitehead, MD
Carlos Gonzales, MD
Jay M. Rosin, MD, MPH
Eric Hein, MD
180
Meghan McMillin, CO
Angela Maria Fernandez, MD
Catherine O. Jordan, MD
Genie M. Bang, MD
Erick Bothun, MD, Consultant
Darron A. Bacal, MD, Consultant
Research
Kristina Tarczy-Hornoch, MD, Chair
Gil Binenbaum, MD, Vice Chair
Mays A. El Dairi, MD
Gena Heidary, MD, PhD
Sudha Nallasamy, MD
Iris S. Kassem, MD, PhD
Stacy L. Pineles, MD
Jingyum Wang, PhD
Jing Jin, MD, PhD
Sylvia R. Kodsi, MD
Daniel J. Salchow, MD
Joost Felius, PhD, Consultant
Graham E. Quinn, MD, Consultant
Socioeconomic
Michael J. Bartiss, OD, MD, Chair
Deborah S. Lenahan, MD, Vice Chair
Janine N. Smith-Marshall, MD
Aaron M. Miller, MD, MBA
Shira L. Robbins, MD
Garima Lal, MD
Derek B. Hess, MD
Marc F. Greenberg, MD
Rebecca S. Leenheer, MD
Lisa P. Rovick, MHSc, CO, COMT
Irene H. Ludwig, MD
John E. Bishop, MD
Eric A. Lichtenstein, MD
Robert W. Enzenauer, MD, MPH
A. Melinda Rainey, MD
Edward W. Cheeseman, Jr, MD
Eric A. Packwood, MD
Robert E. Wiggins, Jr, MD
Robert S. Gold, MD, Consultant
Sheryl M. Handler, MD, Consultant
Lance Siegel, MD, Consultant
Michael X. Repka, MD, Consultant
Nils K. Mungan, MD, FRCSC
Merrill L. Stass-Isern, MD
Daniel M. Laby, MD
Vision Screening
Mae Millicent W. Peterseim, MD, Chair
Geoffrey E. Bradford, MD, Vice Chair
Shiva Bohn, MD
Daniel J. Karr, MD
James W. O’Neil, MD
Natario L. Couser, MD
Deborah R. Fishman, MD
Andrew C. Black, MD
David I. Silbert, MD
Noelle Matta, CO, COT
Robert W. Arnold, MD
Amy K. Hutchinson, MD
Todd J. Murdock, MD
Robert W. Lingua, MD
Kimberly Merrill, CO
Jennifer A. Dunbar, MD
Linda M. Lawrence, MD
Jeffrey D. Colburn, MD
Todd A. Goldblum, MD
Daniel E. Neely, MD, Consultant
P. Kay Nottingham Chaplin, Ed.D, Consultant
Kurt Simons, PhD, Consultant
Young Ophthalmologists
Kartik S. Kumar, MD, Chair
Rebecca S. Leenheer, MD, Vice Chair
Lisa Bohra, MD
Sasapin G. Prakalapakorn, MD, MPH
Javaneh Abbasian, MD
Sudha Nallasamy, MD
Megan E. Collins, MD
Kara M. Cavuoto, MD
Michael E. Gray, MD
Jonathan H. Salvin, MD
Raymond G. Areaux, MD
Irene Tung, MD
Janine E. Collinge, MD
Eniolami O. Dosunmu, MD
Wendy S. Chen, MD
Shaival S. Shah, MD
Casey Mickler, MD
Lauren Beth Yeager, MD
Jasleen K. Singh, MD
Martha Grace Green, MD
Courtney Lynn Kraus, MD
Stephanie Dotchin, MD, FRCSC
Learning Disabilities and Vision Therapy Task Force
Sheryl M. Handler, MD, Chair
Walter M. Fierson, MD, Vice Chair
Gregory I. Ostrow, MD
William O. Young, MD
Jorie L. Jackson, CO
Sharon S. Lehman, MD
A. Melinda Rainey, MD
Mark Cascairo, DO
Lisa S. Abrams, MD
Mae Millicent Peterseim, MD
Linda M. Lawrence, MD
Amy R. Wexler, MD
Jane C. Edmond, MD
Michael J. Spedick, MD
Leemor Rotberg, MD
Laura Kirkeby, Consultant
Michael J. Bartiss, OD, MD, Consultant
181
Long Range Planning Task Force
David A. Plager, MD, Chair
C. Gail Summers, MD, Vice Chair
Sherwin J. Isenberg, MD
M. Edward Wilson, Jr, MD
Christie L. Morse, MD
Jennifer Hull - SF AMS
Children’s Eye Foundation Board of Directors
George R. Beauchamp, MD; Chairman of the Board
William E. Gibson, PhD, President
Thomas Rogers, Secretary
John D. Baker, MD, Treasurer
Michael Abrams, MD, Director
Randy Bailey, Director
Denise Chamblee, MD, Director
Mary Louise Collins, MD, Director
Sean P. Donahue, MD, PhD, Director
K. David Epley, MD, Director
Carter Groome, Director
Sebastian Heersink, MD, Director
Mohamad S. Jaafar, MD, Director
Colleen Kuzmich, Director
Sheryl J. Menacker, MD, Director
Grace Mitchell, Director
Sidney Silver, Esq; Director
Merrie Spaeth, Director
Marshall M. Parks, MD, Founder
182
Index of Authors
KEYNOTE: Numbers represent the abstract number, NOT the page number.
Paper abstract: number only / Poster abstract: number plus “p” / E-Poster abstract: number plus “e” /
Workshop abstract: number plus “w”
Abcouwer, Steven 72e
Abdelhafez, Moustafa 1e
Abrahams, Katherine 20p
Acera, Erika 3w
Acevedo-Gonzalez, Pedro 40e
Achim, Catherine 39p
Adams, Gillian 30e, 63e
Adebona, Olumuyiwa 48p, 51p, 26e
Adesina, Ore-Ofe 80e
Agarkar, Sumita 14e
Agarwal, Swati 14
Alamos, Bernardita 39e, 106e, 108e
Albert, Desiree 29e
Alcorn, Deborah 25w
Alfreihi, Shatha 91e
AlHarkan, Dora 4e
Ali, Asim 27p, 35p, 12e
Alniemi, Saba 92e
Altschwager, Pablo 39e, 106e
Anand, Shweta 18
Andorf, Jeaneen 26
Antonetti, David 72e
Apple, Annie 30p
Araneda, Sylvia 106e
Archer, Steven 20, 95e, 18w
Areaux, Raymond 3w
Armstrong, Greg 24p
Arnold, Robert 33, 45e, 126e, 25w
Arnoldi, Kyle 15w
Ashworth, Jane 34p, 49p
Avery, Robert 22p, 8w
Aviles, Claudia 31e
Aznauryan, Erik 9
Aznauryan, Igor 9
Bahl, Reecha 7e
Bakri, Sophie 92e
Balasanyan, Victoria 9
Barker-Griffith, Ann 54p
Barnett, Joshua 12p
Barry, Gerard 11e, 51e
Bartiss, Michael 26w
Bates, Adam 93e
Baumritter, Agnieshka 16p, 17p, 64e
Bdolach, Tali 69e
Beauchamp, George presentation,
CEF awards, CEF update
Beck, Allen 20e, 17w
Ben-Zion, Itay 25p, 113e, 5w
Berrocal, Audina 14p, 20p
Berry, Shauna 78e
Bhatt, Amit 19p
Bhattacharyya, Jina 5
Bhoiwala, Devang 21p
Bhola, Rahul 32e, 107e
Bhoompally, Venkateshwar 79e
Billinghurst, Lori 15p
Binder, Nicholas 33e
Binenbaum, Gil disc of 11&12, 10, 15,
16, 15p, 59e, 4w, 12w
Birch, Eileen 8, 30, 31, 124e
Bishop, John 26w
Biswas, Susmito 34p, 49p
Bitner, Derek, 80e
Black, Brad 24w
Black, Graeme 49p
Boente, Charline 52p
Bolon, Veronica 20p
Bonsall, Dean 66e
Borbolla-Pertierra, Ana 40e
Borchert, Mark 33e
Bosch-Canto, Vanessa 40e
Bothun, Erick disc of 33, 1p, 104e
Bowsher, James 28, 2e
Bragg, Tara 81e
Branson, Bonnie 6p
Bratton, Monica 19e
Braverman, Rebecca 11, 41p, 23w
Breazzano, Mark 54p
Bregman, Jana 34
Briceland, Daniel 24w
Broening, James 1w
Brooks, Steven 98e
Buckley, Edward JAAPOS update,
18w, 30w
Bunce, Catey 63e
Byington, Christopher 50e
Calderwood, Julie 24p
Camero, Kathryn 44p
Cansizoglu, Esra 20p
Cao, Jennifer 11, 12
Capo, Hilda 11p, 23w
Carden, Susan 114e
Carlsson, Birgitta 53e
Carrai, Paola 61e
Cavuoto, Kara 11p, 36p, 27e, 49e,
120e, 20w
Celano, Marianne 27
Cerda, Ashlee 11, 12
Chamblee, Denise 1w
Chan, Robison Paul 14p, 20p
Chandrasekharan, Anjali 5p
Chang, Melinda 82e
Chang, Ta Peter 27e, 49e, 120e
Chang, Yoon-Hee 101e
Chaudhri, Imran 11e
Cheeseman, Edward 32, 71e
Cheng, Ken 24w
Chernodrinska, Violeta 3e
Chiang, Michael 14p, 20p, 6w, 20w
Chisholm, Smith Ann 13p
Choe, Ja-Yoon Uni 13
Choi, Catherine 20
Choi, Young Je 31p
Christiansen, Stephen disc of 18, 1p,
104e
Chung, Daniel 16w
Chung, Sophia 36e
Ciardella, Antonio 61e
Cimino, Heather 42p
183
Clark, Tiana 37p
Clark, Robert 83e
Clayton-Smith, Jill 49p
Coakley, Rebecca 21w
Coats, Brittany 59e
Coats, David 19p, 39p
Cobb, Patricia 77e
Cohen, Ali 40p
Coleman, Anne 82e, 122e
Collinge, Janine 34e, 20w
Colon, Beth 52p
Contractor, Dilshad 9e
Conway, Miriam 29
Corn, Anne 117e
Cotton, C. Michael 119e
Crockett, Charlene 44p
Cruz, Oscar disc of 24, 36e, 30w,
poster tour
Cunningham, Emmett 42e
Curtis, Theodore 20w
Dagi, Linda 7, 23, 23p, 101e, 30w
Dahlmann-Noor, Annegret 30e,
63e
Dale, Talitha 128e
Damarjian, Tina 28, 33p, 2e
Dang, Sabin 7e
Daniel, Ebenezer 16p, 2w
Dao, Lori 30, 109e, 124e
Daugherty, William 11w
Davidson, Jennifer 32, 45p, 23e,
25e, 71e,
Davidson, Stephanie 16
Davis, Ryan 50p
Day, Susan 42e, 125e
de Alba, Manuel 43e
De La Cruz, Angie 30, 31
Dean, Trevano 25
Dean, Will 26e
Dearwater, Brandy 50e
Debenedictis, Caroline 90e
Del Monte, Monte 95e, 112e
Delman, Noa 6e
DeLuca, Adam 26
Demer, Joseph 8, 4p, 82e, 83e,
84e, 89e, 5w
Demny, Ann 19p
DeRispinis, Patrick 116e
Desai, Roshni 14e
Devould, Chantel 24, 52e
Dhannawat, Sneh 85e
Diao, Wei 55e
Diehl, Nancy 88e, 99e
Dikova, Stela 3e
Ding, Kai 62e
Ditta, Lauren 52e
Dodobara, Luz 67e
Donahue, Sean welcome,
moderator, International meeting update, 34, 25w, 30w
Donaldson, Dana 28, 33p, 2e
KEYNOTE: Numbers represent the abstract number, NOT the page number.
Paper abstract: number only / Poster abstract: number plus “p” / E-Poster abstract: number plus “e” /
Workshop abstract: number plus “w”
Doshi, Poonam 34e
Dotan, Gad 6e, 46e, 94e
Downing, Eric 32e
Drack, Arlene 26, 41e, 16w, 29w
Drews-Botsch, Carolyn 27, 24e
Duncan, Jared 65e
Eagle, Ralph 4, 38e
Edmond, Jane 8w, 10w
Eisenberg, Marina 95e
Ekdawi, Noha 115e
Ela-Dalman, Noa 46e
Elbaz, Uri 27p, 12e
El-Dairi, Mays 2, 3, 4w
Eldweik, Luai 15e
Elliott, Alexandra 44e
Ellis, Forrest J 18w, 29w
Ellis, George 3w, 22w
Enweronu-Laryea, Christabel 70e
Enzenauer, Robert 11
Erdogmus, Deniz 20p
Erenler, Feyza 6
Essuman, Vera 70e
Estephane, Noura 32e
Eustis, H. Sprague 96e
Evans, Shaun 59e
Fabian, Ido Didi 25p
Faron, Nicholas 38p
Farris, Bradley 80e
Fasiuddin, Airaj 56p
Felius, Joost 109e, 4w
Fierson, Walter 7w
Forbes, Brian 15, 15p, 12w
Forcina, Blake 66e
Forster, Richard 13e
Fredrick, Douglas 55p
Freedman, Sharon intro Costenbader,
moderator, 2, 3, 25, 50p, 65e, 73e,
76e, 119e, 5w, 17w, 22w
Freeman, Richard 15w
Friess, Amanda 30p
Fritz, Traci 15w
Gaffar, Majida 17e, 74e
Gajdosova, Eva 34p
Galli, Jay 28, 2e
Galli, Marlo 97e, 103e
Gandham, Sai 21p
Gandhi, Nandini 22e
Gasper, Catherine 16e
Geloneck, Megan 15
Ghasia, Fatema 35, 32p, 53p
Gil, Arminda 67e
Gillespie, Rachel 49p
Gilmore, John 31
Glasgow, Ben 91e
Gode, Vaibhav 123e
Gofman, Nina 46e
Goldchmit, Mauro 58e
Gordillo, Luz 67e
Gore, Charlotte 12, 23, 51p
Grace, Bithiah 5
Grace, Sara 11p
Graeber, Carolyn 9p
Granet, David 8p, 25p, 3w, 18w, 22w
Grannis, Charity 39p
Grant, Simon 29
Graves, Emily 52e
Greebel, Gennifer 17e
Greenberg, Marc 30w
Greenberg, Matthew 27e
Greene, Alan 25w
Griepentrog, Gregory 28p
Griffith, Joseph 42p
Gunton, Kammi 90e
Guo, Suqin 48e, 116e
Guyton, David 2p, 18w
Habib, Larissa 98e
Haering, Celia 45e
Hahn-Parrott, Laurie 15w
Haider, Kathryn 28, 33p, 2e, 68e
Hamming, Nancy poster tour
Handler, Sheryl 7w
Hans, Amneet 56e
Hansberry, David 48e
Hariharan, Luxme 9e, 24w
Hartmann, Eugenie 27, 46p
Hassan, Mohamed 99e
Hatt, Sarah 10p, 43p
Heidary, Gena 23p, 8w
Hellgren, Kerstin 53e
Hellström, Ann 53e, 77e
Hendler, Karen 122e
Hendricks, Dorothy 30p
Henson, Karl 15w
Hermann, Alyssa 51e
Hess, Robert 30
Hildebrand, P. Lloyd 2w
Hilely, Assaf 18e
Ho, Tiffany 13
Hoehn, Mary 24p
Hoekel, James 38p
Holgado, Sandra 119e
Holmes, Jonathan 22, 10p, 43p, 85e,
28w
Holmström, Gerd 53e
Hoover, Darren 3p
House, Robert 118e
House, Ryan 127e
Hsu, Benson 57e
Huang, Jiayan 10
Hubbard, George 18p
Hug, Denise 25
Hunter, David 17, 23, 9p, 18w
Huston, Pamela 3p
Hutchinson, Amy 18p
Hynes, Patrick 24w
Iannaccone, Alessandro 12p
Ireland, Kathryn 78e
Isaac, Maram 75e
Isenberg, Sherwin remarks, awards,
intro of Parke, moderator, 8, 82e
Ismaeil, Noor 16
Issaho, Dayane 19e
184
Jaafar, Mohamad 29w
Jackson, Jorie 3w, 5w
Jain, Piyush 123e
Jain, Saurabh 18, 5e, 8e, 87e
Jakobsson, Peter 53e
Jensen, Anne 10, 15p
Jewsbury, Hugh 100e, 121e
Jin, Jing 30p, 4w
Jiramongkolchai, Kim 2, 3, 50p
John, Ann 48e
John, Elizabeth 56p, 48e
Johnston, Julia 9e
Jonas, Karyn 14p
Jones, Alistair 18, 87e
Jordan, Catherine 10e
Jost, Reed 30, 31, 124e
Juárez-Echenique, Juan 40e
Jung, Jaeho 22
Jung, Jennifer 11
Jung, Ji Sung 31p
Kalashnikova, Mariya 43e
Kaliki, Swathi 4
Källén, Karin 53e
Kalpathy, Jayashree 20p
Karp, Karen 17p, 64e, 2w
Karr, Daniel 128e
Kassem, Iris 4w
Katz, Scott 124e
Kauffman, David 12
Kay, Matthew 78e
Kazlas, Melanie 17, 23
Keeffe, Jill 114e
Kehl, Sue 7p
Kekunnaya, Ramesh 5p, 79e, 19w,
28w
Kellogg, Clint 78e
Kelly, Krista 31
Kemp, Pavlina 101e
Kemper, Alex 2w
Kerr, Natalie 24, 12p, 52e, 3w
Khan, Arif 4e, 14w, 19w
Khan, M. Saad 35p
Kim, Anna 102e, 105e
Kim, Dae Hyun 31p
Kinori, Michael 8p, 25p
Klein, Shelley 110e
Klufas, Michael 14p
Ko, Ashley 41e
Koller, Harold intro Apt
Kong, Lingkun 12, 19p, 39p, 44p
Kotecha, Sailesh 121e
Kothari, Mihir 123e
Kovarik, Jessica 28, 2e, 34e
Kowal, Lionel 18w
Kraker, Raymond 25
Krishan-Dave, Nisha 23w
Krishnamoorthy, Mala 21p
Kruger, Stacey 1p, 24w
Kruglyakova, Jacqueline 33e
Kumar, Atul 5
Kumar, Priyanka 32p
KEYNOTE: Numbers represent the abstract number, NOT the page number.
Paper abstract: number only / Poster abstract: number plus “p” / E-Poster abstract: number plus “e” /
Workshop abstract: number plus “w”
Lal, Garima 78e
Lally, Sara 26p, 38e
Lambert, Scott 26, 27, 1p, 46p, 47p,
20e, 24e, 19w
Lang, Richard 77e
Larson, Scott 21, 26, 40p, poster tour
Lavrich, Judith 90e
Lawrence, Linda 118e, 127e, 11w
Lazar, Elizabeth 25
Lee, Rachel 55p
Lee, Thomas 13
Lee, Vivian 59e
Leenheer, Rebecca 20w
Lehman, Sharon AAP update,
presentation, 30p
Leiba, Hana 18e, 69e
Lenahan, Deborah 26w
Lenhart, Phoebe 25, 19w
Lenius, Laura 104e
Lenk, Mary Anne 50e
Leske, David 10p, 43p, 85e
Levin, Alex 19, 55e, 5w, 9w, 12w, 17w
Li, Simone 30
Lichtenstein, Eric 26w
Lim, Shin 86e
Lindner, Heather 72e
Ling, Maya 42e
Lizama, Macarena 39e
Lloyd, Christopher disc of 26, 34p, 49p
Lo, Phey Feng 93e
Lodhia, Vaishali 87e
Lofqvist, Chatarina 77e
Logan, April 35e
Loh, Allison 20p
Longmuir, Susannah 26
Lueck, Amanda 11w
Lueder, Gregg disc of 15, 13p, 97e,
103e, 5w
Lundgren, Pia 53e, 77e
Lusk, Kelly 117e, 11w, 21w
Lynch, Anne 11, 12
Lynn, Michael 1p, 46p, 47p, 24e
Lyon, David 56e
MacKinnon, Sarah 7
Magdalene, Damaris 5
Mali, Yasmin 11e
Manchandia, Ajay 6
Manley, Donnelson 90e
Mannis, Tova 9e
Mantagos, Iason 17
Marsh, Justin 2p
Martin, Daniel 42p
Martin, Lisa 35e
Martin, Taliva 42e
Martinez-Helfman, Sarah 55e
Matalia, Jyoti 79e
Matsui, Kyoko-Ohno 61e
Mawrie, Darilang 5
Mayo Ortega, Liliana 118e
McCannel, Colin 91e
McCannel, Tara 91e
McClatchey, Scott 8p
McCourt, Emily 11, 12
McDonald, Russ 124e
McKeown, Craig 120e
Mehravaran, Shiva 122e
Melnik, Pesah 69e
Melvin, Patrice 101e
Merrill, Kimberly 104e
Mezad-Koursh, Daphna 6e, 46e
Mezer, Eedy 58e
Miller, Aaron 3w, 15w
Miller, Ellen 35e
Miller, Kyle 8p
Mills, Monte 16
Minakaran, Neda 5e
Mireskandari, Kamiar 27p, 35p, 12e,
75e
Mohammad, A. Sadiq 23
Mohney, Brian 28p, 88e, 92e, 99e
Mohomed, Faheem 56e
Moke, Pamela 43p
Monsalve, Pedro 49e
Morale, Sarah 30
Morales, Cristóbal 108e
Morara, Mariachiara 61e
Morgado, Alvaro 106e
Morris, Caleb 73e
Morrison, David disc of 10, 12, 47p,
24e
Morse, Christie 6w, 22w
Motley, William 50e, 23w
Moya, Diana 29e
Mungan, Nils 26w
Murchison, Ebony 52e
Musa, Pablo 39e
Mutchnick, Ian 32e
Nallasamy, Sudha 13, 4w
Nash, Bertha 56p
Neely, Daniel 28, 1p, 33p, 2e,
Nejad, Mitra 105e
Nelson, Leonard 94e
Nguyen, Matthew 20e
Nihalani-Gangwani, Bharti 21e, 26e
Niles, Philip 40p
Nti, Akosua 64e, 70e
Nucci, Paolo 58e, 61e
O’Hara, Mary 22e
Ofori-Darko, Asiedua 70e
Okeya, Marian 121e
Olayanju, Jessica 28p
Olitsky, Scott 6p
Olson, Richard 26, 40p
Ordaz-Favila, Juan 40e
Orge, Faruk 47p, 52p, 47e
Ostmo, Susan 14p
Owen, Leah 45p, 23e, 25e, 71e
Owings, Sandy 34
Oyama Ganiko, Rosa Yemi 118e
Packer, Roger 22p
Padovani-Claudio, Dolly 72e
Páez, Juan Homar 31e, 43e
185
Papa, Carrie 32
Papadopoulos, Maria 30e
Parikh, Ruby 56e
Park, Sunju 54e
Parke, David address
Parness-Yossifon, Reut 18e
Parrucci, Nick 43p
Patel, Jinali 55e
Patel, Samir 14p
Patel, Sejal 54e
Patterson, Barron 34
Patthoff, Mayme 42p
Paysse, Evelyn 39p, 28w
Pearson, Denise 17p
Peragallo, Jason 23w
Peterseim, Mae Millicent 32
Petru, Ann 42e
Pfeifer, Wanda 41e
Pham, Chengde 114e
Pichi, Francesco 61e
Pihlblad, Matthew 6, 29e
Pineles, Stacy 8, 82e, 91e, 102e,
105e, 4w, 8w, 30w
Pistilli, Maxwell 17p
Plager, David moderator, 28, 33p,
2e, 34e
Pogrebniak, Alexander 60e
Pond, Michael 55e
Prabhu, Sanjay 7
Prakalapakorn, S. Grace 65e, 73e,
76e, 20w
Pritchard, Cindy 3w, 22w
Puente, Michael 12
Quinn, Graham 10, 16p, 17p, 64e,
67e, 70e, 2w
Qureshi, Hanya 94e
Racette, Lyne 33p
Rachdan, Diyaa 35p
Radinson Alvarado, Ivonne 118e
Raghu, Preethi 21p
Rahmani, Bahram 25
Rainey, A. Melinda 7w, 11w
Rajjoub, Raneem 22p
Ramasubramanian, Aparna 9w
Ramsden, Simon 49p
Ramsey, Jean 24w
Ramskold, Louise 87e
Raufi, Nikolas 73e
Read, Sarah 36p
Reddy, Anvesh 56e
Reese, J. Jeffrey 43p
Reid, Julia 15p
Reiser, Bibiana Jin 9e, 28w
Repka, Michael 25, 16p, 6w, 28w
Reynaud, Alexandre 30
Reynolds, James 6, 29e
Robbins, Shira 12, 8p, 25p
Roberts, Gavin 28, 33p, 2e
Rodrigues, Ana Paula 19w
Rodriguez, Maria Teresa 31e, 43e
Rogers, David 15p, 10e, 35e
KEYNOTE: Numbers represent the abstract number, NOT the page number.
Paper abstract: number only / Poster abstract: number plus “p” / E-Poster abstract: number plus “e” /
Workshop abstract: number plus “w”
Romano, Simona 61e
Roper-Hall, Gill 36e
Rosenberg, Jamie 54e
Rosenthal, Elyssa 1w
Rotberg, Leemor 23w
Rothman, Adam 119e
Rotruck, Jill 125e
Rovick, Lisa 3w
Ruben, James 43p
Rubin, Steve 12w
Rutar, Tina 23w, poster tour
Ruttum, Mark 7p
Ryan, Michael 14p, 20p
Sabah, Judith 22e
Sachdeva, Virender 5p
Salgado, Cristián 39e, 106e, 108e
Salunkhe, Nitesh 107e
Salvin, Jonathan 30p
Sanhueza, Felipe 106e
Santa Maria, Kathleen 55e
Sarin, Neeru 119e
Saunders, Richard 71e
Saunte, Jon Peiter 37e
Saxena, Rohit 107e
Schenkman, Nathan 118e
Schliesser, Joshua 28, 33p, 2e, 56e
Schmitt, Melanie 23w
Schnall, Bruce 90e, 9w
Schwartz, Terry 117e, 21w
Schwarzlose, Rebecca 7e
Schweigert, Anna 3w
Scott, William 40p
Senft, Susan 28e
Serafino, Massimiliano 61e
Serenius, Fredrik 53e
Sethi, Shivani 16
Shaffer, James 15, 16
Shah, Ankoor 17, 48p, 51p
Shah, Dipal 74e
Shah, Pulin 96e
Shaikh, Aasef 32p, 53p
Shainberg, Marla 20e
Shanmugam, Sumathi 72e
Sharma, Aman 6, 29e
Sharma, Pradeep 32e, 107e
Sheeley, Megan 29e
Sheth, Shivanand 114e
Shields, Carol 4, 26p, 38e, 9w, 13w
Shields, Jerry 4, 26p, 9w, 13w,
Shinwell, Eric 69e
Shirer, Sarah 71e
Siatkowski, R. Michael 62e, 80e, 10w,
22w
Silbert, David 33, 126e, 3w, 20w, 25w
Silverstein, Evan 2, 50p
Simmer-Beck, Melanie 6p
Simmons, Steven 21p
Simon, John 21p, 11e, 51e
Sindt, Christina 81e
Singh, Jasleen 11, 20
Sloper, John 29
Smith, Heather 28, 33p, 2e, 68e
Smith, Lois 77e
Snitzer, Melanie 55e
Solanes, Federica 108e
Song, Yong Ju 31p
Sowell, Michael 32e
Spierer, Abraham 25p
Spierer, Oriel 13e, 120e
Sprunger, Derek IPOSC update,
moderator, 28, 33p, 2e
Stafford, Lucy 8e
Stager Jr, David 30, 109e, 124e
Stager Sr, David 109e, 18w
Steinkuller, Paul 19p
Stjernqvist, Karin 53e
Stolovitch, Chaim 6e, 46e
Stone, Edwin 26
Strauss, Nicholas 29e
Strominger, Mitchell 110e
Stout, Ann poster tour
Struble, Roger 127e
Strungaru, Hermina 27p, 12e
Suh, Soh Youn 89e
Sulewski, Melanie 16
Surti, Kavita 28e
Sussenbach, Evan 62e
Suttle, Catherine 29
Suwannaraj, Sirinya 120e
Tadros, Dina (Sabry) 45p, 23e
Tae, Tara 24
Tai, Vincent 119e
Tailor, Vijay 30e
Tan, Roland Joseph 4p
Tarcy-Hornoch, Kristina intro Young
Investigator, 4w, 6w
Tawse, Kirstin 110e
Tehrani, Nasrin 75e
Terveen, Daviel 57e
Todani, Amit 21p
Tornqvist, Kristina 53e
Toth, Cynthia 119e
Traboulsi, Elias 42p, 24e, 14w, 29w
Tran, Hang 78e
Trimboli-Heidler, Carmelina 22p
Trivedi, Rupal 32, 45p, 16e, 23e, 25e,
71e
Trower, Joyce 127e
Tsui, Irena 12
Tsukikawa, Mai 38e
Tufty, Geoffrey 57e
Turlapati, Namratha 7p
Turner, Reid 25e
Tychsen, Lawrence 38p
Unkrich, Kelly 54p
Utz, Virginia 29w
VanderVeen, Deborah 1p, 15e, 21e,
24e, 26e, 29w
Vaughan, Joannah 128e
Velez, Federico 8, 82e, 91e, 102e,
105e, 28w
Vicchrilli, Sue 27w
Vickers, Laura 76e
Vieson, Kelli 50e
186
Viet, Du Tran 119e
Villanueva, Ana 67e
Wade, Kelly 16p, 2w
Wagner, Brandie 11, 12
Wagner, Rudolph 116e
Wallace, David 65e, 73e, 76e
Walton, David 1
Wan, Michael 17
Wang, Daniel 39p
Wang, Jingyun 28, 33p, 2e, 68e, 4w
Wang, Serena 25, 19e
Wang, Yi-Zhong 30
Warner, Naomie 90e
Wasserman, Barry 38e, 90e
Watkins, William John 121e
Watts, Patrick 100e, 121e
Way, Amanda 14
Weakley, David 19e, 2w
Weaver, Daniel 2w
Weber, Paul 1w
Weed, Matthew 21, 26
Weikert, Mitchell 39p
Weil, Natalie 18p
Weiner, Rachel 55e
Weng, Frank 23p
West, Constance 50e
Whitlow, Bryan 39p
Wiggins, Robert moderator, 6w, 22w,
26w
Williams, Pamela 24w
Wilson, M. Edward moderator, 32,
45p, 16e, 23e, 25e, 19w
Wilson, Machelle 22e
Wilson, Rhonda 42p
Winkler, Kathryn 7e
Wong, Inez 86e
Wong, Ryan 12
Wong, Susie 28e
Wong, Wan 86e
Woodward, Lee 19w
Wright, Kenneth 20w
Wu, Chris 112e
Wygnanaski-Jaffe, Tamara 25p, 58e,
5w
Yamada, Tomohiko 43p
Yang, Michael 77e
Yanovitch, Tammy 62e
Yen, Kimberly 25, 44p
Ying, Gui-shuang 10, 16p, 17p
Young, William 7w
Yu, Fei 122e
Zobal-Ratner, Jitka 11e, 23w
Zou, Di 8e
hrno.sales@hyatt.com
neworleans.hyatt.com
Hyatt Regency New Orleans Floor Plan
3-D FLOOR PLAN
All Levels
RELIANCE 1-5
RELIANCE BOARDROOM
STAIRS TO THIRD
ATRIUM ELEVATORS
RESTROOMS
2
1
IMPERIAL BOARDROOMS
3
5A
4
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LOBBY ELEVATOR
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12A
10A
10B
11A
9
11B
8
5
7
4
12B
6
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Notes
188
Notes
189
Notes
190