What’s New and Important in Pediatric Ophthalmology and Strabismus in 2021 Complete Unabridged Handout AAPOS Virtual Meeting April 2021 Presented by the AAPOS Professional Education Committee Tina Rutar, MD - Chairperson Austin E Bach, DO Kara M Cavuoto, MD Robert A Clark, MD Marina A Eisenberg, MD Ilana B Friedman, MD Jennifer A Galvin, MD Michael E Gray, MD Gena Heidary, MD PhD Laryssa Huryn, MD Alexander J Khammar MD Jagger Koerner, MD Eunice Maya Kohara, DO Euna Koo, MD Sharon S Lehman, MD Phoebe Dean Lenhart, MD Emily A McCourt, MD - Co-Chairperson Julius Oatts, MD Jasleen K Singh, MD Grace M. Wang, MD PhD Kimberly G Yen, MD Wadih M Zein, MD 1 TABLE OF CONTENTS 1. Amblyopia page 3 2. Vision Screening page 12 3. Refractive error page 20 4. Visual Impairment page 31 5. Neuro-Ophthalmology page 37 6. Nystagmus page 48 7. Prematurity page 52 8. ROP page 55 9. Strabismus page 65 10. Strabismus surgery page 82 11. Anterior Segment page 101 12. Cataract page 108 13. Cataract surgery page 110 14. Glaucoma page 120 15. Refractive surgery page 127 16. Genetics page 128 17. Trauma page 151 18. Retina page 156 19. Retinoblastoma / Intraocular tumors page 167 20. Orbit page 171 21. Oculoplastics page 175 22. Infections page 183 23. Pediatrics / Infantile Disease/ Syndromes page 186 24. Uveitis page 190 25. Practice management / Health care systems / Education page 192 2 1. AMBLYOPIA Self-perception in Preschool Children With Deprivation Amblyopia and Its Association With Deficits in Vision and Fine Motor Skills. Birch EE, Castaneda YS, Cheng-Patel CS, Morale SE, Kelly KR, Wang SX. JAMA Ophthalmol. 2020 Dec; 138(12): 1307-1310. This is a cross-sectional study from 2016 to 2019 at a pediatric vision research laboratory in Dallas, Texas. The authors enrolled children ages 3 to 6 years old, 15 with deprivational amblyopia and 20 controls. Self-perception was assessed using the Pictorial Scale of Competence and Acceptance for Young Children, including: cognitive competence, peer acceptance, physical competence, and maternal acceptance. Fine motor skills were evaluate with Manual Dexterity and Aiming & Catching Scales of the Movement ABC-2 test. Demographics of the study included 37% girls and 80% non-Hispanic White children. Results showed that children with deprivational amblyopia had significantly lower peer acceptance and physical competence scores when compared with control children (mean difference 0.45, P=0.002 and mean difference 0.47, P=0.002, respectively). Regarding the 15 children with amblyopia, the authors noted an associate between self-perception domain scores and motor skills, including peer acceptance and manual dexterity (r+0.68, P=0.005), peer acceptance and aiming (r+0.54, P=0.03) and physical competence and aiming (r=0.55, P=0.03). Conclusions revealed lower self-perception of peer acceptance and physical competence were associated with early visual deprivation in children. Limitations of the study include small sample size of less than 50 children, the lack of racial diversity, and single-center study. Strengths of this study include the evaluation of self-perception from the children directly, rather than from a proxy. In summary, this small study is helpful reminder that self-perception and fine motor skills in young children with deprivational amblyopia have an impact on their visual development and learning. In the future, larger studies, with more racial and ethnic diversity, will be important to do. Interocular Suppression as Revealed by Dichoptic Masking Is Orientation-Dependent and Imbalanced in Amblyopia Ling Gong, Alexandre Reynaud, Zili Wang, et al Invest Ophthalmol Vis Sci. 2020 Dec;61, 28 This small study looked at suppression in amblyopic subjects in both monocular and binocular testing. They compared these individuals to age appropriate controls. They firstly noted similar measurable amounts of suppression under monocular conditions of amblyopic eyes when compared to prior studies. When testing under binocular conditions, masking of the amblyopic eye was noted to have less of an effect on the fellow eye than masking of the fellow eye. This is yet another study that shows that best corrected vision is far from the only end goal of amblyopia treatment and that amblyopia does not only affect high contrast vision. Understanding the Impact of Residual Amblyopia on Functional Vision and Eye-related Quality of Life Using the PedEyeQ Sarah R. Hatt, David A. Leske, Yolanda S. Castañeda, Suzanne M. Wernimont, Laura Liebermann, Christina S. Cheng-Patel, Eileen E. Birch and Jonathan M. Holmes American Journal of Ophthalmology 2020 October; 218: 173-181. This prospective cross-sectional study was designed with the purpose of understanding the effects of residual amblyopia and functional vision and vision related quality of life. The authors used a specific questionnaire (PedEyeQ) in children aged 8-11 and compared 17 children with residual amblyopia, 48 visually normal controls without glasses and 19 controls without amblyopia who wear glasses. The median acuity in the patients with amblyopia was 20/50. The authors found that residual amblyopia does affect both functional vision and eye related quality of life. Additionally, the parents of the amblyopic children also had lower QOL scores. This paper is important not only because it validates the work that we do but it emphasizes the importance of amblyopia treatment for the entire family. Amblyopia 3 Amblyopia Outcomes Through Clinical Trials and Practice Measurement: Room for Improvement: The LXXVII Edward Jackson Memorial Lecture. Michael X. Repka American Journal of Ophthalmology 2020 November; 219: A1-A26. This literature review and analysis of data from the intelligent research in sight (IRIS) registry is a personal perspective from one respected pediatric ophthalmologist on the topic of amblyopia prevalence and outcomes. The author provides a very comprehensive review of amblyopia studies. I would recommend this as a great read for residents before they start their pediatric ophthalmology rotation and a staple before starting fellowship. The use of atropine for treatment of amblyopia using the OptumLabs Data Warehouse Pineles SL, Repka MX, Yu F, Velez FG, Perez C, Sim D, Coleman AL, Journal of AAPOS (2021), doi: https://doi.org/10.1016/j.jaapos.2020.11.003. Both occlusive patching and atropine penalization are accepted methods to treat amblyopia and have been determined to have similar outcomes when studied by Pediatric Eye Disease Group (PEDIG) and other investigators. The frequency of use of atropine penalization has not been determined. The authors used a “big data” study to determine the frequency of the use of atropine penalization for the treatment of amblyopia. The OptumLabs Data Warehouse claims data was mined to identify the use of atropine in children with a diagnosis of amblyopia. Amblyopic patients were divided into 2 groups: those who had been prescribed atropine on at least 2 claims and those who had not been prescribed atropine or were prescribed only once. The authors found 55.2% of children with a diagnosis of amblyopia were prescribed atropine on 2 or more occasions. Children who lived in families with the highest familial net worth and household income had the highest rate of atropine use, 81.5% and 83.8%. Use of atropine was higher in the South (59.4%) compared to the Northeast (47.1%). This study is important for helping to understand the frequency of use of atropine penalization for the treatment of amblyopia in the United States. The geographic and socioeconomic data findings suggest more study is necessary to ensure that equity exists in treatment of children with amblyopia. Prevalence of amblyopia and its determinants in a rural population: a population-based cross-sectional study. Hashemi H, Nabovati P, Pakzad R, Yekta A, Aghamirsalim M, Sardari S, Rafati S, Ostadimoghaddam H, Khabazkhoob M. Strabismus. 2021 Jan 16:1-9. The authors performed a cross-sectional population-based study of 3314 participants from 3-93 years old from two different underserved areas of Iran to determine the prevalence and causes of amblyopia. They found the prevalence to be 2.23% of unilateral and 0.50% of bilateral amblyopia, which overall which similar to prior reports from Iran and reports from other countries such as China. Amblyopia was most common in children 6-20 years old (1.36%) and adults over 70 years old (5.97%). There was also an inverse relationship between amblyopia prevalence and education, with lower prevalence in patients with higher education. Amblyopia was most often due to anisometropia (53%), followed by strabismus (29.5%) and mixed (17.5%) types. The authors note that amblyopia screening began in 1996, which likely played a role in the overall decrease in prevalence by age. Although helpful in determining the characteristics of amblyopia, the design of the study does not allow for analysis of eye care access or conclusions regarding causality. Clinical Aniseikonia in Anisometropia and Amblyopia. South J, Gao T, Collins A, Lee A, Turuwhenua J, Black J. British and Irish Orthoptic Journal. 2020;16(1), 44–54. Amblyopia 4 The authors state that, clinically, aniseikonia is often neglected in anisometropic amblyopia due to assumed measurement difficulties and that lack evidence on whether correction of aniseikonia is beneficial. This study aimed to determine whether subjective aniseikonia is measurable in anisometropia with or without amblyopia. The study included participants (15–52 years) with Anisometropic Amblyopia (n = 7), Anisometropia without amblyopia (n = 6) and Isometropic Controls (n = 6). Subjective aniseikonia was measured using three clinical techniques: Robertson Technique (RT) (penlight and Maddox rod), Aniseikonia Inspector Version 3 (AI3), and the New Aniseikonia Test booklet (NAT), and a psychophysical adaptive method, the Contrast-balanced Aniseikonia Test (CAT), where dichoptic contrast adjustments compensate for any suppression. The authors found that eighteen participants completed all tests, one Anisometropic Amblyopia participant could only complete the CAT and NAT due to fusion loss.