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Visual Outcome and Success of Amblyopia Treatment in Unilateral Small Posterior Lens Opacities and Lenticonus Initially Treated Nonsurgically
Visual Outcome and Success of Amblyopia Treatment in Unilateral Small Posterior Lens Opacities and Lenticonus Initially Treated Nonsurgically Giovanni M. Travi, MD,a Bruce M. Schnall, MD,b Sharon S. Lehman, MD,c Christopher J. Kelly, MD,d Denise Hug, MD,e Vânia N. Hirakata,f and Joseph H. Calhoun, MDb Purpose: We sought to assess the success of amblyopia treatment in patients with small posterior lens opacities as well as the factors associated with a good visual outcome. Methods: This was a retrospective study of patients with posterior lens opacities that initially were thought to be too small in size to warrant cataract surgery. The following variables were examined: cataract type, location, diameter, persistent hyaloid vessel, anisometropia, strabismus, and age of detection. Success of treatment of amblyopia was defined as improvement by at least 0.3 logMAR units. Good visual outcome was defined as 20/40 or better. Amblyopia was treated by glasses, patching, and/or atropine. Patients who failed with conservative treatment or had an increase in cataract size underwent surgery. Results: Fourty-eight (91%) of 53 eyes were amblyopic. Thirty amblyopic eyes had pre- and post-treatment Snellen acuities. Twenty (67%) had their visual acuity (VA) improved by 0.3 logMAR units or greater. None of the measured variables were associated with successful amblyopia treatment. Twenty-five (49%) of 51 patients had a final VA of 20/40 or better. The only variable associated with good visual outcome was cataract type: 18 of 25 (72%) posterior subcapsular cataract and 6 of 23 (32%) posterior lenticonus eyes achieved VA of 20/40 or better (P ⫽ 0.008). Six patients who went on to have cataract surgery experienced a larger improvement in BCVA (4.50 logMar units ⫾ 2.52 lines) compared with patients treated without cataract surgery (2.36 logMar units ⫾ 3.11 lines). Discussion: Amblyopia treatment was successful in most cases. A small group of patients who underwent cataract surgery experienced a greater VA improvement; however, it was not statistically significant. Further studies are needed to determine which patients would benefit from cataract surgery. (J AAPOS 2005;9:449-454) ataract surgery is recommended in children with lens opacities of 3 mm or larger.1 Young children with posterior lenticonus and posterior lens opacities smaller than 3 mm often have visual loss. The cause of the visual loss may be from the opacity blocking the visual axis, refractive error, posterior oil droplet-induced optical distortion,2 or amblyopia,3-5 and this sometimes cannot be
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differentiated. The purpose of this study is to determine the success of amblyopia treatment and visual outcomes in children with posterior lenticonus and posterior lens opacities not initially treated with surgery. We will try to determine if there are any factors that are associated with successful treatment of amblyopia or good visual outcome. We will also assess the visual acuity improvement on those patients who ultimately went on to have cataract surgery.
From the aDepartment of Pediatric Ophthalmology, Santa Casa de Porto Alegre Hospital, Porto Alegre, Brazil, bDepartment of Pediatric Ophthalmology, Wills Eye Hospital, Philadelphia, Pennsylvania, cDepartment of Ophthalmology, Alfred I Dupont Hospital for Children, Wilmington, Delaware, dUniversity of Connecticut, Farmington, Connecticut, e Children’s Mercy Hospital, Kansas City, Missouri, and the fDepartment of Research and Postgraduation, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil. Presented as a poster at the 30th Annual meeting of the American Association of Pediatric Ophthalmology and Strabismus, Washington, DC, March 2004. This study was conducted at Wills Eye Hospital, Philadelphia, Pennsylvania, Alfred I Dupont Hospital for Children, Wilmington, Delaware, and Children’s Eye Care, PC. Submitted April 12, 2004. Revision accepted June 20, 2005. Reprint requests: Giovanni M. Travi, MD, Rua André Puente, 226, 90035-150, Porto Alegre, RS, Brazil (e-mail: [email protected]). Copyright © 2005 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2005/$35.00 ⫹ 0 doi:10.1016/j.jaapos.2005.06.001
SUBJECTS AND METHODS
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This study was approved by the Institutional Review Board at Wills Eye Hospital, Thomas Jefferson College, Philadelphia, Pennsylvania, and Alfred I Dupont Hospital for Children, Wilmington, Delaware. A retrospective chart review was performed on all patients who were identified by a medical record search to have posterior lens opacities and/or lenticonus in the clinical practices of the four of the authors (B.M.S., S.S.L., C.J.K., and J.H.C.). Only patients with a posterior cataract or posterior lenticonus that initially were treated without surgery were eligible for this study. Patients with posterior segment disease, Mittendorf’s dot, bilateral cataracts, or cataracts October 2005
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450 Travi et al that had been caused by trauma, radiation, topical, or systemic steroid use were excluded. Patients were required to have a minimal follow-up of 3 months. A final Snellen visual acuity was needed to determine the visual outcome and, therefore, those patients unable to provide this were excluded from this study. The following information was collected from the patient chart: age of presentation, presenting sign, associated ocular and systemic disease, type and size of cataract, location of cataract, presence of abnormalities in the surrounding lens cortex, persistent hyaloid vessel, anisometropia, strabismus, increase in size of cataract, visual acuity (VA) before and after treatment, type of treatment, and visual outcome. We elected to separate the posterior cataracts into 4 types: posterior lenticonus (without opacity), posterior lenticonus with opacity, posterior subcapsular cataract (PSC), and anterior persistent hyperplastic primary vitreous (PHPV). Location of the cataracts was divided into central, paracentral, and peripheral. If the cataract was located within 3 mm of the center of the lens but not centered over the visual axis, it was classified as paracentral. Cataracts more than 3 mm from the center of the lens were categorized as peripheral. Diameter of the lens abnormality was measured in millimeters (mm). In some cases this was estimated while in others it was measured using the millimeter ruler on the slit lamp. Progression of the cataract was considered any increase in size noted by the ophthalmologist. Anisometropia was defined as the presence of ⱖ0.5 D spherical equivalent or ⱖ1.50 D difference in astigmatism in any meridian.6 Best-corrected visual acuity (BCVA) was recorded in log of the minimum angle of resolution units (log MAR units).7 Amblyopia was considered to be present if there were 0.2 or more log MAR units of difference in bestcorrected visual acuity with or without dilation. It was not possible to differentiate whether the visual loss associated with small posterior lens opacities was entirely due to amblyopia or it was related to the cataract blocking the visual axis. Success of amblyopia treatment was similar to how it was defined in the recent Patching versus Atropine study by the PEDIG.6 A patient was considered to be successfully treated when the amblyopic eye’s visual acuity had an improvement of 0.3 or more logMAR units.6 When the initial VA was 20/30 or better, a patient was considered to be successfully treated when the amblyopic eye’s visual acuity reached 20/20. Those patients that were too young to perform eye chart testing before starting treatment were excluded from the success of amblyopia treatment portion of the data analysis. In this group of patients, amblyopia was determined to be present by fixation preference. The period of treatment was considered the period in which the VA reached the its best level, or the treatment was abandoned or interrupted. This period did not include the time that patching was continued to maintain VA (period of maintenance). Recurrent amblyopia was defined as loss of 0.1 or more logMAR units of final best-corrected
VA without any increase in size of the cataract. A patient was considered to be full-time patched when the patient was unpatched 2 hours or less per day. Six patients eventually went on to cataract surgery. The indication for surgery was failure of amblyopia treatment in 4 patients (deterioration of BCVA to 20/80 or worse, during amblyopia treatment) and increase in cataract size in 2 patients (mean increase of 3.8 mm). Success of surgery was defined as improvement of 0.3 log MAR units in VA. The success response could be measured in 4 patients, and visual outcome was analyzed 6 patients. The outcomes measured were success of amblyopia treatment, success of cataract surgery, visual acuity improvement in logMar units, and final visual outcome. For the same patient different methods of treatment could be employed at different times. The success of each of these different methods of treatment was measured and considered separately. Success of treatment was defined as an improvement in BCVA of 0.3 or more logMAR units. The response after the first interval of amblyopia therapy was measured to see whether it was predictive of a better visual outcome with additional patching. Cataract surgery was considered to be successful if resulted in a BCVA improvement of 0.3 or more logMAR units. Final visual outcome was examined in all cases. In an effort to determine whether those patients who were detected to have cataracts at an earlier age were associated with a better visual outcome, we analyzed final visual outcome in all patients who were able to provide a final BCVA. This included patients that were too young on their initial visit to provide an initial Snellen BCVA and were therefore excluded from the success of amblyopia treatment portion of this study. Eyes with a final visual acuity of 20/40 or better were considered to have a good visual outcome. The SPSS for Windows version 10.0 statistical software (SPSS Inc., Chicago, IL) was used to analyze the data obtained. Chi-square tests and Fisher’s exact test, when necessary, and independent sample t-test were conducted to evaluate whether any of the studied variables was associated with amblyopia, treatment success, or good visual outcome. Nonparametric Mann–Whitney test was used for comparative analysis. P values of less than 0.05 were considered statistically significant.
RESULTS Fifty-three patients meet the inclusion criteria. The average follow-up period was 5 years and 8 months (range, 3 to 228 months). At the time of data collection, 9 patients were still being treated for amblyopia, 7 in maintenance therapy, 26 completed treatment, 5 lost for follow-up, and 6 being followed with no treatment. The clinical characteristics of the patients are shown in Table 1. Posterior lenticonus (with and without opacity) and posterior subcapsular cataract were the most prevalent forms. Two patients had cataracts that could not be clas-
Journal of AAPOS Volume 9 Number 5 October 2005 TABLE 1. Clinical characteristics of the studied patients (n ⫽ 53) Sex male 28 (52.8%) Age at first visit (months) 48.09 ⫾ 27.98 (2–102) Age of detection (months) 44 ⫾ 29.14 (2–96) Involved eye (OD) 32 (60.4%) Lens characteristics Type Post. Lenticonus 10 (18.9%) Post. Lenticonus ⫹ opacity 14 (26.4%) Post. Subcapsular cataract 25 (47.2%) Anterior PHPV 2 (3.8%) Other 2 (3.8%) Location Central 34 (64.2%) Paracentral 18 (34%) Peripheral 1 (1.9%) Mean initial size (mm) (n ⫽ 44) 2.01 ⫾ 0.83 (0.5–4.2) Mean final size (mm) (n ⫽ 38) 2.25 ⫾ 0.96 (0.5–5.8) The numbers are shown as frequency (%), mean ⫾ standard deviation (minimum– maximum value).
sified: one patient had a peripheral opacity associated with posterior lens opacity, in one patient no cataract type was noted. The mean age of detection was similar between PSC (3 years and 6 months), lenticonus (3 years and 7 months), and lenticonus with opacity (3 years and 10 months). Mean age of detection of anterior PHPV was 2 years-old (P ⫽ 0.72). Presenting signs or symptoms were failed vision screening (n ⫽ 16), abnormal red reflex found by the pediatrician (n ⫽ 13), strabismus (n ⫽ 5), squinting one eye in the sun (n ⫽ 4), and low visual acuity (n ⫽ 4). Two patients were found to have a systemic abnormality. One had an abdominal rhabdomyosarcoma, and one had speech delay. Strabismus was found in 8 patients: 2 esotropia, 4 exotropia, 1 dissociated vertical deviation (DVD), and 1 Duane’s syndrome. One patient showed an iris coloboma inferonasally and another patient with posterior subcapsular cataract was noted to have anterior cortical changes when he was 9 years old. No patients had an afferent pupillary defect. Of the 53 patients, we had information about their presenting VA in 48 cases. Thirty-five were able to provide a Snellen BCVA on presentation. The BCVA of these 35 patients on presentation was 20/60⫺2 ⫾ 3 lines (0.5 ⫾ 0.36 logMAR). Of 13 preverbal cases, 8 infants could fixate and maintain, 2 fixate and not maintain, and 3 could not fixate. Twenty patients were followed initially without treatment, mainly for 2 reasons: either they were thought not to have amblyopia in the initial visits or decided not to treat because of the slight difference in BCVA between both eyes (difference of less than 0.2 log MAR units). They were followed from 2 to 72 months (29.56 ⫾ 26.00 months). Of this group, 15 (75%) were later determined to have amblyopia. Ultimately amblyopia was determined to be present in 48 (90.6%) patients. Its diagnosis was based on clinical assessment in 11 patients and on Snellen BCVA in 42 cases. The mean age of detection of amblyopia was
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4 years old (50.54 ⫾ 26.98 months; median ⫽ 58.5 months). There was no statistically significant difference between size of the lens opacity in patients with amblyopia (2.1 mm; range, 1.0 – 4.2) compared with the eyes without amblyopia (1.7 mm; range, 0.5–2.5; P ⫽ 0.37). All the patients (n ⫽ 12) with cataract with a size ⬎2.5 mm had amblyopia. Seventeen (34%) patients had progression of their cataract (mean increase ⫽ 1.0 ⫾ 0.4 mm). All of the patients with posterior lenticonus (with and without opacity) and 80% (n ⫽ 20) of the patients with PSC developed amblyopia, but this difference was not statistically significant (P ⫽ 0.09). Location of the lens abnormality was not correlated with development of amblyopia (P ⫽ 0.43). Anisometropia was found in 67.3% (n ⫽ 33) of the patients. In 22 cases the major component of the anisometropia was hyperopia, in 9 myopia, and in 2 hyperopic astigmatism. Anisometropia was not statistically related to cataract type (P ⫽ 0.15). It was present in 91% (n ⫽ 10) of the lenticonus with opacity, 67% (n ⫽ 6) in the lenticonus without opacity, and 56% (n ⫽ 14) in the patients with PSC. Thirty-one (94%) of the patients with anisometropia developed amblyopia, whereas 13 (81%) of the patients without anisometropia developed amblyopia (P ⫽ 0.31). Thirty amblyopic patients had pretreatment and posttreatment Snellen BCVA. Several of these patients had treatment of their amblyopia by more than one modality. Eighteen patients (60%) in this group had glasses prescribed. Twenty-five patients were treated with part time patching, 14 with full-time patching and 3 with atropine. Full-time patching, part-time patching, and atropine were considered as different treatment modalities. Atropine was not used as an initial treatment modality. Treatment ranged from 1 to 54 months (median, 4 months). For the same patient different kinds of treatment could be instituted at different times. Forty-two different treatments were analyzed in 30 patients. Treatment was successful 52.4% of time. Of 12 patients who were unsuccessful with their first treatment modality 2 were successful with their second treatment modality. Overall, the amblyopia of 20 of 30 patients (67%) was treated successfully, including 2 patients who required more than one treatment modality to achieve this success. The success of amblyopia treatment is recorded in Table 2. None of the measured variables were associated with successful amblyopia treatment. Recurrent amblyopia occurred in 13 (36%) cases. BCVA was measured as first response at 5.86 ⫾ 2.68 weeks (median, 4.5) and as final response at 9.21 ⫾ 12.72 months (median, 4.0) after starting treatment, respectively. Mean first and final VA improvement in logMAR units was 2.06 ⫾ 3.00 (median, 1.20) and 2.41 ⫾ 3.12 (median, 3.0), respectively. The first VA improvement in logMAR units was predictive of the improvement obtained as a final response. (r ⫽ 0.92; P ⬍ 0.001). The visual outcome of 51 patients who were treated without surgery is recorded in Table 3. Several patients
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452 Travi et al TABLE 2. Treatment Success and Good Visual Outcome of patients treated without surgery Response to Amblyopia Treatment (n ⴝ 30)* Type Lenticonus Lenticonus ⫹ opacity PSC Anterior PHPV Other Location Central Noncentral Abnormalities in surrounding cortex Y N Vessel in vitreous Y N Anisometropia Y N Strabismus Y N Mean size of cataract (mm) Initial size Final size Progression of cataract Y N
Visual Outcome (n ⴝ 51)†
Success‡
Failures
P Value
VA >20/40
VA <20/40
P Value
4 (67%) 5 (56%) 9 (70%) 1 (100%) 1 (100%)
2 (33%) 4 (44%) 4 (30%) 0 0
–
3 (33%) 3 (21%) 18 (72%) 0 1 (50%)
6 (67%) 11 (79%) 7 (28%) 1 (100%) 1 (50%)
–
12 (63%) 8 (73%)
7 (37%) 3 (30%)
P ⫽ 0.70
15 (47%) 10 (53%)
17 (53%) 9 (47%)
P ⫽ 0.91
2 (50%) 18 (69%)
2 (50%) 8 (31%)
P ⫽ 0.58
1 (25%) 24 (51%)
3 (75%) 23 (49%)
P ⫽ 0.61
3 (100%) 17 (63%)
0 10 (37%)
P ⫽ 0.53
2 (50%) 23 (49%)
2 (50%) 24 (51%)
P ⫽ 1.0
15 (65%) 5 (83%)
8 (35%) 1 (17%)
P ⫽ 0.63
14 (44%) 9 (60%)
18 (56%) 6 (40%)
P ⫽ 0.47
5 (83%) 15 (62%)
1 (17%) 9 (38%)
P ⫽ 0.63
3 (43%) 22 (50%)
4 (57%) 22 (50%)
P ⫽ 1.0
1.99 ⫾ 0.74 2.18 ⫾ 0.74
2.13 ⫾ 0.95 2.43 ⫾ 1.04
P ⫽ 0.71 P ⫽ 0.50
1.99 ⫾ 0.83 2.14 ⫾ 0.86
2.01 ⫾ 0.83 2.39 ⫾ 1.07
P ⫽ 0.93 P ⫽ 0.40
5 (56%) 14 (74%)
4 (44%) 5 (26%)
P ⫽ 0.41
6 (63%) 16 (50%)
10 (37%) 16 (50%)
P ⫽ 0.61
The numbers are shown as frequency (%), mean ⫾ standard deviation (minimum-maximum value). *Treatment success in any treatment employed (n ⫽ 30). †Visual outcomes of 51 patients, including the VA before surgery of the ones submitted to surgery (n ⫽ 51). ‡Success of treatment of amblyopia was defined as improvement by at least 0.3 logMAR units.
who went onto cataract surgery have their final BCVA after amblyopia treatment but before cataract surgery recorded in this table. Eyes with a final visual acuity of 20/40 or better were considered to have a good visual outcome. Good visual outcome was found in 25 of 51 (49%) eyes. The mean final BCVA was 20/50-2 ⫾ 3 lines (range, 20/20 to 20/400; 0.00-1.30 logMAR). Good visual outcome was not associated with cataract size or location, or progression of cataract (Table 2). The vast majority of patients had PSC or posterior lenticonus type cataracts. Therefore, we compared visual outcome in posterior lenticonus patients (with and without opacity) to the PSC patients. Eighteen (72%) of patients with PSC achieved a good visual outcome compared with 6 (32%) in the posterior lenticonus group, and this was statistically significant (P ⫽ 0.008). There was no association between age of cataract detection and good visual outcome (P ⫽ 1.0). However, patients who achieved a good visual outcome tended to be older at the time of starting treatment (P ⫽ 0.07). None of the 5 patients that had their treatment started at 24 months of age or younger achieved a good visual outcome (P ⫽ 0.14). Their final VA was 20/100⫹4 ⫾ 2 lines (0.66 ⫾
0.20 logMAR). The group that started treatment after 24 months had a final VA of 20/60 ⫾ 3 lines (0.48 ⫾ 0.30 logMAR; P ⫽ 0.21). Six patients had cataract surgery (Table 3). Their ages at surgery ranged from 13 to 133 months (67.14 ⫾ 46.12 months). An intraocular lens was implanted in 4 patients. All patients who underwent cataract surgery did experience a BCVA improvement. Three (75%) patients experienced a large enough improvement in their BCVA to be considered to have had a successful response to surgery. These 4 patients had been treated with patching prior to surgery. In 3 of these patients the success of amblyopia treatment could be measured before cataract surgery. One patient did not improve with patching, one patient’s vision worsened during patching, and one patient had improvement with patching, followed by deterioration of BCVA. Patients who underwent cataract surgery experienced a larger improvement in BCVA (4.50 logMar units ⫾ 2.52 lines) compared with patients treated without cataract surgery (2.36 logMar units ⫾ 3.11 lines), however this was not statistically significant (Table 3).
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TABLE 3. BCVA Response and Final Visual Outcomes of Patients treated without and with Cataract Surgery Amblyopia treated without surgery Cataract surgery and amblyopia treatment BCVA response to treatment BCVA before treatment‡ Mean ⫾ SD Median Range BCVA after treatment‡ Mean ⫾ SD Median Range BCVA improvement after treatment Mean ⫾ SD Median Range Final visual outcomes Mean final BCVA‡ Mean ⫾ SD Median Range Good visual outcome§
453
P value
(n ⫽ 30)*
(n ⫽ 44)***
0.68 ⫾ 0.40 (20/100⫹2 ⫾ 4 lines†) 0.60 (20/80) 0.18–2.0 (20/30–20/2000¶)
0.80 ⫾ 0.23 (20/125 ⫾ 2 lines†) 0.80 (20/125) 0.60–1.0 (20/80–20/200)
P ⫽ 0.58
0.45 ⫾ 0.29 (20/60⫹2 ⫾ 3 lines†) 0.35 (20/40⫺2) 0.00–1.30 (20/20–20/400)
0.26 (20/40⫹2 ⫾ 2 lines†) 0.18 (20/30) 0.00–0.60 (20/20–20/80)
P ⫽ 0.48
2.4 ⫾ 3.1 ⫽ lines† 3 lines ⫺3 to 14 n ⫽ 46**
4.5 ⫾ 2.5 ⫽ lines† 4 lines 2 to 8 n ⫽ 6****
P ⫽ 0.19
0.47 ⫾ 0.29 (20/60⫹1 ⫾ 3 lines) 0.44 (20/60⫹2) 0.0–1.30 (20/20–20/400) 20 (43.5%)
0.40 ⫾ 0.23 (20/50 ⫾ 2 lines) 0.40 (20/50) 0.10–0.70 (20/25–20/100) 2 (33.3%)
P ⫽ 0.57 P ⫽ 1.0
*It refers to BCVA response available in 30 patients. **Final visual outcomes of patients treated clinically refers to visual outcomes of 46 patients, including the VA before surgery of the patients who had cataract surgery. Nonamblyopic patients were excluded. ***Snellen BCVA before and after surgery was available in 4 patients. ****Visual outcomes of 6 patients submitted to surgery. ‡The numbers are shown as logMAR (Snellen). §The numbers are shown as number of patients (%). Snellen is estimated from logMAR score, where one letter ⫽ 0.02 logMAR. †Lines in Snellen VA (each line of standardized Snellen VA chart increases by 0.1 logMAR units).7 ¶Counting fingers (20/2000 for statistical purposes).7 LogMAR ⫽ logarithm of the minimum angle of resolution.
DISCUSSION Cataracts that are deemed too small in size to warrant removal may result in significant visual loss from amblyopia. This was first described by Bangerter in 19558 who reported functional amblyopia superimposed on organic visual loss in patients with retinal abnormalities and congenital cataracts. Amblyopia was suspected to be present in 91% of the patients in our series. It is not possible to determine whether the visual loss associated with small posterior lens opacities is entirely caused by amblyopia or whether some of the visual loss is from the cataract blocking the visual axis. It is therefore possible that we are overestimating the incidence of amblyopia. Fifteen of the 20 (75%) patients who were felt on their initial evaluations not to have amblyopia were determined to have amblyopia on subsequent office visits. We conclude from the experience of our 4 clinicians that the incidence of amblyopia in these disorders is high and tends to be underestimated. The amblyopia associated with small posterior lens opacities and posterior lenticonus may be caused by the lens opacity obscuring the visual axis,9,10 anisometropia, or posterior oil droplet induced optical distortion.2 This visual loss from amblyopia can be treated with or without dilation of the affected eye. Few studies have tried to determine the outcomes of this practice.11,12 Bradford et al5 found good results in patching patients with partial
cataracts and poor results in posterior lenticonus. Cheng et al2 found an improvement in VA in 41% of the posterior lenticonus cases treated with nonsurgical approach. In our current series, treatment success of amblyopia and good visual outcome could not be related to location of cataract, presence of vessel in the vitreous, anomalies in surrounding cortex, anisometropia, and strabismus. The vast majority of cataracts were either PSC or posterior lenticonus and, therefore, we compared treatment success and good visual outcome in patients with posterior lenticonus (with and without opacity) to the PSC patients. In this way, we could observe that there was no statistical difference in success in treatment of amblyopia (P ⫽ 0.70). However, 18 (72%) patients with PSC type achieved a good visual outcome compared with 6 (32%) in the posterior lenticonus group, which was statistically significant (P ⫽ 0.008). The better visual outcome associated with PSC may be attributed to this disorder being acquired later in childhood than posterior lenticonus. Size of cataract was not correlated to treatment success (P ⫽ 0.71) or good visual outcome (P ⫽ 0.65). The progression of the cataract seemed not to influence either the visual outcome (P ⫽ 0.53) or the treatment success (P ⫽ 0.41). Patients without anisometropia tended to have a slight better response in treatment and a better visual outcome as well, but it was not statistically significant.
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454 Travi et al Patients discovered to have cataracts earlier in childhood tended to have a poorer visual outcome although this was not statistically significant. Only a small number of patients went on to cataract surgery and, therefore, it is difficult to draw any conclusions that would be supported by statistical analysis. However, there was a tendency for patients who underwent cataract surgery to have a better mean BCVA after surgery and a better BCVA improvement compared with patients who did not have surgery. The patients who went on to cataract surgery required amblyopia treatment after cataract surgery to achieve their final BCVA. Improvements in childhood cataract surgery, such as IOL placement, may make this a more viable procedure for patients with small posterior cataracts. More studies are needed to determine which patients with posterior lens opacities would benefit from cataract surgery. In conclusion, amblyopia is common in patients with small PSC and posterior lenticonus. Success in treating this amblyopia without surgery is approximately 67%. PSC is more often associated with a better visual outcome than posterior lenticonus. Serious consideration should be given to initiating treatment for amblyopia at the time of diagnosis of a small unilateral posterior cataract. Some patients who fail amblyopia treatment may experience a significant visual improvement with cataract surgery.
We would like to thank Maynard B. Wheeler, MD, Paul R. Mitchell, MD, and Peter G. Walden, MD, for supplying clinical information on some of the patients in this study. References 1. Parks MM. Visual results in aphakic children. Am J Ophthalmol 1982;94:441. 2. Cheng KP, Hiles DA, Biglan AW, Pettapiece MC. Management of posterior lenticonus. J Pediatr Ophthalmol Strabismus 1991;28: 143-9. 3. Kushner BJ. Functional amblyopia associated with organic ocular disease. Am J Ophthalmol 1981;91:39-45. 4. Kushner BJ. Functional amblyopia associated with abnormalities of the optic nerve. Arch Ophthalmol 1984;102:683-5. 5. Bradford GM, Kutschker PJ, Scott WE. Results of amblyopia therapy in eyes with unilateral structural abnormalities. Ophthalmology 1992;99:1616-21. 6. The Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2002;120:268-78. 7. Holladay JT. Proper method for calculating average visual acuity. J Refract Surg 1997;13:388-91. 8. Bangerter A. Amblyopiebehandlung. 2nd ed. Basel: S. Karger, 1955. p. 141. 9. Merin S, Crawford JS. Assessment of incomplete congenital cataract. Can J Ophthalmol 1972;7:56-62. 10. Crouch ER, Parks MM. Management of posterior lenticonus complicated by unilateral cataract. Am J Ophthalmol 1978;85:503-8. 11. Drummond GT, Hinz BJ. Management of monocular cataract with long-term dilation in children. Can J Ophthalmol 1994;29:227-30. 12. Crawford JS. Conservative management of cataracts. Int Ophthalmol Clin 1977;17:31-5.
An Eye on the Arts – The Arts on the Eye
There’s a sore at the top of my nose between my eyebrows, gray and red and itching. Grandma says, Don’t touch that sore and don’t put water near it or it’ll spread. If you broke your arm she’d say don’t touch that with water it’ll spread. The sore spreads into my eyes anyway and now they’re red and yellow from the stuff that oozes and makes them stick in the morning. They stick so hard I have to force my eyelids open with my fingers and Mam has to scrub off that yellow stuff with a damp rag and boric powder. The eyelashes fall off and every bit of dust in Limerick blows into my eyes on windy days. Grandma tells me I have naked eyes and she says it’s my own fault, all that eye trouble comes from sitting up there at the top of the lane under the light pole in all kinds of weather with my nose stuck in books and the same thing will happen to Malachy if he doesn’t give over with the reading. You can see little Michael is getting just as bad sticking his nose in books when he should be out playing like a healthy child. Books, books, books, says Grandma, ye will ruin yeer eyes entirely. She’s having tea with Mam and I hear her whisper, The thing to do is give him St. Anthony’s spit. What’s that? says Mam. Your fasting spit in the morning. Go to him before he wakes and spit on his eyes for the spit of a fasting mother has powerful cures in it. But I’m always awake before Mam. I force my eyes open long before she stirs. I can hear her coming across the floor and when she stands over me for the spit I open my eyes. God, she says, your eyes are open. I think they’re getting better. That’s good, and she goes back to bed. —Frank McCourt (from Angela’s Ashes, Scribner)
C
differentiated. The purpose of this study is to determine the success of amblyopia treatment and visual outcomes in children with posterior lenticonus and posterior lens opacities not initially treated with surgery. We will try to determine if there are any factors that are associated with successful treatment of amblyopia or good visual outcome. We will also assess the visual acuity improvement on those patients who ultimately went on to have cataract surgery.
From the aDepartment of Pediatric Ophthalmology, Santa Casa de Porto Alegre Hospital, Porto Alegre, Brazil, bDepartment of Pediatric Ophthalmology, Wills Eye Hospital, Philadelphia, Pennsylvania, cDepartment of Ophthalmology, Alfred I Dupont Hospital for Children, Wilmington, Delaware, dUniversity of Connecticut, Farmington, Connecticut, e Children’s Mercy Hospital, Kansas City, Missouri, and the fDepartment of Research and Postgraduation, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil. Presented as a poster at the 30th Annual meeting of the American Association of Pediatric Ophthalmology and Strabismus, Washington, DC, March 2004. This study was conducted at Wills Eye Hospital, Philadelphia, Pennsylvania, Alfred I Dupont Hospital for Children, Wilmington, Delaware, and Children’s Eye Care, PC. Submitted April 12, 2004. Revision accepted June 20, 2005. Reprint requests: Giovanni M. Travi, MD, Rua André Puente, 226, 90035-150, Porto Alegre, RS, Brazil (e-mail: [email protected]). Copyright © 2005 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2005/$35.00 ⫹ 0 doi:10.1016/j.jaapos.2005.06.001
SUBJECTS AND METHODS
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This study was approved by the Institutional Review Board at Wills Eye Hospital, Thomas Jefferson College, Philadelphia, Pennsylvania, and Alfred I Dupont Hospital for Children, Wilmington, Delaware. A retrospective chart review was performed on all patients who were identified by a medical record search to have posterior lens opacities and/or lenticonus in the clinical practices of the four of the authors (B.M.S., S.S.L., C.J.K., and J.H.C.). Only patients with a posterior cataract or posterior lenticonus that initially were treated without surgery were eligible for this study. Patients with posterior segment disease, Mittendorf’s dot, bilateral cataracts, or cataracts October 2005
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450 Travi et al that had been caused by trauma, radiation, topical, or systemic steroid use were excluded. Patients were required to have a minimal follow-up of 3 months. A final Snellen visual acuity was needed to determine the visual outcome and, therefore, those patients unable to provide this were excluded from this study. The following information was collected from the patient chart: age of presentation, presenting sign, associated ocular and systemic disease, type and size of cataract, location of cataract, presence of abnormalities in the surrounding lens cortex, persistent hyaloid vessel, anisometropia, strabismus, increase in size of cataract, visual acuity (VA) before and after treatment, type of treatment, and visual outcome. We elected to separate the posterior cataracts into 4 types: posterior lenticonus (without opacity), posterior lenticonus with opacity, posterior subcapsular cataract (PSC), and anterior persistent hyperplastic primary vitreous (PHPV). Location of the cataracts was divided into central, paracentral, and peripheral. If the cataract was located within 3 mm of the center of the lens but not centered over the visual axis, it was classified as paracentral. Cataracts more than 3 mm from the center of the lens were categorized as peripheral. Diameter of the lens abnormality was measured in millimeters (mm). In some cases this was estimated while in others it was measured using the millimeter ruler on the slit lamp. Progression of the cataract was considered any increase in size noted by the ophthalmologist. Anisometropia was defined as the presence of ⱖ0.5 D spherical equivalent or ⱖ1.50 D difference in astigmatism in any meridian.6 Best-corrected visual acuity (BCVA) was recorded in log of the minimum angle of resolution units (log MAR units).7 Amblyopia was considered to be present if there were 0.2 or more log MAR units of difference in bestcorrected visual acuity with or without dilation. It was not possible to differentiate whether the visual loss associated with small posterior lens opacities was entirely due to amblyopia or it was related to the cataract blocking the visual axis. Success of amblyopia treatment was similar to how it was defined in the recent Patching versus Atropine study by the PEDIG.6 A patient was considered to be successfully treated when the amblyopic eye’s visual acuity had an improvement of 0.3 or more logMAR units.6 When the initial VA was 20/30 or better, a patient was considered to be successfully treated when the amblyopic eye’s visual acuity reached 20/20. Those patients that were too young to perform eye chart testing before starting treatment were excluded from the success of amblyopia treatment portion of the data analysis. In this group of patients, amblyopia was determined to be present by fixation preference. The period of treatment was considered the period in which the VA reached the its best level, or the treatment was abandoned or interrupted. This period did not include the time that patching was continued to maintain VA (period of maintenance). Recurrent amblyopia was defined as loss of 0.1 or more logMAR units of final best-corrected
VA without any increase in size of the cataract. A patient was considered to be full-time patched when the patient was unpatched 2 hours or less per day. Six patients eventually went on to cataract surgery. The indication for surgery was failure of amblyopia treatment in 4 patients (deterioration of BCVA to 20/80 or worse, during amblyopia treatment) and increase in cataract size in 2 patients (mean increase of 3.8 mm). Success of surgery was defined as improvement of 0.3 log MAR units in VA. The success response could be measured in 4 patients, and visual outcome was analyzed 6 patients. The outcomes measured were success of amblyopia treatment, success of cataract surgery, visual acuity improvement in logMar units, and final visual outcome. For the same patient different methods of treatment could be employed at different times. The success of each of these different methods of treatment was measured and considered separately. Success of treatment was defined as an improvement in BCVA of 0.3 or more logMAR units. The response after the first interval of amblyopia therapy was measured to see whether it was predictive of a better visual outcome with additional patching. Cataract surgery was considered to be successful if resulted in a BCVA improvement of 0.3 or more logMAR units. Final visual outcome was examined in all cases. In an effort to determine whether those patients who were detected to have cataracts at an earlier age were associated with a better visual outcome, we analyzed final visual outcome in all patients who were able to provide a final BCVA. This included patients that were too young on their initial visit to provide an initial Snellen BCVA and were therefore excluded from the success of amblyopia treatment portion of this study. Eyes with a final visual acuity of 20/40 or better were considered to have a good visual outcome. The SPSS for Windows version 10.0 statistical software (SPSS Inc., Chicago, IL) was used to analyze the data obtained. Chi-square tests and Fisher’s exact test, when necessary, and independent sample t-test were conducted to evaluate whether any of the studied variables was associated with amblyopia, treatment success, or good visual outcome. Nonparametric Mann–Whitney test was used for comparative analysis. P values of less than 0.05 were considered statistically significant.
RESULTS Fifty-three patients meet the inclusion criteria. The average follow-up period was 5 years and 8 months (range, 3 to 228 months). At the time of data collection, 9 patients were still being treated for amblyopia, 7 in maintenance therapy, 26 completed treatment, 5 lost for follow-up, and 6 being followed with no treatment. The clinical characteristics of the patients are shown in Table 1. Posterior lenticonus (with and without opacity) and posterior subcapsular cataract were the most prevalent forms. Two patients had cataracts that could not be clas-
Journal of AAPOS Volume 9 Number 5 October 2005 TABLE 1. Clinical characteristics of the studied patients (n ⫽ 53) Sex male 28 (52.8%) Age at first visit (months) 48.09 ⫾ 27.98 (2–102) Age of detection (months) 44 ⫾ 29.14 (2–96) Involved eye (OD) 32 (60.4%) Lens characteristics Type Post. Lenticonus 10 (18.9%) Post. Lenticonus ⫹ opacity 14 (26.4%) Post. Subcapsular cataract 25 (47.2%) Anterior PHPV 2 (3.8%) Other 2 (3.8%) Location Central 34 (64.2%) Paracentral 18 (34%) Peripheral 1 (1.9%) Mean initial size (mm) (n ⫽ 44) 2.01 ⫾ 0.83 (0.5–4.2) Mean final size (mm) (n ⫽ 38) 2.25 ⫾ 0.96 (0.5–5.8) The numbers are shown as frequency (%), mean ⫾ standard deviation (minimum– maximum value).
sified: one patient had a peripheral opacity associated with posterior lens opacity, in one patient no cataract type was noted. The mean age of detection was similar between PSC (3 years and 6 months), lenticonus (3 years and 7 months), and lenticonus with opacity (3 years and 10 months). Mean age of detection of anterior PHPV was 2 years-old (P ⫽ 0.72). Presenting signs or symptoms were failed vision screening (n ⫽ 16), abnormal red reflex found by the pediatrician (n ⫽ 13), strabismus (n ⫽ 5), squinting one eye in the sun (n ⫽ 4), and low visual acuity (n ⫽ 4). Two patients were found to have a systemic abnormality. One had an abdominal rhabdomyosarcoma, and one had speech delay. Strabismus was found in 8 patients: 2 esotropia, 4 exotropia, 1 dissociated vertical deviation (DVD), and 1 Duane’s syndrome. One patient showed an iris coloboma inferonasally and another patient with posterior subcapsular cataract was noted to have anterior cortical changes when he was 9 years old. No patients had an afferent pupillary defect. Of the 53 patients, we had information about their presenting VA in 48 cases. Thirty-five were able to provide a Snellen BCVA on presentation. The BCVA of these 35 patients on presentation was 20/60⫺2 ⫾ 3 lines (0.5 ⫾ 0.36 logMAR). Of 13 preverbal cases, 8 infants could fixate and maintain, 2 fixate and not maintain, and 3 could not fixate. Twenty patients were followed initially without treatment, mainly for 2 reasons: either they were thought not to have amblyopia in the initial visits or decided not to treat because of the slight difference in BCVA between both eyes (difference of less than 0.2 log MAR units). They were followed from 2 to 72 months (29.56 ⫾ 26.00 months). Of this group, 15 (75%) were later determined to have amblyopia. Ultimately amblyopia was determined to be present in 48 (90.6%) patients. Its diagnosis was based on clinical assessment in 11 patients and on Snellen BCVA in 42 cases. The mean age of detection of amblyopia was
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4 years old (50.54 ⫾ 26.98 months; median ⫽ 58.5 months). There was no statistically significant difference between size of the lens opacity in patients with amblyopia (2.1 mm; range, 1.0 – 4.2) compared with the eyes without amblyopia (1.7 mm; range, 0.5–2.5; P ⫽ 0.37). All the patients (n ⫽ 12) with cataract with a size ⬎2.5 mm had amblyopia. Seventeen (34%) patients had progression of their cataract (mean increase ⫽ 1.0 ⫾ 0.4 mm). All of the patients with posterior lenticonus (with and without opacity) and 80% (n ⫽ 20) of the patients with PSC developed amblyopia, but this difference was not statistically significant (P ⫽ 0.09). Location of the lens abnormality was not correlated with development of amblyopia (P ⫽ 0.43). Anisometropia was found in 67.3% (n ⫽ 33) of the patients. In 22 cases the major component of the anisometropia was hyperopia, in 9 myopia, and in 2 hyperopic astigmatism. Anisometropia was not statistically related to cataract type (P ⫽ 0.15). It was present in 91% (n ⫽ 10) of the lenticonus with opacity, 67% (n ⫽ 6) in the lenticonus without opacity, and 56% (n ⫽ 14) in the patients with PSC. Thirty-one (94%) of the patients with anisometropia developed amblyopia, whereas 13 (81%) of the patients without anisometropia developed amblyopia (P ⫽ 0.31). Thirty amblyopic patients had pretreatment and posttreatment Snellen BCVA. Several of these patients had treatment of their amblyopia by more than one modality. Eighteen patients (60%) in this group had glasses prescribed. Twenty-five patients were treated with part time patching, 14 with full-time patching and 3 with atropine. Full-time patching, part-time patching, and atropine were considered as different treatment modalities. Atropine was not used as an initial treatment modality. Treatment ranged from 1 to 54 months (median, 4 months). For the same patient different kinds of treatment could be instituted at different times. Forty-two different treatments were analyzed in 30 patients. Treatment was successful 52.4% of time. Of 12 patients who were unsuccessful with their first treatment modality 2 were successful with their second treatment modality. Overall, the amblyopia of 20 of 30 patients (67%) was treated successfully, including 2 patients who required more than one treatment modality to achieve this success. The success of amblyopia treatment is recorded in Table 2. None of the measured variables were associated with successful amblyopia treatment. Recurrent amblyopia occurred in 13 (36%) cases. BCVA was measured as first response at 5.86 ⫾ 2.68 weeks (median, 4.5) and as final response at 9.21 ⫾ 12.72 months (median, 4.0) after starting treatment, respectively. Mean first and final VA improvement in logMAR units was 2.06 ⫾ 3.00 (median, 1.20) and 2.41 ⫾ 3.12 (median, 3.0), respectively. The first VA improvement in logMAR units was predictive of the improvement obtained as a final response. (r ⫽ 0.92; P ⬍ 0.001). The visual outcome of 51 patients who were treated without surgery is recorded in Table 3. Several patients
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452 Travi et al TABLE 2. Treatment Success and Good Visual Outcome of patients treated without surgery Response to Amblyopia Treatment (n ⴝ 30)* Type Lenticonus Lenticonus ⫹ opacity PSC Anterior PHPV Other Location Central Noncentral Abnormalities in surrounding cortex Y N Vessel in vitreous Y N Anisometropia Y N Strabismus Y N Mean size of cataract (mm) Initial size Final size Progression of cataract Y N
Visual Outcome (n ⴝ 51)†
Success‡
Failures
P Value
VA >20/40
VA <20/40
P Value
4 (67%) 5 (56%) 9 (70%) 1 (100%) 1 (100%)
2 (33%) 4 (44%) 4 (30%) 0 0
–
3 (33%) 3 (21%) 18 (72%) 0 1 (50%)
6 (67%) 11 (79%) 7 (28%) 1 (100%) 1 (50%)
–
12 (63%) 8 (73%)
7 (37%) 3 (30%)
P ⫽ 0.70
15 (47%) 10 (53%)
17 (53%) 9 (47%)
P ⫽ 0.91
2 (50%) 18 (69%)
2 (50%) 8 (31%)
P ⫽ 0.58
1 (25%) 24 (51%)
3 (75%) 23 (49%)
P ⫽ 0.61
3 (100%) 17 (63%)
0 10 (37%)
P ⫽ 0.53
2 (50%) 23 (49%)
2 (50%) 24 (51%)
P ⫽ 1.0
15 (65%) 5 (83%)
8 (35%) 1 (17%)
P ⫽ 0.63
14 (44%) 9 (60%)
18 (56%) 6 (40%)
P ⫽ 0.47
5 (83%) 15 (62%)
1 (17%) 9 (38%)
P ⫽ 0.63
3 (43%) 22 (50%)
4 (57%) 22 (50%)
P ⫽ 1.0
1.99 ⫾ 0.74 2.18 ⫾ 0.74
2.13 ⫾ 0.95 2.43 ⫾ 1.04
P ⫽ 0.71 P ⫽ 0.50
1.99 ⫾ 0.83 2.14 ⫾ 0.86
2.01 ⫾ 0.83 2.39 ⫾ 1.07
P ⫽ 0.93 P ⫽ 0.40
5 (56%) 14 (74%)
4 (44%) 5 (26%)
P ⫽ 0.41
6 (63%) 16 (50%)
10 (37%) 16 (50%)
P ⫽ 0.61
The numbers are shown as frequency (%), mean ⫾ standard deviation (minimum-maximum value). *Treatment success in any treatment employed (n ⫽ 30). †Visual outcomes of 51 patients, including the VA before surgery of the ones submitted to surgery (n ⫽ 51). ‡Success of treatment of amblyopia was defined as improvement by at least 0.3 logMAR units.
who went onto cataract surgery have their final BCVA after amblyopia treatment but before cataract surgery recorded in this table. Eyes with a final visual acuity of 20/40 or better were considered to have a good visual outcome. Good visual outcome was found in 25 of 51 (49%) eyes. The mean final BCVA was 20/50-2 ⫾ 3 lines (range, 20/20 to 20/400; 0.00-1.30 logMAR). Good visual outcome was not associated with cataract size or location, or progression of cataract (Table 2). The vast majority of patients had PSC or posterior lenticonus type cataracts. Therefore, we compared visual outcome in posterior lenticonus patients (with and without opacity) to the PSC patients. Eighteen (72%) of patients with PSC achieved a good visual outcome compared with 6 (32%) in the posterior lenticonus group, and this was statistically significant (P ⫽ 0.008). There was no association between age of cataract detection and good visual outcome (P ⫽ 1.0). However, patients who achieved a good visual outcome tended to be older at the time of starting treatment (P ⫽ 0.07). None of the 5 patients that had their treatment started at 24 months of age or younger achieved a good visual outcome (P ⫽ 0.14). Their final VA was 20/100⫹4 ⫾ 2 lines (0.66 ⫾
0.20 logMAR). The group that started treatment after 24 months had a final VA of 20/60 ⫾ 3 lines (0.48 ⫾ 0.30 logMAR; P ⫽ 0.21). Six patients had cataract surgery (Table 3). Their ages at surgery ranged from 13 to 133 months (67.14 ⫾ 46.12 months). An intraocular lens was implanted in 4 patients. All patients who underwent cataract surgery did experience a BCVA improvement. Three (75%) patients experienced a large enough improvement in their BCVA to be considered to have had a successful response to surgery. These 4 patients had been treated with patching prior to surgery. In 3 of these patients the success of amblyopia treatment could be measured before cataract surgery. One patient did not improve with patching, one patient’s vision worsened during patching, and one patient had improvement with patching, followed by deterioration of BCVA. Patients who underwent cataract surgery experienced a larger improvement in BCVA (4.50 logMar units ⫾ 2.52 lines) compared with patients treated without cataract surgery (2.36 logMar units ⫾ 3.11 lines), however this was not statistically significant (Table 3).
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TABLE 3. BCVA Response and Final Visual Outcomes of Patients treated without and with Cataract Surgery Amblyopia treated without surgery Cataract surgery and amblyopia treatment BCVA response to treatment BCVA before treatment‡ Mean ⫾ SD Median Range BCVA after treatment‡ Mean ⫾ SD Median Range BCVA improvement after treatment Mean ⫾ SD Median Range Final visual outcomes Mean final BCVA‡ Mean ⫾ SD Median Range Good visual outcome§
453
P value
(n ⫽ 30)*
(n ⫽ 44)***
0.68 ⫾ 0.40 (20/100⫹2 ⫾ 4 lines†) 0.60 (20/80) 0.18–2.0 (20/30–20/2000¶)
0.80 ⫾ 0.23 (20/125 ⫾ 2 lines†) 0.80 (20/125) 0.60–1.0 (20/80–20/200)
P ⫽ 0.58
0.45 ⫾ 0.29 (20/60⫹2 ⫾ 3 lines†) 0.35 (20/40⫺2) 0.00–1.30 (20/20–20/400)
0.26 (20/40⫹2 ⫾ 2 lines†) 0.18 (20/30) 0.00–0.60 (20/20–20/80)
P ⫽ 0.48
2.4 ⫾ 3.1 ⫽ lines† 3 lines ⫺3 to 14 n ⫽ 46**
4.5 ⫾ 2.5 ⫽ lines† 4 lines 2 to 8 n ⫽ 6****
P ⫽ 0.19
0.47 ⫾ 0.29 (20/60⫹1 ⫾ 3 lines) 0.44 (20/60⫹2) 0.0–1.30 (20/20–20/400) 20 (43.5%)
0.40 ⫾ 0.23 (20/50 ⫾ 2 lines) 0.40 (20/50) 0.10–0.70 (20/25–20/100) 2 (33.3%)
P ⫽ 0.57 P ⫽ 1.0
*It refers to BCVA response available in 30 patients. **Final visual outcomes of patients treated clinically refers to visual outcomes of 46 patients, including the VA before surgery of the patients who had cataract surgery. Nonamblyopic patients were excluded. ***Snellen BCVA before and after surgery was available in 4 patients. ****Visual outcomes of 6 patients submitted to surgery. ‡The numbers are shown as logMAR (Snellen). §The numbers are shown as number of patients (%). Snellen is estimated from logMAR score, where one letter ⫽ 0.02 logMAR. †Lines in Snellen VA (each line of standardized Snellen VA chart increases by 0.1 logMAR units).7 ¶Counting fingers (20/2000 for statistical purposes).7 LogMAR ⫽ logarithm of the minimum angle of resolution.
DISCUSSION Cataracts that are deemed too small in size to warrant removal may result in significant visual loss from amblyopia. This was first described by Bangerter in 19558 who reported functional amblyopia superimposed on organic visual loss in patients with retinal abnormalities and congenital cataracts. Amblyopia was suspected to be present in 91% of the patients in our series. It is not possible to determine whether the visual loss associated with small posterior lens opacities is entirely caused by amblyopia or whether some of the visual loss is from the cataract blocking the visual axis. It is therefore possible that we are overestimating the incidence of amblyopia. Fifteen of the 20 (75%) patients who were felt on their initial evaluations not to have amblyopia were determined to have amblyopia on subsequent office visits. We conclude from the experience of our 4 clinicians that the incidence of amblyopia in these disorders is high and tends to be underestimated. The amblyopia associated with small posterior lens opacities and posterior lenticonus may be caused by the lens opacity obscuring the visual axis,9,10 anisometropia, or posterior oil droplet induced optical distortion.2 This visual loss from amblyopia can be treated with or without dilation of the affected eye. Few studies have tried to determine the outcomes of this practice.11,12 Bradford et al5 found good results in patching patients with partial
cataracts and poor results in posterior lenticonus. Cheng et al2 found an improvement in VA in 41% of the posterior lenticonus cases treated with nonsurgical approach. In our current series, treatment success of amblyopia and good visual outcome could not be related to location of cataract, presence of vessel in the vitreous, anomalies in surrounding cortex, anisometropia, and strabismus. The vast majority of cataracts were either PSC or posterior lenticonus and, therefore, we compared treatment success and good visual outcome in patients with posterior lenticonus (with and without opacity) to the PSC patients. In this way, we could observe that there was no statistical difference in success in treatment of amblyopia (P ⫽ 0.70). However, 18 (72%) patients with PSC type achieved a good visual outcome compared with 6 (32%) in the posterior lenticonus group, which was statistically significant (P ⫽ 0.008). The better visual outcome associated with PSC may be attributed to this disorder being acquired later in childhood than posterior lenticonus. Size of cataract was not correlated to treatment success (P ⫽ 0.71) or good visual outcome (P ⫽ 0.65). The progression of the cataract seemed not to influence either the visual outcome (P ⫽ 0.53) or the treatment success (P ⫽ 0.41). Patients without anisometropia tended to have a slight better response in treatment and a better visual outcome as well, but it was not statistically significant.
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454 Travi et al Patients discovered to have cataracts earlier in childhood tended to have a poorer visual outcome although this was not statistically significant. Only a small number of patients went on to cataract surgery and, therefore, it is difficult to draw any conclusions that would be supported by statistical analysis. However, there was a tendency for patients who underwent cataract surgery to have a better mean BCVA after surgery and a better BCVA improvement compared with patients who did not have surgery. The patients who went on to cataract surgery required amblyopia treatment after cataract surgery to achieve their final BCVA. Improvements in childhood cataract surgery, such as IOL placement, may make this a more viable procedure for patients with small posterior cataracts. More studies are needed to determine which patients with posterior lens opacities would benefit from cataract surgery. In conclusion, amblyopia is common in patients with small PSC and posterior lenticonus. Success in treating this amblyopia without surgery is approximately 67%. PSC is more often associated with a better visual outcome than posterior lenticonus. Serious consideration should be given to initiating treatment for amblyopia at the time of diagnosis of a small unilateral posterior cataract. Some patients who fail amblyopia treatment may experience a significant visual improvement with cataract surgery.
We would like to thank Maynard B. Wheeler, MD, Paul R. Mitchell, MD, and Peter G. Walden, MD, for supplying clinical information on some of the patients in this study. References 1. Parks MM. Visual results in aphakic children. Am J Ophthalmol 1982;94:441. 2. Cheng KP, Hiles DA, Biglan AW, Pettapiece MC. Management of posterior lenticonus. J Pediatr Ophthalmol Strabismus 1991;28: 143-9. 3. Kushner BJ. Functional amblyopia associated with organic ocular disease. Am J Ophthalmol 1981;91:39-45. 4. Kushner BJ. Functional amblyopia associated with abnormalities of the optic nerve. Arch Ophthalmol 1984;102:683-5. 5. Bradford GM, Kutschker PJ, Scott WE. Results of amblyopia therapy in eyes with unilateral structural abnormalities. Ophthalmology 1992;99:1616-21. 6. The Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2002;120:268-78. 7. Holladay JT. Proper method for calculating average visual acuity. J Refract Surg 1997;13:388-91. 8. Bangerter A. Amblyopiebehandlung. 2nd ed. Basel: S. Karger, 1955. p. 141. 9. Merin S, Crawford JS. Assessment of incomplete congenital cataract. Can J Ophthalmol 1972;7:56-62. 10. Crouch ER, Parks MM. Management of posterior lenticonus complicated by unilateral cataract. Am J Ophthalmol 1978;85:503-8. 11. Drummond GT, Hinz BJ. Management of monocular cataract with long-term dilation in children. Can J Ophthalmol 1994;29:227-30. 12. Crawford JS. Conservative management of cataracts. Int Ophthalmol Clin 1977;17:31-5.
An Eye on the Arts – The Arts on the Eye
There’s a sore at the top of my nose between my eyebrows, gray and red and itching. Grandma says, Don’t touch that sore and don’t put water near it or it’ll spread. If you broke your arm she’d say don’t touch that with water it’ll spread. The sore spreads into my eyes anyway and now they’re red and yellow from the stuff that oozes and makes them stick in the morning. They stick so hard I have to force my eyelids open with my fingers and Mam has to scrub off that yellow stuff with a damp rag and boric powder. The eyelashes fall off and every bit of dust in Limerick blows into my eyes on windy days. Grandma tells me I have naked eyes and she says it’s my own fault, all that eye trouble comes from sitting up there at the top of the lane under the light pole in all kinds of weather with my nose stuck in books and the same thing will happen to Malachy if he doesn’t give over with the reading. You can see little Michael is getting just as bad sticking his nose in books when he should be out playing like a healthy child. Books, books, books, says Grandma, ye will ruin yeer eyes entirely. She’s having tea with Mam and I hear her whisper, The thing to do is give him St. Anthony’s spit. What’s that? says Mam. Your fasting spit in the morning. Go to him before he wakes and spit on his eyes for the spit of a fasting mother has powerful cures in it. But I’m always awake before Mam. I force my eyes open long before she stirs. I can hear her coming across the floor and when she stands over me for the spit I open my eyes. God, she says, your eyes are open. I think they’re getting better. That’s good, and she goes back to bed. —Frank McCourt (from Angela’s Ashes, Scribner)