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A New Method for Determining an AgeIndependent Axial Length Percentage Reduction for Myopia Therapies
Published 2020 by Joseph Rappon
Co-Author(s): Jay Neitz, Maureen Neitz, Thomas Chalberg
Program Number: 205349
Article Type: Scientific Program
Purpose: New therapies are being developed to combat the myopia epidemic and therapeutic efficacy is being compared across clinical trials. The most robust clinical studies include change from baseline in axial length (AL) as a primary endpoint and this is often evaluated as a percentage reduction versus the control arm. However, it is well-established that the AL of even emmetropic children’s eyes continues to increase until at least the mid-teens. The effect of this physiological, as opposed to pathological, AL growth needs to be considered. The aim of this research was to determine the expected physiological AL growth of subjects in the CYPRESS study such that a therapeutic effect, accounting for expected physiological AL growth, could be estimated for these novel spectacle lenses.
Methods: CYPRESS (NCT03623074) is a multi-center, randomized, controlled, double-masked, clinical trial designed to evaluate two investigational spectacle lenses (T1 and T2) vs. control lenses. Two hundred and fifty-six myopic subjects, aged 6 to 10 years at screening, who met criteria were randomized and dispensed lenses across 14 sites. For each study arm, the AL growth of an aged-matched, emmetropic cohort was calculated based on published data from the Orinda Longitudinal Study of Myopia study and then compared to AL growth observed in the CYPRESS study.
Results: After 12 months in CYPRESS, the AL change from baseline was 0.15 mm, 0.20 mm, and 0.30 mm for T1, T2, and control respectively. The differences in mean axial length progression rates between T1 vs. control at 12 months was 0.15 mm (95% CI: 0.10 to 0.20 mm, p<0.0001), which represents a 50% reduction. The difference in axial length for T2 versus control at 12 months was 0.10 mm (95% CI: 0.04 to 0.17 mm, p=0.0018), which represents a 33% reduction. The calculated age-matched AL change from baseline of emmetropic eyes, representing expected physiological AL growth, was 0.15 mm, 0.14 mm, and 0.15 mm for the T1, T2, and control arms respectively. The percent reduction in pathological AL growth was obtained by subtracting the expected physiological growth from each study arm, giving 99% reduction in pathological AL progression for T1 and 63% reduction for T2.
Results: Practitioners need to evaluate the safety and efficacy of different myopia therapies to determine treatment recommendations for individual patients. This can be difficult due to the challenges inherent in cross-trial comparisons, which often enroll subjects of different baseline demographics, including age, that are known to influence rates of myopia progression. Here, we present a method for evaluating treatment effects by removing expected physiological AL change, and therefore estimating pathological AL change, in an age-independent manner.
Methods: CYPRESS (NCT03623074) is a multi-center, randomized, controlled, double-masked, clinical trial designed to evaluate two investigational spectacle lenses (T1 and T2) vs. control lenses. Two hundred and fifty-six myopic subjects, aged 6 to 10 years at screening, who met criteria were randomized and dispensed lenses across 14 sites. For each study arm, the AL growth of an aged-matched, emmetropic cohort was calculated based on published data from the Orinda Longitudinal Study of Myopia study and then compared to AL growth observed in the CYPRESS study.
Results: After 12 months in CYPRESS, the AL change from baseline was 0.15 mm, 0.20 mm, and 0.30 mm for T1, T2, and control respectively. The differences in mean axial length progression rates between T1 vs. control at 12 months was 0.15 mm (95% CI: 0.10 to 0.20 mm, p<0.0001), which represents a 50% reduction. The difference in axial length for T2 versus control at 12 months was 0.10 mm (95% CI: 0.04 to 0.17 mm, p=0.0018), which represents a 33% reduction. The calculated age-matched AL change from baseline of emmetropic eyes, representing expected physiological AL growth, was 0.15 mm, 0.14 mm, and 0.15 mm for the T1, T2, and control arms respectively. The percent reduction in pathological AL growth was obtained by subtracting the expected physiological growth from each study arm, giving 99% reduction in pathological AL progression for T1 and 63% reduction for T2.
Results: Practitioners need to evaluate the safety and efficacy of different myopia therapies to determine treatment recommendations for individual patients. This can be difficult due to the challenges inherent in cross-trial comparisons, which often enroll subjects of different baseline demographics, including age, that are known to influence rates of myopia progression. Here, we present a method for evaluating treatment effects by removing expected physiological AL change, and therefore estimating pathological AL change, in an age-independent manner.
A Nonsurgical Approach to the Treatment of a Fullthickness Macular Hole
Published 2020 by Elizabeth Choi
Co-Author(s): NULL
Article Type: Residents Day
Abstract: While surgery is the standard intervention for macular holes, successful resolution has been observed in the literature using non-invasive
Methods:. This case describes the use of topical medications in the treatment of a macular hole.
Case History: 73 yo WM c/o "�metamorphopsia"� in the right eye x2 months.
- Present at distance and near, OS vision unaffected.
- Denies flashes, floaters, transient/total loss of vision.
- MHx: HTN, OSA, cluster HA, rosacea, tinnitus (-) DM
- OHx: vertical phoria, DES (-) ocular surgeries
- Ocular meds: herbal bella donna supplements, boric acid eye wash
Pertinent Findings: - VA cc: OD 20/50 PH NI (prev 20/20), OS 20/20
- Externals unremarkable OU
- Amsler grid: OD metamorphopsia of central 4 squares, no scotoma; OS wnl.
- SLE OU: capped glands, 2+ anterior cortical spoking and 1+ nuclear sclerosis
(-) Watzke Allen OD; light bends without break
- DFE/mac OCT:
OD: full thickness macular hole, vitreous focally adhered to temporal fovea. Tenting of outer retina with intra-retinal cystic spaces.
OS: vitreomacular adhesion, foveal contour intact.
Differential Diagnosis: - Full-thickness macular hole
- Central serous chorioretinopathy
- Epi-retinal membrane with pseudohole/lamellar hole
- Cystoid macular edema
Diagnosis and Discussion: The full-thickness macular hole secondary to vitreomacular traction was diagnosed based on clinical appearance and OCT findings. The patient's medical/ocular history precluded other differentials e.g. diabetic macular edema, CME secondary to ocular surgeries or active pathology.
Macular holes secondary to vitreal traction are traditionally understood to have a mechanical etiology. However, the hydration theory suggests an additional inflammatory component, in which vitreal fluid seeps into the retina through an inner retinal break. In line with this theory, a course of anti-inflammatory treatment could encourage hole closure by decreasing intra-retinal edema
Treatment, Management: The patient was counseled on the post-operative details of pars plana vitrectomy with gas bubble. He felt concerned about laying face-down for an extended time frame, given his back pain. He asked specifically to first trial topical corticosteroids, based on literature he had read prior to his appointment. Weighing the risks and benefits with the attending retinal specialist, we concluded that a short course of topical medication would be non-inferior to a conservative wait-and-see approach. Furthermore, the patient was more receptive to our counseling on surgical outcomes and expectations and, if needed at follow-up, open to pursuing the surgical route. The patient will be seen in 4 weeks to determine the outcome and requisite next steps. He was appreciative to be involved in his own care, and in agreement with his treatment plan going forward.
Results: Cases in the literature describe resolution of full-thickness macular holes using topical anti-inflammatory monotherapy. In most of these cases, the underlying etiology was not vitreo-macular traction alone (e.g. trauma, recurrent hole without vitreal involvement). However, this patient strongly favored non-invasive homeopathy, and wanted to attempt a non-surgical method. Involving the patient in his/her own care, with extensive education and counseling, yields better compliance and long-term clinical outcomes, and more patient-centric care. Bibliography: 1. Bonnell, Alyssa C, et al. "�MACULAR HOLE CLOSURE WITH TOPICAL STEROIDS."� Retinal Cases & Brief Reports, U.S. National Library of Medicine, 2 Mar. 2020, www.ncbi.nlm.nih.gov/pubmed/32132390.
2. Duker, Jay S., et al. "�The International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Hole."� Ophthalmology, vol. 120, no. 12, 2013, pp. 2611"�2619., doi:10.1016/j.ophtha.2013.07.042.
3. Li, Albert S., and Philip J. Ferrone. "�Traumatic Macular Hole Closure And Visual Improvement After Topical Nonsteroidal Antiinflammatory Drug Treatment."� RETINAL Cases & Brief Reports, Publish Ahead of Print, 2018, doi:10.1097/icb.0000000000000705.
Methods:. This case describes the use of topical medications in the treatment of a macular hole.
Case History: 73 yo WM c/o "�metamorphopsia"� in the right eye x2 months.
- Present at distance and near, OS vision unaffected.
- Denies flashes, floaters, transient/total loss of vision.
- MHx: HTN, OSA, cluster HA, rosacea, tinnitus (-) DM
- OHx: vertical phoria, DES (-) ocular surgeries
- Ocular meds: herbal bella donna supplements, boric acid eye wash
Pertinent Findings: - VA cc: OD 20/50 PH NI (prev 20/20), OS 20/20
- Externals unremarkable OU
- Amsler grid: OD metamorphopsia of central 4 squares, no scotoma; OS wnl.
- SLE OU: capped glands, 2+ anterior cortical spoking and 1+ nuclear sclerosis
(-) Watzke Allen OD; light bends without break
- DFE/mac OCT:
OD: full thickness macular hole, vitreous focally adhered to temporal fovea. Tenting of outer retina with intra-retinal cystic spaces.
OS: vitreomacular adhesion, foveal contour intact.
Differential Diagnosis: - Full-thickness macular hole
- Central serous chorioretinopathy
- Epi-retinal membrane with pseudohole/lamellar hole
- Cystoid macular edema
Diagnosis and Discussion: The full-thickness macular hole secondary to vitreomacular traction was diagnosed based on clinical appearance and OCT findings. The patient's medical/ocular history precluded other differentials e.g. diabetic macular edema, CME secondary to ocular surgeries or active pathology.
Macular holes secondary to vitreal traction are traditionally understood to have a mechanical etiology. However, the hydration theory suggests an additional inflammatory component, in which vitreal fluid seeps into the retina through an inner retinal break. In line with this theory, a course of anti-inflammatory treatment could encourage hole closure by decreasing intra-retinal edema
Treatment, Management: The patient was counseled on the post-operative details of pars plana vitrectomy with gas bubble. He felt concerned about laying face-down for an extended time frame, given his back pain. He asked specifically to first trial topical corticosteroids, based on literature he had read prior to his appointment. Weighing the risks and benefits with the attending retinal specialist, we concluded that a short course of topical medication would be non-inferior to a conservative wait-and-see approach. Furthermore, the patient was more receptive to our counseling on surgical outcomes and expectations and, if needed at follow-up, open to pursuing the surgical route. The patient will be seen in 4 weeks to determine the outcome and requisite next steps. He was appreciative to be involved in his own care, and in agreement with his treatment plan going forward.
Results: Cases in the literature describe resolution of full-thickness macular holes using topical anti-inflammatory monotherapy. In most of these cases, the underlying etiology was not vitreo-macular traction alone (e.g. trauma, recurrent hole without vitreal involvement). However, this patient strongly favored non-invasive homeopathy, and wanted to attempt a non-surgical method. Involving the patient in his/her own care, with extensive education and counseling, yields better compliance and long-term clinical outcomes, and more patient-centric care. Bibliography: 1. Bonnell, Alyssa C, et al. "�MACULAR HOLE CLOSURE WITH TOPICAL STEROIDS."� Retinal Cases & Brief Reports, U.S. National Library of Medicine, 2 Mar. 2020, www.ncbi.nlm.nih.gov/pubmed/32132390.
2. Duker, Jay S., et al. "�The International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and Macular Hole."� Ophthalmology, vol. 120, no. 12, 2013, pp. 2611"�2619., doi:10.1016/j.ophtha.2013.07.042.
3. Li, Albert S., and Philip J. Ferrone. "�Traumatic Macular Hole Closure And Visual Improvement After Topical Nonsteroidal Antiinflammatory Drug Treatment."� RETINAL Cases & Brief Reports, Publish Ahead of Print, 2018, doi:10.1097/icb.0000000000000705.
A Novel OPA3 Mutation in Costeff Syndrome
Published 2020 by Stephanie Aigbe
Co-Author(s): NULL
Article Type: Residents Day
Abstract: Costeff Syndrome causes visual and motor impairments primarily in Iraqi-Jewish populations. This report details an affected case in a consanguineous family who presents with optic atrophy, cerebellar ataxia, and spasticity with hyperreflexia.
Case History: 31-year-old Afghan male
Chief complaint: difficulty viewing school material on phone screen (online classes due to COVID-19)
History: bilateral optic atrophy, nystagmus, large-angle alternating exotropia, refractive error, headaches, depression
Medications: coenzyme Q10, levocarnitine, nortriptyline, magnesium oxide, propranolol, and sumatriptan
Followed by genetics, neurology, ophthalmology, physical therapy (PT), the Commission for the Blind
Pertinent Findings: Clinical:
BCVA OD 20/200; OS 20/400
Nystagmus, visual field loss, optic nerve pallor OU
Physical:
Cerebellar ataxia, spasticity with hyperreflexia, lumbar spondylosis without myelopathy, radicular syndrome of lower limbs with worsening gait
Social:
Fled Afghanistan five years ago; father and one sister currently missing
3/6 siblings affected (parents are unaffected)
Completed six years of education
Not using low vision/mobility aids; "�embarrassed"� to use them
Multiple hospitalizations due to falls
Declined counseling services in the past; history of poor medication compliance
After extensive education, he agreed to a social work referral to assist with integration of low vision aids and to discuss more suitable mobility aids with PT
Genetic/lab studies:
Genetics: A novel homozygous variant of uncertain significance, c.142+2_142+3dupTG (intronic) identified in OPA3
Lab: Elevated levels of 3-methylglutaconic (3-MGC) aciduria type III
Radiology studies:
Lumbar spine CT without contrast: Chronic bilateral pars defect at L5 with grade 1 anterolisthesis of L5 on S1. No evidence of acute fracture or dislocation.
Brain MRI: Unremarkable
Head CT: Unremarkable
Differential Diagnosis: Primary differential: autosomal dominant optic atrophy. Others include Leber Hereditary Optic Neuropathy, Cerebral Palsy, and Wolfram syndrome.
Diagnosis and Discussion: Costeff Syndrome is a rare autosomal recessive neuro-ophthalmologic condition that affects 1 in 10,000 Iraqi-Jewish indiviudals.1 Very few affected individuals outside of this population have been identified. It is characterized by infantile optic atrophy, movement disorder, and 3-MGC aciduria. Other features include nystagmus, strabismus, spastic paraplegia, ataxia, and cognitive deficiency. This disorder was first identified in Iraqi-Jewish people in which relationships between the affected individuals were unknown3. Mutations in the OPA3 outer mitochondrial membrane lipid metabolism regulator gene are causative and can be analyzed with genetic testing. The condition may progress overtime.
Treatment, Management: Treatment is supportive and provided by a multidisciplinary team pertaining to symptoms (low vision, neurology, PT/OT, genetics, behavioral health).
Results: Different mutations of the OPA3 gene produce distinct clinical phenotypes and underscore the critical role of mitochondrial health in optic nerve function2. A multidisciplinary approach including integration of social work will ensure the comprehensive management of symptoms. Bibliography: 1. Anikster Y et al (2001) Type III 3-Methylglutaconic Aciduria (Optic Atrophy Plus Syndrome, or Costeff Optic Atrophy Syndrome): Identification of the OPA3 Gene and Its Founder Mutation in Iraqi Jews, AJHG, 69:6, 1218-1224.
2. Gaier E, et al (2019) Novel Homozygous OPA3 Mutation in an Afghani Family with 3-Methylglutaconic Aciduria Type III and Optic Atrophy, Ophthalmic Genetics, 40:6, 570-573.
3. Nystuen A, et al (1997) Iraqi-Jewish Kindreds with Optic Atrophy Plus (3-Methylglutaconic Aciduria Type 3) Demonstrate Linkage Disequilibrium with the CTG Repeat in the 3"� Untranslated Region of the Myotonic Dystrophy Protein Kinase Gene, Human Molecular Genetics, 6:4, 563-569.
Case History: 31-year-old Afghan male
Chief complaint: difficulty viewing school material on phone screen (online classes due to COVID-19)
History: bilateral optic atrophy, nystagmus, large-angle alternating exotropia, refractive error, headaches, depression
Medications: coenzyme Q10, levocarnitine, nortriptyline, magnesium oxide, propranolol, and sumatriptan
Followed by genetics, neurology, ophthalmology, physical therapy (PT), the Commission for the Blind
Pertinent Findings: Clinical:
BCVA OD 20/200; OS 20/400
Nystagmus, visual field loss, optic nerve pallor OU
Physical:
Cerebellar ataxia, spasticity with hyperreflexia, lumbar spondylosis without myelopathy, radicular syndrome of lower limbs with worsening gait
Social:
Fled Afghanistan five years ago; father and one sister currently missing
3/6 siblings affected (parents are unaffected)
Completed six years of education
Not using low vision/mobility aids; "�embarrassed"� to use them
Multiple hospitalizations due to falls
Declined counseling services in the past; history of poor medication compliance
After extensive education, he agreed to a social work referral to assist with integration of low vision aids and to discuss more suitable mobility aids with PT
Genetic/lab studies:
Genetics: A novel homozygous variant of uncertain significance, c.142+2_142+3dupTG (intronic) identified in OPA3
Lab: Elevated levels of 3-methylglutaconic (3-MGC) aciduria type III
Radiology studies:
Lumbar spine CT without contrast: Chronic bilateral pars defect at L5 with grade 1 anterolisthesis of L5 on S1. No evidence of acute fracture or dislocation.
Brain MRI: Unremarkable
Head CT: Unremarkable
Differential Diagnosis: Primary differential: autosomal dominant optic atrophy. Others include Leber Hereditary Optic Neuropathy, Cerebral Palsy, and Wolfram syndrome.
Diagnosis and Discussion: Costeff Syndrome is a rare autosomal recessive neuro-ophthalmologic condition that affects 1 in 10,000 Iraqi-Jewish indiviudals.1 Very few affected individuals outside of this population have been identified. It is characterized by infantile optic atrophy, movement disorder, and 3-MGC aciduria. Other features include nystagmus, strabismus, spastic paraplegia, ataxia, and cognitive deficiency. This disorder was first identified in Iraqi-Jewish people in which relationships between the affected individuals were unknown3. Mutations in the OPA3 outer mitochondrial membrane lipid metabolism regulator gene are causative and can be analyzed with genetic testing. The condition may progress overtime.
Treatment, Management: Treatment is supportive and provided by a multidisciplinary team pertaining to symptoms (low vision, neurology, PT/OT, genetics, behavioral health).
Results: Different mutations of the OPA3 gene produce distinct clinical phenotypes and underscore the critical role of mitochondrial health in optic nerve function2. A multidisciplinary approach including integration of social work will ensure the comprehensive management of symptoms. Bibliography: 1. Anikster Y et al (2001) Type III 3-Methylglutaconic Aciduria (Optic Atrophy Plus Syndrome, or Costeff Optic Atrophy Syndrome): Identification of the OPA3 Gene and Its Founder Mutation in Iraqi Jews, AJHG, 69:6, 1218-1224.
2. Gaier E, et al (2019) Novel Homozygous OPA3 Mutation in an Afghani Family with 3-Methylglutaconic Aciduria Type III and Optic Atrophy, Ophthalmic Genetics, 40:6, 570-573.
3. Nystuen A, et al (1997) Iraqi-Jewish Kindreds with Optic Atrophy Plus (3-Methylglutaconic Aciduria Type 3) Demonstrate Linkage Disequilibrium with the CTG Repeat in the 3"� Untranslated Region of the Myotonic Dystrophy Protein Kinase Gene, Human Molecular Genetics, 6:4, 563-569.
A Novel Ophthalmology TeleTriage System During the COVID19 Era
Published 2020 by Angel Scanzera
Co-Author(s): Emily Cole, Nita Valikodath, Chau Pham, Thasarat Vajaranant, Deepak Edward, Yannek Leiderman, Ahmad Aref, Elmer Tu, R.V. Paul Chan
Program Number: 205030
Article Type: Scientific Program
Purpose: In response to Phase 1 of the COVID-19 pandemic, we created a web-based tele-triage system to limit any in-person clinic visits and ensure safety at the University of Illinois at Chicago (UIC) Department of Ophthalmology and Visual Sciences. We aim to describe urgent visit requests at a tertiary referral eye center and determined level of urgency in the early phases of the COVID-19 pandemic.
Methods: Surveys of all individuals requesting an urgent in-person clinic visit between April 6, 2020 and June 6, 2020 at the UIC Department of Ophthalmology were reviewed. Demographic data, reason for visit, referral source, determined level of urgency, and COVID-19 status were reviewed. At risk for COVID-19 included symptoms of shortness of breath, cough, fever, anosmia, or contact with a person with known COVID-19. Descriptive statistics as well as t-tests and chi-square tests were used to compare variables with a p-value of 0.05. Data was analyzed using SAS Institute Inc. 2018 (SAS 9.4M6, Cary, NC, USA).
Results: A total of 358 surveys were completed. Mean age was 49.7 ± 18.8 years (range 2-91). The majority of requests were determined as urgent (63.0%, n=229) or emergent (0.8%, n=3) by the evaluating eye care provider. Of those requests, 11 patients (3.1%) were COVID-19 positive and an additional 33 patients (9.2%) were at risk for COVID-19. Forty-nine patients had recent eye trauma (13.7%), and the most common reason for visit request was new onset eye pain (25.7%, n=92), followed by new symptoms of photophobia (22.9%, n=82), vision loss (17.9%, n=64), eye redness (16.8%, n=60), lid edema (15.4%, n=55), floaters (13.7%, n=49), flashing lights (9.8%, n=35), new or worsening diplopia (5.9%, n=21), droopy eyelid (5.9%, n=21), or curtain over vision (2.8%, n=10). The majority of patients were self-referred (63.7%), or referred by an outside eye doctor (14.8%), primary care provider (12.3%), emergency room physician (7.3%), or other specialist (2.0%). Patients were more commonly referred by a provider versus self-referral if they had symptoms of new onset diplopia (p<0.0001), flashing lights (p=0.02), or droopy eyelid (p=0.0006). Patients presenting with a symptom onset within 48 hours (36%) tended to be younger (45.8 ± 18.8 years) versus those with duration of symptoms greater than 48 hours (51.9 ± 18.4 years; p=0.003).
Results: This novel web-based tele-triage system was able to screen out one third of visit requests, which limited in-person visits to those that were urgent during the pandemic. Older patients presented with later onset of symptoms. Further studies are needed to understand the reason for this delay in care during the pandemic. For future emergency preparedness, consideration should be taken into increasing patient and referring physician education regarding urgent eye conditions.
Methods: Surveys of all individuals requesting an urgent in-person clinic visit between April 6, 2020 and June 6, 2020 at the UIC Department of Ophthalmology were reviewed. Demographic data, reason for visit, referral source, determined level of urgency, and COVID-19 status were reviewed. At risk for COVID-19 included symptoms of shortness of breath, cough, fever, anosmia, or contact with a person with known COVID-19. Descriptive statistics as well as t-tests and chi-square tests were used to compare variables with a p-value of 0.05. Data was analyzed using SAS Institute Inc. 2018 (SAS 9.4M6, Cary, NC, USA).
Results: A total of 358 surveys were completed. Mean age was 49.7 ± 18.8 years (range 2-91). The majority of requests were determined as urgent (63.0%, n=229) or emergent (0.8%, n=3) by the evaluating eye care provider. Of those requests, 11 patients (3.1%) were COVID-19 positive and an additional 33 patients (9.2%) were at risk for COVID-19. Forty-nine patients had recent eye trauma (13.7%), and the most common reason for visit request was new onset eye pain (25.7%, n=92), followed by new symptoms of photophobia (22.9%, n=82), vision loss (17.9%, n=64), eye redness (16.8%, n=60), lid edema (15.4%, n=55), floaters (13.7%, n=49), flashing lights (9.8%, n=35), new or worsening diplopia (5.9%, n=21), droopy eyelid (5.9%, n=21), or curtain over vision (2.8%, n=10). The majority of patients were self-referred (63.7%), or referred by an outside eye doctor (14.8%), primary care provider (12.3%), emergency room physician (7.3%), or other specialist (2.0%). Patients were more commonly referred by a provider versus self-referral if they had symptoms of new onset diplopia (p<0.0001), flashing lights (p=0.02), or droopy eyelid (p=0.0006). Patients presenting with a symptom onset within 48 hours (36%) tended to be younger (45.8 ± 18.8 years) versus those with duration of symptoms greater than 48 hours (51.9 ± 18.4 years; p=0.003).
Results: This novel web-based tele-triage system was able to screen out one third of visit requests, which limited in-person visits to those that were urgent during the pandemic. Older patients presented with later onset of symptoms. Further studies are needed to understand the reason for this delay in care during the pandemic. For future emergency preparedness, consideration should be taken into increasing patient and referring physician education regarding urgent eye conditions.
A Piece of the Pie a case of rare Sectoral Retinitis Pigmentosa
Published 2020 by Alexandra Budd
Co-Author(s): NULL
Article Type: Residents Day
Abstract: Sectoral retinitis pigmentosa (RP) is an atypical and rare form of RP that is often misdiagnosed, warranting thorough workup. This poster will discuss low vision rehabilitation used to improve such a case's visual function.
Case History: Demographics
73 y/o white male
Chief Complaint
Established patient presents with complaint of progressive peripheral vision loss OU and difficulty driving at night
Ocular History
Bilateral Superior Temporal Defects
Nuclear Cataracts OU
Medical History
HTN
(+)Head Trauma in 1985
(+)MVA in 1995
Family History
(-)AMD/Glaucoma/Blindness
Medications
Amlodipine
Pertinent Findings: Clinical
BCVA: OD 20/20
OS 20/20
DFE
C/D 0.4 OD, 0.4 OS
Vessels attenuated
Retinal atrophy with associated pigmentary changes located inferiorly OU
Imaging
HVF 24-2 OD: Superior Temporal defect
OS: Superior Temporal defect
Fundus Autofluorescence: Hyper-fluorescence of inferior area of atrophy
OCT:
OD/OS: outer retinal atrophy with inner segment/outer segment disruption, greatest inferior
MRI: No chiasmal lesion
CT: Clear, No mass
Bloodwork: (-) VDRL (-) TSPO
ffERG: Normal OU
Esterman VF: 160 degrees
Differential Diagnosis: Leading
Sectoral Retinitis Pigmentosa
Others
Cone/Rod Dystrophy
Chorioretinal Infections
Vitamin A Deficiency
Trauma
Diagnosis and Discussion: Sectoral RP resulting in progressive constricted visual fields and nyctalopia
Initial examination speculated the bilateral retinal atrophy was due the patient's history of head trauma, however the CT scan was unremarkable.
Symmetrical defects on HVF testing warranted an MRI which ruled out a chiasmal lesion.
Due to laterality, suspicion of an infectious or inflammatory process lead to VDRL and TSPO testing which also came back normal.
Based on the patient's progressive visual field loss and symptoms of nyctalopia, ERG testing was performed.
Upon ruling out all differentials above, the progressive nature of the retinal atrophy/visual field loss, complaint of nyctalopia dating from 1990, the patient is presumed to have sectoral RP.
Treatment, Management: Though there is no standard treatment for RP, Vitamin A supplementation has shown to be effective in some studies in decelerating disease progression. A newer study by Cochrane found no benefit of Vitamin A.
Newer studies have been investigating gene augmentation therapy.
Since there are limited treatment options available, management should be targeted towards tools to improve visual function hence quality of life.
Low vision rehabilitation aims to maintain a patient's independence in the home and in the community. I also offers devices such as telescopes, handheld magnifiers, filter lenses, and electronic aids.
In this case, given his excellent acuity and adequate binocular visual field, he's successful with bifocal spectacles and still meets legal daytime driving requirements.
Results: Sectoral RP, although rare, still presents initially with nyctalopia, followed by constriction of peripheral vision, and therefore can dramatically impact a patient's life.
A thorough workup is imperative to rule out other sight threatening and treatable etiologies to ensure best management.
Despite lack of treatment options, low vision rehabilitation can provide a patient with the tools and resources to improve their overall quality of life. Bibliography: Coussa RG, Basali D, Maeda A, DeBenedictis M, Traboulsi EI. Sector retinitis pigmentosa: Report of ten cases and a review of the literature. Mol Vis. 2019 Dec 30;25:869-889. PMID: 31908405; PMCID: PMC6937219.
Parmeggiani F, Sato G, De Nadai K, Romano MR, Binotto A, Costagliola C. Clinical and Rehabilitative Management of Retinitis Pigmentosa: Up-to-Date. Curr Genomics. 2011 Jun;12(4):250-9. doi: 10.2174/138920211795860125. PMID: 22131870; PMCID: PMC3131732.
Case History: Demographics
73 y/o white male
Chief Complaint
Established patient presents with complaint of progressive peripheral vision loss OU and difficulty driving at night
Ocular History
Bilateral Superior Temporal Defects
Nuclear Cataracts OU
Medical History
HTN
(+)Head Trauma in 1985
(+)MVA in 1995
Family History
(-)AMD/Glaucoma/Blindness
Medications
Amlodipine
Pertinent Findings: Clinical
BCVA: OD 20/20
OS 20/20
DFE
C/D 0.4 OD, 0.4 OS
Vessels attenuated
Retinal atrophy with associated pigmentary changes located inferiorly OU
Imaging
HVF 24-2 OD: Superior Temporal defect
OS: Superior Temporal defect
Fundus Autofluorescence: Hyper-fluorescence of inferior area of atrophy
OCT:
OD/OS: outer retinal atrophy with inner segment/outer segment disruption, greatest inferior
MRI: No chiasmal lesion
CT: Clear, No mass
Bloodwork: (-) VDRL (-) TSPO
ffERG: Normal OU
Esterman VF: 160 degrees
Differential Diagnosis: Leading
Sectoral Retinitis Pigmentosa
Others
Cone/Rod Dystrophy
Chorioretinal Infections
Vitamin A Deficiency
Trauma
Diagnosis and Discussion: Sectoral RP resulting in progressive constricted visual fields and nyctalopia
Initial examination speculated the bilateral retinal atrophy was due the patient's history of head trauma, however the CT scan was unremarkable.
Symmetrical defects on HVF testing warranted an MRI which ruled out a chiasmal lesion.
Due to laterality, suspicion of an infectious or inflammatory process lead to VDRL and TSPO testing which also came back normal.
Based on the patient's progressive visual field loss and symptoms of nyctalopia, ERG testing was performed.
Upon ruling out all differentials above, the progressive nature of the retinal atrophy/visual field loss, complaint of nyctalopia dating from 1990, the patient is presumed to have sectoral RP.
Treatment, Management: Though there is no standard treatment for RP, Vitamin A supplementation has shown to be effective in some studies in decelerating disease progression. A newer study by Cochrane found no benefit of Vitamin A.
Newer studies have been investigating gene augmentation therapy.
Since there are limited treatment options available, management should be targeted towards tools to improve visual function hence quality of life.
Low vision rehabilitation aims to maintain a patient's independence in the home and in the community. I also offers devices such as telescopes, handheld magnifiers, filter lenses, and electronic aids.
In this case, given his excellent acuity and adequate binocular visual field, he's successful with bifocal spectacles and still meets legal daytime driving requirements.
Results: Sectoral RP, although rare, still presents initially with nyctalopia, followed by constriction of peripheral vision, and therefore can dramatically impact a patient's life.
A thorough workup is imperative to rule out other sight threatening and treatable etiologies to ensure best management.
Despite lack of treatment options, low vision rehabilitation can provide a patient with the tools and resources to improve their overall quality of life. Bibliography: Coussa RG, Basali D, Maeda A, DeBenedictis M, Traboulsi EI. Sector retinitis pigmentosa: Report of ten cases and a review of the literature. Mol Vis. 2019 Dec 30;25:869-889. PMID: 31908405; PMCID: PMC6937219.
Parmeggiani F, Sato G, De Nadai K, Romano MR, Binotto A, Costagliola C. Clinical and Rehabilitative Management of Retinitis Pigmentosa: Up-to-Date. Curr Genomics. 2011 Jun;12(4):250-9. doi: 10.2174/138920211795860125. PMID: 22131870; PMCID: PMC3131732.
A Pilot Study of Glaucoma Detection and Classification from Visual Field Images using a Deep Learning Technique
Published 2020 by Nahida Akter
Co-Author(s): Sherry Li, Mikki Poon, Stuart Perry, John Fletcher, Maitreyee Roy
Program Number: 205389
Article Type: Scientific Program
Purpose: To investigate the interpretation of peripheral vision information in central 24-2 threshold test of visual fields (VFs) trained in a Convolutional Neural Network (CNN) classifier for differentiating normal vs glaucoma and staging glaucoma from early to advanced stages.
Methods: In this study, images of Humphrey 24-2 visual fields (Zeiss FORUM Viewer 4.2.1.66) were collected from the two subject groups: 50 images for normal and 51 for glaucoma patients consisting of 29 early, 9 advanced and 13 moderate seen at the Centre for Eye Health, UNSW Sydney. All the VFs were cross-checked for reliability test, and only validated images have been used for this study. From the VF image, we only cropped the probability map of pattern deviation (PD) image and resized into 128×128 pixels. For the labelling of glaucoma classification, we rely on glaucoma staging systems suggested by Mills and his colleagues. Firstly, a deep learning (DL) model was used to train the network with PD images to detect normal and glaucomatous eyes. Secondly, the same CNN was applied to the only glaucomatous PD images to classify the stages of glaucoma into three categories: early, moderate, and advanced. The result of the second CNN has been compared with another DL result which was trained from the numeric values of Mean Deviation (MD), Pattern Standard Deviation (PSD) and Visual Field Index (VFI) from the VF images.
Results: The classification accuracy on validation data was measured using confusion matrix and found the accuracy for the first CNN 96.67%, sensitivity 100% and specificity 93%. The result of the second CNN for staging glaucoma was very promising with 100% accuracy. We also observed that the CNN trained with directly from PD images has better performance than the combination of numeric values of MD, PSD and VFI. For the numeric data of VF, the DL’s overall accuracy was 93.8%, sensitivity for both early and moderate classes were 100%, and for advanced, one was misclassified as moderate among three advanced glaucoma.
Results: In this pilot study, our deep learning models trained from VF’s PD images found promising in differentiating glaucoma vs normal eyes and staging early to advanced glaucoma. Our study also demonstrates that the single PD image can classify glaucoma than the perimetric information (numeric values of MD, PSD and VFI) of VF data. Though the DL
Results: of the pilot study are promising for glaucoma detection and classification, further data collection and comparative study are warranted to train the algorithm with a vast amount of VF datasets to validate our
Results: and make it clinically worthy and reliable.
Methods: In this study, images of Humphrey 24-2 visual fields (Zeiss FORUM Viewer 4.2.1.66) were collected from the two subject groups: 50 images for normal and 51 for glaucoma patients consisting of 29 early, 9 advanced and 13 moderate seen at the Centre for Eye Health, UNSW Sydney. All the VFs were cross-checked for reliability test, and only validated images have been used for this study. From the VF image, we only cropped the probability map of pattern deviation (PD) image and resized into 128×128 pixels. For the labelling of glaucoma classification, we rely on glaucoma staging systems suggested by Mills and his colleagues. Firstly, a deep learning (DL) model was used to train the network with PD images to detect normal and glaucomatous eyes. Secondly, the same CNN was applied to the only glaucomatous PD images to classify the stages of glaucoma into three categories: early, moderate, and advanced. The result of the second CNN has been compared with another DL result which was trained from the numeric values of Mean Deviation (MD), Pattern Standard Deviation (PSD) and Visual Field Index (VFI) from the VF images.
Results: The classification accuracy on validation data was measured using confusion matrix and found the accuracy for the first CNN 96.67%, sensitivity 100% and specificity 93%. The result of the second CNN for staging glaucoma was very promising with 100% accuracy. We also observed that the CNN trained with directly from PD images has better performance than the combination of numeric values of MD, PSD and VFI. For the numeric data of VF, the DL’s overall accuracy was 93.8%, sensitivity for both early and moderate classes were 100%, and for advanced, one was misclassified as moderate among three advanced glaucoma.
Results: In this pilot study, our deep learning models trained from VF’s PD images found promising in differentiating glaucoma vs normal eyes and staging early to advanced glaucoma. Our study also demonstrates that the single PD image can classify glaucoma than the perimetric information (numeric values of MD, PSD and VFI) of VF data. Though the DL
Results: of the pilot study are promising for glaucoma detection and classification, further data collection and comparative study are warranted to train the algorithm with a vast amount of VF datasets to validate our
Results: and make it clinically worthy and reliable.
A Preliminary Analysis of Visual Disability and VisionRelated Quality of Life in Patients with Severe Paralytic Blepharoptosis
Published 2020 by Renitarul Sebastin
Co-Author(s): Sheryl Erwin, Melanie Nadeau, Kevin Houston
Program Number: 205203
Article Type: Scientific Program
Purpose: Paralytic ptosis occurs when innervation to the levator muscle is disrupted, most often by head trauma, stroke, aneurysm, or more rarely neuromuscular disease (e.g. MG, CPEO, and OPMD). It is often severe, unilateral or bilateral, and associated with paralytic strabismus, optic neuropathies, and cognitive and physical impairments. Vision-related quality of life (VRQOL) and visual disability in this population have not been reported previously.
Methods: The Visual Functioning Questionnaire-25 (VFQ-25) was administered (n=7) and the Impact of Vision Impairment Questionnaire (IVI) (n=6) was pulled from the low vision clinic record. Scores were tabulated and compared against prior studies of RP (Retinitis Pigmentosa) and AMD (Age Related Macular Degeneration) as a benchmark for the VFQ, and against the rest of the low vision clinic population for the IVI (CY 2019). Subjects who completed the VFQ had a mean palpebral fissure height of 4.67 ± 2.36 mm and mean age of 44.7 ± 22.2 years. Of this group, 85.7% had ptosis for longer than one year, 57.1% of cases were bilateral, and 42.9% were female. Subjects who completed the IVI had a mean palpebral fissure height of 5.15 ± 0.89 mm and mean age of 67.7 ± 10.6 years. 50% of these cases for bilateral, 50% were female, and all of these subjects had ptosis for longer than one year.
Results: Ptosis subjects had a mean visual disability score of 43 ± 21.42 (IVI), making them similarly disabled to patients with more traditional low vision (41.62 ± 17.67, p = 0.62). The VFQ composite score mean was 61.2 ± 21.5, which was significantly worse than normal controls (90.1± 7.4, p = 3.58E-09) and equivalent to RP (Sugawara, T. et al., 2010) 68.4 ± 15 and AMD (Revicki, D. et al., 2010) 69.5 ± 19.91 (p = 0.43). Ptosis subjects scored considerably higher in the general vision and distance activities VFQ subscales compared to the AMD and RP samples. Means for the general vision subscale were 63.3 ± 18.0 for ptosis subjects, 55.4 ± 19.9 for the AMD sample, and 59.4 ± 17.4 for the RP sample. Means for the distance activities subscale were 84.8 ± 17.7 for ptosis subjects, 66.2 ± 25.3 for the AMD sample, and 67.8 ± 17.4 for the RP sample.
Results: These early
Results: suggest that patients with severe paralytic ptosis have visual disability and VRQOL scores similar to patients with AMD, RP, and Low Vision. Continued study with a larger sample size is warranted.
Methods: The Visual Functioning Questionnaire-25 (VFQ-25) was administered (n=7) and the Impact of Vision Impairment Questionnaire (IVI) (n=6) was pulled from the low vision clinic record. Scores were tabulated and compared against prior studies of RP (Retinitis Pigmentosa) and AMD (Age Related Macular Degeneration) as a benchmark for the VFQ, and against the rest of the low vision clinic population for the IVI (CY 2019). Subjects who completed the VFQ had a mean palpebral fissure height of 4.67 ± 2.36 mm and mean age of 44.7 ± 22.2 years. Of this group, 85.7% had ptosis for longer than one year, 57.1% of cases were bilateral, and 42.9% were female. Subjects who completed the IVI had a mean palpebral fissure height of 5.15 ± 0.89 mm and mean age of 67.7 ± 10.6 years. 50% of these cases for bilateral, 50% were female, and all of these subjects had ptosis for longer than one year.
Results: Ptosis subjects had a mean visual disability score of 43 ± 21.42 (IVI), making them similarly disabled to patients with more traditional low vision (41.62 ± 17.67, p = 0.62). The VFQ composite score mean was 61.2 ± 21.5, which was significantly worse than normal controls (90.1± 7.4, p = 3.58E-09) and equivalent to RP (Sugawara, T. et al., 2010) 68.4 ± 15 and AMD (Revicki, D. et al., 2010) 69.5 ± 19.91 (p = 0.43). Ptosis subjects scored considerably higher in the general vision and distance activities VFQ subscales compared to the AMD and RP samples. Means for the general vision subscale were 63.3 ± 18.0 for ptosis subjects, 55.4 ± 19.9 for the AMD sample, and 59.4 ± 17.4 for the RP sample. Means for the distance activities subscale were 84.8 ± 17.7 for ptosis subjects, 66.2 ± 25.3 for the AMD sample, and 67.8 ± 17.4 for the RP sample.
Results: These early
Results: suggest that patients with severe paralytic ptosis have visual disability and VRQOL scores similar to patients with AMD, RP, and Low Vision. Continued study with a larger sample size is warranted.
A Qualitative Study Exploring Access to Low Vision Rehabilitation Services in Australia
Published 2020 by Khyber Alam
Co-Author(s): Heather Connor, Sharon Bentley, Alexander Gentle
Program Number: 205273
Article Type: Scientific Program
Purpose: To investigate barriers and enablers to accessing low vision care from both patient and practitioner perspectives.
Methods: This study took place in the year 2019 in Australia. It included patients and clinicians who were living and or practicing in Australian Capital Territory, New South Wales, Northern Territory, Queensland, South Australia, Tasmania, Victoria and Western Australia. Ten focus groups were conducted with 41 patients and five focus groups were conducted with 21 practitioners. The focus groups were audio-recorded and transcribed. The resulting data were de-identified, cleaned, independently coded by two researchers and compared. The data were analysed using an interpretative phenomenological approach that included inductive thematic analysis.
Results: The patient focus groups comprised 51% females and 49% males. Of the 41 patients with a primary cause of visual impairment recorded, age-related macular degeneration was the main cause (32%), closely followed by glaucoma (29%). There were 11 major themes identified such as barriers to low vision services, emotions associated with diagnosis and referral, reasons for not attending when referred and actions that could be taken to improve low vision services.
Of the 21 practitioners attending the five practitioner focus groups, 67% were female and 33% were male. The participants were optometrists, orthoptists and educators with a wide range of years of experience. Six major themes were identified, including factors impacting frequency of patient referral, practitioner knowledge about low vision clinics, experiences of referral to low vision clinics and actions that could be taken to improve low vision services.
Results: Most patients were either not referred at all, or only referred when their vision loss was very significant. Miscommunication between patients and clinicians, limited access, cost and social stigma were major barriers preventing patients from receiving low vision services. Most practitioners admitted limited knowledge of the scope of services provided by low vision organisations, suggesting there is a need for professional development, improved communication between service providers, enhanced referral guidelines and increased public awareness.
Methods: This study took place in the year 2019 in Australia. It included patients and clinicians who were living and or practicing in Australian Capital Territory, New South Wales, Northern Territory, Queensland, South Australia, Tasmania, Victoria and Western Australia. Ten focus groups were conducted with 41 patients and five focus groups were conducted with 21 practitioners. The focus groups were audio-recorded and transcribed. The resulting data were de-identified, cleaned, independently coded by two researchers and compared. The data were analysed using an interpretative phenomenological approach that included inductive thematic analysis.
Results: The patient focus groups comprised 51% females and 49% males. Of the 41 patients with a primary cause of visual impairment recorded, age-related macular degeneration was the main cause (32%), closely followed by glaucoma (29%). There were 11 major themes identified such as barriers to low vision services, emotions associated with diagnosis and referral, reasons for not attending when referred and actions that could be taken to improve low vision services.
Of the 21 practitioners attending the five practitioner focus groups, 67% were female and 33% were male. The participants were optometrists, orthoptists and educators with a wide range of years of experience. Six major themes were identified, including factors impacting frequency of patient referral, practitioner knowledge about low vision clinics, experiences of referral to low vision clinics and actions that could be taken to improve low vision services.
Results: Most patients were either not referred at all, or only referred when their vision loss was very significant. Miscommunication between patients and clinicians, limited access, cost and social stigma were major barriers preventing patients from receiving low vision services. Most practitioners admitted limited knowledge of the scope of services provided by low vision organisations, suggesting there is a need for professional development, improved communication between service providers, enhanced referral guidelines and increased public awareness.
A Randomized Trial Evaluating Effectiveness of Overminus Spectacles Treatment in Children 3 to 10 Years of Age with Intermittent Exotropia
Published 2020 by Angela Chen
Co-Author(s): S Erzurum, Danielle Chandler, Jonathan Holmes, Susan Cotter, Amra Hercinovic, Lingkun Kong, Raymond Kraker, Justin Marsh, Stacy Martinson, B. Michele Melia, Birva Shah, Donny Suh, Jenna Titelbaum, Marilyn Vricella
Program Number: 205111
Article Type: Scientific Program
Purpose: In a previous pilot randomized clinical trial (RCT), overminus spectacles improved short-term (8-week) distance intermittent exotropia (IXT) control.1 In the present full scale RCT of overminus vs non-overminus spectacles, we report 12-month on-treatment and 18-month off-treatment outcomes.
Methods: We enrolled 386 children 3 to 10 years of age with IXT and a mean distance control score of 2 or worse (mean of 3 measures during a single examination) using an office control scale2 ranging from 0 (exophoria) to 5 (constant exotropia) points and spherical equivalent refractive error between -6.00 diopters (D) and +1.00 D. Participants were randomly assigned to full-time overminus spectacles (-2.50 D over cycloplegic refraction; N=196) or non-overminus spectacles (refractive error correction when needed or plano spectacles when refractive correction not needed; N=190). Follow-up visits occurred at 6, 12, 15, and 18 months. Overminus lenses were reduced to -1.25 D over the cycloplegic refraction at the 12-month visit and then non-overminus was prescribed at the 15-month visit. Masked outcomes were distance IXT control score at 12 months (on-treatment as primary outcome) and 18 months (off-treatment as secondary outcome).
Results: The 12-month exam was completed by 96% (N = 189) of the overminus and 89% (N =169) of the nonoverminus groups. As of 6/17/2020, 81% (N = 158) of the overminus and 74% (N = 140) of the non-overminus groups completed the 18-month visit. At 12 months (on treatment), mean distance control was better in children treated with overminus spectacles than with non-overminus spectacles (1.8 vs 2.8 points, adjusted difference = -0.82; 95% confidence interval (CI) = -1.07 to -0.56; P < 0.0001), but at 18 months (off treatment), mean distance control did not differ between treatment groups (2.4 vs 2.7 points, adjusted difference = -0.20; 95% CI = -0.54 to 0.13; P = 0.23).
Conclusion: In children aged 3 to 10 years with IXT, overminus spectacles improved distance control while they were being worn, but the effect was not maintained after weaning and discontinuation of overminus treatment.
Methods: We enrolled 386 children 3 to 10 years of age with IXT and a mean distance control score of 2 or worse (mean of 3 measures during a single examination) using an office control scale2 ranging from 0 (exophoria) to 5 (constant exotropia) points and spherical equivalent refractive error between -6.00 diopters (D) and +1.00 D. Participants were randomly assigned to full-time overminus spectacles (-2.50 D over cycloplegic refraction; N=196) or non-overminus spectacles (refractive error correction when needed or plano spectacles when refractive correction not needed; N=190). Follow-up visits occurred at 6, 12, 15, and 18 months. Overminus lenses were reduced to -1.25 D over the cycloplegic refraction at the 12-month visit and then non-overminus was prescribed at the 15-month visit. Masked outcomes were distance IXT control score at 12 months (on-treatment as primary outcome) and 18 months (off-treatment as secondary outcome).
Results: The 12-month exam was completed by 96% (N = 189) of the overminus and 89% (N =169) of the nonoverminus groups. As of 6/17/2020, 81% (N = 158) of the overminus and 74% (N = 140) of the non-overminus groups completed the 18-month visit. At 12 months (on treatment), mean distance control was better in children treated with overminus spectacles than with non-overminus spectacles (1.8 vs 2.8 points, adjusted difference = -0.82; 95% confidence interval (CI) = -1.07 to -0.56; P < 0.0001), but at 18 months (off treatment), mean distance control did not differ between treatment groups (2.4 vs 2.7 points, adjusted difference = -0.20; 95% CI = -0.54 to 0.13; P = 0.23).
Conclusion: In children aged 3 to 10 years with IXT, overminus spectacles improved distance control while they were being worn, but the effect was not maintained after weaning and discontinuation of overminus treatment.
A Randomized Trial of Binocular Dig Rush Game Treatment for Amblyopia in Children 4 to 7 Years of Age
Published 2020 by Ruth E Manny, OD, PhD, FAAO
Co-Author(s): Jonathan M Holmes, BM, BCh, Raymond T Kraker, MSPH, Zhuokai Li, PhD, B. Michele Melia, ScM, Eileen E Birch, Krista Kelly, PhD, Lingkun Kong, MD, Earl Crouch, MD, Ingryd Lorenzana, OD, FCOVD, FAAO, CBHC, Maan S Alkharashi, MD.
Program Number: 200008
Article Type: Scientific Program
Purpose: To compare visual acuity (VA) improvement in children aged 4 to lt; 7 years with amblyopia treated with a binocular iPadsup/sup game plus continued spectacle correction versus continued spectacle correction alone.
Methods: Design: Multi-center randomized clinical trialParticipants: One hundred eighty-two participants 4 to lt; 7 years old (mea5.7 years) with amblyopia 20/40 to 20/200 (mea20/63) from strabismus (17%), anisometropia (63%), or both (20%), and with no strabismus at near by the simultaneous prism and cover test were enrolled. Sixty-four percent reported prior amblyopia treatment other than spectacles. Participants wearing spectacles were required to have at least 16 weeks of optical treatment or demonstrate no improvement in amblyopic-eye VA for at least 8 weeks (0.1 logMAR) prior to enrollmentMethods: Participants were randomly assigned to treatment for 8 weeks with the dichoptic binocular Dig Rush iPadsup/sup game (prescribed 1 hour/ day for 5 days/ week with 20% contrast to the non-amblyopic eye; contrast incremented based on game performance) plus spectacle wear if needed (92) or continued spectacle correction alone if needed (90). VA at outcome was measured by a masked examiner using the ATS-HOTV protocol. Time spent in game play was objectively tracked through the game.
Results: Main Outcome Measures: Change in amblyopic-eye VA from baseline to 4 weeks and from baseline to 8 weeks were the primary and secondary outcomes, respectively. Other secondary outcomes included the proportion of participants with amblyopic-eye VA improvement of 2 logMAR lines at 4 and 8 weeks and adherence to the prescribed treatment.Results: For 169 completing the 4-week exam, mean change in amblyopic-eye VA was significantly greater with binocular treatment than spectacles alone after adjusting for baseline VA (1.1 vs 0.6 logMAR lines, adjusted difference 0.5 lines; 95.1% CI: 0.1 to 0.9). For 169 completing the 8-week exam, the difference adjusted for baseline VA was not significant (1.3 vs 1.0 logMAR lines, adjusted difference 0.3 lines; 98.4% CI: -0.2 to 0.8). Thirty-six percent of the binocular group and 19% of the spectacle alone group improved by 2 logMAR lines after 4 weeks (difference 17%; 98.4% CI: 1% to 34%) and after 8 weeks 41% of the binocular group and 30% of the spectacle alone group improved by 2 logMAR lines (difference 11%; 98.4% CI: -7% to 29%). For the binocular group, adherence data from the iPad indicated that 47% and 42% completed gt;75% of prescribed treatment by the 4- and 8-week visits, respectively.
Conclusion: Compared with spectacles alone, binocular treatment improved change in amblyopic eye VA at 4 weeks. The effect was not significant at 8 weeks, due to continuing VA improvement with spectacles, and possibly a reduced binocular treatment effect related to the game design.
Methods: Design: Multi-center randomized clinical trialParticipants: One hundred eighty-two participants 4 to lt; 7 years old (mea5.7 years) with amblyopia 20/40 to 20/200 (mea20/63) from strabismus (17%), anisometropia (63%), or both (20%), and with no strabismus at near by the simultaneous prism and cover test were enrolled. Sixty-four percent reported prior amblyopia treatment other than spectacles. Participants wearing spectacles were required to have at least 16 weeks of optical treatment or demonstrate no improvement in amblyopic-eye VA for at least 8 weeks (0.1 logMAR) prior to enrollmentMethods: Participants were randomly assigned to treatment for 8 weeks with the dichoptic binocular Dig Rush iPadsup/sup game (prescribed 1 hour/ day for 5 days/ week with 20% contrast to the non-amblyopic eye; contrast incremented based on game performance) plus spectacle wear if needed (92) or continued spectacle correction alone if needed (90). VA at outcome was measured by a masked examiner using the ATS-HOTV protocol. Time spent in game play was objectively tracked through the game.
Results: Main Outcome Measures: Change in amblyopic-eye VA from baseline to 4 weeks and from baseline to 8 weeks were the primary and secondary outcomes, respectively. Other secondary outcomes included the proportion of participants with amblyopic-eye VA improvement of 2 logMAR lines at 4 and 8 weeks and adherence to the prescribed treatment.Results: For 169 completing the 4-week exam, mean change in amblyopic-eye VA was significantly greater with binocular treatment than spectacles alone after adjusting for baseline VA (1.1 vs 0.6 logMAR lines, adjusted difference 0.5 lines; 95.1% CI: 0.1 to 0.9). For 169 completing the 8-week exam, the difference adjusted for baseline VA was not significant (1.3 vs 1.0 logMAR lines, adjusted difference 0.3 lines; 98.4% CI: -0.2 to 0.8). Thirty-six percent of the binocular group and 19% of the spectacle alone group improved by 2 logMAR lines after 4 weeks (difference 17%; 98.4% CI: 1% to 34%) and after 8 weeks 41% of the binocular group and 30% of the spectacle alone group improved by 2 logMAR lines (difference 11%; 98.4% CI: -7% to 29%). For the binocular group, adherence data from the iPad indicated that 47% and 42% completed gt;75% of prescribed treatment by the 4- and 8-week visits, respectively.
Conclusion: Compared with spectacles alone, binocular treatment improved change in amblyopic eye VA at 4 weeks. The effect was not significant at 8 weeks, due to continuing VA improvement with spectacles, and possibly a reduced binocular treatment effect related to the game design.