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“It does matter”: outcomes of prescribing glasses in students with neuro-developmental disabilities
Volume 19 Number 4 / August 2015 Discussion: Neroinflammation following retinal IR injury included microglial activation, disruption of endothelial tight junctions, and leukocyte infiltration. Future studies using bone marrow chimeras may help elucidate whether additional Iba1+ cells are derived from resident microglia or from infiltrating monocytes. Conclusions: CCL2 appears to modulate the activation of microglia after IR.
173 A comparison between pediatric and adult ophthalmology consults in an urban academic institution. Sunju Park, Sejal H. Patel, Jamie B. Rosenberg Introduction: The purpose of this study is to compare pediatric and adult ophthalmology consults in an urban academic center. Methods: Retrospective chart review was conducted of patients evaluated by the ophthalmology consultation service from January to March 2014. Patient charts were abstracted for data related to reasons for consult and findings/recommendations made. Results: 379 patients were evaluated, 72 (19.0%) children and 307 (81.0%) adults. More children (38.9%) than adults (7.5%) were seen with an attending (P \ 0.001). More adults (81.1%) than children (61.1%) had an eye complaint (P \ 0.001). More adults (92.2%) than children (76.4%) had abnormal findings on examination (P \ 0.001). The other variables were not significantly different: an alteration in management was recommended for 50% of patients; outpatient follow-up was recommended for 70% of patients. Discussion: There are several differences between pediatric and adult consults in our institution. More adult patients had a chief complaint, because many pediatric exams were done to screen for systemic diseases or nonaccidental trauma. Many of these screens result in negative examinations, which explains why more of the adult patients had abnormal findings. Despite the higher rate of abnormal findings in adults, patient management was changed at similar rates among children and adults. Conclusions: Comparing pediatric and adult consults allows for the identification of patterns among both providers and patients. These patterns can be used to help educate primary care physicians and ophthalmology residents on the best management of inpatient consults.
174 The effectiveness of a mobile clinic in improving follow-up eye care for at-risk children. Jinali Patel, Wei Diao, Melanie Snitzer, Michael Pond, Rachel Weiner, Sarah Martinez-Helfman, Kathleen Santa Maria, Alex V. Levin Introduction: Every year over 22,000 Philadelphia public school students fail a school vision screen but only approximately 4,000 see an ophthalmologist. While mobile optometric care units have had success in delivering primary eye care, only 53% of patients referred to pediatric ophthalmologists complete this consultation. This study investigates whether a mobile eye unit with the same equipment as a pediatric ophthalmologists office could improve the rate of successful consultation. Methods: Cohort study of students from schools in socioeconomically disadvantaged communities, referred to a mobile ophthalmic unit after failing an in-school optometric exam and obtained consent to be seen by a mobile unit instead of at a local hospital.
Journal of AAPOS
e57 Results: A total of 132 students were referred by the optometric program to the mobile unit. 101 students had signed consent forms of which 82 (81%; CI, 74%-89%) were seen by the mobile ophthalmic unit, which represents a follow-up rate of 62% (CI, 54-70%). The rate of successful completions of ophthalmology consultation increased compared with the historical rate of 53% (P 5 0.036). School nurses responded favorably to this program citing improved convenience, simpler logistics, and more effective use of personnel time. Discussion: Our data suggest that a mobile eye unit can increase the ability to successfully provide ophthalmic care to high risk children. Conclusions: As screening without follow-up does not adequately address the needs of pediatric patients, the use of mobile eye clinics in schools may allow consultation completion to be more successful. 175 Circumferential macular folds associated with reduced macular hemorrhages in non-accidental trauma: implications for the theory of vitreous traction. Alexander E. Pogrebniak Introduction: The direct intraocular mechanisms and forces required to create retinal hemorrhages in nonaccidental head injury remain a matter of controversy and conjecture. The predominant theory implicates vitreous traction on retinal vessels; however, retinal hemorrhages occur in other settings without history of rapid acceleration-deceleration injury, such as in healthy newborns. Circumferential macular folds are seen almost exclusively in severe non-accidental trauma. We sought to document the pattern of retinal hemorrhages relative to macular folds to determine if the altered vitreoretinal interface may influence the formation of retinal hemorrhages. Methods: We present a report of two cases of nonaccidental trauma with circumferential macular folds to examine the location of hemorrhages related to the macular schisis cavities. Results: As seen in the analysis of photographs, in both cases retinal hemorrhage was almost confluent peripheral to the circumferential macular folds, was prominent on the apex and sides of the folds, but almost absent central to the folds (ratio area hemorrhage peripheral to fold: central to fold .5:1). Discussion: The pattern of retinal hemorrhages post severe nonaccidental trauma appears altered by the presence of retinal folds, with decreased hemorrhage central to the folds where macular schisis has occurred, in contrast to the typical finding of widespread macular hemorrhages when nonaccidental trauma occurs without macular folds. Conclusions: The findings may support the theory of vitreous traction causing retinal hemorrhages whereby retinal hemorrhage is prominent on and peripheral to the retinal folds where vitreous attachments persist and minimized central to the folds where schisis has occurred. 176 "It does matter": outcomes of prescribing glasses in students with neuro-developmental disabilities. Ivonne M. Radinson Alvarado, Nathan Schenkman, Robert J. House, Linda M. Lawrence, Rosa Yemi, Oyama Ganiko, Liliana Mayo Ortega Introduction: The purpose of this study is to determine if students with neurodevelopmental disorders and significant refractive errors, can demonstrate behavioral and communication improvements by adapting to wearing glasses. Methods: Sixty students with neurodevelopmental disorders at an educational center in Lima, Peru were identified by a pediatric
e58 ophthalmologist as needing glasses to improve functional vision, and prescribed accordingly. Ten months later the parents completed a survey regarding the use of glasses. Parents reported on the frequency of use, the activities and locations when glasses were used and any changes in behavior when wearing the glasses. Results: A total of 51 students (85%) were using the glasses 10 months after they were prescribed. Thirty-three (55%) used glasses at home, at school and in the street, with the remaining students using glasses in one or two of these environments. Fourteen (23%) of the students reportedly cleaned and cared for their own glasses. Forty-three (72%) of the parents surveyed reported seeing positive behaviors ranging from increased help around the house to more interest in books and improved general behavior and communication when glasses were worn. Discussion: Ten months after glasses prescription a vast majority of the students had obtained glasses and were using them. Conclusions: Visual impairment in students with neurodevelopmental disorders is under diagnosed. The results collected from the current study demonstrate that students with developmental disorders and vision problems can adapt to wearing glasses when given proper diagnosis, intervention, and support leading to an increase in quality of life.
177 Facilitated versus self-guided training for grading of retinal images for ROP. Nikolas N. Raufi, Caleb K. Morris, Sharon F. Freedman, David K. Wallace, Sasapin G. Prakalapakorn Introduction: Retinopathy of prematurity (ROP) remains an important cause of preventable blindness; screening barriers necessitate novel approaches. While trained non-physicians can accurately grade wide-field retinal images for ROP, effective training protocols have not been determined. This study compares the effectiveness of facilitated versus self-guided training for grading retinal images for ROP. Methods: Thirty undergraduate and graduate students were trained to analyze narrow-field (ie, from indirect ophthalmoscopy) still retinal imagesii for the presence of preplus or plus disease. Students were randomized into one of two training protocols. Both utilized identical electronic slideshows, but one was guided by an in-person facilitator, and the other was self-guided. After completing their respective training, students showing proficiency in grading pre-plus and plus disease graded a 107-retinal-image screening scenario. Accuracy of grading for ROP was compared to a reference standard (ie, clinical examination). Results: Of trained students, 80% (24/30; 89% in the facilitated vs 76% in the self-guided group [P 5 0.6]) qualified to grade the ROP screening scenario. Median accuracy for grading normal, pre-plus or plus disease was 71% (71% in the facilitated vs 70% in the self-guided group). When considering the designation of plus or pre-plus disease by graders as a screening test for detecting plus disease (confirmed on clinical examination), the median sensitivity of both groups was 97% and the median specificity 63%. Discussion: Both facilitated- and self-guided teaching protocols yielded similar performance in ROP image grading. Conclusions: Self-guided training protocols may be adequate to train non-ophthalmologists to appreciate retinal blood vessel changes and detect plus disease with high sensitivity.
Volume 19 Number 4 / August 2015 178 The post-concussion syndrome: influence on binocular function. Gill Roper-Hall, Oscar A. Cruz, Sophia M. Chung Introduction: The post-concussion syndrome encompasses a constellation of findings, including convergence paresis, disequilibrium and cognitive changes. Ocular symptoms may be exacerbated by head movement or motion. Associated findings include memory loss, difficulty concentrating, and depression. There has been recent media interest in the long-term effects of sports-related concussion, particularly repeated concussions. Methods: A retrospective study was conducted at our institution of adult patients evaluated and treated between 2002 and 2012 for binocular symptoms occurring after concussion. Exclusion criteria were previous strabismus, concurrent ocular injury, facial or orbital fracture, or vision loss. Results: Eight patients (5 females) met the inclusion criteria; patients were 22-51 years of age (mean, 35.1). Convergence near point and amplitudes were decreased in all patients. Accommodation was decreased in 5. Pupils were normal. Initial symptoms included blurred vision, asthenopia and headache (8), diplopia (7), cognitive difficulty (7), nausea, dizziness or disequilibrium (6), photophobia or hyperacusis (5). Initial response to convergence therapy was slow despite a modified approach, especially in the motion-intolerant group, necessitating deferred treatment for several months. Full recovery following therapy (1); normal convergence function but persistent concussion-related symptoms (3); partial improvement with no further recovery (4). Discussion: Concussions or "mild" traumatic brain injuries, while not life-threatening, can have lasting effects on a patients ability to function at work or in daily life. Convergence paresis is common and should be differentiated from convergence insufficiency. Conclusions: Binocular management techniques after concussion should be modified and simplified in face of associated cognitive and otoneurological signs. Rest is an important adjunct to therapy. 179 Functional outcomes of young infants with and without macular edema. Adam L. Rothman, Du Tran-Viet, Vincent Tai, Neeru Sarin, Sandra Holgado, C. Michael Cotten, Sharon F. Freedman, Cynthia A. Toth Introduction: We relate posterior segment microanatomy from perinatal spectral-domain optical coherence tomography (SD-OCT) to visual acuity (VA), brain abnormalities, and neurodevelopment. Methods: Twelve infants (10 preterm, 2 term birth), imaged in the nursery with portable SDOCT, had VA and sensorimotor testing at age 9-15 months (grating acuity) or 4-5 years (optotype), and medical records reviewed for brain magnetic resonance imaging (MRI) reports and Bayley Scales testing at age 18-24 months. Two children with retinal detachments or dense vitreous hemorrhages and suboptimal acuity were excluded from analysis. Results: Five children with age-appropriate macular microanatomy without edema on perinatal SDOCT had optimal (.20/40) or within normal limits (grating acuity) VA. Five children with perinatal macular edema and some with additional OCT anomalies had suboptimal VA (in 9/10 eyes) and either sensorimotor deficits, MRI abnormalities or poor neurodevelopment. Macular edema persisted in one infant through 9 months corrected age. Discussion: Maturation of the visual system and evolution of retinal anomalies can be monitored with posterior segment SD-OCT. Macular edema on perinatal SD-OCT appears as a potential indicator of
Journal of AAPOS
173 A comparison between pediatric and adult ophthalmology consults in an urban academic institution. Sunju Park, Sejal H. Patel, Jamie B. Rosenberg Introduction: The purpose of this study is to compare pediatric and adult ophthalmology consults in an urban academic center. Methods: Retrospective chart review was conducted of patients evaluated by the ophthalmology consultation service from January to March 2014. Patient charts were abstracted for data related to reasons for consult and findings/recommendations made. Results: 379 patients were evaluated, 72 (19.0%) children and 307 (81.0%) adults. More children (38.9%) than adults (7.5%) were seen with an attending (P \ 0.001). More adults (81.1%) than children (61.1%) had an eye complaint (P \ 0.001). More adults (92.2%) than children (76.4%) had abnormal findings on examination (P \ 0.001). The other variables were not significantly different: an alteration in management was recommended for 50% of patients; outpatient follow-up was recommended for 70% of patients. Discussion: There are several differences between pediatric and adult consults in our institution. More adult patients had a chief complaint, because many pediatric exams were done to screen for systemic diseases or nonaccidental trauma. Many of these screens result in negative examinations, which explains why more of the adult patients had abnormal findings. Despite the higher rate of abnormal findings in adults, patient management was changed at similar rates among children and adults. Conclusions: Comparing pediatric and adult consults allows for the identification of patterns among both providers and patients. These patterns can be used to help educate primary care physicians and ophthalmology residents on the best management of inpatient consults.
174 The effectiveness of a mobile clinic in improving follow-up eye care for at-risk children. Jinali Patel, Wei Diao, Melanie Snitzer, Michael Pond, Rachel Weiner, Sarah Martinez-Helfman, Kathleen Santa Maria, Alex V. Levin Introduction: Every year over 22,000 Philadelphia public school students fail a school vision screen but only approximately 4,000 see an ophthalmologist. While mobile optometric care units have had success in delivering primary eye care, only 53% of patients referred to pediatric ophthalmologists complete this consultation. This study investigates whether a mobile eye unit with the same equipment as a pediatric ophthalmologists office could improve the rate of successful consultation. Methods: Cohort study of students from schools in socioeconomically disadvantaged communities, referred to a mobile ophthalmic unit after failing an in-school optometric exam and obtained consent to be seen by a mobile unit instead of at a local hospital.
Journal of AAPOS
e57 Results: A total of 132 students were referred by the optometric program to the mobile unit. 101 students had signed consent forms of which 82 (81%; CI, 74%-89%) were seen by the mobile ophthalmic unit, which represents a follow-up rate of 62% (CI, 54-70%). The rate of successful completions of ophthalmology consultation increased compared with the historical rate of 53% (P 5 0.036). School nurses responded favorably to this program citing improved convenience, simpler logistics, and more effective use of personnel time. Discussion: Our data suggest that a mobile eye unit can increase the ability to successfully provide ophthalmic care to high risk children. Conclusions: As screening without follow-up does not adequately address the needs of pediatric patients, the use of mobile eye clinics in schools may allow consultation completion to be more successful. 175 Circumferential macular folds associated with reduced macular hemorrhages in non-accidental trauma: implications for the theory of vitreous traction. Alexander E. Pogrebniak Introduction: The direct intraocular mechanisms and forces required to create retinal hemorrhages in nonaccidental head injury remain a matter of controversy and conjecture. The predominant theory implicates vitreous traction on retinal vessels; however, retinal hemorrhages occur in other settings without history of rapid acceleration-deceleration injury, such as in healthy newborns. Circumferential macular folds are seen almost exclusively in severe non-accidental trauma. We sought to document the pattern of retinal hemorrhages relative to macular folds to determine if the altered vitreoretinal interface may influence the formation of retinal hemorrhages. Methods: We present a report of two cases of nonaccidental trauma with circumferential macular folds to examine the location of hemorrhages related to the macular schisis cavities. Results: As seen in the analysis of photographs, in both cases retinal hemorrhage was almost confluent peripheral to the circumferential macular folds, was prominent on the apex and sides of the folds, but almost absent central to the folds (ratio area hemorrhage peripheral to fold: central to fold .5:1). Discussion: The pattern of retinal hemorrhages post severe nonaccidental trauma appears altered by the presence of retinal folds, with decreased hemorrhage central to the folds where macular schisis has occurred, in contrast to the typical finding of widespread macular hemorrhages when nonaccidental trauma occurs without macular folds. Conclusions: The findings may support the theory of vitreous traction causing retinal hemorrhages whereby retinal hemorrhage is prominent on and peripheral to the retinal folds where vitreous attachments persist and minimized central to the folds where schisis has occurred. 176 "It does matter": outcomes of prescribing glasses in students with neuro-developmental disabilities. Ivonne M. Radinson Alvarado, Nathan Schenkman, Robert J. House, Linda M. Lawrence, Rosa Yemi, Oyama Ganiko, Liliana Mayo Ortega Introduction: The purpose of this study is to determine if students with neurodevelopmental disorders and significant refractive errors, can demonstrate behavioral and communication improvements by adapting to wearing glasses. Methods: Sixty students with neurodevelopmental disorders at an educational center in Lima, Peru were identified by a pediatric
e58 ophthalmologist as needing glasses to improve functional vision, and prescribed accordingly. Ten months later the parents completed a survey regarding the use of glasses. Parents reported on the frequency of use, the activities and locations when glasses were used and any changes in behavior when wearing the glasses. Results: A total of 51 students (85%) were using the glasses 10 months after they were prescribed. Thirty-three (55%) used glasses at home, at school and in the street, with the remaining students using glasses in one or two of these environments. Fourteen (23%) of the students reportedly cleaned and cared for their own glasses. Forty-three (72%) of the parents surveyed reported seeing positive behaviors ranging from increased help around the house to more interest in books and improved general behavior and communication when glasses were worn. Discussion: Ten months after glasses prescription a vast majority of the students had obtained glasses and were using them. Conclusions: Visual impairment in students with neurodevelopmental disorders is under diagnosed. The results collected from the current study demonstrate that students with developmental disorders and vision problems can adapt to wearing glasses when given proper diagnosis, intervention, and support leading to an increase in quality of life.
177 Facilitated versus self-guided training for grading of retinal images for ROP. Nikolas N. Raufi, Caleb K. Morris, Sharon F. Freedman, David K. Wallace, Sasapin G. Prakalapakorn Introduction: Retinopathy of prematurity (ROP) remains an important cause of preventable blindness; screening barriers necessitate novel approaches. While trained non-physicians can accurately grade wide-field retinal images for ROP, effective training protocols have not been determined. This study compares the effectiveness of facilitated versus self-guided training for grading retinal images for ROP. Methods: Thirty undergraduate and graduate students were trained to analyze narrow-field (ie, from indirect ophthalmoscopy) still retinal imagesii for the presence of preplus or plus disease. Students were randomized into one of two training protocols. Both utilized identical electronic slideshows, but one was guided by an in-person facilitator, and the other was self-guided. After completing their respective training, students showing proficiency in grading pre-plus and plus disease graded a 107-retinal-image screening scenario. Accuracy of grading for ROP was compared to a reference standard (ie, clinical examination). Results: Of trained students, 80% (24/30; 89% in the facilitated vs 76% in the self-guided group [P 5 0.6]) qualified to grade the ROP screening scenario. Median accuracy for grading normal, pre-plus or plus disease was 71% (71% in the facilitated vs 70% in the self-guided group). When considering the designation of plus or pre-plus disease by graders as a screening test for detecting plus disease (confirmed on clinical examination), the median sensitivity of both groups was 97% and the median specificity 63%. Discussion: Both facilitated- and self-guided teaching protocols yielded similar performance in ROP image grading. Conclusions: Self-guided training protocols may be adequate to train non-ophthalmologists to appreciate retinal blood vessel changes and detect plus disease with high sensitivity.
Volume 19 Number 4 / August 2015 178 The post-concussion syndrome: influence on binocular function. Gill Roper-Hall, Oscar A. Cruz, Sophia M. Chung Introduction: The post-concussion syndrome encompasses a constellation of findings, including convergence paresis, disequilibrium and cognitive changes. Ocular symptoms may be exacerbated by head movement or motion. Associated findings include memory loss, difficulty concentrating, and depression. There has been recent media interest in the long-term effects of sports-related concussion, particularly repeated concussions. Methods: A retrospective study was conducted at our institution of adult patients evaluated and treated between 2002 and 2012 for binocular symptoms occurring after concussion. Exclusion criteria were previous strabismus, concurrent ocular injury, facial or orbital fracture, or vision loss. Results: Eight patients (5 females) met the inclusion criteria; patients were 22-51 years of age (mean, 35.1). Convergence near point and amplitudes were decreased in all patients. Accommodation was decreased in 5. Pupils were normal. Initial symptoms included blurred vision, asthenopia and headache (8), diplopia (7), cognitive difficulty (7), nausea, dizziness or disequilibrium (6), photophobia or hyperacusis (5). Initial response to convergence therapy was slow despite a modified approach, especially in the motion-intolerant group, necessitating deferred treatment for several months. Full recovery following therapy (1); normal convergence function but persistent concussion-related symptoms (3); partial improvement with no further recovery (4). Discussion: Concussions or "mild" traumatic brain injuries, while not life-threatening, can have lasting effects on a patients ability to function at work or in daily life. Convergence paresis is common and should be differentiated from convergence insufficiency. Conclusions: Binocular management techniques after concussion should be modified and simplified in face of associated cognitive and otoneurological signs. Rest is an important adjunct to therapy. 179 Functional outcomes of young infants with and without macular edema. Adam L. Rothman, Du Tran-Viet, Vincent Tai, Neeru Sarin, Sandra Holgado, C. Michael Cotten, Sharon F. Freedman, Cynthia A. Toth Introduction: We relate posterior segment microanatomy from perinatal spectral-domain optical coherence tomography (SD-OCT) to visual acuity (VA), brain abnormalities, and neurodevelopment. Methods: Twelve infants (10 preterm, 2 term birth), imaged in the nursery with portable SDOCT, had VA and sensorimotor testing at age 9-15 months (grating acuity) or 4-5 years (optotype), and medical records reviewed for brain magnetic resonance imaging (MRI) reports and Bayley Scales testing at age 18-24 months. Two children with retinal detachments or dense vitreous hemorrhages and suboptimal acuity were excluded from analysis. Results: Five children with age-appropriate macular microanatomy without edema on perinatal SDOCT had optimal (.20/40) or within normal limits (grating acuity) VA. Five children with perinatal macular edema and some with additional OCT anomalies had suboptimal VA (in 9/10 eyes) and either sensorimotor deficits, MRI abnormalities or poor neurodevelopment. Macular edema persisted in one infant through 9 months corrected age. Discussion: Maturation of the visual system and evolution of retinal anomalies can be monitored with posterior segment SD-OCT. Macular edema on perinatal SD-OCT appears as a potential indicator of
Journal of AAPOS