Importance Increased myopic shift was found to be associated with 1 year of overminus spectacle treatment for children with intermittent exotropia (IXT). Persistence of myopic shift after discontinuing overminus spectacles is unknown. Objective To compare refractive error change over 3 years in children with IXT originally treated with overminus vs nonoverminus spectacles. Design, Setting, and Participants This study was an 18-month extension of the Trial of Overminus Spectacle Therapy for Intermittent Exotropia cohort, which previously randomized children aged 3 to 10 years with IXT and baseline spherical equivalent refractive error (SER) between −6.00 diopters (D) and 1.00 D to overminus spectacles (−2.50 D for 12 months, −1.25 D for 3 months, and nonoverminus for 3 months) or nonoverminus spectacles. Children were recruited from 56 sites from July 2010 to February 2022. Data were analyzed from February 2022 to January 2024. Interventions After trial completion at 18 months, participants were followed up at 24 and 36 months. Treatment was at investigator discretion from 18 to 36 months. Main Outcomes and Measures Change in SER (cycloplegic retinoscopy) from baseline to 36 months. Results Of 386 children in the Trial of Overminus Spectacle Therapy for Intermittent Exotropia, 223 (57.8%) consented to 18 months of additional follow-up, including 124 of 196 (63.3%) in the overminus treatment group and 99 of 190 (52.1%) in the nonoverminus treatment group. Of 205 children who completed 36-month follow-up, 116 (56.6%) were female, and the mean (SD) age at randomization was 6.2 (2.1) years. Mean (SD) SER change from baseline to 36 months was greater in the overminus group (−0.74 [1.00] D) compared with the nonoverminus group (−0.44 [0.85] D; adjusted difference, −0.36 D; 95% CI, −0.59 to −0.12; P = .003), with 30 of 112 (26.8%) in the overminus group having more than 1 D of myopic shift compared with 14 of 91 (15%) in the nonoverminus group (risk ratio, 1.8; 95% CI, 1.0-3.0). From 12 to 36 months, mean (SD) myopic shift was −0.34 (0.67) D and −0.36 (0.66) D in the overminus and nonoverminus groups, respectively (adjusted difference, −0.001 D; 95% CI, −0.18 to 0.18; P = .99). Conclusions and Relevance The greater myopic shift observed after 1 year of −2.50-D overminus lens treatment remained at 3 years. Both groups had similar myopic shift during the 2-year period after treatment weaning and cessation. The risk of myopic shift should be discussed with parents when considering overminus lens treatment. Trial Registration ClinicalTrials.gov Identifier: NCT02807350

PURPOSE:This study aimed to identify baseline factors associated with greater myopia progression and axial elongation in children with myopia. METHODS:This study performed a post hoc analysis of data from a 30-month randomized trial of atropine 0.01% versus placebo in children 5 to <13 years old with baseline spherical equivalent refractive error (SER) of -1.00 to -6.00 D, astigmatism of ≤1.50 D, and anisometropia of <1.00 D SER. Data from atropine 0.01% and placebo groups were pooled given outcomes were similar. Baseline factors of age, SER, axial length, race, sex, parental myopia, and iris color were evaluated for association with changes in SER and with changes in axial length at 30 months (24 months on treatment and then 6 months off) using backward model selection. RESULTS:Among 187 randomized participants, 175 (94%) completed 30 months of follow-up. The mean change in SER was greater among younger children (-0.19 D per 1 year younger; 95% confidence interval [CI], -0.25 to -0.14 D; p<0.001) and children with higher myopia (-0.14 D per 1 D more myopia at baseline; 95% CI, -0.23 to -0.05 D; p=0.002). The mean change in axial length was also greater among younger children (0.13 mm per 1 year younger; 95% CI, 0.10 to 0.15 mm; p<0.001) and children with higher baseline myopia (0.04 mm per 1 D more myopia; 95% CI, 0.002 to 0.08; p=0.04). CONCLUSIONS:Younger children with higher myopia had greater myopic progression and axial elongation over 30 months than older children with lower myopia. Developing effective treatments to slow the faster myopic progression in younger children should be a target of further research.

We evaluated the effect of part-time patching versus observation on distance exodeviation control in post hoc analyses of 3- to <11-year-olds with intermittent exotropia who were assigned to either patching 3 hours/day or observation in a previously reported randomized clinical trial. The present analysis was limited to a subgroup of 306 participants who at distance fixation spontaneously manifested either a constant or intermittent exotropia or had prolonged recovery after monocular occlusion (a distance control score of 2 or worse using the 0-5 Office Control Score scale) at baseline. We assessed change in control at distance and near fixation, from baseline to 3 months and baseline to 6 months (1 month after discontinuing patching). We found greater improvement in the distance control score with patching than with observation at 3 months (mean difference, 0.4 points; 95% CI, 0.1-0.7) and 6 months (mean difference, 0.3 points; 95% CI, 0.02-0.6). These analyses suggest that part-time patching may improve distance control in children with intermittent exotropia and a control score ≥ 2; however, because this conclusion is based on post hoc subgroup analyses, further studies are needed.

Importance:Controlling myopia progression is of interest worldwide. Low-dose atropine eye drops have slowed progression in children in East Asia. Objective:To compare atropine, 0.01%, eye drops with placebo for slowing myopia progression in US children. Design, Setting, and Participants:This was a randomized placebo-controlled, double-masked, clinical trial conducted from June 2018 to September 2022. Children aged 5 to 12 years were recruited from 12 community- and institution-based practices in the US. Participating children had low to moderate bilateral myopia (-1.00 diopters [D] to -6.00 D spherical equivalent refractive error [SER]). Intervention:Eligible children were randomly assigned 2:1 to 1 eye drop of atropine, 0.01%, nightly or 1 drop of placebo. Treatment was for 24 months followed by 6 months of observation. Main Outcome and Measures:Automated cycloplegic refraction was performed by masked examiners. The primary outcome was change in SER (mean of both eyes) from baseline to 24 months (receiving treatment); other outcomes included change in SER from baseline to 30 months (not receiving treatment) and change in axial length at both time points. Differences were calculated as atropine minus placebo. Results:A total of 187 children (mean [SD] age, 10.1 [1.8] years; age range, 5.1-12.9 years; 101 female [54%]; 34 Black [18%], 20 East Asian [11%], 30 Hispanic or Latino [16%], 11 multiracial [6%], 6 West/South Asian [3%], 86 White [46%]) were included in the study. A total of 125 children (67%) received atropine, 0.01%, and 62 children (33%) received placebo. Follow-up was completed at 24 months by 119 of 125 children (95%) in the atropine group and 58 of 62 children (94%) in the placebo group. At 30 months, follow-up was completed by 118 of 125 children (94%) in the atropine group and 57 of 62 children (92%) in the placebo group. At the 24-month primary outcome visit, the adjusted mean (95% CI) change in SER from baseline was -0.82 (-0.96 to -0.68) D and -0.80 (-0.98 to -0.62) D in the atropine and placebo groups, respectively (adjusted difference = -0.02 D; 95% CI, -0.19 to +0.15 D; P = .83). At 30 months (6 months not receiving treatment), the adjusted difference in mean SER change from baseline was -0.04 D (95% CI, -0.25 to +0.17 D). Adjusted mean (95% CI) changes in axial length from baseline to 24 months were 0.44 (0.39-0.50) mm and 0.45 (0.37-0.52) mm in the atropine and placebo groups, respectively (adjusted difference = -0.002 mm; 95% CI, -0.106 to 0.102 mm). Adjusted difference in mean axial elongation from baseline to 30 months was +0.009 mm (95% CI, -0.115 to 0.134 mm). Conclusions and Relevance:In this randomized clinical trial of school-aged children in the US with low to moderate myopia, atropine, 0.01%, eye drops administered nightly when compared with placebo did not slow myopia progression or axial elongation. These results do not support use of atropine, 0.01%, eye drops to slow myopia progression or axial elongation in US children. Trial Registration:ClinicalTrials.gov Identifier: NCT03334253.

suture and 7 (32%) showed xt .10D ; 6 months postoperative 14(64%) cases were successful and 8 (36%) cases required redo.Conclusion/Relevance: Bilateral medial rectus plication could be an option for the treatment of basic type intermittent XT, it is relatively a quick, simple and safe procedure with a fair success rate, minimal postoperative side effects and its a reversible procedure.

PURPOSE: To determine whether age at surgery is associated with surgical outcome of intermittent exotropia (IXT) at 3 years. DESIGN: Secondary analysis of pooled data from a randomized trial. METHODS: A total of 197 children 3 to < 11 years of age with basic-type IXT of 15-40 prism diopters (Delta) were randomly assigned to 1 of 2 surgical procedures for treatment of intermittent exotropia. Masked examinations were conducted every 6 months for 3 years. The primary outcome was suboptimal surgical outcome by 3 years, defined as constant or intermittent exotropia of >= 10 Delta at distance or near by simultaneous prism and cover test (SPCT); constant esotropia of >= 6 Delta at distance or near by SPCT; or decrease in near stereoacuity of >= 2 octaves, at any masked examination; or reoperation without meeting any of these criteria. RESULTS: The cumulative probability of a suboptimal surgical outcome by 3 years was 28% (19 of 72) for children 3 to < 5 years of age, compared with 50% (57 of 125) for children 5 to < 11 years of age (adjusted hazard ratio = 2.05; 95% confidence interval = 1.16 to 3.60). No statistically significant associations were found between suboptimal outcome and other baseline factors (magnitude of deviation, control score, fixation preference, or near stereoacuity) (P values >= .20). CONCLUSIONS: This analysis suggests that in children with IXT, younger age at surgery (3 to < 5 years) is associated with better surgical outcomes; however, further evidence from a randomized trial comparing immediate with delayed surgery is needed for confirmation. (C) 2019 Elsevier Inc. All rights reserved.

Importance:Cataract is an important cause of visual impairment in children. Outcomes reported from a large clinical disease-specific registry can provide real-world estimates of visual outcomes and rates of adverse events in clinical practice.Objective:To describe visual acuity and refractive error outcomes, as well as rates of amblyopia, glaucoma, and additional eye surgery, during the first year after lensectomy in children.Design, Setting, and Participants:A prospective observational study was conducted from June 18, 2012, to July 8, 2015, at 61 pediatric eye care practices among 880 children younger than 13 years at the time of lensectomy in at least 1 eye with follow-up within 15 months after surgery. Statistical analysis was performed from December 12, 2016, to December 14, 2018.Exposures:Lensectomy with or without implantation of an intraocular lens.Main Outcomes and Measures:Visual acuity as well as rates of amblyopia, glaucoma, suspected glaucoma, and other intraocular surgery.Results:Among the 880 children (432 girls and 448 boys; mean [SD] age at annual follow-up, 4.9 [3.8] years) in the study, lens surgery was bilateral in 362 (41.1%; 95% CI, 37.9%-44.4%) children and unilateral in 518 (58.9%; 95% CI, 55.6%-62.1%). An intraocular lens was implanted in 654 of 1132 eyes (60.2%; 95% CI, 57.0%-63.4% [proportions reported for eye-level outcomes account for the potential correlation induced by enrolling both eyes of some individuals; for participants who received bilateral surgery, these numbers will differ from the quotient of the number of cases divided by the total sample size]). Amblyopia was identified in 449 children (51.0%; 95% CI, 47.7%-54.3%). In children age 3 years or older, mean visual acuity was 0.30 logMAR (about 20/40) in 153 bilateral pseudophakic eyes, 0.49 logMAR (about 20/63) in 141 unilateral pseudophakic eyes, 0.47 logMAR (about 20/63) in 21 bilateral aphakic eyes, and 0.61 logMAR (about 20/80) in 17 unilateral aphakic eyes. Mean visual acuity improved with older age at surgery in eyes with bilateral pseudophakia by 0.2 logMAR line (99% CI, 0.02-0.4; P = .005) and by 0.3 logMAR line (99% CI, 0.04-0.60; P = .004) in eyes with unilateral pseudophakia. A new diagnosis of glaucoma or suspected glaucoma was made in 67 of 1064 eyes that did not have glaucoma prior to lensectomy (5.9%; 95% CI, 4.6%-7.7%); 36 of 273 eyes with bilateral aphakia (13.2%; 95% CI, 9.0%-19.0%), 5 of 308 eyes with bilateral pseudophakia (1.5%; 95% CI, 0.6%-4.2%), 14 of 178 eyes with unilateral aphakia (7.9%; 95% CI, 4.7%-12.8%), and 12 of 305 eyes with unilateral pseudophakia (3.9%; 95% CI, 2.2%-6.8%). Additional intraocular surgery, most commonly vitrectomy or membranectomy to clear the visual axis, was performed in 189 of 1132 eyes (17.0%; 95% CI, 14.8%-19.6%).Conclusions and Relevance:Amblyopia was frequently observed during the first year after lensectomy in this cohort of children younger than 13 years. For children age 2 years or older at surgery visual acuity was typically less than normal for age and was worse with unilateral cataract. Management of visual axis obscuration was the most common complication requiring surgical intervention during the first year after surgery.

PURPOSE:To compare visual acuity (VA) and binocularity outcomes in moderately hyperopic children with normal VA and binocularity assigned to glasses versus observation. DESIGN:Prospective randomized clinical trial (RCT). METHODS:One hundred nineteen 3- to 5-year-old children with hyperopia between +3.00D and +6.00D spherical equivalent were randomly assigned to glasses versus observation (with glasses prescribed if deteriorated for subnormal distance VA or near stereoacuity, or manifest strabismus). Follow-up occurred every 6 months. At 3 years, the treatment strategy was classified as "failed" if any of the following were met, both with and without correction: subnormal distance VA or stereoacuity; manifest strabismus; or strabismus surgery during follow-up. RESULTS:Of 84 (71%) children who completed the primary outcome examination, failure occurred in five (12%; 95% confidence interval [CI]: 4%-26%) of 41 assigned to glasses and four (9%; 95% CI: 3%-22%) of 43 assigned to observation (difference = 3%; 95% CI: -12%-18%; P = .72). Deterioration prior to 3 years (requiring glasses per protocol) occurred in 29% (95% CI: 19%-43%) assigned to glasses and 27% (95% CI: 17%-42%) assigned to observation. CONCLUSIONS:In an RCT comparing glasses to observation for moderately hyperopic 3- to 5-year-old children with normal VA and binocularity, failure for VA or binocularity was not common. With insufficient enrollment and retention, our study was unable to determine whether immediate glasses prescription reduces failure rate, but low failure rates suggest that immediate glasses prescription for these children may not be needed to prevent failure for VA and/or binocularity.

Purpose: To compare long-term outcomes after bilateral lateral rectus recession (BLRc) or unilateral lateral rectus recession combined with medial rectus resection in the same eye (R&R) for primary treatment of childhood intermittent exotropia (IXT). Design: Multicenter, randomized clinical trial. Participants: One hundred ninety-seven children 3 to younger than 11 years of age with basictype IXT, a largest deviation by prism and alternate cover test at any distance of 15 to 40 prism diopters (PD), and near stereoacuity of at least 400 seconds of arc. Methods: Random assignment to BLRc or R&R and masked examinations conducted every 6 months after surgery for 3 years. Main Outcome Measures: Proportion of participants meeting suboptimal surgical outcome by 3 years, defined as: (1) exotropia of 10 PD or more at distance or near using simultaneous prism and cover test (SPCT); or (2) constant esotropia of 6 PD or more at distance or near using SPCT; (3) loss of 2 octaves or more of stereoacuity from baseline, at any masked examination; or (4) reoperation without meeting any of these criteria. Results: Cumulative probability of suboptimal surgical outcome by 3 years was 46% (43/101) in the BLRc group versus 37% (33/96) in the R&R group (treatment group difference of BLRc minus R&R, 9%; 95% confidence interval [CI], 6% to 23%). Reoperation by 3 years occurred in 9 participants (10%) in the BLRc group (8 of 9 met suboptimal surgical outcome criteria) and in 4 participants (5%) in the R&R group (3 of 4 met suboptimal surgical outcome criteria; treatment group difference of BLRc minus R&R, 5%; 95% CI, 2% to 13%). Among participants completing the 3year visit, 29% (25 of 86) in the BLRc group and 17% (13 of 77) in the R&R group underwent reoperation or met suboptimal surgical outcome criteria at 3 years (treatment group difference of BLRc minus R&R, 12%; 95% CI, 1% to 25%). Conclusions: We did not find a statistically significant difference in suboptimal surgical outcome by 3 years between children with IXT treated with BLRc compared with those treated with R&R. Based on these findings, we are unable to recommend one surgical approach over the other for childhood IXT. (C) 2018 by the American Academy of Ophthalmology

Interstitial deletions of 11p13 involving MPPED2, DCDC5, DCDC1, DNAJC24, IMMP1L, and ELP4 are previously reported to have downstream transcriptional effects on the expression of PAX6, due to a downstream regulatory region (DRR). Currently, no clear genotype–phenotype correlations have been established allowing for conclusive information regarding the exact location of the PAX6 DRR, though its location has been approximated in mouse models to be within the Elp4 gene. Of the clinical reports currently published examining patients with intact PAX6 genes but harboring deletions identified in genes downstream of PAX6, 100% indicate phenotypes which include aniridia, whereas approximately half report additional eye deformities, autism, or intellectual disability. In this clinical report, we present a 12‐year‐old male patient, his brother, and mother with pericentric inversions of chromosome 11 associated with submicroscopic interstitial deletions of 11p13 and duplications of 11q22.3. The inversions were identified by standard cytogenetic analysis; microarray and FISH detected the chromosomal imbalance. The patient's phenotype includes intellectual disability, speech abnormalities, and autistic behaviors, but interestingly neither the patient, his brother, nor mother have aniridia or other eye anomalies. To the best of our knowledge, these findings in three family members represent the only reported cases with 11p13 deletions downstream of PAX6 not demonstrating phenotypic characteristics of aniridia or abnormal eye development. Although none of the deleted genes are obvious candidates for the patient's phenotype, the absence of aniridia in the presence of this deletion in all three family members further delineates the location of the DRR for PAX6. © 2015 Wiley Periodicals, Inc.

BACKGROUND AND PURPOSE:The Convergence Insufficiency Symptom Survey (CISS) is a questionnaire used as an outcome measure in treatment of convergence insufficiency. The current prospective randomized trial evaluates the diagnostic specificity of the CISS.PATIENTS AND METHODS:Surveys were completed by 118 adolescent patients who presented for routine eye examinations. Scores were compared between patients who could be classified as having convergence insufficiency (CI) or normal binocular vision (NBV). In addition, a comparison was done between self-and practitioner-administered CISS scores within these groups.RESULTS:The mean CISS score did not differ significantly between NBV patients (14.1±11.3, range of 0 to 43) and CI patients (12.3±6.7, range of 3 to 28); P=0.32. Mean CISS scores were lower when physician-administered (11.4±7.9) than when self-administered (16.3±11.4); P=0.007.CONCLUSION:CISS scores tend to be higher when self-vs. practitioner-administered. This study suggests that the CISS questionnaire is not specific for convergence insufficiency.

The Convergence Insufficiency Symptom Survey (CISS) is a 15-item questionnaire used as both a diagnostic tool and measure of symptomatology in the Convergence Insufficiency Treatment Study (CITS) and ongoing Convergence Insufficiency Treatment Trial (CITT) to quantify the severity of symptoms associated with convergence insufficiency (CI).

To determine how often nasolacrimal duct obstruction (NLDO) resolves with 6 months of nonsurgical management in infants aged 6 to <10 months old.

OBJECTIVE:To determine how often nasolacrimal duct obstruction (NLDO) resolves with 6 months of nonsurgical management in infants aged 6 to less than 10 months.METHODS:As part of a randomized trial evaluating the cost-effectiveness of immediate office probing vs observation with deferred probing for unresolved cases, 107 infants aged 6 to less than 10 months who had NLDO and no history of nasolacrimal duct surgery were prescribed 6 months of nasolacrimal duct massage and topical antibiotics as needed. Resolution of the NLDO was assessed 6 months after study entry and was defined as the absence of all clinical signs of NLDO (epiphora, increased tear lake, or mucous discharge) and not having undergone NLDO surgery. Exploratory analyses assessed whether baseline characteristics, including age, sex, laterality, and prior treatment, were associated with the probability of NLDO resolving without surgery.RESULTS:At the 6-month examination, which was completed for 117 of the 133 eyes (88%), the NLDO had resolved without surgery in 77 eyes (66% [95% CI, 56%-74%]). None of the baseline characteristics we evaluated were found to be associated with resolution.CONCLUSIONS:In infants 6 to less than 10 months of age, more than half of eyes with NLDO will resolve within 6 months with nonsurgical management. Knowledge of the rate of NLDO resolution in infancy without surgery will help clinicians and parents effectively discuss treatment options.

Purpose: Rhabdomyosarcoma (RMS) is the most common pediatric soft tissue sarcoma, accounting for approximately 3% of all childhood malignancies. However, primary conjunctival presentation of RMS is uncommon. The purpose of this presentation is to present the largest reported case series of conjunctival RMS, highlighting the dramatic evolution of clinical awareness, diagnostic studies and treatment modalities over the past five decades.

Objective: To report the first case of prophylactic laser treatment to prevent blindness in a patient who was diagnosed with Norrie's disease by genetic testing with amniocentesis.Design: Case report.Participants: A 2-year-old white boy with Norrie's disease.Methods: A 37-week gestational age male with a family history of Norrie's disease was born via Cesarean section after the mother had undergone prenatal amniocentesis fetal-genetic testing at 23 weeks of gestation. A C520T (nonsense) mutation was found in the Norrie's disease gene. After examination under anesthesia confirmed the diagnosis on the first day of life, laser photocoagulation was applied to the avascular retina bilaterally. The patient was followed closely by ophthalmology, pediatrics, and occupational therapy departments.Main Outcome Measures: Functional outcome, as documented by Teller visual acuity and formal occupational therapy testing, and anatomic outcome, as documented by Retcam photography and fluorescein angiography.Results: Complete regression of extraretinal fibrovascular proliferation was observed 1 month after laser treatment. No retinal detachment had occurred to date at 24 months. Teller visual acuity at 23 months of life was 20/100 in both eyes. The patient's vision and developmental milestones were age appropriate.Conclusions: Pre-term genetic diagnosis with immediate laser treatment after birth may preserve vision in individuals affected with Norrie's disease.Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Ophthalmology 2010;117:2402-2406 (C) 2010 by the American Academy of Ophthalmology.

This report describes a new finding of iris transillumination defects in Pallister-Killian syndrome, a rare multi-system disorder resulting from mosaic tetrasomy of the short arm of chromosome 12.

The acquisition and enhancement of surgical skills in the treatment of strabismus is a lifelong journey. During the course of a career, each surgeon develops a range of surgical secrets to facilitate care. These secret personal techniques may make a difficult step easier, make surgery more efficient, make surgery safer, or may enhance outcomes. The purpose of this workshop is to reveal an assortment of these surgical secrets that both the novice and expert surgeon will find valuable. With a heavy emphasis on video presentations, 15 individual presenters, with varying levels of surgical experience, will be allowed a maximum of 5 minutes to present her or his favorite surgical tip(s). This workshop promises to be fast-paced, entertaining, and very informative. Unfinished presentations that are still in progress will be terminated at exactly 5 minutes to assure that this workshop remains both dynamic and on schedule.

PURPOSE:To report the outcome of nasolacrimal duct intubation as the primary treatment of congenital nasolacrimal duct obstruction (NLDO) in children younger than 4 years of age. METHODS:A total of 182 eyes of 139 children receiving intubation with planned tube retention for 2 to 5 months were enrolled in a prospective, nonrandomized observational multicenter study (19 sites). Children were ages 6 months to <45 months at the time of surgery, with no previous nasolacrimal surgical procedures and had at least one of the following clinical signs of NLDO: epiphora, mucous discharge, and/or increased tear lake. RESULTS:Treatment success was defined as absence of epiphora, mucous discharge, and increased tear lake at the outcome visit, 1 month after tube removal. The surgical outcome was assessed in 150 eyes (82% of cohort). The proportion of eyes treated successfully was 91% (95% CI: 86%-95%). The outcome dye disappearance test was normal in 125 (86%) eyes, indeterminate in 13 (9%), and abnormal in 7 (5%) of the 145 eyes tested. Monocanalicular tubes were used in 74% of cases. The tube was removed before the planned minimum retention time of 2 months in 61 eyes (41%). For 23 eyes, the early removal was attributed to inadvertent displacement by the patient. CONCLUSIONS:In children 6 months to <45 months of age, nasolacrimal duct intubation in a nonrandomized and noncomparative trial was a successful primary treatment of NLDO in about 90% of cases not lost to follow-up.