Background: The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) issued a 2021 update of Uniform Validation Guidelines for instrument-based pediatric vision screeners. With each update it is important for each manufacturer to update the Instrument Referral Criteria (IRC) programed into their devices in order to optimize sensitivity and specificity to detect AAPOS criteria. Methods: De-identified data comparing photoscreening with simultaneous confirmatory examinations constituted separate cohorts for the development of IRC via receiver operating characteristic (ROC) curves. The refractions of the devices were also compared. Results: This study defines three sets of refractive IRC (Sensitive, Medium, and Specific) for three leading infrared photoscreening devices, PlusoptiX A12, Welch-Allyn SPOT, and Adaptica 2WIN for children < 4 and ≥ 4 years in order to better target the 2021 AAPOS guidelines. The cohorts were similar but the SPOT group (n=755, mean age 9) was older with more astigmatism and the 2WIN (n=1362, mean age 7) was younger with more hyperopia and anisometropia compared to the cohort for PlusoptiX A12 (n=616, mean age 8). The age-based, medium magnitude IRC for anisometropia, hyperopia, astigmatism and myopia for SPOT were: <4y: 1.5, 1.75, 3.25, 3.5 and ≥4y: 1.5, 1.75, 2.25, 2.0; for PlusoptiX: <4y: 1.75, 3.0, 3.5, 3.5 and ≥4y: 1.75, 3.0, 2.5, 2.5; and for 2WIN: <4y: 1.75, 2.5, 3.5, 3.5 and ≥4y: 1.5, 2.0, 2.5, 2.0. The mean ABCD ellipsoid spectacle matches differed; SPOT: 1.8±1.3 (better) versus PlusoptiX: 1.9±1.6 and 2WIN: 2.2±1.4 (p<0.001). Conclusion: The 2021 AAPOS exam guidelines foster early specificity before age 4 and sensitivity after age 4. These evidencebased IRC for current SPOT, PlusoptiX, and 2WIN photoscreeners should allow device manufacturers the data necessary to adjust their device IRC to maximize specificity, sensitivity or a medium between the two. This paper provides practical suggestions for better validation. Improved early screening combined with thorough treatment should reduce life-long vision impairment due to amblyopia.

PURPOSE:To determine whether smartphone photographs of children's eyelids are reliable for diagnosing the presence of chalazia. METHODS:In this prospective cross-sectional study, 60 participants, 7 months to 16.5 years of age, at four sites were enrolled; all participants had a chalazion measuring at least 2 mm on at least one eyelid based on an in-person clinical examination by a pediatric eye care professional. Smartphone photographs taken by the parent during the office visit were uploaded to the study website. A masked reader assessed each photograph for the presence or absence of chalazia; results were compared with the gold standard clinical examination results. Sensitivity and specificity for the presence of chalazion by eyelid were calculated. RESULTS:Photographs were available for 240 eyelids; 85 had at least one chalazion and 155 were without a chalazion based on clinical examination. The masked reader correctly classified 68 of 85 eyelids with at least one chalazion and 151 of 155 eyelids without chalazia for a sensitivity of 80% (95% CI, 72%-86%) and a specificity of 97% (95% CI, 94%-99%). Sensitivity improved to 89% for chalazia 5 mm or larger and 94% when superficially located within the eyelid. CONCLUSIONS:Parental smartphone photographs appear to be useful in assessing chalazia in children as an alternative to in-office follow-up examinations. These photographs may be a valuable outcome measure in future clinical trials of chalazia treatment, especially when assessing larger lesions.

The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) issued a 2021 update of Guidelines for instrument-based vision screeners. Manufacturers need evidence to update the Instrument Referral Criteria (IRC) in their devices.

Background The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) issued a 2021 update of Uniform Validation Guidelines for instrument-based pediatric vision screeners. With each update it is important for each manufacturer to update the Instrument Referral Criteria (IRC) programed into their devices in order to optimize sensitivity and specificity to detect AAPOS criteria. Methods De-identified data comparing photoscreening with simultaneous confirmatory examinations constituted separate cohorts for the development of IRC via receiver operating characteristic (ROC) curves. The refractions of the devices were also compared. Results This study defines three sets of refractive IRC (Sensitive, Medium, and Specific) for three leading infrared photoscreening devices, PlusoptiX A12, Welch-Allyn SPOT, and Adaptica 2WIN for children < 4 and ≥ 4 years in order to better target the 2021 AAPOS guidelines. The cohorts were similar but the SPOT group (n=755, mean age 9) was older with more astigmatism and the 2WIN (n=1362, mean age 7) was younger with more hyperopia and anisometropia compared to the cohort for PlusoptiX A12 (n=616, mean age 8). The age-based, medium magnitude IRC for anisometropia, hyperopia, astigmatism and myopia for SPOT were: <4y: 1.5, 1.75, 3.25, 3.5 and ≥4y: 1.5, 1.75, 2.25, 2.0; for PlusoptiX: <4y: 1.75, 3.0, 3.5, 3.5 and ≥4y: 1.75, 3.0, 2.5, 2.5; and for 2WIN: <4y: 1.75, 2.5, 3.5, 3.5 and ≥4y: 1.5, 2.0, 2.5, 2.0. The mean ABCD ellipsoid spectacle matches differed; SPOT: 1.8±1.3 (better) versus PlusoptiX: 1.9±1.6 and 2WIN: 2.2±1.4 (p<0.001). Conclusion The 2021 AAPOS exam guidelines foster early specificity before age 4 and sensitivity after age 4. These evidence-based IRC for current SPOT, PlusoptiX, and 2WIN photoscreeners should allow device manufacturers the data necessary to adjust their device IRC to maximize specificity, sensitivity or a medium between the two. This paper provides practical suggestions for better validation. Improved early screening combined with thorough treatment should reduce life-long vision impairment due to amblyopia.

BACKGROUND The effectiveness of amblyopia therapy can be limited by poor adherence. Dichoptic therapies are a new approach, but recent trials have demonstrated difficulty maintaining high adherence over extended periods of at-home treatment. We evaluated the efficacy and adherence of Luminopia One-a dichoptic treatment that applies therapeutic modifications to streaming content chosen by the patient. METHODS This single-arm, multicenter prospective pilot study enrolled children aged 4-12 with anisometropic, strabismic, or mixed amblyopia at 10 pediatric ophthalmic and optometric practices across the United States. The therapeutic was prescribed for 1 hour/day, 6 days/ week for 12 weeks of at-home use. The primary endpoint was best-corrected visual acuity (BCVA) at the 12-week follow-up visit. RESULTS In total, 90 participants (mean age, 6.7 +/- 2.0 years) were enrolled, and 73/90 participants (81%) had prior treatment beyond refractive correction. For those who completed the 12-week visit, mean amblyopic eye BCVA improved from 0.50 logMAR to 0.35 logMAR (1.5 logMAR lines; 95% CI, 1.2-1.8 lines; P < 0.0001). Mean stereoacuity improved by 0.28 log arcsec (95% CI, 0.14-0.42 log arcsec; P < 0.0001). Median adherence was 86% (interquartile range, 70%-97%). CONCLUSIONS In our study cohort, adherence over the 12-week study period was high, and participants demonstrated clinically and statistically significant improvements in visual acuity and stereoacuity.

Aim To report five children with posttraumatic orbital subperiosteal hematoma. Methods In this study, five cases with posttraumatic orbital subperiosteal hematoma were studied and reviewed along with similar cases in a systematic literature review. Results The mean age of our patients was 9.40 ± 3.51 years, ranging from 4 to 13 years, and all were male. Mechanisms of injuries were blunt trauma, falling from a building, car accident, and falling from a bicycle. All patients had unilateral involvement. Treatment options included needle aspiration, surgical drainage, and observation for spontaneous resolution. Except for one patient, positive outcomes were achieved. Conclusion The most common location for posttraumatic orbital subperiosteal hematoma is the superior orbital wall. Traumatic optic neuropathy and permanent visual loss are uncommon. Observation, surgical drainage, and aspiration are common treatment options.

Background Assessment is a necessary part of training postgraduate medical residents. The implementation of methods located at the “shows how” level of Miller’s pyramid is believed to be more effective than previous conventional tools. In this study, we quantitatively compared electronic and conventional methods in assessing ophthalmology residents. Methods In this retrospective study, eight different conventional methods of assessment including residents’ attendance, logbook, scholarship and research skills, journal club, outpatient department participation, Multiple Choice Question (MCQ), Objective Structured Clinical Examination (OSCE), and professionalism/360-degree (as one complex) were used to assess 24 ophthalmology residents of all grades. Electronic media consisting of an online Patient Management Problem (e-PMP), and modified electronic OSCE (me-OSCE) tests performed 3 weeks later were also evaluated for each of the 24 residents. Quantitative analysis was then performed comparing the conventional and electronic assessment tools, statistically assessing the correlation between the two approaches. Results Twenty-four ophthalmology residents of different grades were included in this study. In the electronic assessment, average e-PMP scores (48.01 ± 12.40) were much lower than me-OSCE (65.34 ± 17.11). The total average electronic score was 56.67 ± 11.28, while the total average conventional score was 80.74 ± 5.99. Female and male residents’ average scores in the electronic and conventional method were (59.15 ± 12.32 versus 83.01 ± 4.95) and (55.19 ± 10.77 versus 79.38 ± 6.29), respectively. The correlation between modified electronic OSCE and all conventional methods was not statistically significant ( P -value >0.05). Correlation between e-PMP and six conventional methods, consisting of professionalism/360-degree assessment tool, logbook, research skills, Multiple Choice Questions, Outpatient department participation, and Journal club active participation was statistically significant (P-value < 0.05). The overall correlation between conventional and electronic methods was significant (P-value = 0.017). Conclusion In this study, we conclude that electronic PMP can be used alongside all conventional tools, and overall, e-assessment methods could replace currently used conventional methods. Combined electronic PMP and me-OSCE can be used as a replacement for currently used gold-standard assessment methods, including 360-degree assessment.

This workshop will discuss oculoplastic cases and oculoplastic surgical procedures relevant to pediatric ophthalmologists. These cases may include ptosis, epiblepharon, blepharophimosis syndrome, orbital dermoid cysts, and nasolacrimal duct obstruction. Emphasis will be on surgical treatment of these conditions including pre-operative evaluation and planning, and a post-operative care and complications.

PURPOSE To demonstrate the benefits of using braided polyester in the management of severe or recurrent ptosis in children and young adults and to compare the efficacy of two surgical techniques. METHODS Retrospective, non-randomized record review of 30 patients (43 eyelid procedures) affected by congenital or acquired severe ptosis who underwent frontalis suspension with braided polyester from 2008 to 2016. Two surgical techniques were compared: the base-down triangle and the Fox pentagon, both of which were performed using a closed technique. Functional success was defined as clearing of the visual axis. Complications and results were examined. RESULTS Functional success was obtained in 39 eyes of 43 procedures. Marginal reflex distance increased an average of 2.51 mm with the base-down triangle technique and 1.70 mm with the Fox pentagon technique (P = .05). The vertical palpebral fissure height increased an average of 4.60 mm with the base-down triangle technique and 2.45 mm with the Fox pentagon technique (P < .001). Mean follow-up duration was 38.6 months. Complications included untied suture (n = 2), suture dehiscence (n = 1), cellulitis (n = 2), and granuloma (n = 1). CONCLUSIONS Braided polyester was found to be a safe, effective, easy-to-handle, and low-cost sling material for frontalis suspension and should be considered for clinical use, especially in developing countries where the cost and availability of other materials represents a significant barrier to treatment. In the authors' experience, the base-down triangle technique appeared superior to the Fox pentagon technique. [J Pediatr Ophthalmol Strabismus. 2018;55(4):229-233.].

PURPOSE:To determine the specificity and sensitivity of a smartphone app (GoCheckKids [GCK] used as a photoscreening tool on the iPhone 7 to detect refractive amblyopia risk factors in children aged 1-6 years.PARTICIPANTS AND METHODS:A prospective, multicenter, 10-month evaluation of children aged 1-6 years old who underwent photoscreening with the GCK app to detect amblyopia risk factors. The first acceptable quality photograph of each study subject was evaluated by trained technicians using GCK's proprietary automated image processing algorithm to analyze for amblyopia risk factors. Trained graders, masked to the cycloplegic clinical data, remotely reviewed photographs taken with the app and compared results to the gold standard pediatric ophthalmology examinations using the 2013 American Association for Pediatric Ophthalmology & Strabismus amblyopia risk factor guidelines. Primary outcome was the ability of the GCK app to identify amblyopia risk factors compared to the cycloplegic refraction.RESULTS:There were 287 patient images analyzed. The overall sensitivity and specificity in detecting amblyopia risk factors were 76% and 85%, respectively using manual grading. The overall automated grading results had a sensitivity and sensitivity in detecting amblyopia risk factors of 65% and 83%, respectively.CONCLUSION:The GCK smartphone app is a viable photoscreening device for the detection of amblyopia risk factors in children aged 1-6 years.

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

Purpose: To study The Kaneka Lacriflow Stent, a self-retaining bicanalicular intubation set that can be placed under local anesthetic, providing a new option to treat epiphora and partial NLDO. Design: Retrospective chart review. Subjects: 93 adult patients requiring treatment for a partial NLDO were evaluated. Stents were placed in office setting under local/topical anesthetic or in OR (MAC or GEN). The stent is placed with a stylet, and self-retains due to a widened portion sitting distal to the common canaliculis. It does not require recovery from the nose. Methods:: Outcomes analyzed to evaluate success of stent placement. Main outcome measure: Success rate of placement of the stent in adults. Results: Stents left in place for 3 months. Results recorded 1 month after removal. Stents successfully placed in 124 of 136 (91%) eyes. Under local anesthesia in the office setting, 83 of 92 (90%) were placed successfully. Records were complete in 59 patients (78 eyes) and were analyzed further. 33 patients (52 eyes) had stents retained for the full 90 days and had follow-up recorded one-month post removal. Of the patients who retained the stents for 90 days and had full follow-up, 32 patients (51 eyes, 98%) reported improvement in their symptoms, while 1 patient reported no improvement. Conclusion: Silicone intubation of the NLD in adults is rarely done due to need for general anesthesia. The Lacriflow stent can be successfully placed in the office under local anesthesia offering a new approach for tearing in adults.

Frontalis suspension is a surgical procedure performed to address severe ptosis with poor levator function. Several different techniques and sling materials are commonly used. The purpose of this study is to demonstrate the benefits of using green braided polyester (Ethibond EXCEL- ETHICON) in the management of severe or recurrent ptosis in children and young adults.

Traditional vision screening utilizes visual acuity charts, requiring a subjective response from a child. This can be especially challenging for nonverbal, preverbal, and early verbal children and can lead to over-referral of young children for confirmatory examinations with significant cost implications. This has led to the wide use of photoscreeners.

Automated vision screening can identify preschool children with amblyopia risk factors (ARFs). A smart phone platform has potential benefits of portability and implementation. This represents an interim analysis of a prospective study to introduce and assess a mobile smart phone (GoCheckKids) with automated image-processing analysis for a vision-screening device.