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Depressive symptoms associated with poor health-related quality of life in adult strabismus
e4
Volume 18 Number 4 / August 2014
Conclusion: Polypseudophakia does not cause accelerated axial growth in patients undergoing primary placement within the first 24 months of life. However, the age at planned IOL removal varies from less than 1 year to more than 7 years after implantation. 010 Optic nerve volumetric measurements in pediatric papilledema with spectral domain OCT. Jose Efren Gonzalez Monroy, Frank Weng, Linda R. Dagi, Gena Heidary Introduction: In pediatric patients with papilledema, determining response to treatment may be difficult due to inherent limitations in the clinical exam. Spectral domain optical coherence tomography (SD-OCT) of optic nerve volume (ONV) has begun to be explored as a relevant measure in adult patients with papilledema.1,2 We evaluated whether SD-OCT of ONV may be a useful adjunct in the assessment of pediatric papilledema. Methods: Single center, three year retrospective review of patients with confirmed papilledema. Patients with Heidelberg Spectralis SD-OCT ONV measurements within 1 month of diagnosis were included. Data including gender, age, visual field results, optic nerve edema grade and lumbar puncture opening pressure were recorded. Results: Eighteen patients (10 female [53%]) were included. Mean age at presentation was 12 years (SD 5.6 years). Data from the right eyes only were evaluated; no difference between eyes was noted (P 5 0.26). Mean ONV OD in patients with papilledema was significantly increased at 4.74 mm3 (SD 1.52) compared with 2.51 mm3 (SD 0.25) in age and sex matched control subjects (P \ 0.001). A moderate positive correlation of 0.55 was identified between initial ONV and lumbar puncture opening pressure. Longitudinally, ONV measurements improved with a significant decrease in volumetric measurements at most recent follow-up (P 5 0.001). Discussion: ONV appeared to reflect well optic nerve edema at time of diagnosis and correlated well with response to treatment as measured by improved edema longitudinally. Conclusion: SD-OCT ONV measurements may provide an important tool towards the assessment of treatment response in pediatric patients with papilledema. References 1. Kaufhold F, Kadas EM, Schmidt C, et al. Optic nerve head quantification in idiopathic intracranial hypertension by spectral domain OCT. PLOS One 2012;7:e36965. 2. Wang J-K, Kardon RH, Kupersmith MJ, Garvin MK. Automated quantification of volumetric optic disc swelling in papilledema using spectral-domain optical coherence tomography. Invest Ophthalmol Vis Sci 2012;53:4069-75.
011 Serial fundus photography and fluorescein angiography after off-label intravitreal bevacizumab treatment for retinopathy of prematurity: importance of monitoring regression by angiography in off-label bevacizumab treated eyes. Luxme Hariharan, Aleksandra Rachitskaya, Ditte J. Hess, CRA, Ann Rodriquez, RN, Catherine Negron, BA, Audina M. Berrocal, MD Introduction: Intravitreal bevacizumab has been reported as an offlabel treatment in retinopathy of prematurity (ROP). The purpose of this study is to demonstrate the importance of fluorescein angiography (FA) in the management of ROP regression after an intravitreal bevacizumab treatment. Methods: This is an IRB-approved retrospective consecutive case series of 38 eyes of 19 infants with ROP from 2006 to 2013. Eleven patients were treated solely with intravitreal bevacizumab while 8
received both bevacizumab and laser. Clinical exam, RetCam (Clarity, Pleasanton, CA) fundus photography and fluorescein angiography were performed prior to the treatment. A 10% solution of sodium fluorescein dye was administered intravenously as a bolus at a dose of 7.7 mg/kg followed by a saline flush. All eyes were injected with 0.625 mg of bevacizumab. RetCam photos and fluorescein angiograms were documented post-treatment. All treatments including clinical examination, fundus photography, fluorescein angiography, bevacizumab injections and laser were performed at the bedside. Results: All 38 eyes showed regression of ROP by the appearance of advanced vascular growth as depicted by FA. It was difficult to assess regression or progression of disease solely by digital fundus photographs and clinical exam. Serial photography and clinical exam were often hazy and did not show the distinct nature of the enhanced vasculature as clearly as the FA. Discussion: For advanced and referral warranted ROP it is critical to have fluorescein angiograms to follow infants post-treatment, especially those treated with off-label bevacizumab. If digital photographs and clinical examination are done alone, changes in vasculature may be often missed. Conclusion: Fluorescein angiograms are critical in demonstrating the details in the vasculature needed to follow post-bevacizumab treated eyes and to more clearly demonstrate regression or progression of ROP. References 1. Lepore, et al. Atlas of florescein angiographic findings in eyes undergoing laser for retinopathy of prematurity. Ophthalmology 2011;118. 2. Yokoi, et al. Vascular abnormalities in aggressive posterior retinopathy detected by fluorescein angiography. Ophthalmology 2009;116.
012 Depressive symptoms associated with poor health-related quality of life in adult strabismus. Sarah R. Hatt, David A. Leske, Laura Liebermann, Kemuel L. Philbrick, Jonathan M. Holmes Introduction: Health-related quality of life (HRQOL) often improves following successful surgery in adult strabismus. Nevertheless, in cases where HRQOL does not improve there may be other factors reducing HRQOL. We investigated associations between psychological, clinical or demographic factors, and HRQOL in adults with strabismus. Methods: A total of 177 adult strabismus patients were prospectively recruited and completed the following questionnaires: Adult Strabismus-20 (AS-20) HRQOL questionnaire (self-perception, interactions, reading function and general function domains), CESD-R depression questionnaire, DS-14 type D (distressed) personality questionnaire and the diplopia questionnaire. Factors considered for association with HRQOL score were: CESD-R score, type D personality (Yes/No), diplopia score, best-eye VA, comorbidity affecting facial appearance, deviation direction, deviation magnitude, age at assessment, age at onset, and sex. Multiple linear regression analyses were performed for each AS-20 domain. Factors were considered associated with poor HRQOL if P \ 0.05. Results: For both reading function and general function, lower scores (poorer HRQOL) were associated with higher (worse) CESD-R scores (P 5 0.0001 and P 5 0.0008, resp.) and higher (worse) diplopia scores (P \ 0.0001 for both). For Interaction, lower scores were associated with higher CESD-R score (P 5 0.02), greater magnitude of deviation (P 5 0.0002), and younger age (P 5 0.0007). For Self-Perception, lower scores were associated with younger age (P \ 0.0001) and greater magnitude of deviation (P\0.0001).
Journal of AAPOS
Volume 18 Number 4 / August 2014 Discussion: For 3 of 4 AS-20 domains, poorer HRQOL was associated with higher depression scores, indicating subthreshold depressive symptoms. Conclusion: The association of subthreshold depressive symptoms with poor HRQOL should be considered when interpreting patient reported outcomes.
013 The role of health-related quality of life when evaluating outcomes of strabismus surgery. Jonathan M. Holmes, Sarah R. Hatt, David A. Leske, Laura Liebermann Introduction: Strabismus surgery outcomes are typically defined using motor and diplopia criteria. Nevertheless, some patients designated failure by these criteria report subjective improvement. We aimed to evaluate the role of health-related quality of life (HRQOL) measures in patients who might be classified as failures. Methods: We studied adults undergoing strabismus surgery who had preoperative and 1-year postoperative HRQOL data using the Adult Strabismus-20 (AS-20) questionnaire. Motor and diplopia criteria were applied to classify outcomes as: success, partial success, or failure. For those classified as failure, the medical record was reviewed to determine whether there was subjective improvement at 1 year, independent of AS-20 scores. Improvement in HRQOL score was defined as exceeding 95% limits of agreement on at least one AS-20 domain. To determine whether HRQOL scores reflected subjective improvement in patients otherwise classified as failure, we compared HRQOL scores between those who reported improvement and those who did not. Results: Of 227 patients, 39 (17%) were classified as failure by motor and diplopia criteria; 25 of 39 reported subjective improvement, of which 16 (64%) met improved HRQOL score criteria. Fourteen of 39 had no subjective improvement, of which 5 (36%) met improved HRQOL criteria. Discussion: For many apparent surgical failures, objective motor and diplopia criteria do not capture subjective improvement, but improvement is often reflected in HRQOL scores. The few patients who had no subjective improvement but better HRQOL scores may represent a placebo effect. Conclusion: Quantitative HRQOL criteria should be considered when evaluating outcomes following strabismus surgery.
014 Factors affecting stereopsis after surgical alignment of acquired partially accommodative esotropia. Yiannis Iordanous, Inas Makar Introduction: The goal of strabismus surgery is to correct ocular alignment, promoting the development of stereopsis and binocular single vision (BSV). Despite successful surgical ocular alignment, many children do not develop stereopsis postoperatively. The purpose of this study was to determine preoperative factors that affect stereopsis in patients with acquired partially accommodative esotropia (APAET). Methods: We retrospectively reviewed the charts of all patients who underwent strabismus surgery for APAET from a single surgeons practice. Patients were eligible for inclusion if they had a final motor alignment within 8D of orthophoria for distance and near (successful alignment). We compared preoperative factors between patients achieving postoperative stereopsis better than 100 arcsec (i.e. achieving BSV) versus those with worse than 100 seconds of stereopsis. These factors included age of onset, delay in referral, duration of misalignment and age at surgery.
Journal of AAPOS
e5 Results: A total of 65 patients met our inclusion criteria. 27 (42%) had a final stereopsis of 100 arcsec or better. The mean AO for patients achieving postoperative BSV was 32.3 12.5 months, versus 22.4 9.2 months (P \ 0.0005) for the group not attaining BSV. Those achieving BSV presented to clinic later (57.4 19.2 vs 41.6 23.6 months; P 5 0.005) and had a later age at surgery (66.4 18.2 vs 50.3 21.7 months; P 5 0.002) when compared to those not achieving BSV. There was no significant difference in the duration of misalignment between the two groups (34.0 16.4 for those attaining BSV versus 27.9 19.0 for those not attaining BSV; P 5 0.2). A regression analysis found only older age of onset to be predictive of better postoperative BSV (OR 1.08; 95% CI 1.03-1.14). Discussion: Our results suggest that for every month delay in onset of esodeviation, a child with APAET is 8% more likely to regain BSV postoperatively. Surprisingly, DOM did not appear to be related to final stereoacuity outcomes in this patient population. Conclusion: These results may allow physicians to better predict surgical outcomes for children with APAET. It may also aid in surgical planning, as DOM appears to not be correlated with final outcomes.
015 Type I ROP, treatment with bevacizumab versus laser: comparison of visual function, structural outcome and frequency of follow-up. Maram Isaac, Kamiar Mireskandari, Nasrin Tehrani Purpose: To further elucidate the visual function, structural outcomes and frequency of follow up visits for infants with type I ROP treated with intravitreal Bevacizumab (IVB) versus laser. Methods: Retrospective comparative chart review. Results: Thirteen infants were treated with IVB and 14 infants with laser. There was no statistically significant difference in gestational age or birth weight. Eight eyes developed ROP in zone I and 15 eyes in zone II in each group. None developed unfavorable structural outcome at 6 months post treatment (1). Visual acuity (VA) was measurable for 16/23 eyes in laser and 13/23 eyes for IVB groups at 6-12 months corrected age (CA). Mean VA was (1.20 0.3) and (0.92 0.34) logMAR, (P 5 0.054) for laser and IVB groups respectively. Refraction was available for 17/23 eyes for laser and 23/23 eyes for IVB groups. Mean spherical equivalent (SE) was (-4.41 4.71) for laser and (-3.42 5.89) for IVB groups (p 5 0.5572), respectively. Infants in laser group had an average of (5.00 3.00) follow up visits versus (14.00 5.00) in IVB group, (P \ 0.001) in the 6 months post treatment. Discussion: Both treatments resulted in good structural outcome. At 6-12 months CA, there was no statistically significant difference in refractive error or VA between two groups, however more frequent follow up was observed in the IVB group. Conclusion: In view of similar structural outcomes between the two groups, frequency of follow up post IVB may need reconsideration to reduce patient exposure to distressful eye examinations and optimize resource allocation. References 1. Early Treatment for Retinopathy of Prematurity Cooperative Group. Revised indications for the treatment of retinopathy of prematurity: results of the Early Treatment for Retinopathy of Prematurity randomized trial. Arch Ophthalmol 2003;121:1684-94.
016 High sensitivity of binocular retinal birefringence screening for anisometropic amblyopia without strabismus. Reed M. Jost, Joost Felius, Eileen E. Birch Introduction: Binocular retinal birefringence scanning can detect whether fixation is bifoveal by identifying the unique polarization
Volume 18 Number 4 / August 2014
Conclusion: Polypseudophakia does not cause accelerated axial growth in patients undergoing primary placement within the first 24 months of life. However, the age at planned IOL removal varies from less than 1 year to more than 7 years after implantation. 010 Optic nerve volumetric measurements in pediatric papilledema with spectral domain OCT. Jose Efren Gonzalez Monroy, Frank Weng, Linda R. Dagi, Gena Heidary Introduction: In pediatric patients with papilledema, determining response to treatment may be difficult due to inherent limitations in the clinical exam. Spectral domain optical coherence tomography (SD-OCT) of optic nerve volume (ONV) has begun to be explored as a relevant measure in adult patients with papilledema.1,2 We evaluated whether SD-OCT of ONV may be a useful adjunct in the assessment of pediatric papilledema. Methods: Single center, three year retrospective review of patients with confirmed papilledema. Patients with Heidelberg Spectralis SD-OCT ONV measurements within 1 month of diagnosis were included. Data including gender, age, visual field results, optic nerve edema grade and lumbar puncture opening pressure were recorded. Results: Eighteen patients (10 female [53%]) were included. Mean age at presentation was 12 years (SD 5.6 years). Data from the right eyes only were evaluated; no difference between eyes was noted (P 5 0.26). Mean ONV OD in patients with papilledema was significantly increased at 4.74 mm3 (SD 1.52) compared with 2.51 mm3 (SD 0.25) in age and sex matched control subjects (P \ 0.001). A moderate positive correlation of 0.55 was identified between initial ONV and lumbar puncture opening pressure. Longitudinally, ONV measurements improved with a significant decrease in volumetric measurements at most recent follow-up (P 5 0.001). Discussion: ONV appeared to reflect well optic nerve edema at time of diagnosis and correlated well with response to treatment as measured by improved edema longitudinally. Conclusion: SD-OCT ONV measurements may provide an important tool towards the assessment of treatment response in pediatric patients with papilledema. References 1. Kaufhold F, Kadas EM, Schmidt C, et al. Optic nerve head quantification in idiopathic intracranial hypertension by spectral domain OCT. PLOS One 2012;7:e36965. 2. Wang J-K, Kardon RH, Kupersmith MJ, Garvin MK. Automated quantification of volumetric optic disc swelling in papilledema using spectral-domain optical coherence tomography. Invest Ophthalmol Vis Sci 2012;53:4069-75.
011 Serial fundus photography and fluorescein angiography after off-label intravitreal bevacizumab treatment for retinopathy of prematurity: importance of monitoring regression by angiography in off-label bevacizumab treated eyes. Luxme Hariharan, Aleksandra Rachitskaya, Ditte J. Hess, CRA, Ann Rodriquez, RN, Catherine Negron, BA, Audina M. Berrocal, MD Introduction: Intravitreal bevacizumab has been reported as an offlabel treatment in retinopathy of prematurity (ROP). The purpose of this study is to demonstrate the importance of fluorescein angiography (FA) in the management of ROP regression after an intravitreal bevacizumab treatment. Methods: This is an IRB-approved retrospective consecutive case series of 38 eyes of 19 infants with ROP from 2006 to 2013. Eleven patients were treated solely with intravitreal bevacizumab while 8
received both bevacizumab and laser. Clinical exam, RetCam (Clarity, Pleasanton, CA) fundus photography and fluorescein angiography were performed prior to the treatment. A 10% solution of sodium fluorescein dye was administered intravenously as a bolus at a dose of 7.7 mg/kg followed by a saline flush. All eyes were injected with 0.625 mg of bevacizumab. RetCam photos and fluorescein angiograms were documented post-treatment. All treatments including clinical examination, fundus photography, fluorescein angiography, bevacizumab injections and laser were performed at the bedside. Results: All 38 eyes showed regression of ROP by the appearance of advanced vascular growth as depicted by FA. It was difficult to assess regression or progression of disease solely by digital fundus photographs and clinical exam. Serial photography and clinical exam were often hazy and did not show the distinct nature of the enhanced vasculature as clearly as the FA. Discussion: For advanced and referral warranted ROP it is critical to have fluorescein angiograms to follow infants post-treatment, especially those treated with off-label bevacizumab. If digital photographs and clinical examination are done alone, changes in vasculature may be often missed. Conclusion: Fluorescein angiograms are critical in demonstrating the details in the vasculature needed to follow post-bevacizumab treated eyes and to more clearly demonstrate regression or progression of ROP. References 1. Lepore, et al. Atlas of florescein angiographic findings in eyes undergoing laser for retinopathy of prematurity. Ophthalmology 2011;118. 2. Yokoi, et al. Vascular abnormalities in aggressive posterior retinopathy detected by fluorescein angiography. Ophthalmology 2009;116.
012 Depressive symptoms associated with poor health-related quality of life in adult strabismus. Sarah R. Hatt, David A. Leske, Laura Liebermann, Kemuel L. Philbrick, Jonathan M. Holmes Introduction: Health-related quality of life (HRQOL) often improves following successful surgery in adult strabismus. Nevertheless, in cases where HRQOL does not improve there may be other factors reducing HRQOL. We investigated associations between psychological, clinical or demographic factors, and HRQOL in adults with strabismus. Methods: A total of 177 adult strabismus patients were prospectively recruited and completed the following questionnaires: Adult Strabismus-20 (AS-20) HRQOL questionnaire (self-perception, interactions, reading function and general function domains), CESD-R depression questionnaire, DS-14 type D (distressed) personality questionnaire and the diplopia questionnaire. Factors considered for association with HRQOL score were: CESD-R score, type D personality (Yes/No), diplopia score, best-eye VA, comorbidity affecting facial appearance, deviation direction, deviation magnitude, age at assessment, age at onset, and sex. Multiple linear regression analyses were performed for each AS-20 domain. Factors were considered associated with poor HRQOL if P \ 0.05. Results: For both reading function and general function, lower scores (poorer HRQOL) were associated with higher (worse) CESD-R scores (P 5 0.0001 and P 5 0.0008, resp.) and higher (worse) diplopia scores (P \ 0.0001 for both). For Interaction, lower scores were associated with higher CESD-R score (P 5 0.02), greater magnitude of deviation (P 5 0.0002), and younger age (P 5 0.0007). For Self-Perception, lower scores were associated with younger age (P \ 0.0001) and greater magnitude of deviation (P\0.0001).
Journal of AAPOS
Volume 18 Number 4 / August 2014 Discussion: For 3 of 4 AS-20 domains, poorer HRQOL was associated with higher depression scores, indicating subthreshold depressive symptoms. Conclusion: The association of subthreshold depressive symptoms with poor HRQOL should be considered when interpreting patient reported outcomes.
013 The role of health-related quality of life when evaluating outcomes of strabismus surgery. Jonathan M. Holmes, Sarah R. Hatt, David A. Leske, Laura Liebermann Introduction: Strabismus surgery outcomes are typically defined using motor and diplopia criteria. Nevertheless, some patients designated failure by these criteria report subjective improvement. We aimed to evaluate the role of health-related quality of life (HRQOL) measures in patients who might be classified as failures. Methods: We studied adults undergoing strabismus surgery who had preoperative and 1-year postoperative HRQOL data using the Adult Strabismus-20 (AS-20) questionnaire. Motor and diplopia criteria were applied to classify outcomes as: success, partial success, or failure. For those classified as failure, the medical record was reviewed to determine whether there was subjective improvement at 1 year, independent of AS-20 scores. Improvement in HRQOL score was defined as exceeding 95% limits of agreement on at least one AS-20 domain. To determine whether HRQOL scores reflected subjective improvement in patients otherwise classified as failure, we compared HRQOL scores between those who reported improvement and those who did not. Results: Of 227 patients, 39 (17%) were classified as failure by motor and diplopia criteria; 25 of 39 reported subjective improvement, of which 16 (64%) met improved HRQOL score criteria. Fourteen of 39 had no subjective improvement, of which 5 (36%) met improved HRQOL criteria. Discussion: For many apparent surgical failures, objective motor and diplopia criteria do not capture subjective improvement, but improvement is often reflected in HRQOL scores. The few patients who had no subjective improvement but better HRQOL scores may represent a placebo effect. Conclusion: Quantitative HRQOL criteria should be considered when evaluating outcomes following strabismus surgery.
014 Factors affecting stereopsis after surgical alignment of acquired partially accommodative esotropia. Yiannis Iordanous, Inas Makar Introduction: The goal of strabismus surgery is to correct ocular alignment, promoting the development of stereopsis and binocular single vision (BSV). Despite successful surgical ocular alignment, many children do not develop stereopsis postoperatively. The purpose of this study was to determine preoperative factors that affect stereopsis in patients with acquired partially accommodative esotropia (APAET). Methods: We retrospectively reviewed the charts of all patients who underwent strabismus surgery for APAET from a single surgeons practice. Patients were eligible for inclusion if they had a final motor alignment within 8D of orthophoria for distance and near (successful alignment). We compared preoperative factors between patients achieving postoperative stereopsis better than 100 arcsec (i.e. achieving BSV) versus those with worse than 100 seconds of stereopsis. These factors included age of onset, delay in referral, duration of misalignment and age at surgery.
Journal of AAPOS
e5 Results: A total of 65 patients met our inclusion criteria. 27 (42%) had a final stereopsis of 100 arcsec or better. The mean AO for patients achieving postoperative BSV was 32.3 12.5 months, versus 22.4 9.2 months (P \ 0.0005) for the group not attaining BSV. Those achieving BSV presented to clinic later (57.4 19.2 vs 41.6 23.6 months; P 5 0.005) and had a later age at surgery (66.4 18.2 vs 50.3 21.7 months; P 5 0.002) when compared to those not achieving BSV. There was no significant difference in the duration of misalignment between the two groups (34.0 16.4 for those attaining BSV versus 27.9 19.0 for those not attaining BSV; P 5 0.2). A regression analysis found only older age of onset to be predictive of better postoperative BSV (OR 1.08; 95% CI 1.03-1.14). Discussion: Our results suggest that for every month delay in onset of esodeviation, a child with APAET is 8% more likely to regain BSV postoperatively. Surprisingly, DOM did not appear to be related to final stereoacuity outcomes in this patient population. Conclusion: These results may allow physicians to better predict surgical outcomes for children with APAET. It may also aid in surgical planning, as DOM appears to not be correlated with final outcomes.
015 Type I ROP, treatment with bevacizumab versus laser: comparison of visual function, structural outcome and frequency of follow-up. Maram Isaac, Kamiar Mireskandari, Nasrin Tehrani Purpose: To further elucidate the visual function, structural outcomes and frequency of follow up visits for infants with type I ROP treated with intravitreal Bevacizumab (IVB) versus laser. Methods: Retrospective comparative chart review. Results: Thirteen infants were treated with IVB and 14 infants with laser. There was no statistically significant difference in gestational age or birth weight. Eight eyes developed ROP in zone I and 15 eyes in zone II in each group. None developed unfavorable structural outcome at 6 months post treatment (1). Visual acuity (VA) was measurable for 16/23 eyes in laser and 13/23 eyes for IVB groups at 6-12 months corrected age (CA). Mean VA was (1.20 0.3) and (0.92 0.34) logMAR, (P 5 0.054) for laser and IVB groups respectively. Refraction was available for 17/23 eyes for laser and 23/23 eyes for IVB groups. Mean spherical equivalent (SE) was (-4.41 4.71) for laser and (-3.42 5.89) for IVB groups (p 5 0.5572), respectively. Infants in laser group had an average of (5.00 3.00) follow up visits versus (14.00 5.00) in IVB group, (P \ 0.001) in the 6 months post treatment. Discussion: Both treatments resulted in good structural outcome. At 6-12 months CA, there was no statistically significant difference in refractive error or VA between two groups, however more frequent follow up was observed in the IVB group. Conclusion: In view of similar structural outcomes between the two groups, frequency of follow up post IVB may need reconsideration to reduce patient exposure to distressful eye examinations and optimize resource allocation. References 1. Early Treatment for Retinopathy of Prematurity Cooperative Group. Revised indications for the treatment of retinopathy of prematurity: results of the Early Treatment for Retinopathy of Prematurity randomized trial. Arch Ophthalmol 2003;121:1684-94.
016 High sensitivity of binocular retinal birefringence screening for anisometropic amblyopia without strabismus. Reed M. Jost, Joost Felius, Eileen E. Birch Introduction: Binocular retinal birefringence scanning can detect whether fixation is bifoveal by identifying the unique polarization