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Septic superior ophthalmic vein and cavernous sinus thrombosis in children
e28 developed varied between patients but was generally during the teenage years for 4 patients (aged 13 to 17 years) and young adulthood for the two others (30 years, 33 years). The diplopia was managed with vision therapy in two patients, use of an occlusion contact lens in one patient while surgery was needed in the other three patients. The diplopia was horizontal only in one patient, but had a vertical component in the rest of the group. Discussion: Diplopia is not a known sensory outcome for patients with infantile esotropia who generally have suppression that prevents diplopia. Infantile esotropia often requires multiple procedures for maintenance of ocular alignment. In these patients diplopia did occur during their teenage years and early adulthood. Conclusions: Though diplopia after age 6 years is usually due to serious conditions and should be well investigated, diplopia can occur in patients with infantile esotropia and become manifest many years after initial corrective surgery. 104 Spontaneous resolution of vertical deviation in intermittent exotropia. Michael C. Struck, Timothy J. Daley Background: Patients with intermittent exotropia often have a concomitant vertical deviation. Surgical management of the hypertropia can be challenging. Methods: We reviewed the charts of 21 consecutive patients with a clinically significant (5 prism diopters or more) hypertropia in the setting of intermittent exotropia. Eleven patients underwent horizontal muscle surgery alone, while ten patients underwent combined horizontal and vertical muscle surgery. Postoperative alignment was measured at 6 months. Success was defined as no postoperative vertical deviation. Results: At 6 months postoperatively, 9 of 11 patients with clinically significant hypertropia who underwent horizontal muscle surgery alone had successful outcomes (82%), whereas 3 of 10 patients with combined vertical muscle surgery had a successful outcome (30%). There were no over-corrections (ie, reversal of hypertropia) in the patients undergoing horizontal muscle surgery alone versus 5 over-corrections in patients undergoing combined horizontal and vertical muscle surgery. Discussion: Our results suggest that clinically significant hypertropia in patients with intermittent exotropia frequently spontaneously resolves with horizontal surgery alone. Adding vertical surgery often leads to overcorrection of the hypertropia in our experience. Conclusions: In patients with intermittent exotropia and a coexisting vertical deviation, surgically treating the horizontal deviation alone is often sufficient to correct the vertical deviation as well. 105 Deficient accommodation in accommodative esotropia and hyperopic anisometropia. Vidhya Subramanian, Eileen E. Birch Background/Purpose: Accommodative esotropia and hyperopic anisometropia are frequently associated with amblyopia. Despite repeated attempts at occlusion therapy, recurrence of amblyopia occurs in 24% and 16% have persistent amblyopia. Here we explore whether accommodation dysfunction in these hyperopic groups might affect the efficacy of amblyopia treatment. Methods: 15 children with accommodative esotropia (7 amblyopic), 15 with hyperopic anisometropia (6 amblyopic), and 20 normal controls aged 3-17 years participated. Monocular accommodation for a letter target at 3 m and 33cm was measured using a Grand Seiko autorefractor with and without spectacle correction. T-tests were conducted to compare patient and control groups and correlation
Volume 16 Number 1 / February 2012 analysis was conducted to evaluate the relationship between visual acuity (VA) and accommodative error. Results: Accommodative error was significantly greater in the two hyperopic groups than in the normal controls at near, without (P \ 0.001) and with (P 5 0.01) correction, and at distance without correction (P \ 0.001). A positive correlation between VA and accommodative error was seen at near without correction (mean error, 3.29 D; r 5 0.5; P \ 0.001), with correction (mean error, 1.79 D; r 5 0.39; P 5 0.02) and at distance without correction (mean error, 2.47 D; r 5 0.47; P \ 0.001). No significant correlation was found for hyperopic children at distance with correction (mean error, 0.46 D). Discussion: Children with accommodative esotropia or hyperopic anisometropia displayed hypoaccommodation, which persisted at near despite spectacle correction. Conclusions: The large hypoaccommodation associated with accommodative esotropia and hyperopic anisometropia results in chronic blur. Spectacle correction significantly reduces blur at distance but the chronic blur that remains at near may hinder responsiveness to amblyopia treatment. 107 Posterior capsule opacification (PCO) in pediatric eyes with and without traumatic cataract surgery with in-the-bag singlepiece hydrophobic acrylic IOL implantation. Nancy Sun, Rupal H. Trivedi, M. Edward Wilson Purpose: To compare incidence of PCO in pediatric eyes with traumatic and non-traumatic cataract. Methods: Control group was matched in reference to age, follow-up, primary management of posterior capsule, and type of IOL (SA60AT, SN60AT & SN60WF). Results: n 5 58 (29 in each group). Traumatic versus non-traumatic group: age 7.3 versus 7.8 years (P 5 0.7); follow-up: 2.8 versus 2.7 years (P 5 0.9); intact posterior capsule: 12 in each group; second procedure for PCO: 11/29 (38%) eyes in traumatic versus 2/29 (7%) in non-traumatic group (P 5 0.005). Discussion: Even with age appropriate management of the posterior capsule, eyes with traumatic cataract are more likely to develop visual axis opacification than eyes with nontraumatic cataract. This difference persists in subgroup analysis of those with primary posterior capsulotomy and vitrectomy. Conclusions: Because of the increased risk for PCO, primary posterior capsulotomy and vitrectomy should be considered in pediatric traumatic cataract, even for older children. 108 Septic superior ophthalmic vein and cavernous sinus thrombosis in children. Daniela Toffoli, Amy K. Hutchinson, Phoebe Lenhart, Scott R. Lambert, Nilesh Desai Purpose: To review a series of children diagnosed with septic cavernous sinus thrombosis and/or superior ophthalmic vein thrombophlebitis to summarize etiology, management, and outcomes. Methods: We retrospectively reviewed the medical records of children presenting with septic superior ophthalmic vein thrombophlebitis and/or cavernous sinus thrombosis at Children's Healthcare of Atlanta between 2000 and 2011. To identify patients, we queried the radiology search engine using the terms superior ophthalmic vein and cavernous sinus and the Ninth International Classification of Diseases diagnosis code for cerebral vein thrombosis. Only patients with complete medical records and radiologically-confirmed cases were included. We documented demographics, comorbidities, infection sites, coagulation studies, cultures, antibiotics, anticoagulation, surgery, follow-up time, and complications.
Journal of AAPOS
Volume 16 Number 1 / February 2012 Results: We identified 11 cases of septic cavernous sinus thrombosis/superior ophthalmic vein thrombophlebitis. Median patient age was 11.5 years. Infection sites included: sinusitis (2/11), orbital cellulitis and sinusitis (5/11), facial cellulitis (2/11), mastoiditis (1/11), and septic arthritis/orbital cellulitis (1/11). Wound cultures (n 5 10) showed S. aureus (6/10), streptococcus (3/10), coagulase-negative staphylococcus (1/10), H. influenzae (1/10), and prevotella (1/10). Three of 6 S. aureus isolates were methicillin resistant. Treatment included antibiotics (11/11), anticoagulation (6/11) and surgery (10/11). Morbidity included ptosis (1/11), diplopia (3/11), septic arthritisrelated complications (1/11) and seventh nerve palsy and hemiparesis from venous infarction (1/11). Anticoagulation-related complications (4/6) included: epistaxis (2/4), hematuria (1/4), and femur hematoma (1/4). There was no mortality. Discussion: Septic cavernous sinus thrombosis occurs mostly secondary to staphylococcus-related sinusitis, but also facial cellulitis and mastoiditis. Morbidity can be significant, and includes venous infarction. Conclusions: Ophthalmologists should be familiar with the course and management of septic cavernous sinus thrombosis and its complications. 109 Visual acuity testing in children using the E-ETDRS protocol and the alternative forced choice E-ETDRS protocol. Irene T. Tung, Lawrence E. Leguire, Mary Lou McGregor, Sireesha A. Clark, Judy Carnevale, David L. Rogers Background/Purpose: Visual acuity is a common outcome in clinical research. The ETDRS chart employs only 10 letters. Respondents are unaware of this fact and may answer using one of the other 16 letters in the alphabet. This study was designed to determine if there was a difference between visual acuity measured using the standard EETDRS protocol compared to an E-ETDRS protocol where the subjects are forced to use only the 10 available letters in the test. Methods: A total of 234 children aged 8 to 11 years of age were tested using the EVA system and the E-ETDRS protocol. They were randomization to one of two groups. One group was tested with the standard E-ETDRS protocol (standard group). The other was tested were only the 10 letters of the ETDRS chart were acceptable answers (forced choice group). Results: The visual acuity was significantly better in the forced choice group for both eyes (OD, P 5 0.003; OS, P 5 0.002). When visual acuity was averaged between the eyes, visual acuity was found to correlate significantly with age when the forced choice method was employed (R 5 0.20, P 5 0.041) but not when the standard method was employed (R 5 0.08, P 5 0.46). Discussion: We found that visual acuity tested with the forced choice E-ETDRS protocol was better than visual acuity tested using the standard E-ETDRS protocol. Conclusions: These data would suggest that the forced choice method is more sensitive than the standard method to detect subtle differences in visual acuity in children between 8-11 years of age. 110 How effective is the PediaVision S09 in detecting ambylopic risk factors in children aged 3-5 years? Joannah M. Vaughan, Allison Summers, Talitha Dale, Rob Arao, Daniel Karr, Dongseok Choi Background/Purpose: PediaVision S09 is an auto refracting vision screener. This study aims to determine the referral accuracy of the PediaVision S09 in detecting the amblyopic risk factor of significant refractive error in children ages 3 to 5. Methods: Five hundred children were screened using the PediaVision S09 screening device. Comprehensive cycloplegic examinations
Journal of AAPOS
e29 were performed on 192 children. PediaVision S09 results (113 passes, 53 referrals) were compared with cycloplegic refraction for the 166 children who completed the protocol. Results: PediaVision S09 correctly identified 31 of 45 children with significant refractive error using the default settings (68.9% sensitivity, 81.8% specificity), and 21 of 26 if settings were adjusted to AAPOS screening guidelines (80.8% sensitivity, 79.3% specificity). Of the 14 children diagnosed as an amblyopia suspect during the masked, cycloplegic examination, 13 were correctly referred by default settings (92.9% sensitivity, 73.7% specificity), 11 by AAPOS referral criteria (78.6% sensitivity, 74.3% specificity). Discussion: Significant refractive error was defined by the referral criteria to which it was being compared. Diagnosis of amblyopia suspect instead of true amblyopia was made as best corrected acuity measure was not possible in this mobile setting. Sensitivity and specificity for each refractive condition will be reported. Conclusions: For the preschool population, PediaVision S09 has a high level of accuracy detecting the amblyopia risk factor of significant refractive error using default settings. 111 Comparison between the Plusoptix and iScreen photoscreeners in detecting amblyopic risk factors in children. Jing G. Wang, Donny W. Suh Purpose: To compare the accuracy of plusoptiX A08 photoscreener (PPS) and iScreen 3000 photoscreener (IPS) in objectively screening for amblyopic risk factors in children age 5 months to 13 years old. Methods: Cross-sectional study of 148 children who received photoscreenings via PPS and IPS and a comprehensive pediatric ophthalmic examination in our office. Patients were considered to have amblyogenic risk factors based on the AAPOS referral criteria guidelines. Results: 45 percent of patients undergoing a pediatric ophthalmology examination were found to have amblyopia or amblyogenic risk factors. In this study, PPS demonstrated an overall sensitivity of 75.4%, specificity of 68.0%, positive predictive value (PPV) of 67.1%, and negative predictive value (NPV) of 76.1%. However, IPS photoscreener had an overall sensitivity of 66.2%, specificity of 87.6%, PPV of 81.8%, and NPV of 75.5%. Discussion: The accuracy of PPS and IPS was compared in different age groups. The sensitivity and specificity were analyzed according to varied amblyogenic risk factors. The statistic results of this study were compared to those of previous studies, including Vision in Preschoolers (VIP) Study and the Iowa PhotoScreening Program. Conclusions: PPS and IPS proved to be useful tools in the objective vision screening in children. PPS was found to have a higher sensitivity, and IPS showed a higher specificity and PPV in detecting amblyopic risk factors. In conclusion, one device may be more beneficial over the other, depending on the patient population and office settings. 112 Sensitivity and specificity of grating and vernier stimuli for detection of amblyopia by sVEP. Joel M. Weinstein, Jason T. Gillon, Marianne E. Boltz, Jade M. Price, Albert Y. Cheung, Ardalan E. Aminlari, Amanda L. Ely Background/Purpose: Although both grating and vernier stimuli have been used in subjective psychophysical studies of amblyopia, the optimal stimulus for detection of amblyopia by objective swept spatial frequency VEP (sVEP) has not been determined. The purpose of this study was to compare the sensitivity and specificity of vernier and grating stimuli for the detection of amblyopia by sVEP.
Volume 16 Number 1 / February 2012 analysis was conducted to evaluate the relationship between visual acuity (VA) and accommodative error. Results: Accommodative error was significantly greater in the two hyperopic groups than in the normal controls at near, without (P \ 0.001) and with (P 5 0.01) correction, and at distance without correction (P \ 0.001). A positive correlation between VA and accommodative error was seen at near without correction (mean error, 3.29 D; r 5 0.5; P \ 0.001), with correction (mean error, 1.79 D; r 5 0.39; P 5 0.02) and at distance without correction (mean error, 2.47 D; r 5 0.47; P \ 0.001). No significant correlation was found for hyperopic children at distance with correction (mean error, 0.46 D). Discussion: Children with accommodative esotropia or hyperopic anisometropia displayed hypoaccommodation, which persisted at near despite spectacle correction. Conclusions: The large hypoaccommodation associated with accommodative esotropia and hyperopic anisometropia results in chronic blur. Spectacle correction significantly reduces blur at distance but the chronic blur that remains at near may hinder responsiveness to amblyopia treatment. 107 Posterior capsule opacification (PCO) in pediatric eyes with and without traumatic cataract surgery with in-the-bag singlepiece hydrophobic acrylic IOL implantation. Nancy Sun, Rupal H. Trivedi, M. Edward Wilson Purpose: To compare incidence of PCO in pediatric eyes with traumatic and non-traumatic cataract. Methods: Control group was matched in reference to age, follow-up, primary management of posterior capsule, and type of IOL (SA60AT, SN60AT & SN60WF). Results: n 5 58 (29 in each group). Traumatic versus non-traumatic group: age 7.3 versus 7.8 years (P 5 0.7); follow-up: 2.8 versus 2.7 years (P 5 0.9); intact posterior capsule: 12 in each group; second procedure for PCO: 11/29 (38%) eyes in traumatic versus 2/29 (7%) in non-traumatic group (P 5 0.005). Discussion: Even with age appropriate management of the posterior capsule, eyes with traumatic cataract are more likely to develop visual axis opacification than eyes with nontraumatic cataract. This difference persists in subgroup analysis of those with primary posterior capsulotomy and vitrectomy. Conclusions: Because of the increased risk for PCO, primary posterior capsulotomy and vitrectomy should be considered in pediatric traumatic cataract, even for older children. 108 Septic superior ophthalmic vein and cavernous sinus thrombosis in children. Daniela Toffoli, Amy K. Hutchinson, Phoebe Lenhart, Scott R. Lambert, Nilesh Desai Purpose: To review a series of children diagnosed with septic cavernous sinus thrombosis and/or superior ophthalmic vein thrombophlebitis to summarize etiology, management, and outcomes. Methods: We retrospectively reviewed the medical records of children presenting with septic superior ophthalmic vein thrombophlebitis and/or cavernous sinus thrombosis at Children's Healthcare of Atlanta between 2000 and 2011. To identify patients, we queried the radiology search engine using the terms superior ophthalmic vein and cavernous sinus and the Ninth International Classification of Diseases diagnosis code for cerebral vein thrombosis. Only patients with complete medical records and radiologically-confirmed cases were included. We documented demographics, comorbidities, infection sites, coagulation studies, cultures, antibiotics, anticoagulation, surgery, follow-up time, and complications.
Journal of AAPOS
Volume 16 Number 1 / February 2012 Results: We identified 11 cases of septic cavernous sinus thrombosis/superior ophthalmic vein thrombophlebitis. Median patient age was 11.5 years. Infection sites included: sinusitis (2/11), orbital cellulitis and sinusitis (5/11), facial cellulitis (2/11), mastoiditis (1/11), and septic arthritis/orbital cellulitis (1/11). Wound cultures (n 5 10) showed S. aureus (6/10), streptococcus (3/10), coagulase-negative staphylococcus (1/10), H. influenzae (1/10), and prevotella (1/10). Three of 6 S. aureus isolates were methicillin resistant. Treatment included antibiotics (11/11), anticoagulation (6/11) and surgery (10/11). Morbidity included ptosis (1/11), diplopia (3/11), septic arthritisrelated complications (1/11) and seventh nerve palsy and hemiparesis from venous infarction (1/11). Anticoagulation-related complications (4/6) included: epistaxis (2/4), hematuria (1/4), and femur hematoma (1/4). There was no mortality. Discussion: Septic cavernous sinus thrombosis occurs mostly secondary to staphylococcus-related sinusitis, but also facial cellulitis and mastoiditis. Morbidity can be significant, and includes venous infarction. Conclusions: Ophthalmologists should be familiar with the course and management of septic cavernous sinus thrombosis and its complications. 109 Visual acuity testing in children using the E-ETDRS protocol and the alternative forced choice E-ETDRS protocol. Irene T. Tung, Lawrence E. Leguire, Mary Lou McGregor, Sireesha A. Clark, Judy Carnevale, David L. Rogers Background/Purpose: Visual acuity is a common outcome in clinical research. The ETDRS chart employs only 10 letters. Respondents are unaware of this fact and may answer using one of the other 16 letters in the alphabet. This study was designed to determine if there was a difference between visual acuity measured using the standard EETDRS protocol compared to an E-ETDRS protocol where the subjects are forced to use only the 10 available letters in the test. Methods: A total of 234 children aged 8 to 11 years of age were tested using the EVA system and the E-ETDRS protocol. They were randomization to one of two groups. One group was tested with the standard E-ETDRS protocol (standard group). The other was tested were only the 10 letters of the ETDRS chart were acceptable answers (forced choice group). Results: The visual acuity was significantly better in the forced choice group for both eyes (OD, P 5 0.003; OS, P 5 0.002). When visual acuity was averaged between the eyes, visual acuity was found to correlate significantly with age when the forced choice method was employed (R 5 0.20, P 5 0.041) but not when the standard method was employed (R 5 0.08, P 5 0.46). Discussion: We found that visual acuity tested with the forced choice E-ETDRS protocol was better than visual acuity tested using the standard E-ETDRS protocol. Conclusions: These data would suggest that the forced choice method is more sensitive than the standard method to detect subtle differences in visual acuity in children between 8-11 years of age. 110 How effective is the PediaVision S09 in detecting ambylopic risk factors in children aged 3-5 years? Joannah M. Vaughan, Allison Summers, Talitha Dale, Rob Arao, Daniel Karr, Dongseok Choi Background/Purpose: PediaVision S09 is an auto refracting vision screener. This study aims to determine the referral accuracy of the PediaVision S09 in detecting the amblyopic risk factor of significant refractive error in children ages 3 to 5. Methods: Five hundred children were screened using the PediaVision S09 screening device. Comprehensive cycloplegic examinations
Journal of AAPOS
e29 were performed on 192 children. PediaVision S09 results (113 passes, 53 referrals) were compared with cycloplegic refraction for the 166 children who completed the protocol. Results: PediaVision S09 correctly identified 31 of 45 children with significant refractive error using the default settings (68.9% sensitivity, 81.8% specificity), and 21 of 26 if settings were adjusted to AAPOS screening guidelines (80.8% sensitivity, 79.3% specificity). Of the 14 children diagnosed as an amblyopia suspect during the masked, cycloplegic examination, 13 were correctly referred by default settings (92.9% sensitivity, 73.7% specificity), 11 by AAPOS referral criteria (78.6% sensitivity, 74.3% specificity). Discussion: Significant refractive error was defined by the referral criteria to which it was being compared. Diagnosis of amblyopia suspect instead of true amblyopia was made as best corrected acuity measure was not possible in this mobile setting. Sensitivity and specificity for each refractive condition will be reported. Conclusions: For the preschool population, PediaVision S09 has a high level of accuracy detecting the amblyopia risk factor of significant refractive error using default settings. 111 Comparison between the Plusoptix and iScreen photoscreeners in detecting amblyopic risk factors in children. Jing G. Wang, Donny W. Suh Purpose: To compare the accuracy of plusoptiX A08 photoscreener (PPS) and iScreen 3000 photoscreener (IPS) in objectively screening for amblyopic risk factors in children age 5 months to 13 years old. Methods: Cross-sectional study of 148 children who received photoscreenings via PPS and IPS and a comprehensive pediatric ophthalmic examination in our office. Patients were considered to have amblyogenic risk factors based on the AAPOS referral criteria guidelines. Results: 45 percent of patients undergoing a pediatric ophthalmology examination were found to have amblyopia or amblyogenic risk factors. In this study, PPS demonstrated an overall sensitivity of 75.4%, specificity of 68.0%, positive predictive value (PPV) of 67.1%, and negative predictive value (NPV) of 76.1%. However, IPS photoscreener had an overall sensitivity of 66.2%, specificity of 87.6%, PPV of 81.8%, and NPV of 75.5%. Discussion: The accuracy of PPS and IPS was compared in different age groups. The sensitivity and specificity were analyzed according to varied amblyogenic risk factors. The statistic results of this study were compared to those of previous studies, including Vision in Preschoolers (VIP) Study and the Iowa PhotoScreening Program. Conclusions: PPS and IPS proved to be useful tools in the objective vision screening in children. PPS was found to have a higher sensitivity, and IPS showed a higher specificity and PPV in detecting amblyopic risk factors. In conclusion, one device may be more beneficial over the other, depending on the patient population and office settings. 112 Sensitivity and specificity of grating and vernier stimuli for detection of amblyopia by sVEP. Joel M. Weinstein, Jason T. Gillon, Marianne E. Boltz, Jade M. Price, Albert Y. Cheung, Ardalan E. Aminlari, Amanda L. Ely Background/Purpose: Although both grating and vernier stimuli have been used in subjective psychophysical studies of amblyopia, the optimal stimulus for detection of amblyopia by objective swept spatial frequency VEP (sVEP) has not been determined. The purpose of this study was to compare the sensitivity and specificity of vernier and grating stimuli for the detection of amblyopia by sVEP.