Table of Contents
Meeting at a Glance
Inside Front Cover
AAPOS Past Presidents2
AAPOS Board of Directors3
AAPOS Honor Award Recipients
4
AAPOS Committee Meetings Schedule
4
CME Credit Information5
Overall Meeting Goals5
Specific Learning Objectives5
FDA Disclaimer Information5
Educational Mission Statement6
Costenbader Lecturer7
Apt Lecturer9
Participant Financial Disclosures11
Program Schedule – Scientific Paper Program
17 (Blue Section)
Scientific Paper Abstracts25
Scientific Poster Program (First Set)
45 (Blue Section)
Scientific Poster Abstracts (First Set)
49
Scientific Poster Program (Second Set)
73 (Blue Section)
Scientific Poster Abstracts (Second Set)
77
Workshop Program101 (Blue Section)
Workshop Abstracts 105
AAPOS Committees121
Index of Authors125
Floor Plan of Meeting Area
129
CME Evaluation Form
Inside Back Pocket
CME Credit Statement
Inside Back Pocket
Future AAPOS meetings
Inside Back Cover
Blank “notes” pages are included at the end of each section of abstracts.
1
AAPOS Past Presidents
AAPOS Board of Directors
Marshall M. Parks, MD
1974-75
Lake Tahoe
Robert D. Reinecke, MD1975-76Bermuda
Jack C. Crawford, MD
1976-77
San Francisco
Robison D. Harley, MD1977-78Williamsburg
David S. Friendly, MD1978-79Toronto
Phillip Knapp, MD1979-80San Diego
Webb Chamberlain, MD1980-81Orlando
Arthur Jampolsky, MD1981-82Monterey
Alfred G. Smith, MD1982-83Vancouver
John A. Pratt-Johnson, MD
1983-84
Vail
Eugene R. Folk, MD
1984-85
Puerto Rico
Thomas D. France, MD1985-86Maui
Gunter K. von Noorden, MD 1986-87
Scottsdale
Arthur L. Rosenbaum, MD
1987-88
Boston
William E. Scott, MD1988-89Kiawah
Eugene M. Helveston, MD
1989-90
Lake George
Henry S. Metz, MD1990-91Montreal
John T. Flynn, MD1991-92Maui
Forrest D. Ellis, MD
1992-93
Palm Springs
David L. Guyton, MD1993-94Vancouver
Malcolm L. Mazow, MD1994-95Orlando
John D. Baker, MD1995-96Snowbird
Earl A. Palmer, MD1996-97Charleston
John W. Simon, MD
1997-98
Palm Springs
Marilyn T. Miller, MD1998-99Toronto
Maynard B. Wheeler, MD
1999-2000
San Diego
Albert W. Biglan, MD2000-01Orlando
Jane D. Kivlin, MD2001-02Seattle
Joseph H. Calhoun, MD2002-03Hawaii
George S. Ellis, Jr., MD
2003-04
Washington DC
Susan H. Day, MD2004-05Orlando
Michael X. Repka, MD2005-06Keystone
Christie L. Morse, MD2006-07Seattle
Edward G. Buckley, MD
2007-08
Washington DC
Bradley C. Black, MD
2008-09
San Francisco
C. Gail Summers, MD2009-10Orlando
David A. Plager, MD
2010-11
San Diego
Steven E. Rubin, MD
2011-12
San Antonio
2
PresidentK. David Epley, MD
Executive Vice President
Christie L. Morse, MD
Vice PresidentSharon F. Freedman, MD
Vice President-ElectSherwin J. Isenberg, MD
Secretary-TreasurerRobert E. Wiggins, Jr., MD
Secretary for Program
Stephen P. Christiansen, MD
Director-At-LargeR. Michael Siatkowski, MD
Director-At-LargeMary Louise Z. Collins, MD
Director-At-LargeDerek T. Sprunger, MD
Past PresidentSteven E. Rubin, MD
AAPOS Councilor to the AAO
David A. Plager, MD
AAPOS Program Committee
Scientific Program Committee Chair
Stephen P. Christiansen, MD
Scientific Program Committee Members
Yasmin S. Bradfield, MD
Katherine A. Lee, MD
Graham E. Quinn, MD
Ann U. Stout, MD
C. Gail Summers, MD
David K. Wallace, MD
Scientific Program Coordinator
Maria A. Schweers, CO
3
AAPOS Lifetime Achievement Award
This activity has been planned and implemented in accordance with the Essential Areas and policies of the
Accreditation Council for Continuing Medical Education through the joint sponsorship of the American
Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus.
The American Academy of Ophthalmology is accredited by the ACCME to provide continuing medical
education for physicians.
Susan H. Day, MD
AAPOS Senior Honor Awards
The American Academy of Ophthalmology designates this live activity for a maximum of 25.75 AMA
PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
Joseph L. Demer, MD, PhD
Sean P. Donahue, MD, PhD
Overall Meeting Goals
AAPOS Honor Awards
Norman B. Medow, MD, FACS
Linda R. Dagi, MD
Scott K. McClatchey, MD
James D. Reynolds, MD
Marc F. Greenberg, MD
Laura B. Enyedi, MD
Joel M. Weinstein, MD
Benjamin H. Ticho, MD
Daniel T. Weaver, MD
Nils K. Mungan, MD, FRCSC
Donny Won Suh, MD
John J. Sloper, FRCOphth
David G. Morrison, MD
Gill Roper-Hall, DBOT, CO
Gillian G. W. Adams, MD
AAPOS Committee Meetings
Wednesday, April 3, 2013
3:00 PM - 4:00 PM
Fellowship Training and Compliance Committee
Parliament
3:00 PM - 5:00 PM
Membership Committee
Baltic
5:00 PM - 6:30 PM
Interorganizational Relations Committee
Adams
12:45 PM - 2:00 PM
Learning Disabilities and Vision Therapy Task Force
Baltic
1:00 PM - 2:00 PM
Journal of AAPOS Editorial Board
Adams
1:00 PM - 2:30 PM
International Affairs Committee
Parliament
1:30 PM - 2:30 PM
Research Committee
Courier
2:30 PM - 3:30 PM
Fellowship Directors Meeting
Empire
Thursday, April 4, 2013
2:30 PM - 4:00 PM
Public Information Committee
North Star
4:00 PM - 5:30 PM
Professional Education Committee
Parliament
4:00 PM - 6:00 PM
Legislative Committee
Courier
4:30 PM - 5:30 PM
Online Media Committee
Mastif
1:00 PM - 2:30 PM
Vision Screening Committee
Baltic
1:00 PM - 5:00 PM
Singapore Program Committee
Adams
2:30 PM - 3:30 PM
Corporate Relations Committee
Parliament
3:30 PM - 5:30 PM
Socioeconomic Committee
Courier
Saturday, April 6, 2013
4
Upon completion of this activity, participants will be able to:
• Describe recent medical advances in the diagnosis, management, and treatment of conditions encountered in the practice of pediatric ophthalmology and strabismus
• Apply improved techniques, compare/contrast methods, and review clinical research and advances in order to provide the best possible treatment options and care to patients
• Demonstrate methods of ethical analysis and resolution of these dilemmas
• Practice newfound expertise in select aspects of surgery pertinent to pediatric ophthalmology and strabismus
Specific Learning Objectives
1. Employ most recent data from RCCTs in the diagnosis and management of amblyopia.
2. Incorporate new preoperative evaluation techniques and surgical strategies to improve outcomes in patients
with comitant, non-paretic strabismus.
3. Utilize new surgical techniques fro complicated strabismus (restrictive, paretic, miswiring syndromes,
scarring, incomitance, etc) to decrease reoperation rate by 10%.
4. Employ up-to-date pateint selection criteria to identify children undergoing cataract surgery who should
receive intraocular lenses.
5. Recognize new treatment techniques for pediatric glaucoma, retinal, and oculoplastic and orbital disease
and make appropriate sub-subspecialty referrals for such cases.
6. Improve identification of high-risk ROP and incorporate new treatment strategies to decrease the incidence
of significant visual loss from this disease.
7. Recognize pediatric ophthalmic disease of neurologic origin and make appropriate referrals to pediatric
neurology.
8. Utilize the latest resources for discussion of visual development, epidemiology of pediatric eye disease,
learning disabilites, vision screening strategies with other physicians and members of the lay community.
9. Improve compliance with current coding rules and regulations for pediatric eye diseases.
10. Recognize current laboratory research with potential translation applicability to pediatric ophthalmology.
FDA Status Disclaimer: The FDA has stated that it is the responsibility of the physician to determine the FDA status
of each drug or device he or she wishes to use in clinical practice, and to use these products with appropriate patient
consent and in compliance with applicable law. The AAPOS provides the opportunity for material to be presented for
educational purposes only. The material represents the approach, ideas, statement, or opinion of the presenter and/or
author, not necessarily the only or best method or procedure in every case, nor the position of AAPOS. The material is
not intended to replace a physician’s own judgement or give specific advice for case management. AAPOS specifically
disclaims any and all claims that may arise out of the use of any technique demonstrated or described in any material
by any presenter and/or author, whether such claims are asserted by a physician or any other person. Please note: The
AAPOS requires all presenters and/or authors to disclose any drug or device that is not approved for use by the FDA in
the manner discussed during any oral presentation and/or on all written materials.
5
AAPOS Educational Mission Statement
The purpose of the American Association for Pediatric Ophthalmology and Strabismus’ (AAPOS) educational activities is to
present pediatric ophthalmologists and strabismologists with the highest quality lifelong learning opportunities that promote
improvement and change in physician practices, performance, or competence through joint sponsorship with the American
Academy of Ophthalmology (AAO), thus enabling such physicians to maintain or improve the competence and professional
performance needed to provide the best possible eye care for their patients.
Due to the nature of the subspecialty, the largest component of AAPOS’ educational program focuses on strabismus, amblyopia,
visual development and binocular function. However, the content also emphasizes the other Practice Emphasis Areas (PEAs)
that been defined by the American Board of Ophthalmology (ABO) for their Maintenance of Certification (MOC) process with
emphasis on these disease processes in children, and adults with strabismus and eye movement disorders. These include:
•
•
•
•
•
•
•
•
Cataract and Anterior Segment
Cornea and External Disease
Glaucoma
Neuro-ophthalmology and Orbit
Oculoplastics and Orbit
Refractive Management and Intervention
Retina and Vitreous
Uveitis
Additionally, AAPOS’ educational program provides content for topics such as effective management of a pediatric
ophthalmology practice, medical ethics, risk management, and other areas deemed relevant by the needs of the membership.
Types of educational activities provided at the annual AAPOS meeting include:
• Didactic lectures
• Original research in the form of free papers and posters
• In-depth focused workshops and symposia on specific topics
• Small-group discussion opportunities with speakers and researchers
All meeting content is reviewed by the AAPOS Program Committee and Secretary for Program with respect to education
qualify and utility. Members are routinely queried regarding their assessment of quality and content, as well as needs for future
meetings, and comments are reviewed by the Program Committee and BOD, with necessary changes incorporated into future
programs.
The expected result of AAPOS’ educational activities is a broad array of ophthalmic knowledge that contributes to the lifelong
learning of members and advances physician performance or competence. Ongoing assessment of the impact of AAPOS’
educational program is important in determining modifications to existing activities and the development of new activities.
Specific expected results include increased knowledge across the ophthalmic community, activities designed to increase
competence and performance with evidence-based standards, current practices, and methods of diagnosis, therapies, and
disease prevention.
40th Annual Frank D. Costenbader Lecturer
A Cut Above - The Role of Vitrectomy in the Evolution of Pediatric
Cataract Surgery
M. Edward Wilson, MD
Thursday, April 4, 2013 - 8:20 - 8:45 am
The Costenbader Lecture is supported by the Children’s Eye Foundation
Dr. Marion Edward “Ed” Wilson Jr. was born in Charleston, South Carolina. He received a
BS degree from Clemson University in 1976 and an M.D. degree from the Medical
University of South Carolina (MUSC) in 1980. After an internal medicine internship at the
National Naval Medical Center in Bethesda, Maryland Dr. Wilson served 2 years as
medical officer for US Navy Destroyer Squadrons Four & Six. He returned to Navy Hospital
Bethesda for his residency in ophthalmology. He was selected Chief Resident for his final
year. He completed a fellowship in pediatric ophthalmology at the Children’s National
Medical Center in Washington D.C. under the direction of Dr. Marshall Parks. After
spending an additional 3 years on the faculty in Bethesda as Director of Residency
Training, Dr. Wilson left the Navy and joined the faculty at MUSC in 1990.
Dr. Wilson is currently the N. Edgar Miles Professor of Ophthalmology and Pediatrics at the
Storm Eye Institute, Medical University of South Carolina, Charleston, SC. He served as
Storm Eye Institute Residency Program Director from 1990-1998 and then as Storm Eye
Institute Director and Pierre G. Jenkins Professor and Chair of Ophthalmology at MUSC for
15 years, from 1996-2011.
Dr. Wilson has received a Lifetime Achievement Award from the American Association for
Pediatric Ophthalmology and Strabismus (AAPOS) and a Senior Honor Award from the
American Academy of Ophthalmology. He was awarded the Claud Worth Medal by the
British Isles Pediatric Ophthalmology & Strabismus Association. He was also awarded the
Statesmanship Award, the highest honor inferred by the Joint Commission for Allied Health
Personnel in Ophthalmology. Dr. Wilson is Board Certified in Ophthalmology and is a
Fellow of the American Academy of Ophthalmology.
Dr. Wilson serves on the editorial Board of the Journal of AAPOS and served as Executive
Editor of the American Journal of Ophthalmology from 2000-2013. He has been elected
to membership in the prestigious American Ophthalmological Society, where he currently
serves on the governing council, and the Association for Research in Strabismus (“The
Squint Club”). He serves on the Board of Directors of the SC Society of Ophthalmology
and is Past President of the Costenbader Society.
Dr. Wilson’s research interests include surgical techniques for use in the treatment of
pediatric cataracts, as well as the full range of strabismus in children and adults. Dr.
Wilson has given more than 600 invited presentations at national and international
conferences including 18 named lectures. He has written or contributed to 27 books and
published over 250 scientific papers, chapters, and invited editorials on a wide variety of
subjects. Dr. Wilson has trained residents and fellows for more than 20 years and
maintains a large referral practice. He has been selected by his peers as one of the “Best
Doctors in America” for more than 15 consecutive years and is among those selected as
“America’s Top Doctors”.
Ed Wilson and his wife Donna (a nurse) enjoy traveling and spending time together. They
met as students at Clemson. They were married in 1975. Their son, Leland, is 33 years old
and despite multiple handicaps from cerebral palsy, he loves to work and to paint. Leland
thinks the world would be better if everyone got a hug every day.
6
7
The Frank D. Costenbader Lecture
2013 Leonard Apt Lecture
The Frank D. Costenbader Lecture was inaugurated in 1974 at the Annual Meeting of the Costenbader Society to honor Dr. Costenbader. The
American Association for Pediatric Ophthalmology, later the American Association for Pediatric Ophthalmology and Strabismus was created at this
meeting. From its inception, AAPOS undertook to sponsor the Costenbader Lecture as the keynote presentation at its annual meeting. Due to failing
health, Dr. Costenbader was unable to attend any of the lectures which honored him.
Dr. Costenbader was born and educated in Virginia and was a true Virginia Gentleman. He received his undergraduate education at Hampton-Sydney
College, his medical degree from the University of Virginia and completed his residency at the Episcopal Eye, Ear and Throat Hospital in Washington,
DC.
Dr. Costenbader started practice in 1932 in the depression and began a lifetime commitment to teaching, which set the stage for the tremendous
influence he had on ophthalmology when he began to only see children. In 1933, Dr. Costenbader was appointed Instructor in Ophthalmology at
Georgetown University and he became Special Lecturer and Conferee there in 1964. He also was on the faculty of George Washington University
advancing to the rank of Clinical Professor. He was known for his enormous patience, generous with his time, always offering complete answers to
even the weakest questions, and he rarely lost his equanimity. He changed the Children’s Hospital Clinic from one of service only to teaching and
clinical care. He committed a full day a week to teaching for many years, spending Tuesday afternoons at Children’s and another half day a week at the
Episcopal EET Hospital. In 1946, the Episcopal residents started rotating at Children’s, and he was able to focus his teaching efforts there.
Dr. Costenbader is referred to as the Father of Pediatric Ophthalmology. That designation is because of his decision in 1943 to limit his practice to
pediatric ophthalmology, and he was the first ophthalmologist to do so. He moved his office to a stately brownstone townhouse on 22nd Street in
Washington, DC. His waiting room was referred to as Dr. Costenbader’s living room by many of his young patients because of its small furniture.
He had two exam rooms on the first floor, which he used, and there were additional exam rooms on the lower level for his orthoptist, Ms. Dorothy
Bair, and associates, fellows and preceptors. It was a center for wonderful patient care and the first real education or training center for pediatric
ophthalmology. His exam tools were limited. Dr. Costenbader had a picture of an airplane and a phone on a rotating box at the end of his room and
kids would beg to come in and see his airplane and talk to him about it. The patient’s examination chair was a kitchen chair placed on a small wooden
platform.
When asked why he limited his practice to pediatrics, the first thing Dr. Costenbader would say was that kids are just so much more fun. He also was
fascinated with the eye problems of children and at that time, ophthalmologists interested in strabismus were more interested in adults and older
children and in cosmetic alignment.
Dr. Costenbader was an advocate for children. His concern for their health and the financial welfare of families in providing for the health of their
children led him to establish and financially support the Eye Fund at Children’s Hospital to pay for indigent patient surgery. This fund is now used to
support the training program at the Children’s National Medical Center in Washington, DC.
Continuing with his concern for providing for children’s health care, he was co- founder of the Medical Service Plan (today Blue Shield) of the District
of Columbia and was the first president from 1946 to 1951. He remained on the board for many years. In addition, he started having parents be with
their child in the anesthesia induction room before surgery, he eliminated bandages on eyes following strabismus surgery, and he changed strabismus
surgery from two inpatient nights to same-day surgery. Dr. Costenbader was Chief of Ophthalmology at Children’s Hospital of Washington, DC, now
The Children’s National Medical Center from 1938 to 1965. He had a remarkable effect on children’s eye care and children’s health in general.
This lecture memorializes the man who had the foresight and the courage to begin a subspecialty in ophthalmology and the talent and dedication to
train and mold the nest generation according to his ideals.
Past Costenbader Lectures
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
Los Angeles
Lake Tahoe
Bermuda
San Francisco
Williamsburg
Toronto
San Diego
Orlando
Monterey
Vancouver
Vail
Puerto Rico
Maui
Scottsdale
Boston
Kiawah
Lake George
Montreal
Maui
Marshall M. Parks, MD
Robert N. Shaffer, MD
Lorenz E. Zimmerman, MD
T. Keith Lyle, MD
Jules Francois, MD
Robison D. Harley, MD
David G. Cogan, MD
Philip Knapp, MD
Joseph Lang, MD
Jack C. Crawford, MD
Gunter K. von Noorden, MD
Arthur J. Jampolsky, MD
Robert M. Ellsworth, MD
John E. Wright, MD
Alan B. Scott, MD
Kenneth C. Swan, MD
John T. Flynn, MD
John A. Pratt-Johnson, MD
Eugene M. Helveston, MD
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
8
Palm Springs
Vancouver
Orlando
Snowbird
Charleston
Palm Springs
Toronto
San Diego
Orlando
Seattle
Hawaii
Washington, DC
Orlando
Keystone
Seattle
Washington, DC
San Francisco
Orlando, FL
San Diego
San Antonio
Henry S. Metz, MD
William E. Scott, MD
Eugene R. Folk, MD
Marilyn T. Miller, MD
Robert D. Reinecke, MD
David L. Guyton, MD
Malcolm L. Mazow, MD
David R. Stager, Sr., MD
Forrest Daryel Ellis, MD
Creig S. Hoyt, MD
Burton J. Kushner, MD
Arthur L. Rosenbaum, MD
Albert W. Biglan, MD
Earl A. Palmer, MD
John D. Baker, MD
Edward G. Buckley, MD
Richard A. Saunders, MD
A. Linn Murphree, MD
Susan H. Day, MD
Michael X. Repka, MD
Strabismus is Gettin’ Old
Joseph L. Demer, MD, PhD
Saturday, April 6, 2013 - 8:35 – 8:55 am
Joseph L. Demer, MD, PhD, was born in Minneapolis, Minnesota, but as the eldest of
eight children was raised in Tucson, where his father was professor at the University of
Arizona (UA). While an Electrical Engineering undergraduate at UA, Joseph worked as
a television broadcast engineer, and was a traveling member of the UA debate team and
coach of a state champion high school debate team. Joseph received his MD and PhD in
Biomedical Engineering from Johns Hopkins in 1983, where his dissertation research in
the Wilmer Institute involved the role of olivocerebellar pathways in plasticity of reflexive
eye movements. While Ophthalmology resident at Baylor College of Medicine in Houston,
Texas, Dr. Demer was appointed to the research faculty and received his first R01 grant
from the National Eye Institute (NEI) for study of human vestibulo-ocular reflexes. With the
blessing of mentor Gunter K. von Noorden, MD, Dr. Demer continued this research during
fellowship in Pediatric Ophthalmology at Texas Children’s Hospital. Also during fellowship,
Dr. Demer published the first functional imaging study of the effect of amblyopia on the
human brain using positron emission tomography, and published on clinical optokinetic
asymmetry in esotropia.
Dr. Demer was recruited in 1988 to the University of California Los Angeles (UCLA), where
he rose to the rank of Chief of the Pediatric Ophthalmology and Strabismus Division in
the Jules Stein Eye Institute and Department of Ophthalmology, David Geffen School of
Medicine. Dr. Demer now holds the Leonard Apt Professorship of Ophthalmology, and is
also Professor of Neurology, Director of the Ocular Motility Clinical Laboratory, Co-director
of the Pediatric Ophthalmology and Strabismus Fellowship program, and committee
chair of the EyeSTAR Training Program (Specialty Training and Advanced Research in
Ophthalmology and Visual Science), a residency-PhD track. Dr. Demer is also a member of
the Neuroscience and Bioengineering Interdepartmental Programs.
Dr. Demer teaches graduate and medical students in several courses, including Neurology,
Ophthalmology, Neuroscience, and Bioengineering. Dr. Demer has served as editor or
editorial board member for the American Journal of Ophthalmology, the Japanese Journal
of Ophthalmology, Investigative Ophthalmology and Visual Science, the Journal of AAPOS,
and Strabismus. He is also a reviewer for many other scientific and clinical publications,
and has chaired numerous study sections for the National Institutes of Health and a section
program committee for the Association for Research in Vision and Ophthalmology (ARVO).
For 35 years, Dr. Demer has investigated regulation of binocular alignment, vestibuloocular reflexes, visual tracking, orbital anatomy, and visual brain function. In 2003, ARVO
awarded Dr. Demer its highest honor, the Friedenwald Award, for his groundbreaking
research on the extraocular muscles and orbital connective tissues that culminated in the
Active Pulley Hypothesis. In 2004, Dr. Demer also received an Achievement Award from
the Alcon Research Institute for this work. He is an inaugural Gold Fellow of ARVO.
Dr. Demer’s research has been supported by NEI since 1985, and by Research to Prevent
Blindness since 1988. He has published over 215 peer-reviewed scientific papers, 40 book
chapters, and six editorials. His medical and surgical practice includes in pediatric and
adult strabismus, nystagmus, magnetic resonance imaging (MRI) of the orbit and cranial
nerves, and children’s eye diseases. Dr. Demer performs consultative clinical imaging
using advanced MRI methods that are undergoing continuing refinement in his laboratory.
In addition to personally operating MRI scanners, Dr. Demer is an active instrument-rated
airplane pilot with nearly 1500 flight hours.
Dr. Demer resides in Los Angeles with his wife Melissa Reider-Demer, DNP, who is a
doctorally-prepared nurse practitioner in Neurosurgery at UCLA. They have three children,
sons Gregory and Eric, and daughter Julia.
9
The Leonard Apt Lecture
Participant Financial Disclosures
The Leonard Apt Lecture was established and first presented in 2000 by the American Academy of Pediatrics (AAP) Section
on Ophthalmology to honor Leonard Apt, MD, for his dedication and contributions in the fields of pediatrics and pediatric
ophthalmology.
Dr. Apt was born in Philadelphia on June 28, 1922. He entered college at the age of 14 at the University of Pennsylvania, and
trained in pediatrics after completing medical school at Jefferson Medical College in Philadelphia. Physicians everywhere will
recall the “Apt Test” for detecting gastrointestinal bleeding in newborns, invented by young pediatrician Leonard Apt in 1955.
Over the objections of leading physicians of the day who thought that pediatric ophthalmology was conceptually absurd, he then
trained in ophthalmology at Harvard, the University of Cincinnati, and the National Institutes of Health. Dr. Apt became the first
physician board-certified in both pediatrics and ophthalmology. As the first National Institutes of Health Special Fellow in
Pediatric Ophthalmology mentored by Drs. Frank Costenbader and Marshall Parks, he organized the first formal training
program for the new specialty.
Dr. Apt served as the first Research Fellow in Pediatric Ophthalmology at Wills Eye Hospital. In 1961, at UCLA, Dr. Apt
established the first full-time service in pediatric ophthalmology at a United States medical school, predating both the AAP
Section on Ophthalmology and AAPOS. For many years, Dr. Apt served as the principal ophthalmology consultant for the AAP.
He organized local and national courses on pediatric eye topics and spoke at Annual Meetings of the AAP. Dr. Apt became a
founding member of UCLA’s Jules Stein Eye Institute.
Every ophthalmologist owes an intellectual debt to Dr. Apt. This towering intellectual figure developed the coating that first
enabled the use of synthetic absorbable sutures for ocular surgery. In 1963, Dr. Apt reported on the use of povidone-iodine as a
potent, safe antiseptic on the eye and surrounding skin area. It eventually became the preferred method of ophthalmic surgical
preparation. In recent years, Dr. Apt and his colleague, Dr. Sherwin Isenberg, used povidone-iodine in developing countries to
prevent and treat blinding eye infections in infants and children.
Dr. Apt authored more than scientific and medical 300 publications. To his numerous honors from professional societies,
Harvard, Jefferson Medical College, and the University of Pennsylvania have recently been added the 2009 UCLA Emeritus
Professorship Award, the 2010 AAP Lifetime Achievement Award, and the 2010 Castle Connolly National Physician of the Year
Award for Lifetime Achievement. Beyond medicine, Dr. Apt was active as a founder, board member, and a major contributor to
the arts, theater, music, humanities, and sports. His philanthropic gifts to UCLA have created the “Leonard Apt Fellowship in
Pediatric Ophthalmology” and the “Leonard Apt Chair in Pediatric Ophthalmology.”
Dr. Apt died of natural causes in Santa Monica, California on February 1, 2013. The Leonard Apt Lecture pays continuing tribute
to the late Dr. Leonard Apt not only for his monumental educational and scientific contributions, but also for his pioneering
leadership in creation of pediatric ophthalmology as a medical subspecialty.
Category
Code
Description
Consultant/
Advisor
C
Consutant fee, paid advisory boards or fees forattending a meeting (for the past 1 year)
Employee
E
Employed by a commercial entity
Lecture Fees
L
Lecture fees (honoraria), travel fees or reimbursements when speaking at the invitation of a
commercial entity (for the past 1 year)
Equity Owner
O
Equity ownership/stock options of publicly or privately traded firms (excluding mutual funds)
with manufacturers of commercial ophthalmic products or commercial ophthalmic services
Patents/Royalty
P
Patents and/or royalties that might be viewed as creating a potential conflict of interest
Grant Support
S
Grant support for the past 1 year (all sources) and all sourcesused for this project if this form is
an update for a specific talk or manuscript with no time limitation
Adams, Gill
S – IRISS to Moorfields (Institutional
Support)
Ainsworth, John
No Financial Interests to Disclose
Alcorn, Deborah
No Financial Interests to Disclose
Ali,Asim
No Financial Interests to Disclose
Anderson, Shirley
No Financial Interests to Disclose
Apkarian, Alexandra
No Financial Interests to Disclose
Past Apt Lectures
2000
San Diego
J. Bronwyn Bateman, MD
2001
Orlando
Bennett A. Shaywitz, MD & Sally E. Shaywitz, MD
2002SeattleMark Siegler, MD
2003HawaiiLinda J. Mason, MD
2005OrlandoEdwin M. Stone, MD, PhD
2007SeattleCarol D. Berkowitz, MD, FAAP
2009
San Francisco
Sherwin J. Isenberg, MD
2011
San Deigo
Carol L. Shields, MD & Jerry A. Shields, MD
Archer, Steven
No Financial Interests to Disclose
Areaux, Raymond
No Financial Interests to Disclose
Arnold, Robert
O – Glacier Medical Software
C – iCheckHC
Capo, Hilda
No Financial Interests to Disclose
Beck, Allen
L – Merck
Chaudhuri, Zia
S – BOYSCAST Fellowship of the
Department of Science and Technology,
Government of India
S – US Public Health Service Grant
EY08313
S – Research to Prevent Blindness
S - ScanMed MRI surface coils (discount)
S – Maning Beef, LLC (discount on beef
heads)
Binenbaum, Gil
S – National Institutes of Health
L – Symposia Medicus
Birch, Eileen
S – National Eye Institute EY022313
S – Thrasher Research Fund
Biswas, Susmito
No Financial Interests to Disclose
Black, Graeme
No Financial Interests to Disclose
Bothun, Erick
No Financial Interests to Disclose
Bradfield, Yasmin
No Financial Interests to Disclose
Bratton, Monica
No Financial Interests to Disclose
Ashworth, Jane
S – Biomarin Europe Ltd
Braverman, Rebecca
No Financial Interests to Disclose
Astudillo, Paulita Pamela
No Financial Interests to Disclose
Breidenstein, Brenda
No Financial Interests to Disclose
Bahl, Reecha
No Financial Interests to Disclose
Brodsky, Michael
No Financial Interests to Disclose
Baldonado, Kira
S – HHS, HRSA, Maternal and Child
Health Bureau
Buckley, Edward
No Financial Interests to Disclose
Bang, Genie
No Financial Interests to Disclose
10
Bartiss, Michael
No Financial Interests to Disclose
Cabrera, Michelle
No Financial Interests to Disclose
11
Chen, Wendy
S – NIH K12 EYE015398, NIH P30
EY01583-26, NIH Loan Repayment
Program
Chiang, Michael
C – Clarity Medical Systems (unpaid
member of Scientific Advisory Board)
S – National Institutes of Health
S – Research to Prevent Blindness
Christiansen, Stephen
No Financial Interests to Disclose
Christoff, Alex
No Financial Interests to Disclose
Chun, Bo Young
No Financial Interests to Disclose
Chung, Seung Ah
No Financial Interests to Disclose
Clark, Robert
S – National Eye Institute
Cline, Cindy
No Financial Interests to Disclose
Coakley, Rebecca
No Financial Interests to Disclose
Collins, Mary Louise
No Financial Interests to Disclose
Conley, Julie
No Financial Interests to Disclose
Cottle, Elizabeth
C – American Academy of Ophthalmology
E – OHSU Casey Eye Institute
L – Elizabeth Cottle, CPC, OCS
Cox, Kyle
No Financial Interests to Disclose
Cruz, Oscar
No Financial Interests to Disclose
Dacey, Mark
L – Allergan Pharmaceuticals
Dagi, Linda
No Financial Interests to Disclose
Dahlmann-Noor, Annegret
S – Iriss Medical Technologies Ltd
S – Fight for Sight
S – Pfizer
S – Allergan
Dankner, Stuart
No Financial Interests to Disclose
D’Arienzo, Peter
L – Alcon
Davidson, Jennifer
No Financial Interests to Disclose
De Alba Campomanes, Alejandra
No Financial Interests to Disclose
De Beaufort, Heather
No Financial Interests to Disclose
Deacon, Brita
No Financial Interests to Disclose
Del Monte, Monte
No Financial Interests to Disclose
Demer, Joseph
S – ScanMed
S – United States Public Health Service
C – U.S. National Eye Institute
S – Research to Prevent Blindness
S – Manning Beef, LLC
L - Cyberonics
Diab, Mohamed Mostafa
C – Alcon
S – Alcon
Doan, Andrew
O – Credential Protection
O – Medrounds
Donahue, Sean
C – Rebiscan
C – Diopsys
C – I Screen
C – Pediavision
Foster, C. Stephen
C – Allergan
C – Alcon
C – Bausch and Lomb
C – Novartis
C – Xoma
S – Santen
C – Eyegate
C, S – LUX
Dosunmu, Eniolami
No Financial Interests to Disclose
Fragkou, Katerina
No Financial Interests to Disclose
Drack, Arlene
S – Foundation Fighting Blindness
S – Vision for Tomorrow
S – Hope for Vision
S – Research to Prevent Blindness
Fray, Katherine
No Financial Interests to Disclose
Droll, Lilly
No Financial Interests to Disclose
Freitag, Suzanne
No Financial Interests to Disclose
Dunbar, Jennifer
No Disclosure on File
Gajdosova, Eva
No Financial Interests to Disclose
Dunn, Heather
No Financial Interests to Disclose
Gamm, David
P – Cellular Dynamics International, Inc
Edmond, Jane
L – Alcon
Garry, Glynnis
No Financial Interests to Disclose
Eggers, Howard
No Disclosure on File
Geloneck, Megan
S – Research to Prevent Blindness
S – NIH Vision Core Grant
Hunter, David
O – REBIScan, Inc
P – Johns Hopkins University
P – Boston Children’s Hospital
Gertsch, Kevin
No Financial Interests to Disclose
Hussein, Mohamed
No Financial Interests to Disclose
Elliott, Alexandra
No Financial Interests to Disclose
Gold, Robert
L – Alcon Labs, Inc
C, L – Bausch and Lomb
C, O – Pediavision
Isenberg, Sherwin
C - Foresight Biotherapeutics
Ellis, Forrest
No Financial Interests to Disclose
Graeber, Carolyn
No Financial Interests to Disclose
Epley, David
L – Alcon
Granet, David
C – Alcon
Faron, Nicholas
No Financial Interests to Disclose
Gurland, Judith
No Financial Interests to Disclose
Felius, Joost
No Financial Interests to Disclose
Guyton, David
P – Johns Hopkins University, Rebiscan
S – Hartwell Foundation
S – National Institutes of Health
El-Dairi, Mays Antoine
C – Prana Pharmaceuticals
El Essawy, Rania
No Financial Interests to Disclose
Fenerty, Cecilia
No Financial Interests to Disclose
Ferris, John
P – Phillips Studio – Simulated Ocular
Surgery website to be launched in March
2013
Fielder, Alister
C – Novartis Pharmaceuticals Corporation
P – Keeler Ltd
12
Freedman, Sharon
C – Pfizer, Inc.
Hamada, Samer
No Financial Interests to Disclose
Hariharan, Luxme
S – ORBIS International
Hartman, E. Eugenie
No Financial Interests to Disclose
Heidary, Gena
No Financial Interests to Disclose
Helveston, Eugene
No Financial Interests to Disclose
Khurram Butt, Darakhshanda
No Financial Interests to Disclose
Lewis, Terri
No Financial Interests to Disclose
Hendler, Karen
No Financial Interests to Disclose
Kipp, Michael
No Financial Interests to Disclose
Li, Simone
S – National Eye Institute EY022313
Hennessey, Claire
No Financial Interests to Disclose
Kirkeby, Laura
E – Scripps Clinic
Hensch, Takao
No Financial Interests to Disclose
Klein, Kathryn
No Financial Interests to Disclose
Lichtenstein, Steven
C, L, S – Alcon Laboratories, Inc.
S – Bausch and Lomb
C – NovaBay
C, L, S – Rapid Screening, Inc.
Holmes, Jonathan
S – National Eye Institute
Kodsi, Sylvia
No Financial Interests to Disclose
Lindquist, Timothy
No Financial Interests to Disclose
Horan, Lindsay
No Financial Interests to Disclose
Kong, Lingkun
No Financial Interests to Disclose
Lloyd, I Christopher
L – Bausch and Lomb UK Ltd
Horwood, Anna
No Financial Interests to Disclose
Kurup, Sudhi
No Financial Interests to Disclose
Lope, Lea Ann
No Financial Interests to Disclose
Hsu, Jennifer
No Financial Interests to Disclose
Kushner, Burton
No Financial Interests to Disclose
Losch, Tim
No Financial Interests to Disclose
Hug, Denise
No Financial Interests to Disclose
Laby, Daniel
O,P – EyeCheck Systems, LLC
Lowry, Eugene
No Financial Interests to Disclose
Hull, Jennifer
No Financial Interests to Disclose
Lambert, Scott
No Financial Interests to Disclose
Lueder, Gregg
No Financial Interests to Disclose
Lambley, Rosemary
No Financial Interests to Disclose
Lusk, Kelly
No Financial Interests to Disclose
Lang, Richard
P – Cincinnati Children’s Hospital Medical
Center
Lyons, Christopher
No Financial Interests to Disclose
Jaafar, Mohamad
No Financial Interests to Disclose
Jackson, Jorie
No Financial Interests to Disclose
Johnston, Suzanne
No Financial Interests to Disclose
Jost, Reed
No Financial Interests to Disclose
Karr, Daniel
No Financial Interests to Disclose
Kazlas, Melanie
No Financial Interests to Disclose
Kekunnaya, Ramesh
No Financial Interests to Disclose
Kerr, Natalie
No Financial Interests to Disclose
Khan, Arif
No Financial Interests to Disclose
Lawrence, Linda
No Financial Interests to Disclose
Leath Alexander, Janet
No Financial Interests to Disclose
MacDonald, John
No Financial Interests to Disclose
MacKenzie, Kelly
No Financial Interests to Disclose
Lee, Jong Bok
No Financial Interests to Disclose
MacKinnon, Sarah
S – NIH R01EY152987
S – HHMI
Lee, Katherine
No Financial Interests to Disclose
Maldonado, Ramiro
No Financial Interests to Disclose
Lehman, Sharon
No Financial Interests to Disclose
Manchandia, Ajay
S – USPHS National Eye Institute
EY08313
Lenahan, Deborah
No Financial Interests to Disclose
Lenhart, Phoebe
No Financial Interests to Disclose
Leske, David
S – NIH EY018810
S – Research to Prevent Blindness
S – Mayo Foundation
Leung, Andrea
No Financial Interests to Disclose
Levin, Alex
No Financial Interests to Disclose
13
Matta, Noelle
No Financial Interests to Disclose
McCarus, Cheryl
No Financial Interests to Disclose
McCourt, Emily
No Financial Interests to Disclose
McCurry, Thomas
No Financial Interests to Disclose
McGaw, Tennille
No Financial Interests to Disclose
McNeer, Keith
E – Virginia Commonwealth University
Olitsky, Scott
No Financial Interests to Disclose
Ron Kella, Yonina
No Financial Interests to Disclose
Soliman, Mohamed
No Financial Interests to Disclose
Tekavcic Pompe, Manca
No Financial Interests to Disclose
Walton, David
No Financial Interests to Disclose
Menke, Anne
No Financial Interests to Disclose
Ostrow, Greg
No Financial Interests to Disclose
Rovick, Lisa
No Financial Interests to Disclose
Stager Sr, David
No Financial Interests to Disclose
Ticho, Benjamin
No Financial Interests to Disclose
Weakley, David
No Financial Interests to Disclose
Merrill, Kimberly
No Financial Interests to Disclose
Paysse, Evelyn
No Financial Interests to Disclose
Sadiq, Sardar Mohammad Ali
No Financial Interests to Disclose
Stager Jr, David
No Financial Interests to Disclose
Whitecross, Sarah
No Financial Interests to Disclose
Mets, Marilyn
No Financial Interests to Disclose
Peragallo, Jason
No Financial Interests to Disclose
Salazar, Barbara
No Financial Interests to Disclose
Stahl, Erin
No Financial Interests to Disclose
Mezer, Eedy
No Financial Interests to Disclose
Peterseim, Mae Millicent
No Financial Interests to Disclose
Salchow, Daniel
No Financial Interests to Disclose
Stass-Isern, Merrill
No Financial Interests to Disclose
Toth, Cynthia
P – Alcon Laboratories
S – Bioptigen
S – Genentech
S – National Eye Institute
S – The Hartwell Foundation
S – The Arnold and Mabel Beckman
Foundation
Miller, Joseph
E – University of Arizona – Ophthalmology
Phillips, Paul
No Financial Interests to Disclose
Salehi Omran, Sina
No Financial Interests to Disclose
Steinkuller, Paul
No Financial Interests to Disclose
Traboulsi, Elias
C – Oxford Biomedica
Williams, Alice
No Financial Interests to Disclose
Pihlblad, Matthew
No Financial Interests to Disclose
Schnall, Bruce
L – Alcon
Stewart, Krista
No Financial Interests to Disclose
Traczy-Hornoch, Kristina
No Financial Interests to Disclose
Pineles, Stacy
S – NIH/NEI K23
Plager, David
S – Alcon
S – Bausch and Lomb
Schwartz, Terry
No Financial Interests to Disclose
Stout, Ann
No Financial Interests to Disclose
Trivedi, Rupal
No Financial Interests to Disclose
Scott, Alan
P – Alan B. Scott
Stout, Rebekah
No Financial Interests to Disclose
Tychsen, Lawrence
No Financial Interests to Disclose
Wilson, M. Edward
P – Springer book publisher
S – Alcon – pharmaceutical multicenter
clinical trial
S – Bausch and Lomb – pharmaceutical
multicenter clinical trial
S – Ophtec – FDA multicenter clinical trial
Plummer, Laura
No Financial Interests to Disclose
Scott, William
No Financial Interests to Disclose
Struck, Michael
S – Vision of Children Foundation
VanderVeen, Deborah
No Financial Interests to Disclose
Pogrebniak, Alexander
No Financial Interests to Disclose
Serafino, Massimiliano
No Financial Interests to Disclose
Sturm, Veit
No Financial Interests to Disclose
Velez, Federico
No Financial Interests to Disclose
Morrison, David
C – Panoptica
Prakalapakorn, Sasapin
S – NHI
S – Research to Prevent Blindness
Shah, Shaival
No Financial Interests to Disclose
Vickers, Laura
No Financial Interests to Disclose
Mungan, Nils
No Financial Interests to Disclose
Pyi Son, Ma Khin
No Financial Interests to Disclose
Subramanian, Vidhya
S – EY022313
S – The Knights Templar Foundation
S – The Thrasher Research Fund
Muthusamy, Brinda
S – The Knights Templar Eye Foundation
Grant
Quinn, Graham
S – NIH/NEI
S – ORBIS
Nischal, Ken
No Financial Interests to Disclose
Raab, Edward
No Financial Interests to Disclose
Nucci, Paolo
L – Alcon
L – Bausch and Lomb
L – Allergan
L – Alfa Intes
L, S – Visufarma
L, S – Thea
C, S – Sooft
C, S – Sifi
C, S – Centrostyle
C, L – Chicco
C, L, S – Novartis Alcon
Rabinovich, Ronen
No Financial Interests to Disclose
Miller, Marilyn
No Financial Interests to Disclose
Mintz-Hittner, Helen
No Financial Interests to Disclose
Mireskandari, Kamiar
No Financial Interests to Disclose
Mohney, Brian
No Financial Interests to Disclose
Morad, Yair
No Financial Interests to Disclose
Nysather, Deborah
No Financial Interests to Disclose
O’Hara, Mary
No Financial Interests to Disclose
O’Neill, John
No Financial Interests to Disclose
Sharma, Vinod
No Financial Interests to Disclose
Shields, Carol
No Financial Interests to Disclose
Ramasubramanian, Aparna
No Financial Interests to Disclose
Ramsey, Jean
No Financial Interests to Disclose
Rao, Sujata
No Financial Interests to Disclose
Repka, Michael
S – National Eye Institute
S – American Academy of Ophthalmology
Rheem, Justin
No Financial Interests to Disclose
14
Shields, Jerry
No Financial Interests to Disclose
Shin, Andrew
No Financial Interests to Disclose
Siatkowski, R. Michael
S – National Eye Institute
Silbert, Ariel
No Financial Interests to Disclose
Silbert, David
C – Kaneka
C – iScreen
S - Plusoptix
Silbert, Jillian
No Financial Interests to Disclose
Sloper, John
No Financial Interests to Disclose
Solebo, Lola
No Financial Interests to Disclose
Suh, Soh-youn
No Financial Interests to Disclose
Summers, Gail
L – BioMarin
C - McKesson
C – Clarion Healthcare Consulting
Teed, Ronald
No Financial Interests to Disclose
Tehrani, Nasrin
No Financial Interests to Disclose
Villegas, Victor
No Financial Interests to Disclose
Whitman, Mary
No Financial Interests to Disclose
Wiggins, Robert
C, L - OMIC
Wong, Agnes
S – Canada Foundation for Innovation
Yang, Michael
S – Research to Prevent Blindness
Yeates, Scott
No Financial Interests to Disclose
Yu, Young Suk
No Financial Interests to Disclose
Vivian, Anthony
S – Wellcome Foundation, UK
Wagner, Rudolph
C, L – Alcon
Wall, Palak
No Financial Interests to Disclose
Wallace, David
C – Allergan
C – Genentech
S – National Eye Institute
S – Research to Prevent Blindness
The American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and
Strabismus have determined that financial interest should not restrict expert scientific, clinical or non-clinical presentation
or publication, provided that appropriate disclosure of such interest is made. As a sponsor
accredited by the ACCME, the Academy must insure balance, independence, objectivity, and scientific rigor
in all its individually sponsored or jointly sponsored continuing medical education activities.
Financial interest has been defined as any financial gain brought to the presenter or the presenter’s immediate family, business partners, or employer by:
• Direct or indirect commission;
• Ownership of greater than .01% of the stock in the producing company; or
• Involvement in any for-profit corporation where the presenter or the presenter’s immediate family is a director or recipient of grant from said entity, including consultant and travel aid.
15
Program Schedule
All scientific sessions and social events are held at the Westin Copley Place, Boston, MA
Wednesday, April 3, 2013
7:00 AM - 8:00 PM
Registration
America Ballroom Foyer
8:00 AM - 5:00 PM
Technician Course - The Art and Science of Examining the Child
St. George A & B
8:00 AM - 5:00 PM
Administrators Meet and Greet and Administrators Roundtable
St. George C & D
9:00 AM - 5:00 PM
Board of Directors Meeting
Empire Room
1:00 PM -4:00 PM
Poster Set Up
Essex Ballroom Foyer
4:00 PM - 6:00 PM
Poster Viewing (First Set of Posters) - Authors Not present
Essex Ballroom Foyer
6:15 PM - 7:15 PM
International Attendees Reception
Gloucester/Newbury
6:15 PM - 7:15 PM
Young Ophthalmologists’ Reception
Parliament
7:00 PM - 9:00 PM
Opening Reception
America Ballroom
6:30 AM - 7:45 AM
Poster Viewing (First Set of Posters) - Authors Not Present
Essex Ballroom Foyer
6:30 AM - 7:45 AM
Breakfast
Staffordshire / Essex Ballroom
8:00 AM - 12:00 PM
Technician Course - COA Review Course
St. George A & B
9:00 AM - 12:00 PM
Administrators Workshop (SEC Practice Managers Program only)
St. George C
7:45 AM - 7:50 AM
Introduction and Welcome
Stephen P. Christiansen, MD
America Ballroom
7:50 AM - 7:55 AM
President’s Remarks
Honor Awards, Senior Honor Awards, Lifetime Achievement Awards
K. David Epley, MD
America Ballroom
7:55 AM - 8:00 AM
PBA Award Presentation
K. David Epley, MD
America Ballroom
8:00 AM - 8:01 AM
Introduction of David W. Park, II, MD
K. David Epley, MD
America Ballroom
8:01 AM - 8:15 AM
AAO & AAPOS: New Challenges and Opportunities
David W. Parke, II, MD
America Ballroom
8:15 AM - 8:48AM
Costenbader Lecture
America Ballroom
Thursday, April 4, 2013
8:50 AM - 9:55 AM
16
8:15 AM - 8:20 AM
Introduction of Costenbader Lecturer
Edward G. Buckley, MD
8:20 AM - 8:45 AM
Paper #1
Costenbader Lecture (Supported by the Children’s Eye Foundation)
A Cut Above - The Role of Vitrectomy in the Evolution of Pediatric Cataract
Surgery
M. Edward Wilson, MD
8:45 AM - 8:48 AM
Presentation Ceremony
George R. Beauchamp, MD
Scientific Session
Cataract - Intraocular Lenses - Anterior Segment - Glaucoma
Moderators: K. David Epley, MD & Stephen P. Christiansen, MD
America Ballroom
8:50 AM - 8:57 AM
Paper #2
Guidelines for Prescribing Initial Contact Lens Power if Refraction is not
Possible: Analysis of Subjects Enrolled in Infant Aphakia Treatment Study
Rupal H. Trivedi
Scott Lambert; Michael J. Lynn; M. Edward Wilson
8:57 AM - 9:04 AM
Paper #3
The Effects of Surgical Factors on Postoperative Astigmatism in Patients
Enrolled in the Infant Aphakia Treatment Study (IATS)
Palak B. Wall
Jason A. Lee; Michael Lynn; Scott R. Lambert; Elias I. Traboulsi
17
9:04 AM - 9:11 AM
Paper #4
9:11 AM - 9:18 AM
Paper #5
Phakic Intraocular Lens (PIOL) Implantation versus INTACS Corneal Rings
to Manage Anisometropic Myopic Amblyopia in Children
Mohamed Mostafa K. Diab, MD
Shrief A. Essaa, MD
9:18 AM - 9:25 AM
Paper #6
Anatomic and Visual Outcomes of Corneal Transplantation During Infancy
Raymond G. Areaux, Jr., MD
Stephen E. Orlin, MD; Gerald W. Zaidman, MD;
Kinneri Kothari, BA; Lorri B. Wilson, MD; Jiayan Huang, MS;
Gui-shuang Ying, PhD; Gil Binenbaum, MD, MSCE
9:25 AM - 9:32 AM
Paper #7
9:55 AM - 10:55 AM
11:00 AM - 12:45 PM
11:00 AM - 11:15 AM
11:15 AM - 11:47 AM
Outcomes of Iris-Enclaved Artisan-Ophtec Intraocular Lens Implantation in
Aphakic Children
Lawrence Tychsen, MD
Nicholas Faron, BA
Computer-Assisted Evaluation of Longitudinal Changes in Optic Nerve Head
Morphology in Children
Mays El-Dairi, MD
Idit Maharshak, MD; Qing Nie, PhD; Sina Farsiu, PhD;
Sujit Itty, MD; Sharon Freedman, MD
9:39 AM - 9:55 AM
PANEL DISCUSSION
All Presenters
Interactive Poster Session - Author Presentation and Q/A First Set of Posters (1-40)
See First Poster Tab Section for Complete List of Posters
Authors Present: Odd Numbered Posters from 9:55 - 10:30
Even Numbered Posters from 10:20 - 10:55
Essex Ballroom Foyer
Moderators:
Sherwin J. Isenberg, MD & R. Michael Siatkowski, MD
America Ballroom
Presentation of Parks Medals, Silver Medals and Children’s Eye
Foundation Update
George R. Beauchamp, MD
America Ballroom
Scientific Session
Cranial Nerve Palsies
America Ballroom
11:22 AM - 11:29 AM
Paper #10
11:29 AM - 11:36 AM
Paper #11
11:36 AM - 11:43 AM
Paper #12
11:47 AM - 12:45 PM
Intraocular Pressure in Children: Effect of Repeat Measurements, Topical
Anesthetic, and Positioning, as Assessed with Icare Compared to Goldmann
Applanation and Tonopen
Eniolami O. Dosunmu
Inna Marcus; Irene Tung; Warakorn Thiamthat; Sharon F. Freedman
9:32 AM - 9:39 AM
Paper #8
11:15 AM - 11:22 AM
Paper #9
11:43 AM - 11:47 AM
Isolated Superior Compartment Lateral Rectus (LR) palsy: A New
Pathophysiologic Diagnosis Defined by Magnetic Resonance Imaging (MRI)
Robert A. Clark
Jospeh L. Demer
Conjugate Surgery vs. Recess-Resect for Lateral Incomitance in 6th Nerve
Paresis
Alexandra O. Apkarian, MD
Monte A. Del Monte, MD; Steven M. Archer, MD
How Sensitive is the 3-Step Test in the Diagnosis of Superior Oblique (SO)
Palsy?
Ajay M. Manchandia, MD
Joseph L. Demer, MD, PhD
2:00 PM - 4:00 PM
DISCUSSION OF PREVIOUS PAPER
Burton J. Kushner, MD
Scientific Session
Strabismus Surgery - Oculoplastics
11:47 AM - 11:54 AM
Paper #13
Abnormal Rectus Muscle Length in Horizontal Strabismus?
Ronen Rabinovich, MD
Joseph L. Demer, MD, PhD
11:54 AM - 12:01 PM
Paper #14
Outcome of Surgery for Non-Restrictive Vertical Strabismus
Sardar Mohammad Ali A. Sadiq, MD
David G. Hunter, MD, PhD; Melanie Kazlas, MD
12:01 PM - 12:08 PM
Paper #15
Graded Rectus Tenotomy (GRT) In Small Angle Hypertropia Due to Sagging
Eye Syndrome (SES)
Zia Chaudhuri, MS, FRCS (Glasg)
Joseph L. Demer, MD, PhD
12:08 PM - 12:15 PM
Paper #16
Silicone Band Loop Myopexy in Treatment of Myopic Strabismus Fixus:
Surgical Outcome of a Novel Modification
Ramesh Kekunnaya, MD, FRCS
Hariprasad B. Shenoy, MD; Virender Sachdeva, MS
12:15 PM - 12:22 PM
Paper #17
The Effects of Strabismus Surgery on Globe Position in the Setting Thyroid
Eye Disease
Reecha S. Bahl, MD
Steven M. Archer, MD; Julie B. Shelton, MD;
Victor M. Elner, MD, PhD; Christopher Gappy, MD;
Sudha Nallasamy, MD; Jennifer A. Kozak, MD;
Monte A. Del Monte, MD
12:22 PM - 12:29 PM
Paper #18
Successful Conjunctival Socket Expansion in Anophthalmic Patients till the
Age of Two: An Outpatient Procedure
Rania A. El Essawy, FRCSEd, MD
12:29 PM - 12:45 PM
PANEL DISCUSSION
All Presenters
Simulated Strabismus Surgery - A Practical and Interactive
Demonstration of Novel Simulation Techniques St. George A & B
(Separate Registration - No Additinal Fee)
2:15 PM - 3:15 PM
John D. Ferris; Anthony J. Vivian
See Workshop Tab Section for Details
America Ballroom
Fiscal Benchmarking Workshop
(SEC Practice Managers Program & AAPOS attendees)
Deborah S. Lenahan, MD, Moderator
See Workshop Tab Section for Details
3:00 PM - 4:00 PM
Interactive Poster Session - Review and Commentary from the Program
Committee (First Set of Posters)
Yasmin Bradfield, MD & David K. Wallace, MD
Essex Ballroom Foyer
3:30 PM - 5:30 PM
Pediatric Coding Workshop
America Ballroom
(Separate Registration - Additional Fee for non-administrators/managers)
Robert S. Gold, MD, Moderator
See Workshop Tab Section for Details
4:00 PM - 6:00 PM
Exhibitor Cocktail Recption
Staffordshire / Essex Ballroom
6:00 PM - 8:00 PM
Parks Medal Reception (by Invitation)
Superior Oblique Tuck: A Self-Dosing Procedure Appropriate for all Classes
of Superior Oblique Palsy
Mary C. Whitman
Howard M. Egggers
18
America Ballroom
19
Friday, April 5, 2013
2:45 PM - 4:00 PM
America Center
Staffordshire / Essex Ballroom
Developing an Integrated System for Children’s Vision Care - Report
on the Work of National Center for Children’s Vision and Eye Health
Collins, Ramsey, Hartman, Miller, Repka, Baldonado
AOC Workshop DVD - A Conceptual, Clinical and Surgical Overview
Christoff, Raab, Bothun, Brodsky, Fray, Guyton,
Hennessey, Merrill, Morrison
America North
AAP/AAPOS Pediatric Neuro-Ophthalmology Workshop - Avoiding
Disaster: Lessons Learned from Difficult Cases
Karr, Buckley, Edmond, Heidary, MacDonald, Siatkowski
America South
Oculoplastic Surgery of Interest to the Pediatric Ophthalmologist
Dagi, Elliott, Freitag
America Center
America North
Genetic and Metabolic Cases you Don’t Want to Miss!
Kodsi, Summers, Alcorn, Edmond, Lehman
St. George A-D
Management Issues in Non-Cataractous Lenticular Disorders in
Children
Kekunnaya, Khan, Levin, Nischal, Plager
St. George A-D
Pediatric Cataract - International Perspectives
Lloyd, Black, Fenerty, Solebo, Ashworth
America South
New Concepts on Visual Cortical Plasticity: Multiple Critical Periods
and Implications for Amblyopia
Wong, Lewis, Hensch
3:45 PM - 4:15 PM
Poster Set Up (Second Set of Posters)
Essex Ballroom Foyer
4:00 PM - 4:30 PM
Pre-Symposium Refreshements: Refuel and Refresh
America Ballroom Foyer
4:30 PM - 6:00 PM
The Child with Developmental Delay: Multispecialty Perspectives on
Improving Care
Epley, Lawrence, McCarus, Anderson, Lehman, Jackson
See Workshop Tab Section for Details
America Ballroom
6:00 PM - 8:00 PM
Poster Viewing (Second Set of Posters) - Authors Not Present
Essex Ballroom Foyer
6:00 PM - 7:30 PM
PEDIG Meeting
St. George B, C, D
6:30 AM - 8:00 AM
Poster Viewing (Second Set of Posters) - Authors Not Present
Essex Ballroom Foyer
6:30 AM - 8:00 AM
Breakfast
Staffordshire / Essex Ballroom
6:30 AM
Third Annual AAPOS Run - March of Dimes 5K Run/Walk
Meet at AAPOS Registration Desk
America Ballroom Foyer
7:00 AM - 8:15 AM
Symposium - Update on Ocular Anti-Infectives for the Pediatric
Ophthalmologist
Wilson, Lichtenstein, Wagner, D’Arienzo
See Workshop Tab Section for Details
America Ballroom
8:30 AM - 10:00 AM
Moderators: Mary Louise Z. Collins, MD & Robert Wiggins, MD
America Ballroom
8:30 AM - 8:58 AM
Apt Lecture
America Ballroom
6:30 AM - 8:00 AM
Poster Viewing (First Set of Posters) Authors not Present
Essex Ballroom Foyer
6:30 AM - 8:00 AM
Breakfast
7:00 AM - 8:15 AM
Workshop Session A - See Workshop Tab Section for Details
8:30 AM - 9:45 AM
Workshop Session B - See Workshop Tab Section for Details
The New Age of Medical Management of Pediatric Non-Infectious
Uveitis
Braverman, Foster, Tehrani, Ainsworth, Dacey
America Center
Apt Lecture Workshop: Cutting No Slack for the Sagging Eye
Syndrome
Demer, Chaudhuri, Clark
America North
Video Demonstrations of Classical or Rare Signs in Pediatric
Ophthalmology and Strabismus
Nischal, Buckley, Plager, Wilson, Granet, Edmond
America South
Rehabilitation of Children with Low Vision: Controversies and
Consensus
Schwartz, Coakley, Lusk
St. George A-D
9:45 AM - 10:30 AM
Refreshment Break and Exhibit Viewing
Essex Ballroom Foyer
10:30 AM - 11:45 AM
Workshop Session C - See Workshop Tab Section for Details
Should Your Patients Get Whole Genome Sequencing? Should You?
Drack
St. George A-D
Elder Wise: Pearls from Pediatric Greats
Epley, Scott A, Miller M, Helveston, O’Neill, Scott W
America South
Rapid Fire Cases in Pediatric Ophthalmology (Non Strabismus) That
Will Change Your Practice
Ramasubramanian, Shields C, Levin, Schnall, Shields J
America North
Optical Coherence Tomography - Pearls for the Pediatric
Ophthalmologist
Salchow, Toth, Sturm
America Center
11:30 AM - 12:00 PM
Poster Removal (First Set of Posters)
Essex Ballroom Foyer
11:45 AM - 1:00 PM
Lunch Break - On Your Own (Non-AAPOS Members)
12:00 PM - 1:00 PM
AAPOS Business Meeting (Lunch Available for a Fee with Pre-Registration)
1:15 PM - 2:30 PM
Workshop Session D - See Workshop Tab Section for Details
No CME for this
workshop
Workshop Session E - See Workshop Tab Section for Details
America South
Through the Eyes of Autism: Eye Care for these Special Patients
Demer, Hartman, Wilson, Dankner
America Center
Protecting Your Online Image
Epley, Doan
St. George A-D
Sticky Situations in Pediatric Glaucoma and What They Taught Us Lessons Learned the Hard Way
Freedman, Beck, Levin, Walton
America North
Adult Strabismus
Stager Jr, Archer, Buckley, Ellis, Granet, Guyton, Hunter
America South
20
Saturday, April 6, 2013
9:00 AM - 9:43 AM
8:30 AM - 8:35 AM
Introduction of the Apt Lecturer
Lawrence Tychsen, MD
8:35 AM - 8:55 AM
Paper #19
Apt Lecture
Strabismus is Gettin’ Old
Joseph L. Demer, MD, PhD
8:55 AM - 8:58 AM
Presentation Ceremony
David B. Granet, MD
America Ballroom
Scientific Session
Strabismus - Public Health
9:00 AM - 9:07 AM
Paper #20
Functional Burden of Strabismus: Decreased Binocular Summation (BiS) and
Binocular Inhibition
Stacy L. Pineles, MD
Federico G. Velez, MD; Sherwin J. Isenberg, MD; Zachary Fenoglio; Eileen Birch, PhD; Steven Nusinowitz, PhD;
Joseph Demer, MD, PhD
9:07 AM - 9:11 AM
DISCUSSION OF PREVIOUS PAPER
John J. Sloper, FRCOphth
21
9:11 AM - 9:18 AM
Paper #21
Refractive Surgery for Accommodative Esotropia in Special Needs Children
and Adolescents
Nicholas Faron, BA
James Hoekel, OD; Lawrence Tychsen, MD
11:45 AM - 11:52 AM
Paper #27
iCheckKids, SPOT, iScreen and Plusoptix Performance in a High-Risk, Young
Pediatric Eye Practice
Robert W. Arnold
Mary D. Armitage
9:18 AM - 9:25 AM
Paper #22
Bilateral Simultaneous Lateral Rectus Botox Injection in Infant and
Childhood Intermittent Exotropia
Keith W. McNeer, MD
Mary G. Tucker, MD
11:52 AM - 11:56 PM
DISCUSSION OF PREVIOUS PAPER
Sean P. Donahue, MD, PhD
9:25 AM - 9:32 AM
Paper #23
The Effect of Effort and Exercise on Convergence and Accommodation
Anna M. Horwood
Sonia S. Toor; Patricia M. Riddell
9:32 AM - 9:36 AM
DISCUSSION OF PREVIOUS PAPER
Katherine J. Fray, CO
9:36 AM - 9:43 AM
Paper #24
Electronic Health Record Implementation in Pediatric Ophthalmology:
Impact on Volume and Time
Michael F. Chiang
Sarah Read-Brown; Daniel C. Tu; Kimberly Beaudet;
Thomas R. Yackel
9:43 AM - 10:00 AM
10:00 AM - 11:00 AM
PANEL DISCUSSION
All Presenters
Interactive Poster Session - Author Presentation and Q/A Second Set of Posters (41-80)
See Second Poster Tab Section for Complete List of Posters
Authors Present: Odd Numbered Posters from 10:00 - 10:35
Even Numbered Posters from 10:25 - 11:00
Essex Ballroom Foyer
11:05 AM - 1:00 PM
Moderators: Stephen P. Christiansen, MD & Sharon F. Freedman, MD America Ballroom
11:05 AM - 11:27 AM
Updates
11:27 AM - 11:56 AM
11:56 AM - 1:00 PM
Scientific Session
Retina - Retinopathy of Prematurity
11:56 PM - 12:03 PM
Paper #28
Uveal Melanoma in Children and Adults in 8033 Cases
Carol L. Shields, MD
Swathi Kaliki, MD; Minoru Furuta, MD; Arman Mashayekhi, MD; Jerry A. Shields, MD
12:03 PM - 12:10 PM
Paper #29
Length of Day During Early Gestation is an Independent Predictor of Risk for
Severe Retinopathy of Prematurity
Michael B. Yang, MD
Sujata Rao, PhD; David R. Copenhagen, PhD; Richard A. Lang, PhD
12:10 PM - 12:14 PM
DISCUSSION OF PREVIOUS PAPER
Graham E. Quinn, MD
12:14 PM - 12:21 PM
Paper #30
Evaluating the Association of Autonomic Drug Use in the Development and
Severity of Retinopathy of Prematurity
Mohamed A. Hussein, MD
David K. Coats, MD; Evelyn A. Paysse, MD; Paul Steinkuller, MD; Lingkun Kong, MD, PhD
12:21 PM - 12:28 PM
Paper #31
Analysis of Plus Disease Using Handheld Spectral Domain Optical Coherence
Tomography in Non-Sedated Neonates
Ramiro S. Maldonado, MD
Du Tran-Viet, BS; Eric Yuan, BS; Adam M. Dubis, PhD;
Francisco Folgar; Sharon F. Freedman, MD; Cynthia A. Toth, MD
12:28 PM - 12:35 PM
Paper #32
BEAT-ROP Refraction Data at Age Two Years
Megan M. Geloneck, MD
Jeffrey D. Chan; Alice Z. Chuang, PhD; Helen A. Mintz-Hittner, MD
12:35 PM - 12:39 PM
DISCUSSION OF PREVIOUS PAPER
David K. Wallace, MD
12:39 PM - 12:46 PM
Paper #33
Visual Acuity and Macular Optical Coherence Tomography Abnormalities in
Children with History of Retinopathy of Prematurity
Victor M. Villegas
Hilda Capo; Kara Cavouto; Audina M. Berrocal
12:46 PM - 1:00 PM
PANEL DISCUSSION
All Presenters
America Ballroom
11:05 AM - 11:10 AM
Surgical Scope Fund Update
Kenneth P. Cheng, MD
11:10 AM - 11:17 AM
American Academy of Pediatrics Update
David B. Granet, MD
11:17 AM - 11:22 AM
JAAPOS Update
Edward G. Buckley, MD
11:22 AM - 11:27 AM
An Intercontinental Perspective of Pediatric Ophthlamolgy and Strabismus AAPOS & SNEC 2013 Update
Sonal Farzavandi, FRCS
America Ballroom
Scientific Session
Amblyopia - Vision Screening
America Ballroom
A Randomized Trial of Increased Patching for Amblyopia
David K. Wallace, MD
Elizabeth L. Lazar, MS, MPH; Donny Suh; Joan Roberts;
Michael X. Repka; David Petersen; Ingryd Lorenzana;
Raymond Kraker; Jonathan M. Holmes; Susan Cotter;
Michael Clarke; Angela Chen; Roy Beck; on behalf of the Pediatric Eye Disease Investigator Group
2:00 PM - 3:15 PM
OMIC Workshop: Lessons Learned From 25 Years of Pediatric
Ophthlamology & Strabismus Claims
Anne M. Menke, RN, PhD; Robert Wiggins, MD, MHA
See Workshop Tab Section
America Ballroom
3:15 PM - 4:15 PM
Essex Ballroom Foyer
11:34 AM - 11:38 AM
DISCUSSION OF PREVIOUS PAPER
Alistair Fielder, MD
Interactive Poster Session - Review and Commentary from the Program
Committee (Second Set of Posters)
Katherine A. Lee, MD, PhD & Ann U. Stout, MD
5:00 PM - 8:00 PM
Poster Viewing (Second Set of Posters) Authors Not Present
Essex Ballroom Foyer
11:38 AM - 11:45 AM
Paper #26
Anisometropia and Amblyopia in Nasolacrimal Duct Obstruction
Michael A. Kipp, MD
Michael A. Kipp, Jr; William Struthers, PhD
6:00 PM - 7:00 PM
New Members Reception
Gloucester/Newbury
7:00 PM - 10:00 PM
Closing Reception
America Ballroom Foyer
11:27 AM - 11:34 AM
Paper #25
22
23
Sunday, April 7, 2013
2013 Frank D. Costenbader Lecture
6:30 AM - 8:00 AM
Poster Viewing (Second Set of Posters) Authors Not Present
Essex Ballroom Foyer
6:30 AM - 8:00 AM
Breakfast
Staffordshire / Essex Ballroom
Scientific Session
Moderator: Stephen P. Christiansen, MD
America Ballroom
7:30 AM - 9:00 AM
Difficult Problems Non Strabismus Workshop
Ken K. Nischal, FRCOphth, Moderator
See Workshop Tab Section for Details
America Ballroom
9:03 AM - 9:05 AM
Introduction of Young Investigator Award
Kristina Tarczy-Hornoch, MD
America Ballroom
9:05 AM - 9:13 AM
Paper #34
Young Investigator Award
Induced Pluripotent Stem Cells: An Emerging Tool for the Study of
Human Inherited Retinal Disease
David M. Gamm, MD, PhD
America Ballroom
9:15 AM - 10:45 AM
Difficult Problems Strabismus Workshop
Sean P. Donahue, MD, PhD, Moderator
See Workshop Tab Section for Details
America Ballroom
10:45 AM
End of 2013 Meeting
10:45 AM - 11:00 AM
Poster Removal (Second Set of Posters)
Indicated CME designated activities
Essex Ballroom Foyer
“A Cut Above”: The Role of Vitrectomy in the Evolution of Pediatric Cataract Surgery
M. Edward Wilson, MD
Purpose: 1) To describe the important and unique role that vitrectomy instrumentation has had
in the ongoing evolution of pediatric cataract surgery. 2) To report on the short and medium term
safety of mechanized posterior capsulectomy and vitrectomy. 3) To describe the current best practices and how those may evolve in the future.
Introduction: Within a few short years of the introduction of the vitrector by Machemer, this new
tool revolutionized the surgical treatment of congenital cataracts and forever changed the outcome
expectations for these babies and young children. Questions remain about the short term and
long term safety of posterior capsulectomy and vitrectomy in young children. In addition, experts
disagree about when a vitrectomy is indicated and how to do it safely.
Methods: A retrospective review was conducted of consecutive eyes operated for childhood-onset
cataract by the author. Eyes with traumatic cataract, Marfan syndrome, Stickler syndrome and
Retinopathy of Prematurity were excluded. Those with an intact posterior capsule at surgery or a
posterior capsulorhexis without vitrectomy were also excluded.
Results: 696 eyes underwent a planned primary posterior capsulectomy and anterior vitrectomy
either from a limbal or a pars plana approach at the time of cataract surgery. The mean age at
surgery was 2.90 years (range 0.01 to 19. 53, SD= 3.42). Mean follow-up was 4.48 years (range
0.1 to 20.92, SD=4.32). Complications included 1 (0.14%) eye with an intraoperative intravitreal
hemorrhage treated with immediate posterior vitrectomy with good visual and anatomical outcome.
1 (0.14%) eye developed a retinal detachment (RD) at 11 years of age after cataract surgery in an
eye with posterior persistent fetal vascular, iris bombe and glaucoma. 2 additional eyes developed
RD after multiple aphakic glaucoma surgeries. One (0.14%) eye developed endophthalmitis after
cataract surgery. 2 additional eyes developed endophthalmitis after multiple surgeries for aphakic
glaucoma (1 of those eyes is also mentioned under RD). 1 eye developed endophthalmitis after
surgery for trauma that dislocated the IOL.
Conclusion: Vitrectomy and posterior capsulectomy are essential steps when pediatric cataract surgery is done on infants and young children. Vision threatening complications from these
interventions are rare. Technological improvements and specific surgical maneuvers can further
improve the safety of these procedures. Indications for vitrectomy when surgery is done later in
childhood are evolving. Newer imaging techniques and careful long follow-up will add to our understanding of the effects our surgery has on the growth and development of the pediatric eye.
Guidelines for Prescribing Initial Contact Lens Power if Refraction is not Possible:
Analysis of Subjects Enrolled in Infant Aphakia Treatment Study
Rupal H Trivedi; Scott Lambert; Michael J Lynn; M Edward Wilson;
Infant Aphakia Treatment Study Group
Storm Eye Institute, Charleston, SC, USA
Introduction: When fitting infant aphakic eyes with a contact lens (CL) immediately after cataract surgery, it may not always be possible to obtain an accurate refraction. For such cases
there is a tendency is to insert a +32 D CL. We sought to provide guidelines for the selection
of an initial CL power if retinoscopy over a diagnostic lens is not possible.
Methods: Patients with a unilateral cataract and randomized to CL treatment in the Infant
Aphakia Treatment Study (IATS) were analyzed. An eye was included if there was a valid preoperative axial length (AL) measurement using immersion and a one-month postoperative refraction. Target CL power was determined using refraction (adjusting for vertex distance of 12
mm) over known CL power one-month postoperatively. We compared it with four techniques
1) physician’s estimated CL power (defined as the prescribed CL power minus 2D overcorrection based on IATS protocol); 2) Regression1, CL power=84.4–3.2×AL; 3) SRK/T IOL power1
calculated using a modified A-constant (112.176); 4) 32 D CL.
Results: There were 36 of 57 eyes that met the inclusion criteria. Age at cataract surgery
was 2.3±1.7months. Preoperative AL was 17.9±1.6 mm. Follow-up refraction was performed
at 31±3 days. Target CL power based on the one-month refraction was 26.0±4.4 D. Mean prediction error was 0.4, -1.0, -2.0 & 6.2 D and mean absolute prediction error was 1.2, 2.2, 2.8
and 6.2 D respectively for physician’s estimated CL power, regression, SRK/T and 32 D CL.
Discussion: The IATS study protocol reads that if an accurate refraction could not be
obtained initially, a +32 D CL should be dispensed, and the lens power should subsequently
refined at the earliest opportunity. If refraction is not possible, instead of using +32 D CL, we
recommend using preoperative biometry to estimate CL power.
Conclusion: If accurate refraction could not be obtained initially, preoperative biometry may
help to estimate CL power.
References: 1. Trivedi RH, Wilson ME. Selection of an Initial Aphakic Contact Lens Power for Infantile Cataract Surgery (accepted pending revisions, Ophthalmology).
24
25
Paper 1
Thursday
8:20 - 8:45 am
JAAPOS Abstract #001
Paper 2
Thursday
8:50 - 8:57 am
JAAPOS Abstract #028
Paper 3
Thursday
8:57 - 9:04 am
JAAPOS Abstract #031
Paper 4
Thursday
9:04 - 9:11 am
JAAPOS Abstract #029
The Effects of Surgical Factors on Postoperative Astigmatism in Patients Enrolled
in the Infant Aphakia Treatment Study (IATS)
Palak B Wall; Jason A Lee; Michael Lynn; Scott R Lambert; Elias I Traboulsi
Cleveland Clinic Foundation, Cleveland, OH
Phakic intraocular lens (PIOL) implantation versus INTACS corneal rings to
manage anisometropic myopic amblyopia in children
MOHAMED MOSTAFA K DIAB; MD, SHRIEF A ESSAA;MD,
MAGRABI HOSPITAL, KSA
Introduction: The purpose of this study is to compare postoperative astigmatism between
patients treated with intraocular lens (IOL) or contact lens (CL) after surgery for an infantile,
unilateral cataract and to evaluate the impact of surgical factors on postoperative astigmatism
among patients treated with an IOL.
Methods: The Infant Aphakia Treatment Study (IATS) is a multicenter clinical trial in which
114 infants <7 months of age with a unilateral congenital cataract were randomized to cataract
extraction with or without IOL placement, with CL correction for those in the aphakic group. A
review of videos of procedures for patients treated with an IOL was performed and data was
collected regarding incision type (clear cornea vs scleral tunnel), whether the incision was extended, the number of sutures, and whether the incision was closed in a running or interrupted
fashion. Corneal astigmatism was measured using a handheld keratometer prior to surgery
and at 1 year of age.
Results: There was a statistically significant greater amount of astigmatism at 1 year of age,
on average, with IOL (2.1 ± 1.1) compared to CL (1.6 ± 1.0) (p=0.023). There was no statistical difference in mean postoperative astigmatism at 1 year of age for IOL patients based
on incision type (p=0.214), extension of incision (p=0.849), number of sutures (p=0.31), or
method of closure (p=0.19) at 1 year.
Discussion: The placement of an IOL significantly increases the postoperative corneal astigmatism when compared to contact lens correction at one year of age. Among patients treated
with an IOL, none of the surgical factors had a statistically significant impact on corneal astigmatism.
Conclusion: The only factor that affected corneal astigmatism at 1 year in our study was the
placement of an IOL. Although this data is unlikely to impact the decision of whether or not to
place an IOL, the lack of impact of wound construction, incision enlargement, and method of
closure on postoperative astigmatism suggests that ease of surgical technique may be a more
important factor to consider.
Introduction: The therapy of amblyopia is essential to be successful for safe vision and restoring binocular fusion and stereopsis. Purpose of our study to compare the safety and efficacy
of phakic posterior chamber intraocular lens (PIOL) implantation versus INTACS intrastromal
Corneal Ring Segments for correcting high myopic anisometropia in amblyopic children.
Methods: Prospective study sinclude30 children 4–12 years old, suffering from unilateral high
myopic anisometropic amblyopia had refractive spherical power from-7to-17 diopters and astigmatism -1to -6 diopters. Patients were subdivided into group A subjected to unilateral phakic
posterior chamber intraocular lens (ICL) implantation and group B treated by INTACS corneal
rings Pre- and post-operative visual acuity, ocular examination, stereoacuity, axial biometry
measurements, cycloplegic refraction and endothelial cell counts were performed in all patients
for follow up was for at least 9 months.
Results: ICL group revealed prevention of amblyopia with improvement in visual acuity was≤6
lines was achieved in 81%of children and just ≤3 lines restricted to 19%of children Improvement
in stereoacuity was noted in 93.33%of cases but INTACS group showed less results with successful improved vision≤6 lines in 73% of children and just ≤2 lines restricted to 27% of children.
Improvement in stereoacuity was noted in 86.66%of cases.Two cases of cataract and one case
of glaucoma with one case of uveitis noticed in ICL group.
Discussion: Posterior chamber phakic IOLs or INTACS may provide a safe alternative in
treatment of anisometropic myopic patients
Conclusion: To eliminate significant anisometropic myopia in children who are noncompliant
with traditional medical treatment, phakic posterior chamber ICL implantation or INTACS be
considered as an alternative modality of treatment. INTACS is more safe and less invasive and
complications than ICL Further studies in this field are recommended.
Outcomes of Iris-Enclaved Artisan-Ophtec Intraocular Lens Implantation
in Aphakic Children
Lawrence Tychsen MD; Nicholas Faron BA
St. Louis Children’s Hospital at Washington University Medical Center, St. Louis, MO
Anatomic and visual outcomes of corneal transplantation during infancy
Raymond G Areaux, Jr MD1; Stephen E Orlin MD2; Gerald W Zaidman MD3;
Kinneri Kothari BA3; Lorri B Wilson MD4; Jiayan Huang MS2; Gui-shuang Ying PhD2;
Gil Binenbaum MD, MSCE1,2
1
Children’s Hospital of Philadelphia; 2Scheie Eye Institute, Perelman School of Medicine
at the University of Pennsylvania, Philadelphia PA; 3New York Medical College, Valhalla
NY; 4Casey Eye Institute, Oregon Health & Science University, Portland OR
Introduction: Children treated by lensectomy for ectopia lentis, traumatic cataract with lens
subluxation or severe persistent fetal vasculature-related cataracts lack capsular support for
implantation of standard, posterior-chamber intraocular lenses (IOL). We reported previously
use of trans-scleral sutured IOLs in this population.1
Here we describe outcomes of Artisan iris-enclaved IOL implantation.
Methods: Clinical outcome data were collated prospectively in 28 aphakic eyes of 17
implanted children (7 Marfan Syndrome; 5 Familial Ectopia Lentis; 5 Persistent Fetal Vasculature). All children had difficulties with contact lens or spectacle wear. Peripheral iridectomy
was performed at IOL implantation. Mean age at surgery was 8.1 yrs (range 1-17 years);
mean follow-up was 3.1 yrs.
Results: Aphakic spherical correction averaged 14.06 D (range +7.75 to +19.75). 26/28 eyes
(93%) were corrected to within +/- 1.0 D of emmetropia and all to within 1.5 D. Uncorrected
visual acuity improved from an average logMAR 1.50 (20/640) to 0.17 (20/30); best-corrected
acuity improved an average 2 Snellen lines (0.18 logMAR). Four eyes (20%) required an additional vitrectomy or laser-iridotomy for pupillary block 1 day to 9 mos after IOL implantation.
Two IOLs (7%) were explanted; one for repeated de-enclavation and one for microcornearelated glaucoma and corneal decompensation.
Discussion: Implantation of the Artisan aphakic IOL improved visual acuity substantially and
was well-tolerated in the majority of children. Repeat vitrectomy at IOL implantation is recommended to reduce the risk of pupillary block caused by vitreous plugging of the iridectomy.
Conclusion: Implantation of the Artisan aphakic IOL improved visual acuity substantially and
was well-tolerated in the majority of children. Repeat vitrectomy at IOL implantation is recommended to reduce the risk of pupillary block caused by vitreous plugging of the iridectomy.
References: Bardorf, C. M., Epley, K. D., Lueder, G. T., and Tychsen, L. Pediatric transscleral sutured intraocular lenses: efficacy and safety in 43
eyes followed an average of 3 years. J AAPOS 2004; 8(4):318-324.
26
Paper 5
Thursday
9:11 - 9:18 am
JAAPOS Abstract #011
References: 1 - Amir Pirouzian, Kenneth C Ip, Henry S O’Halloran Phakic anterior chamber intraocular lens (Verisyseâ„¢) implantation in children
for treatment of severe ansiometropia myopia and amblyopia: Six-month pilot clinical trial and review of literature Journal: Clinical Ophthalmology
June 2009 Volume 2009:3 Pages 367 - 371
2 - Pirouzian A. P. Pediatric phakic intraocular lens surgery: review of clinical studies Curr. opin
Ophthalmol 2010 Jul:21(4);249-254
3 - Huang D, Schallhorn SC, Sugar A, Farjo AA, Majmudar PA, Trattler WB, Tanzer DJ.Phakic intraocular lens
implantation for the correction of myopia: a report by the American Academy of Ophthalmology. Ophthalmology. 2009 Nov;116(11) :2244-2258
Introduction: This study assessed the effect of age at penetrating keratoplasty (PKP) on
graft survival and visual outcome in children transplanted during infancy. We previously
presented (AAPOS, 2011) a pilot study (14 children), suggesting early PKP improves vision without increased graft failure. This study adds outcomes from 53 additional children.
Methods: Multi-center, retrospective cohort study of infants undergoing PKP at Children’s Hosptial of Philadelphia or New York Medical College, 1998-2011. PKP was categorized early (0-90 days) or late (91-365 days). Outcomes were graft survival and vision,
classified poor, fair, good considering method (fixation, teller, optotype) and age norms.
Results: 67 children (79 eyes) were studied: 25 eyes early-PKP, 54 late-PKP; 76/79
congenital opacities; mean follow-up 19.5 months (range 1-147). Kaplan-Meier graft-survival estimates were 0.80 @1.1 years (95%CI 0.69-0.88), 0.47 @5.8 years (0.30-0.61).
Graft survival (64% early-PKP, 64.8% late-PKP, p=1.00) and time to failure (Cox-proportional hazards) did not differ. Among 64 eyes with acuity measurements, no significant
difference existed in proportion with good acuity between early-PKP(36%) and latePKP(57%)(p=0.19).
Discussion: Although early infancy is a critical period of visual development, there was
no advantage to early PKP. Possible confounding factors not controlled for in the analysis
include degree of baseline ocular or neurological abnormalities and intensity of visual
rehabilitation (amblyopia treatment, etc.).
Conclusion: One-half of infant grafts survive >5 years. Clearing congenital corneal
opacities in the first 3 months of life did not improve visual outcome. Early PKP did not
worsen graft survival, but PKP may be technically easier to perform later in infancy.
27
Paper 6
Thursday
9:18 - 9:25 am
JAAPOS Abstract #005
Paper 7
Thursday
9:25 - 9:32 am
JAAPOS Abstract #012
Intraocular pressure in children: Effect of repeat measurements, topical
anesthetic, and positioning, as assessed with Icare compared to Goldmann
applanation and Tonopen
Isolated superior compartment lateral rectus (LR) palsy: A new pathophysiologic
diagnosis defined by magnetic resonance imaging (MRI)
Robert A Clark; Joseph L Demer
Jules Stein Eye Institute, University of California, Los Angeles, Los Angeles
Introduction: Tonometry is critical in evaluation/management of children with known/suspected glaucoma, but cooperation often precludes Goldmann applanation(GAT). Tonopen tonometry offers portability in upright/supine positions, but requires anesthetic. Both Icare- and Icare-PRO-rebound tonometry
circumvent anesthetic, the latter allowing supine intraocular pressure(IOP) measurement. This study
addresses several relevant questions regarding tonometry in children: 1)Does IOP change with repeated
Icare measurements? 2)Does IOP change before/after topical-anesthetic? 3)Does position(sitting-supine)
alter IOP?
Methods: Ongoing, prospective study of children’s eyes (normal,suspected+known glaucoma). In
arm#1 (Reproducibility/Anesthetic), eight sequential pre-topical-anesthetic Icare-IOPs were followed by
three post-topical-anesthetic Icare-IOPs, then masked GAT. In arm#2(Sitting/Supine), two post-topicalanesthetic Icare-PRO(Icare FinlandOy,Helinski,Finland, not FDA-approved) vs. Tonopen(MedtronicsOph
thalmics,Florida) IOPs were taken in random order, followed by masked GAT (all sitting); after 5-minutes
supine positioning, Icare-PRO- vs. Tonopen-IOPs were repeated.
Results: Arm#1(Reproducibility/Anesthetic) has enrolled 10 children(20eyes), median age=11yrs(6-15).
Mean(range) initial IOP(mmHg) by Icare exceeded GAT [18.7(9-42) vs. 16.7(8-32),respectively,p<0.001].
ΔIOP(Icare,1st-8th) was 0.1mmHg,p=NS), with coefficient-of-variation=8.4%; ΔIOP(Icare, pre- vs. posttopical-anesthetic was 0.0(p=NS). Arm#1 was powered(>90%) to find ΔIOP=1.6 mmHg.
Arm#2(Sitting/Supine) has enrolled 17 children(34eyes), median age=12yrs(8-17). Mean sitting
IOP(mmHg) for GAT, Icare-PRO, and Tonopen was 16.4±3.0, 17.7±2.5, and 18.2±3.5, respectively.
Mean supine IOP(mmHg) for Icare-PRO vs. Tonopen was 18.2±2.6 vs. 18.8±3.8, respectively. Compared
with GAT(sitting), ΔIOP(mmHg) was 1.4(Icare-PRO-sitting,p<0.001), 1.8(Icare-PRO-supine,p=0.002);
1.9(Tonopen-sitting,p<0.001), and 2.5(Tonopen-supine,p=0.002). The study was powered(90%) to find
ΔIOP(supine-vs-sitting)=2 mmHg).
Discussion: Neither repeated measurement, nor topical-anesthetic significantly alters iCare-IOPs in
children. Both Tonopen- and Icare-measured IOPs exceed GAT, but position-related IIOP is small.
Conclusion: Icare tonometry may be used following topical anesthetic after attempted Tonopen/GAT.
The Icare-PRO may prove useful in measuring IOP sitting and supine.
Introduction: The LR has bifid, vertically segregated patterns of intramuscular innervation that functionally define superior and inferior neuromuscular compartments, raising
the possibility of a lesion selectively denervating only one compartment. Using MRI, we
prospectively sought evidence of compartmental LR atrophy.
Methods: Surface coil coronal MRI was obtained at 312 micron resolution in quasi-coronal planes 2 mm thick throughout the orbit in 20 normal subjects and 16 subjects with
unilateral LR palsy who fixated monocularly on a target placed as close as possible to
central gaze. Maximum cross-sections and posterior volumes of the superior and inferior
LR compartments were computed and correlated with clinical alignment findings.
Results: Twelve subjects with LR palsy demonstrated symmetric, highly significant
40% reductions in maximum cross-sections and 50% reductions in posterior volumes for
both compartments compared with normals (p<10-7 for all comparisons). Five subjects
with LR palsy demonstrated similar significant but asymetric reductions in those values
only for the superior compartment of the affected LR (p<10-3 for all comparisons), with
insignificant 10% reductions for the inferior compartment (p>0.3 for all comparisons). All
subjects with superior LR compartment atrophy exhibited ipsilateral hypotropia and excylotropia in addition to the expected esotropia.
Discussion: A subset of patients with clinically ‘complete’ LR palsy may instead have
isolated palsy of the superior LR compartment. This new pathophysiologic diagnosis provides further evidence supporting independent innervation of the two LR neuromuscular
compartments.
Conclusion: Paralytic esotropia, particularly if combined with ipsilateral hypotropia and
excyclotropia, may be caused by isolated superior compartment LR palsy.
Computer-Assisted Evaluation of Longitudinal Changes in Optic Nerve Head
Morphology in Children.
Mays El-Dairi MD; Idit Maharshak MD; Qing Nie PhD; Sina Farsiu PhD; Sujit Itty MD;
Sharon Freedman MD
Duke Eye Center, Durham, NC
Conjugate surgery vs. recess-resect for lateral incomitance in 6th nerve paresis
Eniolami O Dosunmu; Inna Marcus; Irene Tung; Warakorn Thiamthat; Sharon F Freedman
Duke University Eye Center, Durham, North Carolina
References: 1. Malihi M, Sit AJ. Effect of head and body position on intraocular pressure. Ophthalmology. 2012 May;119(5):987-91
2. Pakrou N, Gray T, Mills R, Landers J, Craig J. Clinical comparison of the Icare tonometer and Goldmann applanation tonometry. J Glaucoma.
2008 Jan-Feb;17(1):43-7 3. Gaton DD, Ehrenberg M, Lusky M, Wussuki-Lior O, Dotan G, Weinberger D, Snir M. Effect of repeated applanation
tonometry on the accuracy of intraocular pressure measurements. Curr Eye Res. 2010 Jun;35(6):475-9.
Paper 8
Thursday
9:32 - 9:39 am
JAAPOS Abstract #020
Introduction: Discriminating physiologic from pathologic changes in the optic nerve head(ONH) is
essential in the management of pediatric glaucoma. To date, physiologic changes in ONH morphology of normal children are poorly described. Our goal is to develop a tool to facilitate quantitative
analysis of changes in ONH morphology of normal and glaucomatous eyes of children.
Methods: In this ongoing, prospective, longitudinal study, a cohort of children with ONH photographs taken between 1993-2008, were re-photographed between 2010-2012. The ONH discs
and cups were qualitatively assessed from the photographs by two masked readers. A novel
MATLAB(MathWorks,Natick,MA)-based software was created to quantify ONH disc/cup morphology from photographs. For software validation, the ONH disc/cup morphology in another cohort of
26 ONH photographs from pediatric eyes were quantitatively analyzed twice by 2 masked readers,
and intra- and inter-reader agreements were calculated.
Results: For the longitudinal analysis, there were 46 eyes with glaucoma, 43 glaucoma suspects
and 47 normals. Mean initial age and follow-up time were 9.8±3.3 and 7.0±4.7 years, respectively.
6/47(13%) normal eyes developed qualitative ONH morphologic changes over time (peripapillary
atrophy or tilting, inter-grader agreement 95%). The software validation analysis showed 4-10%
intra-grader, and 13-29% inter-grader variability on ONH cup-disc vertical, horizontal and area
ratios.
Discussion: The ONH in healthy eyes of children may qualitatively change over time, due largely
to ONH tilting.
Conclusion: Novel software allows computer-assisted quantitative ONH analysis, and will be applied to augment qualitative assessment of longitudinal changes in ONH morphology of healthy and
glaucomatous eyes of children.
References: 1. Differences in visual function and optic nerve structure between healthy eyes of blacks and whites.Racette et al. Arch Ophthalmol.
2005;123:1547-1553
2. Racial variation of optic disc size.Mansour AM. Ophthalmic Res. 1991; 23 (2):67-72.
3. African Descent and Glaucoma Evaluation Study (ADAGES): II. Ancestry differences in optic disc, retinal nerve fiber layer, and macular structure in healthy subjects.Girkin et
al, Arch Ophthalmol, 2010; 128 (5): 541-510
4. Optic disc change with incipient myopia of childhood. Kim TW, Kim M, Weinreb RN, Woo SJ,
Park KH, Hwang JM. Ophthalmology. 2012 Jan;119(1):21-6
5. Frank J Moya, Luca Brigatti, Joseph Caprioli Effect of aging on optic nerve appearance: a longitudinal study Br J Ophthalmol 1999;83:567-572 doi:10.1136/bjo.83.5.567
28
Paper 9
Thursday
11:15 - 11:22 am
JAAPOS Abstract #010
References: 1. Peng M, Poukens V, da Silva Costa RM, Yoo L, Tyschen L, Demer JL. Compartmentalized innervation of primate lateral rectus
muscle. Invest Ophthalmol Vis Sci 2010;51:4612-4617.
2. da Silva Costa RM, Kung J, Poukens V, Yoo L, Tyschen L, Demer JL. Intramuscular innervation of primate extraocular muscles: Unique compartmentalization in horizontal recti. Invest Ophthalmol Vis Sci 2011;52:2830-2836.
3. Clark
R A, Demer J L. Differential lateral rectus compartmental contraction during ocular counter-rolling. Invest. Ophthalmol Vis. Sci. 2012; 53:2887-2896.
Alexandra O Apkarian MD; Monte A Del Monte MD; Steven M Archer MD
WK Kellogg Eye Center, University of Michigan, Ann Arbor, MI
Introduction: To compare ipsilateral lateral rectus resection and contralateral medial
rectus recession (conjugate surgery) to an ipsilateral recess-resect procedure for the
treatment of 6th nerve paresis to reduce incomitance between right and left gaze.
Methods: This is a retrospective medical record review of patients with 6th nerve paresis
treated with either conjugate surgery or an ipsilateral recess-resect procedure. Patients
with pre-operative deviation difference between right and left gaze (lateral incomitance) of
at least 15 prism diopters were included. Nine patients who underwent conjugate surgery
and fifteen patients who underwent ipsilateral recess-resect procedures were evaluated.
Pre- and post-operative alignment in primary gaze and lateral incomitance were compared.
Results: The mean pre-operative primary gaze esotropia was 25 prism diopters in the
conjugate surgery group and 26 prism diopters in the recess-resect group. The mean
lateral incomitance was 31 prism diopters in the conjugate surgery group and 24 prism diopters in the recess-resect group. The mean post-operative deviation in primary position
was 0 in the conjugate surgery group and 1 prism diopter in the recess-resect group. The
mean post-operative lateral incomitance was 9 prism diopters in the conjugate surgery
group and 16 prism diopters in the recess-resect group; this is a statistically significant
difference in an ANCOVA model adjusting for pre-operative incomitance (p=0.03).
Discussion: Both procedures achieve excellent post-operative primary position alignment and reduce lateral incomitance. Conjugate surgery results in significantly greater
reduction of lateral incomitance.
Conclusion: Conjugate surgery may be preferable to a recess-resect procedure in patients with 6th nerve paresis and more than 15 prism diopters of lateral incomitance.
29
Paper 10
Thursday
11:22 - 11:29 am
JAAPOS Abstract #004
Paper 11
Thursday
11:29 - 11:36 am
JAAPOS Abstract #022
How sensitive is the 3-step test in the diagnosis of superior oblique (SO) palsy?
Abnormal Rectus Muscle Length In Horizontal Strabismus?
Ajay M Manchandia MD; Joseph L Demer MD, PhD
UCLA Jules Stein Eye Institute, Los Angeles, CA
Ronen Rabinovich M.D.; Joseph L Demer M.D., PhD.
Jules Stein Eye Institute 100 Stein Plaza David Geffen School of Medicine at UCLA
Los Angeles CA
Introduction: The Parks-Bielschowsky 3-step test is the classical cornerstone of cyclovertical strabismus. We evaluated sensitivity of the 3-step test in clinical diagnosis of SO
palsy in patients with unequivocal magnetic resonance imaging (MRI) evidence of SO
atrophy.
Methods: 51 patients were selected from a prospective MRI study of strabismus because they exhibited significant SO atrophy. Detailed ocular motility data, including
3-step testing, were evaluated to determine sensitivity of single and combined clinical
findings in diagnosis of SO palsy.
Results: Maximum mean ± SD ipsilesional SO cross-section was reduced to 9.7±3.9
mm2 in SO palsy, representing 53% of the 18.5±4.5 mm2 contralesional SO crosssection, and 53% of the 18.4±3.6 mm2 normal SO cross-section (P<0.0001). Only 35
patients (69%) with SO atrophy fulfilled the entire 3-step test. Two steps were fulfilled
in 16 (29%) patients, and only one step was fulfilled in one patient (2%). Affected SO
cross-section was similar in orbits that fulfilled the 3-step test (10.0±4.1 mm2) vs. those
that did not (9.0±3.4 mm2; P=0.51).
Discussion: Since maximum SO cross section correlates with contractility, it seems
reasonable to regard the MRI finding of SO atrophy as a sufficient objective confirmation
of SO palsy. The complete 3-step test misses 31% of cases of SO atrophy. While acceptance of only two steps would increase sensitivity to 98%, relaxation of diagnostic rigor
would probably make the test non-specific.
Conclusion: The 3-step test fails to detect SO palsy in one-third of cases proven by
MRI. Often, only two of three steps are positive in SO palsy.
Introduction: Sarcomere adaptation has been proposed to adjust rectus muscle lengths
to regulate binocular alignment. We employed magnetic resonance imaging (MRI) to
determine if the horizontal rectus muscles have abnormal lengths, testing the common
presumption that muscles shorten in the direction of the habitual deviation.
Methods: High-resolution, surface-coil MRI was obtained in 2-mm thick axial planes
in strabismic patients who had not undergone prior surgery, and 13 controls verified to
be normal by examination. Eight patients had esotropia (4 with divergence paralysis, 1
with partially accommodative, 2 with decompensated esotropia, and one with V-pattern).
Four patients had exotropia (3 intermittent, 1 with patterns). Lengths of horizontal rectus
muscles were measured digitally in central gaze on the fixating eye only.
Results: Mean (±SD) medial rectus length was 35.0±4.1 mm in controls, not significantly
different from 36.3±1.7 mm in exotropia (P=0.56) or esotropia 35.8±2.9 mm (P=0.62).
Mean lateral rectus length in controls was 35.7±4.0 mm, not significantly different from the
values of 39.6±3.8 mm in exotropia (P=0.09) and 37.8±3.3 (P=0.19) mm in esotropia.
Discussion: Rectus muscle length depends not only upon eye position, which was central during all MRI imaging, but also upon muscle path length and curvature. In theory,
muscles could be longer or shorter than normal in the same eye position, depending upon
muscle path. These data suggest that medial rectus and lateral rectus muscle lengths are
normal in esotropia and exotropia, so muscle length does not contribute to the pathogenesis of these common forms of strabismus.
Conclusion: Abnormal horizontal rectus muscle length is not the cause of commonly
encountered esotropia and exotropia.
References: 1. Kono, R., Okanobu, H., Ohtsuki, and Demer, J. L. Absence of relationship between oblique muscle size and Bielschowsky head
tilt phenomenon in clinically diagnosed superior oblique palsy. Invest. Ophthalmol. Vis. Sci. 50:175-179, 2009.
2. Demer, J. L., Clark, R. A., and
Kung, J. Functional imaging of human extraocular muscles in head tilt dependent hypertropia. Inv. Ophthalmol. Vis. Sci. 52: 3023-3031, 2011.
Paper 12
Thursday
11:36 - 11:43 am
JAAPOS Abstract #033
Superior Oblique Tuck: A Self-Dosing Procedure Appropriate for all Classes of
Superior Oblique Palsy
Mary C Whitman; Howard M Eggers
Harkness Eye Institute Columbia University, New York, NY
Introduction: Superior oblique palsy is a common cause of vertical and torsional
strabismus. Knapp distinguished 6 classes, based on the direction of gaze in which the
maximum deviation occurs. Different surgical procedures have been advocated for different classes. We report a sequential case series of superior oblique palsies of all types,
all treated with the same procedure: a superior oblique tuck, dosed according to intraoperative traction testing and an adjustable recession of the contralateral inferior rectus.
Methods: Retrospective chart review of 32 cases performed by a single surgeon. Each
patient had deviations measured in all nine fields of gaze, on head tilt, and with double
Maddox rods, both pre-op and post-op.
Results: Significant improvement in deviations in all fields of gaze was seen in all patients, regardless of class of deviation, following superior oblique tuck with yoke recession. All patients had resolution of diplopia, with only 2 requiring post-op prisms. We
report on deviations in all fields of gaze.
Discussion: An advantage of our study is that all measurements, both pre- and post-op,
were conducted by the same person, with the same methodology; a disadvantage, is that
he could not be masked as to the intervention. We assess deviations in all fields of gaze,
unlike other studies, which is especially important for an incomitant strabismus.
Conclusion: The superior oblique tuck with yoke recession is an appropriate procedure
for all patients with superior oblique palsy, regardless of direction of maximal deviation.
The amount of tuck necessary is based on intraoperative traction testing, not the pre-op
deviations.
30
Paper 13
Thursday
11:47 - 11:54 am
JAAPOS Abstract #025
Grant Support: US Public Health Service Grant EY08313 and Research to Prevent Blindness.
Outcome of Surgery for Non-Restrictive Vertical Strabismus
Sardar Mohammad Ali A Sadiq, M.D; David G Hunter, M.D, P.H.D; Melanie Kazlas, M.D
Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115
Introduction: Vertical strabismus surgery is commonly performed using a 3 prism diopter
(PD)/mm surgical dosage, with few reports of surgical outcomes, especially in patients
with non-restrictive strabismus. The purpose of this study was to analyze the outcomes
of vertical strabismus surgery and evaluate the dose-response relationship of rectus and
oblique muscle surgery.
Methods: Records of patients undergoing vertical strabismus surgery over a 1 year
period were reviewed. Exclusion criteria included prior vertical surgery, restrictive strabismus, dissociated vertical deviation, and follow-up <4 weeks. Main outcome measures
were change in vertical deviation and collapse of A/V pattern.
Results: Of 85 patients identified, 50.59% were male (age 0.9 - 81.2 years; follow-up
4-31 weeks). Patterns collapsed to 0 PD in 6/8 with A pattern (75%) and 23/32 with V pattern (72%). Of 45 patients without A/V pattern, 32 (71%) attained orthotropia, with mean
change in deviation of 11 PD (91%). In the 18 patients without oblique surgery, surgical
response was 2.7 PD/mm. For pre-op deviations of <5 PD, the change was 1.4 PD/mm;
for 5-9 PD, 2.7 PD/mm, and for 10-14 PD, 3.4 PD/mm. In the 20 patients who underwent
unilateral inferior oblique (IO) weakening procedures without rectus muscle surgery, 11
(55%) attained orthotropia, with an average change in deviation of 10.4 PD.
Discussion: Vertical rectus muscle surgery changed ocular alignment by 2.7 PD/mm,
while IO surgery had an average effect of 10.4 PD. The dose-response was larger for
larger pre-operative deviations.
Conclusion: The dose-response curve for vertical rectus muscle surgery, often cited as
3PD/mm, may be more dependent on the pre-operative deviation than previously believed.
31
Paper 14
Thursday
11:54 - 12:01 pm
JAAPOS Abstract #026
Paper 15
Thursday
12:01 - 12:08 pm
JAAPOS Abstract #008
Graded Rectus Tenotomy (GRT) In Small Angle Hypertropia
Due To Sagging Eye Syndrome (SES)
Zia Chaudhuri, MS, FRCS (Glasg) and Joseph L Demer, MD, PhD
Jules Stein Eye Institute (JSEI), University of California Los Angeles (UCLA)
Los Angeles, CA 90095-7002, USA
Introduction: SES is an orbital connective tissue degeneration in which adnexal laxity is
associated with inferior shift of the lateral rectus (LR) and other rectus pulleys. Asymmetrical
LR sag causes hypotropia and excyclotropia in the more affected eye. We aimed to develop a
surgical nomogram for graded rectus tenotomy (GRT), a minimally invasive surgery, in treatment of small angle vertical strabismus in SES.
Methods: We reviewed a 3-year surgical experience in 21 patients with vertical heterotropia
≤10∆ caused by SES who underwent adjustable GRT under topical anesthesia that permitted
intraoperative alignment measurements. Superior oblique palsy and pattern strabismus were
excluded.
Results: Average patient age was 69±12 years (10 male, 11 female). Mean pre-operative
central gaze hypertropia measured 4.6±2.5∆. The hypotropic inferior rectus (IR) was tenotomized temporally in 17, and the hypertropic superior rectus (SR) in 4 eyes. Mean tenotomy
was 67±18% of width at the scleral insertion, reducing hypertropia to zero intra-operatively and
0.9±1.7∆ at last follow-up 127±104 days postoperatively. Linear regression demonstrated that
30-90% tenotomy corrected 3-6∆ hypertropia (R=0.55, p= 0.008).
Discussion: The effect of peripheral GRT is moderately predictable, making this technique
useful for amelioration of cyclovertical diplopia due to small-angle hypertropia in SES that is
otherwise prone to overcorrection by alternative strabismus surgery. However, adjustable technique under topical anesthesia is preferred for optimal outcomes. Even under topical anesthesia, vessel sparing is readily performed during peripheral GRT of the IR.
Conclusion: GRT precisely corrects small angle hypertropia in SES, and is convenient for
intra-operative adjustment under topical anesthesia.
References: 1. Scott A. Graded rectus muscle tenotomy for small deviations. Paper presented at: Proceedings of the Jampolasky Festschrift 2000;
San Francisco.
2. Wright KW. Mini-tenotomy procedure to correct diplopia associated with small-angle strabismus. Trans Am Ophthalmol Soc
2009;107:97-102.
3. Yim HB, Biglan AW, Cronin TH. Graded partial tenotomy of vertical rectus muscles for treatment of hypertropia. Trans Am
Ophthalmol Soc 2004;102:169-175; discussion 175-166.
Grant Support: US Public Health Service Grant EY08313, Research to Prevent Blindness, and the BOYSCAST Fellowship of the Department of
Science and Technology, Government of India.
Paper 16
Thursday
12:08 - 12:15 pm
JAAPOS Abstract #018
Silicone band Loop Myopexy in treatment of Myopic Strabismus Fixus: Surgical
outcome of a novel modification
Ramesh Kekunnaya MD,FRCS; Hariprasad B Shenoy MS; Virender Sachdeva MS
LV Prasad Eye Institute, Hyderabad, India
Introduction: To describe a novel modification of loop myopexy with silicone band for myopic
strabismus fixus (MSF) and to evaluate its safety profile and surgical outcomes.
Methods: Retrospective review of 24 eyes of 14 patients who underwent silicone band loop
myopexy with/without medial rectus (MR) recession for MSF between June 2008 and June
2012. Improvement in alignment was the primary outcome measure. Success was defined as
deviation within 20PD. Complications related to surgery were secondary outcome measure.
Results: 24 eyes of 14 patients were analysed. 11 patients underwent bilateral loop myopexy.
16 eyes underwent additional MR recession. Mean duration of follow up was 7±8.72 months.
23 eyes had nasalisation of superior rectus (SR) and Inferiorisation of lateral rectus (LR) on
MRI. Mean abduction limitation at presentation was -3±1.23 which improved to -1.93±1.51,
p=0.05 at the last follow-up. Mean esotropia at presentation was 86.42±30.47 prism dioptres
(PD), which improved to 16.71±18.26PD, p=0.0000 at last follow-up. Success i.e. deviation
within 20PD was achieved in 71.5% (95% CI: 53.3 to 80.28%). Mean hypotropia at presentation was 8.92±10.06PD, which improved to 0.64±1.33PD, p=0.0069. Two patients had foreign
body sensation due to silicone band which was removed in 2 eyes. There were no incidence of
anterior segment ischemia or other adverse event in any patients.
Discussion: Conventional Recess-resect procedure is ineffective in management of MSF
and esotropia recurs in few months. Loop myopexy normalises the vector of SR and LR and
effectively corrects the esotropia and abduction limitation. Silicone band loop myopexy additionally prevents cheese wiring of the muscles and also causes less strangulation of ciliary
circulation.
Conclusion: Modified Loop myopexy with silicone band significantly improves alignment and
is a safe and effective procedure for management of MSF.
References: 1.Yokoyama T, Ataka S, Tabuchi H, Shiraki K, Miki T. Treatment of progressive esotropia caused by high myopia-a new surgical procedure based on its pathogenesis. In: de Faber J-T, editor. Transactions: 27th Meeting, European Strabismological Association, Florence, Italy, 2001.
Lisse (Netherlands): Swets & Zeitlinger; 2002:145-8 2. Wong I, Leo SW, Khoo BK. Loop myopexy for treatment of myopic strabismus fixus. J AAPOS 2005;9:589-91 3. Krzizok TH, Kaufmann H, Traupe H. New approach in strabismus surgery in high myopia. Br J Ophthalmol 1997;81:625-630
32
The Effects of Strabismus Surgery on Globe Position in the Setting
Thyroid Eye Disease
Reecha S Bahl, MD; Steven M Archer, MD; Julie B Shelton, MD; Victor M Elner, MD PhD;
Christopher Gappy, MD; Sudha Nallasamy, MD; Jennifer A Kozak, MD; Monte A Del Monte, MD
Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan
Introduction: Surgical management of strabismus in the setting of thyroid eye disease (TED) may worsen
proptosis by releasing restricted muscles from the globe. Previous studies have evaluated the change in proptosis following strabismus surgery, but not the factors that may predict the change in globe position. This study
evaluates the effect of strabismus surgery on proptosis in TED and clinical factors that may predict the change
in globe position following this surgery.
Methods: The medical records of all patients undergoing strabismus surgery for TED between September
2011 and May 2012 were retrospectively examined. Data collection included gender; dates of birth, decompression surgery, and strabismus surgery; pre-decompression, post-decompression, and post-strabismus
exophthalmometry measurements and alignment in primary and down gaze; types of decompression and
laterality performed; intraoperative forced duction findings at time of strabismus surgery; and type and amount
of strabismus surgery performed on each eye. Statistical analysis consisted of paired t-tests regarding change
in exophthalmometry before and after decompression and strabismus surgery. Multiple regression analysis was
used to evaluate the predictive value of several preoperative variables.
Results: Twenty-one patients were identified, 16 of whom underwent unilateral strabismus surgery and 5 of
whom underwent bilateral strabismus surgery. 15 patients (71.53%) were female. Mean intraoperative forced
ductions (maximal restriction identified, on a scale from 0 to 4) were 2.45 (SD 0.65), and mean amount of
strabismus surgery performed (cumulative recession) was 8.05mm (SD 3.63mm). Mean pre-decompression,
post-decompression, and post-strabismus surgery exophthalmometry measurements were 24.78 (SD 3.95),
19.55 (SD 4.88), and 20.95 (SD 5.59) mm, respectively. Decompression reduced exophthalmometry measurements by a mean of 5.0mm (SD 3.62mm; paired t-test p<0.0001). Strabismus surgery increased exophthalmometry measurements by a mean of 1.4mm (SD 1.73mm; p=0.0013). Multiple regression analysis of possible
predictive variables showed that pre-decompression exophthalmometry is the only independent predictor of
exophthalmos after strabismus surgery (p=0.03).
Discussion: Strabismus surgery on patients with TED significantly increases proptosis. This study suggests a
relationship between pre-decompression exophthalmometry and the change in exophthalmos following strabismus surgery: the more proptotic the patient is prior to decompression, the greater the increase in proptosis after
strabismus surgery. Exophthalmometry prior to decompression may indicate the degree of orbital congestion
and account for its predictive value for proptosis following strabismus surgery.
Conclusion: More aggressive decompression may be warrated in TED patients with greater exophthalmometry to anticipate the increased proptosis from subsequent strabismus surgery.
Paper 17
Thursday
12:15 - 12:22 pm
JAAPOS Abstract #007
References: Gomi CF, Yang SW, Granet DB, et al. Change in proptosis following extraocular muscle surgery: Effects of muscle recession in
thyroid-associated orbitopathy. JAAPOS 2007; 11: 377-80.
Successful conjunctival socket expansion in anophthalmic patients till the age of
two: An outpatient procedure.
Rania A El Essawy FRCSEd,MD
Cairo University, Cairo, Egypt
Introduction: Rehabilitation of the congenital anophthalmic socket is frustrating for both
the parents and the ophthalmologist not just because of the cosmetic result but also because it requires many hospital admissions and general anaesthesia. The purpose of this
study is to determine the effectiveness of a technique performed in the outpatient clinic to
increase the volume of the congenital anophthalmic conjunctival socket.
Methods: 17 congenital anophthalmic sockets of 15 infants of a mean age of 4.2 ± 4.4
months were fitted with specially designed serial solid acrylic shapes or hydrogel expanders using cyanoacrylate for eyelids closure when using the latter.
Results: At the age of 2 years, the mean horizontal eyelid length increased from a mean
of 11.6 ± 4.5 to 19.4 ± 4.6 mm and the volume of the last expander from a mean of 0.6 ±
0.2 to 2 ± 0.3 cm3
Discussion: The specially designed acrylic shapes or expandable hydrogel forniceal implantes could be a substitute to the custom made moulds which usually require repeated
general anaesthesia
Conclusion: Successful increase in the horizontal eyelid length as well as the conjunctival socket volume could be achieved by a simple outpatient procedure without the need
for repeated hospitalization and general anaesthesia in those infants.
References: 1. Krastinova D, Kelly MB, Mihaylova M. Surgical management of the anophthalmic orbit, part 1: congenital. Plast Reconstr Surg.
2001 Sep 15; 108(4):817-26.
2. Mazzoli RA, Raymond WR 4th, Ainbinder DJ, Hansen EA. Use of self-expanding, hydrophilic osmotic expanders
(hydrogel) in the reconstruction of congenital clinical anophthalmos. Curr Opin Ophthalmol. 2004 Oct; 15(5):426-31.
33
Paper 18
Thursday
12:22 - 12:29 pm
JAAPOS Abstract #013
Paper 19
Saturday
8:35 - 8:55 am
JAAPOS Abstract #002
2013 Apt Lecture: Strabismus Is Getting’ Old
Joseph L Demer MD, PhD
Jules Stein Eye Institute, UCLA, Los Angeles, California
Purpose: Because extraocular muscle (EOM) connective tissue pulleys determine EOM force directions, pulley heterotopy can induce strabismus. This lecture distinguishes connective tissue related strabismus with early childhood
onset, from acquired strabismus due to connective tissue degeneration. Craniosynostosis causes pulley heterotopy
in childhood. Rutar and Demer proposed that age-related distance esotropia (ARDE, commonly called divergence
paralysis esotropia, ET) and cyclovertical strabismus (CVS) result from connective tissue degeneration termed the
“sagging eye syndrome” (SES). This study used orbital imaging to characerize these differing mechanisms.
Methods: 95 consecutive cases of pulley heterotopy were identified, of whom 56 had pattern strabismus of childhood onset. Surface coil MRI was obtained in 56 orbits of 28 patients of mean age 69±12 (SD) years who had SES.
Control data were obtained from 25 orbits of 14 age-matched normal subjects, and 52 orbits of 28 normal younger
(age 23±5 yrs) subjects. Data was correlated with clinical findings, and with surgical results in 24 patients with ARDE,
and 18 patients with CVS.
Results: Patients with childhood onset strabismus had intact LR-SR band ligaments and relatively straight EOM
paths, but exhibited rectus pulley array cyclorotation: incyclorotation was associated with A pattern, and excyclorotation with V pattern. These internal features were associated with canthal fissure inclination. Transposition of rectus insertions collapsed patterns. Patients with SES commonly exhibited blepharoptosis and superior sulcus defect. There
was significant inferolateral displacement of all rectus pulleys in SES, with elongation of rectus EOMs (P<0.001) that
followed curved paths. Symmetrical lateral rectus (LR) pulley sag was associated with ARDE, and asymmetrical LR
sag >1 mm with CVS. The LR-SR band was ruptured in 91% patients with SES. Both LR resection and medial rectus
(MR) recession were effective treatments for ARDE, but MR recession required dose augmentation. Partial vertical
rectus tenotomy was effective in CVS.
Discussion: Adnexal inspection provides valuable clues to strabismus arising from connective tissue pathology.
Canthal fissure inclination suggests uni- or bilateral heterotopy of a structurally robust rectus pulley array with onset
by early childhood, while adnexal laxity suggests acquired elongation of the rectus EOMs, and age-related degeneration of pulley ligaments. Childhood onset abnormalities are associated with pattern strabismus that may benefit
from clinical imaging, while SES is associated with concomitant ARDE or CVS. Connective tissue changes in SES
are accompanied by adnexal laxity so recognizable by clinical signs that further etiologic investigations are seldom
necessary.
Conclusion: While orbital imaging may be clinically valuable in evaluating childhood onset pattern strabismus, conspicuous external features usually obviate imaging in adult onset distance ET and hypertropia that commonly result
from involutional changes in EOMs and orbital connective tissues.
References: 1. Rutar, T. and Demer, J. L. “Heavy eye syndrome” in the absence of high myopia: A connective tissue degeneration in elderly strabismic patients. JAAPOS 13:36-44, 2009.
2. Chaudhuri, Z. and Demer, J. L. Medial rectus recession is as effective as lateral rectus resection in
divergence paralysis esotropia. Arch. Ophthalmol. 130:1280-1284, 2012.
3. Chaudhuri, Z. and Demer, J. L. Sagging eye syndrome: Connective
tissue involution causes horizontal and vertical strabismus in older patients. JAMA Ophthalmol. (in press), March 2013.
Grant Support: US Public Health Service Grant EY08313, Research to Prevent Blindness, and the BOYSCAST Fellowship of the Department of
Science and Technology, Government of India.
Paper 20
Saturday
9:00 - 9:07 am
JAAPOS Abstract #024
Functional Burden of Strabismus: Decreased Binocular Summation (BiS)
and Binocular Inhibition
Stacy L Pineles MD; Federico G Velez MD; Sherwin J Isenberg MD; Zachary Fenoglio;
Eileen Birch PhD; Steven Nusinowitz PhD; Joseph Demer MD,PhD
University of California, Los Angeles -- Jules Stein Eye Institute, Los Angeles, CA
Introduction: Binocular summation (BiS) is defined as the superiority of visual function for
binocular over monocular viewing. BiS decreases with age and large interocular differences
in visual acuity (VA). BiS has not heretofore been well-studied as a functional measure of
binocularity in strabismus
Methods: Strabismus patients and normal controls underwent a battery of psychophysical
and electrophysiological tests including ETDRS VA, Sloan low contrast acuity (LCA, 2.5%,
1.25%), Pelli-Robson contrast test, and sweep visual evoked potential (sVEP) contrast sensitivity to determine BiS for each. BiS was calculated as the ratio between binocular and better
eye scores.
Results: Sixty strabismic and 80 normal subjects were prospectively examined (age range
8-60 years). Mean BiS was significantly lower in the strabismic patients than controls for the
LCA charts (2.5% and 1.25%, p<0.0001 for both). For 1.25% LCA, strabismics had a mean
BiS score<1, indicating binocular inhibition. There was no significant BiS for contrast thresholds on the ETDRS, Pelli-Robson or sVEP. Regression analysis revealed a significant association between BiS and strabismus for 2.5% (p<0.0001) and 1.25% (p<0.0001) LCA accounting for age and interocular difference in VA.
Discussion: BiS is significantly decreased in strabismus, and some measures of binocular
function with two misaligned eyes viewing are worse than during monocular viewing. This
may explain why strabismic patients who are not diplopic close one eye in visually-demanding
situations. This finding represents an advancement in understanding of the visual deficits
impacting quality of life in strabismic patients.
Conclusion: Strabismic patients demonstrate sub-normal BiS and even binocular inhibition
for low contrast viewing, suggesting that strabismus impairs visual function more than previously appreciated. BiS may represent a novel measure by which to evaluate and monitor
function in strabismus.
34
Refractive Surgery for Accommodative Esotropia in
Special Needs Children and Adolescents
Nicholas Faron BA; James Hoekel OD; Lawrence Tychsen MD
St Louis Children’s Hospital at Washington University Medical Center, St. Louis, MO
Paper 21
Saturday
9:11 - 9:18 am
JAAPOS Abstract #014
Introduction: Reports of refractive surgery performed to treat esotropia have been limited to small series or case reports. Here we analyze outcomes in a sizeable number of
children and adolescents treated using the excimer laser or phakic intraocular lenses.
Methods: Clinical outcome data were collated prospectively in 54 children and adolescents (108 eyes) treated for hyperopia using excimer laser keratectomy or implantation
of phakic IOLs. All children had esotropia; fully accommodative (21 children) or partiallyaccommodative/mixed mechanism (33 children) and difficulties with spectacle or contact
lens wear. Mean age at refractive surgery was 10.2 yrs (range 3 to 18 years); mean
follow-up was 2.9 yrs.
Results: Spherical refractive error averaged 4.86 D (range +2.25 to +6.75) in children
treated using excimer laser and +9.25 (range +6.75 to +11.5) in those treated by IOL
implantation. 90/108 eyes (83%) were corrected to within +/- 1.0 D of target refractive
error and all to within 1.5 D. Best-corrected and uncorrected visual acuity improved 0.12
logMAR and 0.58 logMAR respectively. Pre-operative esotropia averaged 6.1 PD wearing refractive correction and 24.4 D not wearing correction. Esotropia after refractive
surgery (not wearing correction) was reduced to an average 8.3 D. During the follow-up
period 15% (8 children) required strabismus re-operation.
Discussion: Refractive surgery for hyperopia reduces substantially the angle of accommodative esotropia in children who have difficulties with spectacle or contacts lens wear.
Longer term follow-up will reveal whether refractive regression promotes recurrence of
larger heteroptropia.
Conclusion: Excimer laser keratectomy or phakic IOL implantation are unusual but
useful treatment alternatives for accommodative esotropia in a subpopulation of special
needs strabismic children.
Bilateral Simultaneous Lateral Rectus Botox Injection in Infant and Childhood
Intermittent Exotropia.
KEITH W MCNEER M.D.; MARY G TUCKER M.D.
VIRGINIA COMMONWEALTH UNIVERSITY, RICHMND, VIRGINIA
Introduction: Intermittent exotropia X(T) isn’t a constantly manifest strabismus, implying fusion with control.
Infants and children often present with a unique clinical profile; fused distance deviation intermittently dissociating with stable orthophoria at near fixation. Sensory anomalies such as amblyopia and loss of stereopsis,
are typically absent. Accepted therapy includes minus lenses, orthoptics, and surgical intervention. Botox
provides an alternate therapy. The purpose was to determine outcomes following simultaneous bilateral
lateral rectus Botox injection in 120 infant and childhood X(T) patients injected between 2 and 4.5 years each
followed a minimum of 6 years.
Methods: Patient selection profile was based on a previous study1. Bilateral simultaneous Botox lateral
rectus muscle injections were performed without IV or intubation using inhalation anesthesia; anesthesia
administered by Pediatric anesthesiologists at VCU ambulatory surgery center. Each lateral rectus was injected with 2.5u Botox by direct view through the conjunctiva without EMG monitoring. Patients were seen at
frequent intervals until the deviation stabilized. After stabilization, patients were followed at 6 month intervals.
All patients were followed a minimum 6 years after initial injection.
Results: At 6 years, distant deviations were corrected from 25PD to orthophoria in 24 pts (20%), to 8+4 PD
in 88 pts (70%), and in 8 pts. (9%) the distance angle of deviation returned to the original. Second injections
were required in 41 pts. (34%). Transient overcorrection occurred in 83 pts (69%); permanent overcorrection
in 1 pt (0.5) % responded to bimedial Botox injection. Five patients were operated for recurrent exotropia.
Amblyopia, and latent nystagmus, were not seen. One V pattern with overacting inferior obliques occured. By
Titmus array test, 116 (98%) had normal stereopsis. Refractive errors were minimally significant.
Discussion: Bilateral simultaneous lateral rectus Botox injection offers an efficacious, more physiologic
alternative to surgery without producing scar tissue or displacing EOM. The risk of permanent overcorrection
or non-comitance is minimal. It provides ‘forced orthoptics’ by causing viewed images to be placed on the
non-suppressed nasal hemi-macula. It evokes fixation duress in both medial and lateral rectus muscles. In
otherwise normal infants and children, both are strong stimuli invoking CNS visual feedback driving towards
normal alignment and permanent improvement in EOM length/tension parameters.
Conclusion: Simultaneous bilateral lateral rectus Botox injection is efficacious in selected cases of infant
and childhood X(T). Permanent consecutive esotropia is rare. The majority of patients require one injection
when administered between 2 and 4 years age. Botox provides ‘forced orthoptics’ by inducing temporary,
transient esotropia.
References: 1. Spencer RF, Tucker MG, Choi RY, McNeer KW. Botulinum Toxin Management of Childhood Intermittent Exotropia. Ophthalmology.
Nov;104(11): 1762-7 1997
35
Paper 22
Saturday
9:18 - 9:25 am
JAAPOS Abstract #023
Paper 23
Saturday
9:25 - 9:32 am
JAAPOS Abstract #016
Paper 24
Saturday
9:36 - 9:43 am
JAAPOS Abstract #009
The Effect of Effort and Exercise on Convergence and Accommodation
A Randomized Trial of Increased Patching for Amblyopia
Anna M Horwood; Sonia S Toor; Patricia M Riddell
University Of Reading, Reading, UK
David K Wallace MD, MPH; Elizabeth L Lazar MS, MPH; Donny Suh; Joan Roberts;
Michael X Repka; David Petersen; Ingryd Lorenzana; Raymond Kraker;
Jonathan M Holmes; Susan Cotter; Michael Clarke; Angela Chen; Roy Beck;
on behalf or the Pediatric Eye Disease Investigator Group
Jaeb Center for Health Research, Tampa, FL
Introduction: Extravagant claims are made about orthoptic exercises/vision therapy, but
how they act is unclear. Treatment, practice, placebo and effort effects are often confounded and their effect on normals is unknown.
Methods: In order to obtain normative data we studied 101 healthy young adults in a
laboratory setting. Accommodation and convergence response gains were measured
objectively to targets moving in depth to a range of naturalistic and impoverished targets,
both before and after two weeks of daily eye exercises. Participants were randomly allocated to six treatment groups specifically targeting blur resolution, binocular disparity
resolution, near point effort, attention, repetition and ‘encouragement’ effects.
Results: Only exercises targeting disparity resolution produced significant improvements above no-treatment baseline, and only significantly for convergence (p=0.043)
and marginally for accommodation (p=0.09). Mean accommodation improved as much
as vergence from these exercises. Blur, near point effort, or attention exercises produced
insignificant improvements. Greatest improvement in responses was produced by ‘tester
encouragement’ on the re-test visit without any intervening exercises (p=0.002 for both
vergence and accommodation). Greater improvements were seen in the more impoverished conditions and some participants performed at ceiling to the naturalistic target.
Discussion: Effort and encouragement produced greater improvements than exercises
alone. Only treatment targeting disparity resolution produced a significant treatment effect
and improved accommodation as much as vergence.
Conclusion: While vergence exercises have some effect, effort and possibly voluntary
influences are a critical factor in the ‘success’ of orthoptic exercises/and vision therapy.
More careful attention should be paid to these effects when making claims for efficacy of
eye exercises in patient groups.
Electronic Health Record Implementation in Pediatric Ophthalmology:
Impact on Volume and Time
Michael F Chiang; Sarah Read-Brown; Daniel C Tu; Kimberly Beaudet; Thomas R Yackel
Oregon Health & Science University, Portland, OR
Introduction: Electronic health record (EHR) systems have potential to improve quality,
delivery, and cost of ophthalmic care. This study evaluates two measures related to EHR
implementation in pediatric ophthalmology: clinical volume and time requirements compared to traditional paper documentation.
Methods: An academic pediatric ophthalmology practice implemented an institutionwide EHR in 2006 (Epic, Madiwon, WI). A study population was defined of 4 stable faculty
providers who practiced for >/=5 months before and after implementation. Patient volume
data and time use data were abstracted from the EHR reporting system, and volume data
were compared to baseline paper data from the 3-month period before implementation.
Results: There were 12,749 total patient encounters by study providers during this
period. Compared to baseline, EHR patient volume was 9% lower in year 1, 4% lower
after year 2, and 7% lower after year 3. With EHR, 14% of charts were completed during
weekends and 30% were completed during weekday evenings. Half of EHR charts were
completed within 1.4 days, and 75% were completed within 5.3 days.
Discussion: EHR adoption is increasing nationally, is being promoted by major federal
initiatives, and will likely affect every pediatric ophthalmologist [1,2]. Ophthalmology
documentation and workflow requirements are unique compared to other medical fields,
and pediatric ophthalmology requirements are further sub-specialized [3]. Improved EHR
interface design will improve the ability of pediatric ophthalmologists to provide patient
care, and will require collaboration from clinicians.
Conclusion: EHR implementation was associated with a small decrease in clinical volume, and with documentation during non-business hours.
References: [1] Chiang MF, Boland MV, Margolis JW, Lum F, Abramoff MD, Hildebrand PL. Adoption and perceptions of electronic health record
systems by ophthalmologists: an American Academy of Ophthalmology survey. Ophthalmology 2008; 115:1591-7.
[2] Blumenthal D. Implementation of the federal health information technology initiative. N Engl J Med 2011; 365:2426-2431.
[3] Chiang MF, Boland MV, Brewer A, et al.
Special requirements for electronic health record systems in ophthalmology. Ophthalmology 2011; 118:1681-7.
36
Paper 25
Saturday
11:27 - 11:34 am
JAAPOS Abstract #032
Introduction: After treatment with spectacles and patching, some patients have residual
amblyopia. We conducted a clinical trial to evaluate the effectiveness of increasing prescribed daily patching from 2 to 6 daily hours in children with stable residual amblyopia.
Methods: One hundred sixty-seven children 3 to <8 years old with stable residual amblyopia (20/32 to 20/160) after at least 12 weeks of 2 hours of daily patching were randomly assigned to either continue 2 hours of daily patching or increase patching time to
an average of 6 daily hours.
Results: Ten weeks after randomization, amblyopic eye visual acuity had improved an
average of 1.2 lines in the 6-hour group and 0.5 line in the 2-hour group (difference in
mean visual acuity adjusted for acuity at randomization = 0.6 line, 95% confidence interval: 0.2 to 1.0, P=0.003). Improvement of two or more lines occurred in 40% of subjects
patched for 6 hours versus 19% of those patched for 2 hours (P=0.004).
Discussion: When amblyopic eye visual acuity stops improving with 2 hours of daily
patching, increasing the patching dosage to 6 hours results in more improvement in visual
acuity after 10 weeks than continuing with 2 hours.
Conclusion: Clinicians should consider increasing the patching dosage for children
whose amblyopia stops improving after treatment with 2 hours of daily patching.
Anisometropia and amblyopia in nasolacrimal duct obstruction
Michael A Kipp MD; Michael A Kipp Jr.; William Struthers PhD
Wheaton Eye Clinic, Wheaton, IL
Introduction: Childhood nasolacrimal duct obstruction (NLDO) has long been considered to be a benign condition which does not affect vision development.(1) Recent studies
have suggested an association between NLDO and amblyopia.(2)
Methods: A retrospective review was conducted of 1218 patients between ages of birth
to six years with diagnosis of nasolacrimal duct obstruction (NLDO) from 2000-2010. Data
collected included onset of NLDO, laterality of NLDO, cycloplegic refractive error, determination of clinically significant anisometropia (defined as > or equal to one diopter), and
diagnosis of amblyopia with amblyopia sub-type (anisometropic vs. other).
Results: 887/1218 (72.8%) had unilateral NLDO. Anisometropia was found in 79/1218
(6.5%) patients on initial examination, with 67/887 (7.6%) patients with unilateral NLDO
having anisometropia as compared to 12/330 (3.6%) patients with bilateral NLDO. An
additional 26 patients developed anisometropia on follow-up examination for a total of
105/1218 (8.6%). A significant association between same sided unilateral NLDO and
higher hyperopia in the anisometropia patients (χ2= 33.01, p<0.001) was found on initial
examination. Follow-up data of 482 patients showed 28 (5.8%) developed amblyopia, 16
of which were due purely to anisometropia.
Discussion: Unilateral NLDO appears to be associated with anisometropia. The incidence of anisometropia (8.6%), amblyopia (5.8%) and anisometropic amblyopia (3,3%)
in this large NLDO cohort exceeds that found in the general pediatric population.(3) No
cause-effect relationship could be established in this retrospective study.
Conclusion: Measurement of cycloplegic refraction and periodic follow up of children
diagnosed with NLDO is warranted. Future prospective studies could elucidate any benefit
to early spontaneous resolution or surgical intervention.
References: 1.Ellis JD, MacEwen CJ, Young JDH. Can congenital nasolacrimal duct obstruction interfere with visual development? A cohort case
control study. J Pediatr Ophthalmol Strabismus 1998;35:81-85.
2.Piotrowski JT, Diehl NN, Mohney BG. Neonatal dacryostenosis as a risk factor for
anisometropia. Arch Ophthalmol 2010;128:1166-1169.
3.Donahue SP. The relationship between anisometropia, patient age, and the development
of amblyopia. Trans Am Ophthalmol Soc 2005;103:313-336.
37
Paper 26
Saturday
11:38 - 11:45 am
JAAPOS Abstract #019
Paper 27
Saturday
11:45 - 11:52 am
JAAPOS Abstract #006
iCheckKids, SPOT, iScreen and Plusoptix performance
in a high-risk, young pediatric eye practice
Robert W Arnold; Mary D Armitage
Alaska Blind Child Discovery, Anchorage, Alaska
Introduction: Practical pediatric objective screening devices have improved at the same
time the 99174 procedure code came into use. Pediatricians, concerned with practicality
and validity, are asking ‘Which photoscreener should we get?’ A new addition by iCheckHC makes use of an iPhone with software to over-ride the red-eye reduction preflash and
collect patient data.
Methods: Consecutive young patients in a pediatric eye practice had comprehensive exams and four state-of-the-art photoscreeners (iScreen, Pediavision SPOT, Plusoptix A09
and iCheckKids) consistent with the 2003 AAPOS Vision screen Amblyopia Risk Factor
guidelines.
Results: 96 patients aged 6-130 months (mean 46 months) had prescreening probability 53%. The Sensitivity/specificity for each was: iScreen 78%/92%, SPOT 77%/87%,
Plusoptix 83%/90% and the iCheckKids with DCC interpretation: 80%/93%. Additional
statistics highlight the impact of inconclusive screen interpretations.
Discussion: These devices performed well. Each device has advantages with adjustable interpretation by Plusoptix and SPOT, rapid aim and image with online interpretation with iScreen and hand-held portability with iCheckKids. All devices are expected
to improve with enhanced interpretation paradigms. Additional validation efforts include
pediatric offices and community screening.
Conclusion: Recent developments in devices and interpretation promise to improve
early screening for amblyopia.
Paper 28
Saturday
11:56 - 12:03 pm
JAAPOS Abstract #027
Uveal melanoma in children and adults in 8033 cases
Carol L Shields MD; Swathi Kaliki MD; Minoru Furuta MD; Arman Mashayekhi MD;
Jerry A Shields MD
Wills Eye Institute
840 Walnut Street Suite 1400 Philadelphia, PA 19107
Introduction: To evaluate prognosis of uveal melanoma based on age
Methods: Chart Review
Results: Of 8033 patients with uveal melanoma, 106 were young (< 20 years), 4287 in
mid-adults (21-60 years), and 3640 in older adults (>60 years). Based on age (young,
mid-adults, older adults) tumor locations was iris (21%, 4%, 2%), tumor diameter (10.2,
10.8, 11.5 mm) and thickness (5.0, 5.3, 5.7 mm) increased (p<0.0001). Kaplan-Meier
metastasis at 10 and 20 years were 9% and 20% in young (p<0.011); 23% and 34% in
mid-adults (p<0.0001); and 28% and 39% in older adults.
Discussion: Uveal melanoma in children represents only 1% of all uveal melanoma.
More often, it affects the iris and has related ocular melanocytosis. Similar to cutaneous
melanoma, prognosis in children tends to be more favorable than adults. Several reports
have shown younger age as an independent factor influencing reduced risk for metastasis. This, along with smaller tumor size, could be responsible for the more favorable
prognosis for younger patients.
Conclusion: Young patients showed lower melanoma metastasis.
References:
Shields CL, Shields JA, Milite J, et al. Uveal melanoma in teenagers and children. A report of 40 cases. Ophthalmology 1991;98:1662-6.
Singh AD, Shields CL, Shields JA, Sato T. Uveal melanoma in young patients. Arch Ophthalmol. 2000;118:918-23.
Shields CL, Kaliki S, Furuta M, Mashayekhi A, Shields JA. Clinical spectrum and prognosis of uveal melanoma based on age at presentation in 8033
cases. Retina 2012;32:1363-72.
38
Length of Day During Early Gestation is an Independent Predictor of Risk for Severe Retinopathy of Prematurity
Michael B Yang, MD1,3; Sujata Rao, PhD1,2; David R Copenhagen, PhD4;
Richard A Lang PhD1,2,3
Abrahamson Pediatric Eye Institute, 2The Visual Systems Group, Cincinnati Children’s Hospital
Medical Center, 3Department of Ophthalmology, University of Cincinnati, College of Medicine, Cincinnati, OH; 4Departments of Ophthalmology and Physiology, University of California,
San Francisco, San Francisco, CA.
1
Paper 29
Saturday
12:03 - 12:10 pm
JAAPOS Abstract #034
Introduction: We have identified in the mouse a light-response pathway via melanopsin
stimulation that regulates the formation of retinal vasculature during a period that approximates the first trimester of gestation in humans.1 We were thus interested as to whether
average day length (ADL) during early gestation was a predictor of severe ROP (SROP).
Methods: 712 eyes of 357 premature infants [401-1250 g birth weight (BW)] from 1998
to 2003 were included. Multiple logistic regression with generalized estimating equations
to account for inter-eye correlation was performed. The outcome variable SROP was (1)
classic threshold ROP in zone I or zone II, (2) type 1 zone I ROP, or (3) in a few eyes,
type 1 posterior zone II ROP that examiners chose to treat.
Results: Multiple logistic regression analysis evaluating all 712 eyes with 76 eyes developing SROP showed that BW, gestational age, per capita income, multiple birth, black
race and ADL were independent predictors of eyes developing SROP. Each additional
hour of ADL during the first 90 days after the estimated date of conception (EDC), decreased the likelihood of SROP by 29% (p = 0.014). In a model of 146 prethreshold ROP
eyes with 76 eyes developing SROP, each additional hour of ADL during the first 105
days after EDC decreased the likelihood of SROP by 46% (p = 0.001).
Discussion: Higher average day length during early gestation lowers the risk for eyes
developing severe ROP.
Conclusion: This finding may have implications for light during early gestation as a prophylactic treatment to prevent severe ROP.
References: 1. Rao S, Chun C, Fan J, Kofron JM, Yang MB, Hegde RS, Ferrara N, Copenhagen DR, Lang RA. A direct and melanopsin-dependent
fetal light response regulates mouse eye development. Nature 2013 (In press).
Evaluating The Association Of Autonomic Drug Use In The Development and Severity Of Retinopathy Of Prematurity
Mohamed A Hussein MD; David K Coats MD; Evelyn A Paysse MD; Paul Steinkuller MD;
Lingkun Kong MD PHD
Baylor College of Medicine and Texas Children’s Hospital, Houston, TX
Introduction: The purpose of this study was to explore the association of autonomic agents, presumed to regulate
the ocular perfusion, in the development and severity of retinopathy of prematurity.
Methods: We reviewed the charts of infants screened for retinopathy of prematurity at our institution in the years
2009 and 2010. We included in the study infants that had been treated with autonomic agents during their stay in
the neonatal intensive care unit.
Multiple logistic regression analysis was used to assess the association between the development and severity of
ROP and the use and dose(s) of autonomic agents, after adjustment for covariates (the estimated gestational age
and weight of the infants, and development of septicemia, intraventricular hemorrhage, or Respiratory Distress
Syndrome).
Results: 350 infants were included in the study. The most common autonomic agents used were caffeine (n=338)
and dopamine (n=93). After adjustment, there was a significant association between the use of dopamine and development of ROP [P= 0.001, Odds ratio = 3.2 (95% CI from 1.7 to 6.2)] and the need for ROP treatment [P=0.001,
Odds ratio= 5.96 (95% CI from 2.14 to 16.61)]. For infants using dopamine, after adjustment, the estimated percentage of infants needing treatment was 10 % (95% CI from 1% to 19%) and for those developing ROP was 47%
(95% CI from 31% to 64%).Of infants not using dopamine, after adjustment, the estimated percentage of infants
needing laser treatment was 2% (95% CI from 0 to 4%) and for those developing ROP was 22% (95% CI from 12%
to 31%). After adjustment, the number of dopamine doses was significantly associated with the development of
any ROP [P= 0.001, Odds ratio 1.28, (95% CI from 1.01 to 1.48)], the development of severe ROP [P=0.001, Odds
ratio 1.27 (95% CI from 1.11 to 1.45)], and the need for treatment [P=0.002, Odds ratio= 1.3 (95% CI from 1.08
to 1.42)].Each unit increase in the dopamine dose was associated with 24% increase in the odds of the need for
laser treatment and 27% increase in the odds of development of any ROP and in the development of severe ROP.
After adjustment, the total dose of caffeine dose was significantly associated with the development of any ROP [p=
0.025, Odds ratio= 1.001 (95% CI from 1.000 to 1.003)] and the need for treatment ([P=0.03, Odds ratio=1.002
(95% CI from 1.000 to 1.003), Each 50 mgs increase in the dose was associated with 5% increase in the odds of
development of ROP and 9% increase in the odds for the need for ROP treatment.
Discussion: Caffeine and dopamine strongly and independently influenced the development and severity of
retinopathy of prematurity.
Conclusion: While a causal relationship has not been established, autonomic agents may play an important role
in the development of retinopathy of prematurity.
References: 1. De Rogalski Landrot I, Roche F, Pichot V, Teyssier G, Gaspoz JM, Barthelemy JC, Patural H. Autonomic nervous system activity in
premature and full-term infants from theoretical term to 7 years.Auton Neurosci. 2007; 136(1-2):105-9.
2. Delaey C, Van De Voorde J. Regulatory
mechanisms in the retinal and choroidal circulation. Ophthalmic Res. 2000; 32(6):249-56.
3. Mizoguchi MB, Chu TG, Murphy FM, Willits N, Morse
LS. Dopamine use is an indicator for the development of threshold retinopathy of prematurity.Br J Ophthalmol. 1999; 83(4):425-8.
39
Paper 30
Saturday
12:14 - 12:21 pm
JAAPOS Abstract #017
Paper 31
Saturday
12:21 - 12:28 pm
JAAPOS Abstract #021
Analysis of Plus disease using Handheld Spectral Domain Optical Coherence Tomography in Non-sedated Neonates.
Ramiro S Maldonado MD; Du Tran-Viet BS; Eric Yuan BS; Adam M Dubis PhD;
Francisco Folgar; Sharon F Freedman MD; Cynthia A Toth MD
Duke University Eye Center, Durham, North Carolina, USA
Introduction: Spectral Domain Optical Coherence Tomography (SDOCT) has only recently
been explored in neonates with retinopathy of prematurity (ROP).1,2 Vessel architecture has
not been studied. This study provides an SDOCT analysis of vascular features in plus disease
in non-sedated neonates.
Methods: Analysis was of SDOCT images from 94 neonates (30-52 weeks postmenstrual
age) undergoing ROP screening. Ophthalmoscopic findings were obtained from study case
report forms. Fourteen neonates with plus disease were compared to 14 randomly-selected
neonates without plus disease and with ROP stage 0-2. One eye with the best SDOCT scan
quality was graded (masked) from each subject to identify elevated vessels, scalloped retinal
layers, hypointense vessels and retinal spaces. A pediatric ophthalmologist evaluated the
retinal images generated from SDOCT scans for abnormal dilation and tortuosity.
Results: Of 14 eyes with plus disease, SDOCT scans showed elevated vessels in 10 (71%),
scalloped retinal layers in 8 (57%), hypointense vessels in 5 (35%) and retinal spaces in
2 (14%). None of these features were detected in the control group. Retinal images had a
limited field of view (1-2 retinal quadrants in 19/28 images, 3 quadrants in 5/28 and 4 quadrants in 4/28). The dilation and tortuosity on retinal images, correlated with clinical judgment in
25/28 eyes.
Discussion: SDOCT may potentially aid in future analysis of vascular changes signaling
plus disease. Findings from this early feasibility pilot study need to be tested in a larger-scale
investigation.
Conclusion: SDOCT may complement clinical information in the monitoring of disease progression in neonates with ROP.
References: (1)Vinekar A, Avadhani K, Sivakumar M, et al. Understanding clinically undetected macular changes in early retinopathy of prematurity
on spectral domain optical coherence tomography. Invest Ophthalmol Vis Sci. 2011 Jul 15;52(8):5183-8.
(2)Maldonado RS, O’Connell R, Ascher SB, et al. Spectral-domain optical coherence tomographic assessment of severity of cystoid macular edema
in retinopathy of prematurity. Arch Ophthalmol. 2012 May 1;130(5):569-78.
Paper 32
Saturday
12:28 - 12:35 pm
JAAPOS Abstract #015
BEAT-ROP Refraction data at Age Two Years
Megan M Geloneck MD; Jeffrey D Chan; Alice Z Chuang PhD; Helen A Mintz-Hittner MD
University of Texas Health Science Center-Houston Medical School
Houston, Texas
Introduction: Refractive outcomes at age two years of patients treated with intravitreal
bevacizumab (IVB) or with conventional laser therapy (CLT) for zone I or zone II posterior
Stage 3+ ROP (who were enrolled in the BEAT-ROP clinical trial) will be presented.
Methods: BEAT-ROP patients underwent cycloplegic refractions at age two years. Exclusions from the original 150 patients (300 eyes) included 16 patients (32 eyes): [nine
patients (18 eyes) who died before the age of two years; (six patients) (12 eyes with
bilateral retinal detachments); and one patient (two eyes with binocular cataracts).
Results: Cycloplegic refractions were available from 79 (of 134 possible) patients
[154 (of 264 possible) eyes]: (32 zone I and 47 zone II posterior). Spherical equivalent means ± standard deviations were as follows: for zone I: IVB: (17 patients: 34
eyes) -2.56 ± 3.29; CLT: (15 patients: 27 eyes) -12.63 ±6.91--p < 0.0001; and for zone
II posterior: IVB (25 patients: 50 eyes) -0.69 ± 2.51; and for CLT (22 patients: 43 eyes)
-5.72 ± 6.40--p = 0.0005.
Discussion: More myopia was found in eyes treated with peripheral retinal ablation
(CLT) while less myopia was found in eyes treated with intravitreal vascular endothelial
growth factor inhibitor (IVB).
Conclusion: There was a significant difference between the cycloplegic refractions of
infants treated with IVB versus CLT in both zone I and zone II posterior. Confirmation
of these refractive outcomes and the establishment of long term safety of bevacizumab
which does escape into blood to some extent is essential.
40
Visual acuity and macular optical coherence tomography abnormalities in children
with history of retinopathy of prematurity.
Victor M Villegas; Hilda Capo; Kara Cavouto; Audina M Berrocal
Bascom Palmer Eye Institute
Miami, FL
Paper 33
Saturday
12:39 - 12:46 pm
JAAPOS Abstract #030
Introduction: To correlate visual acuity (VA) and macular optical coherence tomography
(OCT) findings in patients with history of retinopathy of prematurity (ROP) and normal
macular fundoscopy.
Methods: This retrospective cohort study reviewed the charts of all ROP patients evaluated during the last 2 years. Children with prior OCT were included. Patients with abnormal macular fundoscopy or prior vitrectomy were excluded. Subjects were divided by VA
into group 1 if >20/40, and group 2 if <20/40.
Results: Forty-five patients were identified: 48 eyes in group 1 and 35 in group 2. Mean
values in groups 1 and 2 included: age in years, 9.4 vs. 7.8, spherical equivalent, -5.86
D vs. -9.51 D, and gestational age in weeks, 24.9 vs. 25.2. Seventy percent of group 1
patients and all patients from group 2 had laser therapy. Mean central foveal thickness in
micrometers was 310 and 303 in groups 1 and 2 respectively. Retention of inner retinal
layers was found in 61% in group 1 and 69% in group 2.
Discussion: Patients with history of ROP frequently have abnormal foveal morphology
by OCT, including retention of inner retinal layers. Abnormal foveal contour associated
with ROP does not necessarily imply poor VA.
Conclusion: Macular structural abnormalities detected by OCT do not always correlate
with VA. Other factors may play a role in the visual development of children with history
of ROP.
2013 AAPOS Young Investigator Award Talk
Induced pluripotent stem cells: An emerging tool for the study
of human inherited retinal disease
David M. Gamm, MD, PhD
Introduction: Human embryonic stem cells (hESCs) and induced pluripotent stem cells (hiPSCs)
are both valuable sources of retinal cell types for in vitro and in vivo studies. However, unlike hESCs,
hiPSCs can be derived from individual patients, and therefore offer a unique opportunity to model human
retinal disease.
Methods: Using protocols developed in our laboratory, hiPSCs derived from patients with selected
inherited retinal disorders (e.g., gyrate atrophy (GA) and Best vitelliform macular dystrophy (BVMD))
and normal controls underwent targeted differentiation to obtain enriched cultures of affected retinal
cell types. Thereafter, the retinal cell cultures were examined to determine whether disease-specific
phenotypes could be recapitulated in vitro.
Results: Molecular, biochemical, and physiological analyses revealed phenotypes in hiPSC-derived cell
populations that could be used to test drug efficacy and/or study the underlying disease mechanism(s).
For the GA culture model, a deficit in ornithine aminotransferase activity was present in differentiated
hiPSC-RPE cells that could be improved with high dose vitamin B6. In the BVMD culture model, hiPSCRPE cells from affected patients showed greater accumulation of ingested photoreceptor outer segment
material and reduced transcellular fluid flux compared to sibling control hiPSC-RPE. Subsequent
investigation suggested a role for BESTROPHIN-1, the protein mutated in BVMD, in the regulation of key
RPE functions.
Discussion: In designing a hiPSC modeling study, care should be taken to select retinal disorders that
have a reasonable expectation of recapitulating key pathophysiological processes in culture. In addition,
a means to enrich for cell type(s) targeted by the disease is necessary; otherwise, the task of assuring
a reproducible culture environment becomes daunting. Taking these and other limitations of hiPSC
modeling into consideration, inherited diseases of the retina remain appealing, particularly monogenetic,
early-onset diseases that affect the RPE. As we improve our understanding of complex disorders
and our ability to build more intricate culture environments, the number and types of retinal diseases
amenable to hiPSC modeling will broaden.
Conclusion: hiPSCs represent a new and potentially powerful tool that can help close the gap between
our knowledge of the genetics and the biology of inherited retinal diseases. In addition, custom hiPSC
retinal model systems could be used to test known therapeutics and develop drug and gene therapy
screening platforms. However, limitations exist in any culture system; thus, hiPSC technology is
envisioned to complement, not supplant, existing laboratory models of disease.
41
Paper 34
Sunday
9:05 - 9:13 am
JAAPOS Abstract #003
Notes
Notes
42
43
Notes
Poster Schedule
1st Set of Posters (1-40) Displayed from Wednesday, April 3, 4:00 PM - Friday, April 5, 11:30 AM,
Essex Ballroom Foyer
Interactive Poster Session - Author Presentation and Q/A - Thursday, April 4, 9:55 - 10:55 AM
STRABISMUS SURGERY
44
Poster #1
Malignant Hyperthermia in Strabismus Surgery: A Survey of AAPOS Members
Mary O’Hara, MD
Mitchell J. Goff, MD; David J. Woods, MD; Jason E. Karo, MD; Frank W. Scribbick, MD
Poster #2
Immediate Post-Operative Angle is the Best Predictor of Long-Term Strabismus Surgery Success in Children
Paulita Pamela P. Astudillo
Cotesta Melissa; Jennifer Schofield; Derek Stephens; Stephen Kraft; Kamiar Mireskandari
Poster #3
Partial Rectus Muscle Tenotomy for Treatment of Small-Angle Strabismus
Timothy P. Lindquist
Alexander I. Zabeneh; Scott E. Olitsky
Poster #4
Comparison of the Efficacy of Medial Rectus Recession and Lateral Rectus Resection for Treatment of Divergence
Insufficiency
Brenda Breidenstein
Shira L. Robbins; David B. Granet; Erika C. Acera
Poster #5
Unilateral Lateral Rectus Resection for Horizontal Diplopia in Adults with Divergence Insufficiency
David R. Stager, Sr., MD
Trevor Black; Joost Felius, PhD
Poster #6
Change in Horizontal Comitance After Symmetric vs. Asymmetric Strabismus Surgery
Carolyn P. Graeber, MD
David G. Hunter, MD, PhD
Poster #7
Adjustable Augmented Rectus Muscle Transposition Surgery With or Without Ciliary Vessel Sparing for
Abduction Deficiencies
Karen Hendler, MD
Stacy L. Pineles, MD; Joseph L. Demer, MD, PhD; Federico G. Velez, MD
Poster #8
Superior Rectus Transposition and Unilateral or Bilateral Medial Rectus Recession for Duane Syndrome and Six
Nerve Palsy
Yair Morad, MD
Ramesh Kekunnaya, MD, FRCS
Poster #9
Surgical Outcomes in Adult Sixth Nerve Palsy
Jason H. Peragallo
Beau B. Bruce; Nancy J. Newman; Amy K. Hutchinson; Phoebe D. Lenhart; Valerie Biousse;
Scott R. Lambert
Poster #10
Early Results of Slanted Recession of the Lateral Rectus Muscle for Intermittent Exotropia with Convergence
Weakness
Bo Young Chun, MD, PhD
Kyung Min Kang, MD
Poster #11
The Effect of Unilateral Strabismus Surgery on Lateral Incomitance in Patients with Exotropia
Brita S. Deacon, MD
A. Paula Grigorian, MD; Hanya M. Qureshi; Katherine J. Fray, CO; Horace J. Spencer, MS;
Paul H. Phillips, MD
Poster #12
Comparative Study of Lateral Rectus Recession versus Recession-Resection in Unilateral Surgery for Intermittent
Exotropia
Soh-youn Suh
Seong-Joon Kim; Young Suk Yu
Poster #13
Biomechanics of Superior Oblique Z-Tenotomy: Is It Different from Unguarded Tenotomy?
Andrew Shin
Lawrence Yoo; Joseph Demer
45
PUBLIC HEALTH
Poster #29
Poster #14
Additional Analyses Regarding Strabismus among Aged Medicare Beneficiaries
Michael X. Repka
Fei Yu; Flora Lum; Anne Coleman
Poster #15
Sight- or Life-Threatening Pediatric Eye Conditions: Assessment of the Baseline Diagnostic Knowledge of
Pediatrics Residents and the Effectiveness of a Self-Study Based Teaching Presentation in Improving Diagnostic
Confidence and Skills
Lilly Droll
Scott Ketner; Aneela Kundnani; Judith Gurland
Poster #16
Poster #17
Incidence of Retinopathy of Prematurity (ROP) in Infants Greater than 31 Weeks Gestational Age Undergoing
Screening Examinations for ROP
Jennifer L. Hsu, MD
Stefan Sillau, MS; Rebecca S. Braverman, MD; Robert E. Enzenauer, MD
Insurance Coverage and Access to Healthcare in the Baltimore Pediatric Eye Disease Study
Kathryn S. Klein, MD, MPH
Joanne Katz, ScD; James M. Tielsch, PhD; David S. Friedman, MD, MPH, PhD;
Michael X. Repka, MD, MBA
Poster #31
Evaluation of an Indirect Ophthalmoscopic Digital Photgraphic System (Keeler) as a Retinopathy of Prematurity
(ROP) Screening Tool
Sasapin G. Prakalapakorn, MD, MPH
Sharon F. Freedman, MD; Yuliya Lokhnygina, PhD; David K. Wallace, MD, MPH
Traumatic Hyphema in Children: A Review of 137 Consecutive Cases
Emily A. McCourt
Brett W. Davies
Poster #32
Improved Speed and Accuracy of Plus Disease Quantification Using Image Fusion Methodology
Laura A. Vickers, MD
David K. Wallace, MD, MPH; Sharon F. Freedman, MD; Rolando Estrada, PhD; Sina Farsiu, PhD;
Grace Prakalapakorn, MD, MPH
Poster #33
Factors Influencing Rates of Retinopathy of Prematurity (ROP) in Argentina: A Case Study of Policy, Legislation
and International Collaboration
Luxme Hariharan, MD, MPH
Graham E. Quinn, MD, MSCE; Clare Gilbert, MD, MSc; Juan E. Silva, MD, MPH; Alicia Benitiz, MD; Celia Lomuto, MD; Ana Quiroga, RN
Poster #34
Comparison of Serum VEGF Levels, Vision and Neurological Development in Laser and Bevacizumab Treated
ROP Patients
Lingkun Kong, MD, PhD
David K. Coats, MD; Kimberly L. Dinh, Pharm.D2; Robert Voigt, MD; Sid Schechet, MS;
Paul G. Steinkuller, MD
Poster #35
Computer-Assisted Quantification of Plus Disease after Treatment of Retinopathy of Prematurity with Intravitreal
Bevacizumab
Kevin R. Gertsch, MD
David Wallace, MD, MPH; J. Niklas Ulrich, MD; Laura Enyedi, MD; Michelle Cabrera, MD
Poster #36
Orbital Ultrasonography in Premature Babies with and without Retinopathy of Prematurity
Yonina D. Ron Kella
David Barash; Miri Erhenberg; Ronit Friling; Micky Osovsky; Rita Ehrlich
Poster #18
Visual Acuity after Secondary Intraocular Lens Implantation in Pediatric Aphakia
Deborah K. VanderVeen
William H. Dean
Poster #19
Treatment of Pseudophakic Posterior Capsular Opacification in Children with Secondary Capsulotomy
Kyle F. Cox
Brian Jerkins; Mary Ellen Hoehn; Wonsuk Yoo; Natalie C. Kerr
Poster #20
Visual Outcomes and Stability of Transscleral-Sutured Intraocular Lenses in Children
Shaival S. Shah, MD
Yasmin Bradfield, MD; Michael Struck, MD
Poster #21
Review of Surgical Treatment of Bilateral Congenital Cataracts
Scott W. Yeates
M. Edward Wilson; Rupal Trivedi; Leah A. Bonaparte
Poster #22
Long-Term Cumulative Incidence of Glaucoma after Congenital Cataract Surgery
Scott R. Lambert
Amitabh Purohit; Hillary M. Superak; Michael J. Lynn; Allen D. Beck
Poster #24
RETINOPATHY OF PREMATURITY
Poster #30
CATARACT - GLAUCOMA
Poster #23
Incidence of Pineal Gland Cyst and Pineoblastoma in Children with Retinoblastoma During the Chemoreduction
Era
Aparna Ramasubramanian
Christina Kytasty; Jerry A. Shields; Anna T. Meadows; Ann Leahey; Carol L. Shields
The Role of Goniotomy in the Management of Aphakic Glaucoma - extended follow up
Eva Gajdosova, MD, PhD
William Moore, FRCOphth; Ken K. Nischal, FRCOphth
Ocular and Systemic Findings in Peters’ Anomaly
Darakhshanda Khurram
Jayaprakash Patil; Eva Gajdosova; Will Moore; Samer Hamada
OPTIC NERVE - UVEITIS - CORNEA
Poster #37
The Association of Prematurity and Nonglaucomatous Optic Disc Cupping in Children
Alexander E. Pogrebniak, MD
Poster #38
The Role of Magnetic Resonance Imaging in Diagnosing Optic Nerve Hypoplasia
Phoebe D. Lenhart
Nilesh K. Desai; Beau B. Bruce; Amy K. Hutchinson; Scott R. Lambert
Poster #39
Anti-TNF Therapy for Childhood and Adolescent Uveitis
Janet D. Leath
Breno da Rocha Lima; Nida Sen; Mohamad S. Jaafar
Poster #40
Corneal Anesthesia in Childhood
Rosemary G. Lambley, FRCOphth
Naira Pereyra, MD; Asim Ali, MD, FRCSC; Kamiar Mireskandari, FRCSEd, FRCOphth, PhD
RETINA - RETINOBLASTOMA
Poster #25
Dexamethasone Intravitreal Impact (Ozurdex) in the Treatment of Pediatric Uveitis
Monica L. Bratton, MD
Yu Guang He, MD; David Weakley, MD
Poster #26
Natural History of Retinal Hemorrhage in Children with Abusive or Accidental Head Trauma
Wendy S. Chen, MD, PhD
Brian Forbes, MD, PhD; Gui-shuang Ying, PhD; Jiayan Huang, MS; Gil Binenbaum, MD, MSCE
Poster #27
Retinal Vasoproliferative Tumors in Patients with Neurofibromatosis. An Analysis of 6 Patients
Jerry A. Shields, MD
Marco Pellegrini, MD; Swathi Kaliki, MD; Carol L. Shields, MD
Poster #28
Retinal Astrocytic Hamartoma: Spectral-Domain Optical Coherence Tomography Classification and Correlation
with Tuberous Sclerosis Complex
Massimiliano Serafino, MD
Francesco Pichi, MD; Gian Paolo Giuliari, MD; Carol L. Shields, MD; Antonio P. Ciardella, MD;
Paolo Nucci, MD
46
47
Malignant Hyperthermia in Strabismus Surgery: A Survey of AAPOS Members
Mary O’Hara MD; Mitchell J Goff MD; David J Woods MD; Jason E Karo MD;
Frank W Scribbick MD
University of California, Davis, Sacramento, California
Poster 1
Thursday
9:55 - 10:55 am
JAAPOS Abstract #086
Introduction: To determine the incidence, management and outcomes of malignant
hyperthermia occurring during strabismus surgery in children and adults.
Methods: North American AAPOS members were surveyed about their experiences with
malignant hyperthermia during child and adult strabismus surgery.
Results: A total of 320 surveys (47%) were returned. Twenty-nine malignant hyperthermia (MH) cases were reported in an estimated 1,068,206 surgical strabismus procedures
(1/36,000 estimated incidence). Three MH cases were found to have a prior family history
of malignant hyperthermia; one case had known positive muscle biopsy with caffeine testing prior to surgery. Only 2 cases were reported to have underlying medical problems (1
neuroblastoma, 1 cerebral palsy). Death from malignant hyperthermia was not reported
in any strabismus surgery. Management of malignant hyperthermia included dantrolene
in 11/29 cases, aborted surgery in 5/29 cases, switched anesthetic agents in 4/29 cases,
sodium bicarbonate or core body cooling in 7/29 cases and unknown in 13/29 cases.
Discussion: The AAPOS membership reports a lower incidence of malignant hyperthermia in strabismus surgery than reported in earlier papers. While family history is known to
play a role in MH susceptibility, our survey found a positive family history in only 3 of 29
cases.
Conclusion: The low incidence rate and nonexistent fatality rate from strabismussurgery- related MH reported in this survey may be related to increased awareness and
earlier detection, use of dantrolene, and the use of Intensive Care Unit facilities to improve outcomes.
References: Britt, B., and Kalow, W.: Malignant Hyperthermia. A statistical review. Can. Anesth. Soc. J. 17;293, 1970.
Tammisto T, Brander P,
Airaksinen MM et al. Strabismus as a possible sign of latent muscular disease predisposing to suxamethonium-induced muscular injury. Ann Clin
Res. 1970; 2; 126-130.
Immediate Post-Operative Angle is the Best Predictor of long-term Strabismus
Surgery Success in Children.
Paulita Pamela P Astudillo; Cotesta Melissa; Jennifer Schofield; Derek Stephens;
Stephen Kraft; Kamiar Mireskandari
Department of Ophthalmology and Vision Sciences, University of Toronto
Toronto, ON, Canada
Introduction: Strabismus surgery is a common procedure, however prediction of longterm success remains elusive. The objective of this study was to determine if achievement of an ideal post-operative target range can predict the surgical outcome in children.
Methods: The charts of patients aged 0 to 12 years old who underwent horizontal
strabismus surgery were reviewed. The ideal post-operative target range was defined as
within 4 prism diopters (PD) of orthotropia in esotropic patients and 0-8 PD of esotropia
in exotropic patients at the first post-op visit within 7 days of surgery. Surgical success
was defined as a measurement within 10 PD of orthotropia with a minimum of 6 months’
follow-up.
Results: A total of 352 patients were included in the study. The mean follow-up was 18
months. Patients who were within the target range had a higher success rate than those
outside the target range (73.5 % vs 54.3 %, p=0.0004). Although exotropic patients had
higher success rate when they were within target range (71.1% vs 37%, p=0.0002), esotropic patients had a trend towards higher success, which was not statistically significant
(74.6% vs 67.2% p=0.3972).
Discussion: This study shows that regardless of strabismus type, children have higher
chances of obtaining long-term surgical success when they are within target range after
surgery. This is explained by the expected alignment drift post-operatively.
Conclusion: Achieving the ideal target range in children is associated with obtaining
long-term surgical success in horizontal strabismus surgery and may support the use of
adjustable sutures in this age group.
48
49
Poster 2
Thursday
9:55 - 10:55 am
JAAPOS Abstract #035
Poster 3
Thursday
9:55 - 10:55 am
JAAPOS Abstract #076
Partial rectus muscle tenotomy for treatment of small-angle strabismus
Timothy P Lindquist; Alexander I Zabeneh; Scott E Olitsky
Children’s Mercy Hospitals and Clinics, Department of Ophthalmology
Kansas City, Missouri
Introduction: Small deviations of ocular alignment are often treated with prism in spectacle correction. Circumstances in which patients desire not to wear spectacles preclude
use of prism. Surgical correction of deviations is commonly accomplished by recession,
resection or transposition of the extraocular muscles. Situations where the deviating
angle is too small to be reliably corrected by these procedures present need for alternative management.
This study sought to analyze the efficacy and predictability of partial tenotomy for treating
small angle deviations. Patients treated by partial tenotomy were undergoing strabismus
surgery for a second deviation along a different axis.
Methods: A single-center, 21-month retrospective chart review performed of patients
with a small-angle deviation [< 6 prism diopters (PD)] who underwent partial tenotomy
of a rectus muscle without concomitant procedures to correct deviations along the same
axis returned nine subjects. Pre- and post-operative measurements were compared to
analyze the efficacy and predictability of partial tenotomy.
Results: Mean pre-op deviation was 4.7 PD (+/- 1.6 PD), mean post-operative deviation
was 0 PD (+/- 1 PD). Six patients underwent partial tenotomy of an inferior rectus muscle,
two of a medial rectus, and one of a lateral rectus. A paired t-test showed the means difference of 4.67 PD to be statistically significant (p< 0.0001).
Discussion: Partial rectus muscle tenotomy can produce predictable results, with halftendon width tenotomies producing an average of 4.67 PD of correction.
Poster 4
Thursday
9:55 - 10:55 am
JAAPOS Abstract #038
Conclusion: Partial rectus muscle tenotomy should be considered a reliable treatment
option for small-angle strabismus.
Comparison of the Efficacy of Medial Rectus Recession and Lateral Rectus
Resection for Treatment of Divergence Insufficiency
Brenda Breidenstein; Shira L Robbins; David B Granet; Erika C Acera
University of California San Diego
La Jolla, CA
Introduction: Surgical approaches for divergence insufficiency esotropia include medial
rectus recession and lateral rectus resection. A retrospective chart review was undertaken to compare the efficacy of each surgical approach.
Methods: We performed a retrospective chart review of patients over 50 with divergence
insufficiency esotropia who were operated on between 2005 and 2012 by two surgeons
(DBG and SLR).
Results: Eighteen patients with divergence insufficiency were identified. Nine underwent medial rectus recession (Group 1; 5 unilateral, 4 bilateral) and nine underwent
lateral rectus resection (Group 2; 3 unilateral, 6 bilateral). Adjustable sutures were used
in all cases; two patients in each group required postoperative adjustment. The average
distance esotropia in Group 1 decreased from 19.75 prism diopters preoperatively to 3.2
prism diopters postoperatively (p-value 0.001) and in Group 2 decreased from 17.7 to
2.6 (p-value 0.0002). The disparity between distance and near alignment decreased in
Group 1 from 7.25 preoperatively to 3.4 postoperatively (p-value 0.019) and in Group 2
from 9 to 5.4 (p-value 0.004).
Discussion: Both surgical approaches have previously been reported as effective treatment for divergence insufficiency. Medial rectus recession has specifically been shown
to decrease the distance-near disparity. Our results confirm prior data and also showed
that lateral rectus resection too decreased the distance-near disparity. Dose response
relationship will be discussed.
Conclusion: Both medial rectus recession and lateral rectus resection are effective
treatment for divergence insufficiency, with both decreasing distance-near disparity.
References: Chaudhuri Z, Demer J. Medial Rectus Recession is as Effective as Lateral Rectus Resection in Divergence Paralysis Esotropia. Arch
Ophthalmology. 2012;130(10):1280-1284.
Bothun E, Archer S. Bilateral Medial Rectus Muscle Recession for Divergence Insifficiency Pattern Esotropia. Journal of AAPOS. 2005: 9:3-6.
50
Unilateral lateral rectus resection for horizontal diplopia in adults
with divergence insufficiency
David R Stager Sr MD; Trevor Black; Joost Felius PhD
Center for Misaligned Eyes; Ophthalmology, UT Southwestern Medical Center;
Retina Foundation of the Southwest, Dallas, Texas USA
Poster 5
Thursday
9:55 - 10:55 am
JAAPOS Abstract #105
Introduction: Divergence insufficiency (DI) is an acquired comitant strabismus in aging
individuals characterized by esotropia and diplopia at distance. Treatment options include
occlusion, base-out prism glasses and various surgical procedures to the horizontal rectus muscles. Here we present a large cohort of patients with DI who underwent unilateral
resection of the lateral rectus (LR) muscle. This procedure is simple, performed on the
non-dominant eye, and typically under local anesthesia with relatively minimal risks.
Methods: Clinical characteristics and complaints were collected from all patients with
DI who underwent unilateral LR resection over a 5-year period. Treatment success was
defined as the elimination of the horizontal deviation and horizontal diplopia.
Results: The cohort consisted of 60 patients (age 54-93 years; 77% were female). The
majority sought surgical care after prism glasses were no longer tolerated or after rapidonset of a larger deviation (typically 12 to 20 prism diopters), often following cataract or
refractive surgery. After surgery (minimum 6 weeks follow-up; median 10 weeks), 82%
showed successful results, although a few developed a mild vertical deviation causing
continued diplopia.
Discussion: Treatment of DI with unilateral lateral rectus resection generally appeared
successful. Some of the treatment failures may have been due to pre-existing or lateronset vertical deviation.
Conclusion: Unilateral lateral rectus resection appears to be a valid option for treatment
of DI.
Change in horizontal comitance after symmetric
vs. asymmetric strabismus surgery
Carolyn P Graeber MD; David G Hunter MD, PhD
Children’s Hospital of Boston
300 Longwood Ave, Fegan 4, Boston, MA 02115
Introduction: Horizontal strabismus surgery outcomes evaluate alignment in primary
gaze, yet misalignment in side gaze also causes symptoms. Here we elucidate the effect
of surgical approach on strabismus comitance to inform surgical planning.
Methods: Records of patients undergoing horizontal strabismus surgery over a 3.5 year
period were reviewed. Inclusion criteria included patients with side gaze measurements
recorded <6 months before and <1 year after surgery. Minimum follow-up was 6 weeks.
Main outcome measure was change in comitance (difference between right and left gaze
before and after surgery).
Results: Of the 95 patients who met inclusion criteria, 79 (83%) were comitant preoperatively, of whom 6 developed post-operative incomitance. Of 16 with incomitant strabismus preoperatively, all of whom had asymmetric surgery, 3 (19%) were restored to
comitance. The largest change in comitance occurred with 1 muscle surgery (7 ), then 3
muscle (5 ), 2 muscle (4 ), and 4 muscle (3 ). Of the 6 cases developing postoperative
incomitance, 83% had unilateral surgery, but 1 muscle versus 2 muscle surgery showed
no difference in induced incomitance.
Discussion: Asymmetric strabismus surgery was associated with changes in postoperative comitance. Unilateral surgery was associated with induced postoperative incomitance. Single muscle surgery produced the largest change.
Conclusion: Unilateral surgery is a powerful tool for treating patients with incomitance,
but it can cause incomitance in patients who were previously comitant. This should be
factored into surgical planning, especially in patients who are prone to diplopia or who
are sensitive to the social implications of suboptimal reconstruction.
51
Poster 6
Thursday
9:55 - 10:55 am
JAAPOS Abstract #054
Poster 7
Thursday
9:55 - 10:55 am
JAAPOS Abstract #057
Adjustable Augmented Rectus Muscle Transposition Surgery With or Without
Ciliary Vessel Sparing For Abduction Deficiencies
Karen Hendler MD; Stacy L Pineles MD; Joseph L Demer MD, PhD; Federico G Velez MD
Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, CA
Introduction: Vertical rectus transposition (VRT) is useful in Duane syndrome and
abducens palsy. However, many clinicians avoid transpositions due to the risk of induced
vertical deviations and overcorrections. Posterior fixation sutures enhance the effect of
VRT, but preclude the use of adjustable sutures. An adjustable augmented VRT with or
without ciliary vessel-sparing is described.
Methods: We retrospectively reviewed the records of all patients undergoing adjustable
suture partial or full tendon VRT augmented by resection of the transposed muscles.
Ciliary vessels were preserved by either splitting the transposed muscle or by dragging
the transposed muscle without disrupting the muscle insertion.
Results: Six patients with abducens palsy and one with eso-Duane syndrome were
included. Mean follow up was 2.2±2.2 months. Resection of 3-5 mm was performed in
all patients. Pre-operative central gaze esotropia of 32.6±12.6 PD (range,18-50) decreased to 8.7±7.4 PD (range,0-18) at the final visit (p=0.002). Two patients required
post-operative adjustment with recession of one of the transposed muscles due to an
induced vertical deviation with overcorrection. At the final visit, one patient had a vertical
deviation<4PD, and none had overcorrection or anterior segment ischemia.
Discussion: Unlike posterior fixation sutures, adjustable sutures can be utilized when
augmenting transposition procedures by resection of the transposed muscles. This can
help to overcome induced vertical deviations or overcorrections. In addition ciliary vessels can be spared in these procedures.
Conclusion: Augmentation of VRT by resection of the transposed muscles can be
performed with adjustable sutures and vessel-sparing technique. This allows for postoperative control of overcorrections and induced vertical deviation as well as less risk of
anterior ischemia.
Poster 8
Thursday
9:55 - 10:55 am
JAAPOS Abstract #084
Surgical Outcomes in Adult Sixth Nerve Palsy
Jason H Peragallo; Beau B Bruce; Nancy J Newman; Amy K Hutchinson;
Phoebe D Lenhart; Valerie Biousse; Scott R Lambert
Emory University, Atlanta, GA
Introduction: Sixth nerve palsy (6NP) is the most common adult ocular motor nerve
palsy. Our goal was to identify factors associated with surgical outcomes in 6NP.
JAAPOS Abstract #088
Methods: Medical records of all adult patients from 1988-2012 with 6NP who underwent
strabismus surgery or botulinum toxin injections were retrospectively reviewed. Success
was defined as absence of diplopia without prisms, vertical deviation ≤2PD, and horizontal deviation ≤10PD.
Results: 82 patients from four surgeons were included [49 (60%) women; mean age 52
(range: 20-86)]. 66 (80%) had unilateral 6NP. Palsies were complete in 33 (40%). 21
(26%) had >1 surgery. Underlying etiology was idiopathic/microvascular in 23 (28%),
traumatic in 22 (27%), neoplastic in 19 (23%), and miscellaneous causes in 18 (22%).
Success frequency was similar across etiologies. 16/41 patients (39%) with trauma or
neoplasm required repeat surgery vs. 5/41 (12%) with other etiologies (p<0.05). Success
was more frequent with Hummelsheim-type procedures than vertical rectus transposition
(VRT) among patients with complete palsies (7/9=78% vs. 8/23=35%;p<0.05). Success
was more frequent among all surgically-treated 6NP patients who had adjustable vs.
nonadjustable sutures (20/28=71% vs. 22/44=50%;p=0.07).
Discussion: Etiology of 6NP does not appear to affect surgical success in adults, but
patients with traumatic and neoplastic causes were more likely to require repeat procedures. Despite a small number of patients, success was more frequent using the Hummelshiem-type procedure and with adjustable sutures.
Conclusion: Surgical success in adults does not correlate with the etiology of the sixth
nerve palsy, but may vary based on the type of procedures in this patient population.
Superior rectus transposition and unilateral or bilateral medial rectus recession
for Duane syndrome and six nerve palsy
Early results of slanted recession of the lateral rectus muscle for intermittent
exotropia with convergence weakness
Yair Morad MD1; Ramesh Kekunnaya MD,FRCS2
1.Assaf Harofeh Medical Center, Tel Aviv University, Zrifin, Israel.
2. Jasti V Ramanamma Children’s Eye Care Center, LV Prasad Eye Institute
Hyderabad, India.
Bo Young Chun MD, PhD; Kyung Min Kang MD
Department of Ophthalmology, Kyungpook National University Hospital
Daegu, KOREA
Introduction: We describe our results with augmented superior rectus transposition
(ASRT) for the treatment of esotropic Duane’s syndrome and six nerve palsy and compare the effect adding bi-medial recession or unilateral recession to the procedure.
Methods: Retrospective surgical case review of patients undergoing ASRT which were
operated by the authors. Preoperative and postoperative orthoptic measurements were
recorded. Outcome measures included the angle of esotropia in the primary position,
angle of head turn and the limitation in abduction.
Results: Eight cases of Duane’s syndrome and one case of six nerve palsy were identified. Minimum follow-up was 2 months (range 2-18 months). Mean deviation improved
from 33.3D to 5D esotropia, face turn was improved from 20 degrees to 2.5 degrees,
and abduction limitation improved from -3.9 to -2.0 (p<0.01). Four of the five patient who
had unilateral medial rectus recession added to ASRT were ortho or under-corrected
(preoperative:14-45D postoperative: 0-8D esotropia), while three of the four patients who
had bi-medial recession were ortho or over-corrected (preoperative: 30-50D esotropia
postoperative: 0-8 exotropia). One patient needed re-operation due to intractable torsion.
No patient had vertical deviation.
Discussion: In our series, ASRT combined with medial rectus recession eliminated
head posture, corrected esotropia and improved abduction in all patients. As opposed
to conventional vertical transposition surgery, no vertical deviation occurred. Torsion,
however, necessitated reversal of the SRT in one patient, and added bi-medial recession
caused overcorrection in some patients.
Conclusion: ASRT combined with unilateral or bilateral recession of the medical rectus
is safe and effective. Adding bi-medial recession may result in overcorrection.
52
Poster 9
Thursday
9:55 - 10:55 am
Introduction: To evaluate the efficacy of slanted recession of the lateral rectus (LR)
muscle for intermittent exotropia (IXT) with convergence weakness
Methods: A retrospective analysis was made of all patients who underwent slanted LR
recession between January 2010 and June 2012 for IXT with convergence weakness.
Twenty-nine patients were included in this study. All patients had their follow-up duration
more than 3 months. The medical records were reviewed and the following parameters
were recorded and analyzed: patient’s sex, age, preoperative and postoperative ocular
alignment at distance and near and changes of their stereopsis.
Results: The study group was composed of 14 males and 15 females, with a mean age
of 10.8. Preoperative mean deviation angle was 31.9 ± 5.4 PD at distance and 42.6 ± 5.8
PD at near. Slanted LR recession reduced the deviation angles to 2.7 PD at distance and
3.4 PD at near at 3 months. In addition, the mean difference between the distance and
near deviation angles was significantly reduced from 10.7 PD preoperatively to 0.7 PD at
3 months postoperatively (p<0.05). The mean stereopsis was significantly increased from
435 arcsec preoperatively to 94.4 arcsec at 3 months postoperatiely (p<0.05).
Discussion: Slanted recession of the LR was effective in reducing near-distance differences. This surgical technique also demonstrated a positive impact on stereopsis.
Conclusion: It is suggested that the slanted recession of the LR will decrease relatively
high recurrence rate of IXT with convergence weakness, however, further work will focus
on the long-term stability of ocular alignment in these patients.
53
Poster 10
Thursday
9:55 - 10:55 am
JAAPOS Abstract #040
Poster 11
Thursday
9:55 - 10:55 am
JAAPOS Abstract #046
The effect of unilateral strabismus surgery on lateral incomitance
in patients with exotropia
Brita S Deacon MD; A. Paula Grigorian MD; Hanya M Qureshi; Katherine J Fray CO;
Horace J Spencer MS; Paul H Phillips MD
University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205
Introduction: The purpose of the study was to determine the effect of unilateral strabismus surgery on lateral incomitance in patients with exotropia.
Methods: Prospective evaluation of patients > 7 years old with exotropia who had unilateral horizontal rectus muscle surgery at Arkansas Children’s Hospital between 12/09 and 1/12. Prism and
alternate cover testing was performed with distance fixation in primary position, right gaze, and left
gaze after > 45 minutes of monocular occlusion, within one week prior to surgery, within one week
after surgery, and > 3 months after surgery. The surgical procedure was at the discretion of the
surgeon. Patients with extraocular muscle paralysis, fibrosis or trauma were excluded. The change
in deviation induced by strabismus surgery in lateral gaze was expressed as a percentage of the
change in deviation induced in primary position.
Results: Fourteen patients with an age range of 17-74 years and a preoperative exotropia of
12-85 prism diopters met inclusion criteria. Nine patients had unilateral recessions/resections,
three had unilateral lateral rectus recessions, and two had unilateral medial rectus resections.
Thirteen patients (93%) had greater effect from strabismus surgery with gaze towards the operated eye (p=0.0013). On average, the surgical effect in gaze towards the operated eye was 148%
that achieved in primary position whereas the surgical effect in gaze away from the operated eye
was 82%. Ten patients had >3 months follow-up. Nine of these patients (90%) had greater surgical effect with gaze towards the operated eye (p=0.0114). On average, the surgical effect in gaze
towards the operated eye was 121% that achieved in primary position whereas the surgical effect
in gaze away from the operated eye was 85%.
Discussion: Lateral incomitance from strabismus surgery maybe undesirable. This study is the
first to prospectively quantify the amount of lateral incomitance induced by unilateral strabismus
surgery in patients with exotropia.
Conclusion: Unilateral strabismus surgery induces clinically significant lateral incomitance in patients with exotropia. The lateral incomitance is reduced, but still remains 3 months after surgery.
Poster 12
Thursday
9:55 - 10:55 am
JAAPOS Abstract #108
Comparative study of lateral rectus recession versus recession-resection
in unilateral surgery for intermittent exotropia
Soh-youn Suh; Seong-Joon Kim; Young Suk Yu
Department of Ophthalmology, Seoul National University College of Medicine,
Seoul, Korea
Introduction: To compare outcomes of unilateral lateral rectus recession (ULR) vs
lateral rectus recession-medial rectus resection (RR) in treatment of small to moderate
angle exotropia in children.
Methods: The medical records of intermittent exotropia patients with exodeviation measuring 20 to 25 prism diopters (PD), and underwent ULR or RR between 2002 and 2010
were retrospectively reviewed. The successful alignment after surgery was defined as
esophoria/tropia </=5PD to exophoria/tropia </=10PD. Surgical outcomes were compared between the ULR group and the RR group.
Results: Of 85 patients, 44 underwent ULR and 41 underwent RR. The mean follow-up
period was 43.2 months in the ULR group and 45.1 months in the RR group (P=0.935).
Mean preoperative exodeviation at distance and near was 21.9±2.0PD, 22.3±3.6PD in
the ULR group and 24.3± 1.6PD, 26.1±3.8PD in the RR group, respectively (P<.05). The
incidence of successful outcome at the last follow-up visit was not significantly different
between 2 groups which was 39% in the ULR group and 32% in the RR group (P=.650).
Reoperation rate for recurrence of exodeviation was 18% in the ULR group and 27% in
the RR group (P=0.437). Reoperation for consecutive esotropia was done in 2 patients of
the RR group. Cumulative probability of survival from recurrence did not differ between 2
groups (P=.83, log rank test).
Discussion: Surgical outcomes at a mean of 3.7 years were not significantly different
between the ULR and the RR group.
Conclusion: Unilateral lateral rectus recession could be considered as a primary approach in the treatment of small to moderate angle exotropia.
54
Biomechanics of Superior Oblique Z-tenotomy:
Is It Different From Unguarded Tenotomy?
Andrew Shin; Lawrence Yoo; Joseph Demer
Jules Stein Eye Institute, UCLA, Los Angeles, CA
Introduction: A recent report suggests that 70-80% Z-tenotomy of the superior oblique
(SO) effectively treats A-pattern strabismus associated with overdepression in adduction.
We examined the effect of Z-tenotomy on SO tendon biomechanics.
Methods: Fresh bovine SO tendons were reduced to the 16mm long x 8mm wide dimensions similar to the human SO tendon, and clamped in a custom micro-tensile load
cell under physiological conditions of temperature and humidity. Minimal pre-load was
applied to avoid slackness. Tendons were elongated by 20% of original length following
Z-tenotomies, made with scissors from opposite sides of the tendon, spaced 6.4 mm
apart and each encompassing 0, 40, 60, or 80% tendon width. Transient and sustained
tensions were monitored using a precision strain gauge with digital sampling. Control
experiments were performed in similar-sized specimens of bovine rectus tendon, and
isotropic latex.
Results: Z-tenotomy of latex caused a linear reduction in force transmission reaching zero at ~95% tenotomy. In contrast, Z-tenotomy of SO and rectus tendons caused
progressive reduction in force transmission reaching a negligible value at only 80%
tenotomy.
Discussion: Unlike isotropic latex, the parallel fiber structure of tendons reduces shear
force transfer across tendon width and enhances the biomechanical effect of Z-tenotomy.
Z-tenotomy <80% progressively reduces force transmission in the tendon, but Z-tenotomy of >/=80% reduces force transmission to zero just as complete tenotomy. The marked
SO tendon elongation observed surgically at the end point of 80% Z-tenotomy represents
loss of all SO force transmission.
Conclusion: 80% or greater SO Z-tenotomy is biomechanically equivalent to complete
unguarded tenotomy.
Poster 13
Thursday
9:55 - 10:55 am
JAAPOS Abstract #101
References: Brooks et al. The efficacy of superior oblique Z-tenotomy in the treatment of overdepression in adduction (superior oblique overaction).
Journal of AAPOS., Vol. 16, No. 4:342-4, 2012.
Additional Analyses Regarding Strabismus among Aged Medicare Beneficiaries
Michael X Repka; Fei Yu; Flora Lum; Anne Coleman
Johns Hopkins University School of Medicine, Baltimore, Maryland
Introduction: To describe the impact of general health and region on the prevalence of
strabismus diagnosis and strabismus surgery in the Medicare fee for service population
in the United States.
Methods: A 5% sample of Medicare claims was used to identify beneficiaries diagnosed
with strabismus and those having strabismus surgery between 2002 and 2010. The
Charlson Comorbidity Index (CCI), a measure of overall systemic health, is an ordinal
score from 0 to 6 based on the likelihood of mortality secondary to age and presence or
absence of 20 systemic conditions over the next 10 years. The regional analysis subdivided the sample into East, West, Midwest, and South.
Results: The 5% sample for 2010 included 1,237,469 unique beneficiaries. Strabismus
was diagnosed in 8,470 (0.68%), more often in females (56%), and more often in whites
(92%). Surgery was performed on 197 patients (0.016%).
|In pooled data for 2002 through 2010 the prevalence of strabismus increases significantly with increasing comorbidity, 0.57% (CCI, 0-2), 0.74% (CCI, 3-4), and 0.86% (CCI, 5-6)
(P < 0.0001). Conversely, the prevalence of strabismus surgery declines with increasing
comorbidity, 0.017% (CCI, 0-2), 0.015% (CCI, 3-4), and 0.014% (CCI, 5-6)( P = 0.004).
The diagnosis of strabismus was made less frequently in the South (p<0.0001), whereas
surgery was performed more often in the West (p=0.044).
Discussion: The prevalence of strabismus increases significantly with increasing health
problems. There are regional differences in the rate of strabismus diagnosis and strabismus surgery.
Conclusion: Exploration of the reasons for regional differences in the rates of strabismus and surgery among aged adults is needed.
References: Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis 1987;40:373-83.
55
Poster 14
Thursday
9:55 - 10:55 am
JAAPOS Abstract #094
Poster 15
Thursday
9:55 - 10:55 am
JAAPOS Abstract #047
Sight- or Life-Threatening Pediatric Eye Conditions: Assessment of the Baseline
Diagnostic Knowledge of Pediatrics Residents and the Effectiveness of a SelfStudy Based Teaching Presentation in Improving Diagnostic Confidence and Skills
Lilly Droll; Scott Ketner; Aneela Kundnani; Judith Gurland
Bronx-Lebanon Hospital Center
New York, NY
Introduction: Timely diagnosis and management of ocular disorders in children often times
depend on appropriate referral by general pediatricians. Exposure to ophthalmology is limited
in most pediatric residency programs. The objective of this study was to assess the baseline knowledge of a population of pediatrics residents regarding sight- or life-threatening eye
diseases in children. We further investigated whether providing a teaching presentation can
improve the residents’ knowledge.
Methods: We assessed the baseline knowledge with a written test including 10 questions.
The residents were then provided with a teaching presentation for self-review and the test was
repeated. The change in mean score and subjective diagnostic confidence was compared
using a paired t-test.
Results: 28 residents participated in the baseline test. The mean score was 4.96±1.59. The
mean score after review of the teaching presentation was 5.57±1.40 (p=0.21). The subjective
confidence of residents to diagnose serious pediatric eye conditions (on a scale from 0 to 3)
was 1.46±0.7 and 1.48±0.65 before and after review of the teaching material, respectively.
Discussion: Baseline knowledge and subjective confidence of pediatric residents regarding
diagnosis of serious eye conditions in children are limited. Sight- and life-threatening conditions were frequently missed in our test setting. Distribution of study material for self-review
does not significantly improve diagnostic knowledge.
Conclusion: We would strongly recommend the introduction of more intense teaching efforts
by the ophthalmology departments at all teaching hospitals where such measures are not yet
in place, such as interactive teaching sessions and clinical ophthalmology electives.
References: Freid VM, Makuc DM, Rooks RN. Ambulatory health care visits by children: principal diagnosis and place of visit. National Center for
Health Statistics. Vital Health Stat . 1998; 13(137)
Freed GL, Dunham KM, Gebremariam A, Wheeler JR; Research Advisory Committee of the American Board of Pediatrics. Which Pediatricians Are
Providing Care to America’s Children? An Update on the Trends and Changes During the Past 26 Years. J Pediatr. 2010;157(1):148-152
Poster 16
Thursday
9:55 - 10:55 am
JAAPOS Abstract #066
Insurance Coverage and Access to Healthcare in the
Baltimore Pediatric Eye Disease Study
Kathryn S Klein MD, MPH; Joanne Katz ScD; James M Tielsch PhD;
David S Friedman MD, MPH, PhD; Michael X Repka MD, MBA
Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD
Introduction: The purpose of this study was to determine the prevalence of health insurance
coverage and difficulty accessing healthcare in a cohort of urban children and to compare
these findings to the subgroup with eye disease.
Methods: This was a cross-sectional population based study of white and African-American
children aged 6 through 71 months in Baltimore, Maryland. Among 4132 children identified,
3990 eligible children (97%) were enrolled and 2546 children (62%) were examined. There
was an in-home interview for caregivers followed by an office-based eye examination. Socioeconomic information, insurance status, barriers to accessing health care, and the presence
of ocular disease were obtained from caregivers.
Results: Of those examined 48% were female, and the average age was 39.8 months.
Nearly all of the children had health care insurance (96%), and many had vision care coverage (75%). Eye abnormalities including significant refractive error, strabismus, amblyopia,
unexplained visual loss and other structural abnormalities were identified in 5.1% of subjects;
98% of those with an eye abnormality had health insurance coverage during the past year.
Inability to access health care in the last year was reported for 3% of all children and 4% of
children with any eye condition. The two most common reasons cited for difficulty accessing
care were long wait time for an appointment and lack of access to transportation. In 23.1% of
those with eye disease, caregivers reported the child had been previously diagnosed with an
eye problem by a doctor.
Discussion: In our population-based study in an urban setting, nearly all children, including
those with eye disease, had health insurance. Only a small number were unable to obtain
needed medical care. However, less than a quarter of those with vision problems were aware
they had them.
Conclusion: Improved screening for pediatric eye disease in this urban community may
improve children’s access to needed eye care.
56
Traumatic Hyphema in Children: A review of 137 consecutive cases
Emily A McCourt; Brett W Davies
Children’s Hospital Colorado, Aurora, CO
Introduction: The purpose of this study is to evaluate the mechanisms of injury resulting in traumatic hyphema in children, the settings in which these injuries occur, and the
outcomes of these injuries
Methods: This was a eight-year retrospective review of all patients seen at Children’s
Hospital Colorado between September 1, 2003 and December 31, 2011 and diagnosed
with traumatic hyphema.
Results: One hundred and thirty-seven patients were identified as having a traumatic
hyphema. Eighty-eight percent of cases occurred in boys. The mean and median ages
of the patients was 10 and 11 years respectively.
A small number of these injuries were documented as occurring outside of the home setting (12/135).
Mechanisms of injury were myriad with the most common mechanisms being horseplay
(37), missiles such as ball bearing guns, airsoft pellet guns, or paintball guns (36), and
sports injuries (32). Accidental trauma (14), Bungee cords (10), and assault (5) were
other causes of traumatic hyphema in children.
Of the patients with at least one month of follow up (103), all but four (3.8%) recovered
excellent vision. The vision loss in these four cases was due to retinal scarring, traumatic
optic neuropathy, and amblyopia. The mechanisms of injury in these cases were baseball
(2), paintball (1) and BB(1).
Discussion: This study highlights the frequency in which serious eye injuries occur in
the home setting and the dangers of children using guns and participating in horseplay.
Conclusion: The use of protective eyewear during sports, supervision of children at
home, and the avoidance of children using guns could prevent the majority of the eye
injuries resulting in hyphema. This study is the largest review of pediatric traumatic hyphema.
Visual acuity after secondary intraocular lens implantation in pediatric aphakia
Deborah K VanderVeen; William H Dean
Boston Children’s Hospital, Harvard Medical School
Boston MA
Introduction: To compare visual acuity (VA) pre-and post-operatively in a cohort of patients with pediatric aphakia after secondary intraocular lens(IOL) implantation
Methods: Consecutively operated patients from 1998 to 2011 were reviewed for comparison of best pre-operative Snellen VA to that nearest the 3 month post-operative visit.
Snellen acuity measures were converted to logMAR acuity for analysis. Pre-operative
correction mode (aphakic spectacles vs. contact lens and presence of amblyopia were
analyzed as potential confounding factors.
Results: 75 eyes of 49 patients were identified; Snellen acuities were available for 44
eyes of 24 pts. Mean follow-up was 2.4 months (range 1 - 6). 44 eyes (24 patients) were
analyzed. A mean increase in best corrected(BC) VA post-operatively of almost one line
(-0.084 logMAR) was found (p<0.0005). Eyes with pre-operative contact lens correction had a mean increase in BCVA of -0.11 LogMAR (p=0.0001) and eyes with aphakic
spectacles slightly less, -0.068 logMAR (p=0.01). 28/44 (63.6%) eyes showed improved
BCVA, and 12/44 (27.3%) were the same. Only 4/44 (9.1%) eyes showed a decrease
in BC VA at the studied post-operative visit, but stable measures were seen with longer
follow up.
Discussion: The technique and relative safety of secondary IOL implantation has been
previously reported, and good results can be obtained with implantation within the capsular bag or with sulcus placement. We demonstrate stable or improved best corrected VA
in 90.9% of eyes in which Snellen acuity could be assessed, suggesting improved overall
visual performance.
Conclusion: Secondary IOL implantation can improve BCVA
References: Nihalani BR, Vanderveen DK. Secondary intraocular lens implantation after pediatric aphakia. J AAPOS 2011;15:435-40.
Trivedi RH, Wilson ME, Jr., Facciani J. Secondary intraocular lens implantation for pediatric aphakia. J AAPOS 2005;9:346-52.
Grewal DS, Basti S. Modified technique for removal of Soemmerring ring and in-the-bag secondary intraocular lens placement in aphakic eyes. J
Cataract Refract Surg 2012 May; 38(5):739-42.
57
Poster 17
Thursday
9:55 - 10:55 am
JAAPOS Abstract #081
Poster 18
Thursday
9:55 - 10:55 am
JAAPOS Abstract #111
Poster 19
Thursday
9:55 - 10:55 am
JAAPOS Abstract #043
Treatment of Pseudophakic Posterior Capsular Opacification in Children
with Secondary Capsulotomy
Kyle F Cox; Brian Jerkins; Mary Ellen Hoehn; Wonsuk Yoo; Natalie C Kerr
University of Tennessee Health Science Center, Hamilton Eye Institute
930 Madison Avenue Memphis, TN 38103
Introduction: To study preservation of the posterior capsule at the time of cataract
extraction and IOL implantation with subsequent Nd:YAG capsulotomy or pars plana
vitrectomy with capsulotomy (PPV/C) for treatment of posterior capsular opacification
(PCO) in young children.
Methods: Fifty-eight eyes of 40 patients who underwent cataract extraction with AcrySof
IOL implantation and intact posterior capsules were divided into two groups: younger
(Group A) (6 months - 3 years, n=20) and older (Group B) (3 years - 7 years, n=38).
Upon PCO development, children underwent Nd:YAG laser or PPV/C. Primary outcomes
included elapsed time until first capsulotomy and number of procedures needed to maintain a clear visual axis.
Results: Nineteen eyes (95%) in A and 31 (81.6%) in B required a secondary procedure for PCO. All patients in both groups had a clear visual axis at their last follow-up
visit (range = 8 - 166 months). The mean number of procedures needed to maintain a
clear visual axis in A compared to B was 1.5 vs 1.1, with a range of 1 to 3 procedures
for all patients requiring a secondary procedure to clear the visual axis. Elapsed time
until the first procedure to clear the visual axis was 14.3 months (A) and 22.7 months (B)
(p=0.049). The Kaplan Meier curve of 50% probability for time to capsulotomy procedure
was 9.5 months for A and 21 months for B.
Discussion: Preservation of the posterior capsule at time of cataract extraction and IOL
implantation is a reasonable option.
Conclusion: Secondary Nd:YAG laser capsulotomy and/or PPV/C is a viable alternative
to primary capsulotomy for management of pseudophakic PCO in young children.
Poster 20
Thursday
9:55 - 10:55 am
JAAPOS Abstract #099
Visual Outcomes and Stability of Transscleral-Sutured
Intraocular Lenses in Children
Shaival S Shah MD, Yasmin Bradfield MD, Michael Struck MD
University of Wisconsin, Madison
Madison, Wisconsin
Introduction: Transscleral-sutured intraocular lenses have been shown to improve
visual outcomes, but there is concern about suture-breakage and long-term stability.
Average follow-up in most of the literature is less than 3 years. The purpose of this study
to assess long term-stability and visual outcomes in the use of scleral-sutured intraocular
lenses in pediatric patients with no capsular support.
Methods: A long-term retrospective case series review of 30 eyes of 19 children who
had a sutured IOL at University Wisconsin, Madison with 10-0 prolene. Outcome measures included postoperative best-corrected visual acuity (BCVA), intra-operative and
post-operative complications of surgery.
Results: The average follow-up was 6.4 years. All eyes had vision 20/60 or better, with
81.3% of eyes having vision better than 20/40. 2 eyes required corneal patch grafts, 1
eye required IOL repositioning, 1 eye had vitreous hemorrhage, 1 eye had hyphema, and
2 eyes had a suture that broke and required reoperation.
Discussion: There is limited data regarding long-term stability of scleral-sutured IOLs.
There are well-grounded fears that given enough time, the sutures will eventually break.
It is reassuring that at least in the first 7 years, there seem to be good visual outcomes
and minimal complications with this procedure.
Conclusion: Transscleral-sutured intraocular lenses are able to improve vision. Moderate follow-up data shows 10-0 prolene sutures seem to be stable with an average followup of nearly 7 years.
58
Review of Surgical Treatment of Bilateral Congenital Cataracts
Scott W Yeates; M Edward Wilson; Rupal Trivedi; Leah A Bonaparte
Storm Eye Institute, Medical University South Carolina
Charleston, South Carolina
Introduction: Dense bilateral cataracts presenting early in infancy require early intervention with minimal
time between surgeries for each eye. Recently the Infant Aphakia Treatment Study has reported outcomes of
unilateral cataract surgery in this age group. The purpose of this study is to review visual outcome and adverse
events when infantile cataracts present bilaterally.
Methods: We reviewed charts of consecutive patients who underwent bilateral congenital cataract surgery by
a single surgeon at age 7 months or less. Exclusion criteria were retinopathy of prematurity or preoperative
corneal diameter <9mm. Ages of surgery, causes of cataract, intraocular lens (IOL) placement (if yes primarily
or secondarily), complications, and visual acuity after age 5 when available were analyzed.
Results: 128 eyes of 64 children were included in the study, 37 female and 27 male; 37 Caucasian, 16 African
American, 11 others. Mean age at surgery was 2.7 months with a range of 0-7months. 58% of patients had a
family history of congenital cataract, 17% had an associated syndrome, and 25% were of unknown cause. 54
eyes had an IOL placed during cataract removal. Of the 74 eyes without an IOL placed primarily, 28 received a
secondary IOL. Age at follow-up was 8.96 years (SD 3.76), Follow-up duration 8.72 (SD 3.78). 16/54 eyes with
primary IOL implantation and 5/74 eyes without primary IOL implantation had reoperation for removal of visual
axis opacification. 6/54 eyes with primary IOL implantation and 20/74 eyes without primary IOL implantation had
glaucoma. Visual acuity data were available for 60 eyes when measured at above 5 years of age. Median visual
acuity was 20/50. 28% of eyes recorded to have 20/30 or better vision. 35% had between 20/30 and 20/60,
27% between 20/60 and 20/200, 10 % had worse than 20/200.
Discussion: Visual outcomes are often better for bilateral infantile cataracts compared to the unilateral population of IATS but the range is from normal to legally blind. Visual axis opacification and glaucoma are the most
common adverse events in the months to years after surgery.
Conclusion: Treatment for patients with bilateral congenital cataracts often results in near normal vision.
Patients implanted primarily with an IOL had more returns to the operating room for visual axis opacification but
less glaucoma.
Poster 21
Thursday
9:55 - 10:55 am
JAAPOS Abstract #114
References: Infant Aphakia Treatment Study Group, Lambert SR, Buckley EG, Drews-Botsch C, DuBois L, Hartmann EE, Lynn MJ, Plager DA,
Wilson ME. A randomized clinical trial comparing contact lens with intraocular lens correction of monocular Aphakia during infancy: grating acuity
and adverse events at age 1 year. Arch Ophthalmol.2010 Jul;128(7):810-8.
Infant Aphakia Treatment Study Group, Lambert SR, Buckley EG,
Drews-Botsch C,
DuBois L, Hartmann E, Lynn MJ, Plager DA, Wilson ME. The infant aphakia treatment study: design and clinical measures at
enrollment. Arch Ophthalmol. 2010 Jan;128(1):21-7
Birch EE, Cheng C, Stager DR Jr, Weakley DR Jr, Stager DR Sr. The critical
period for surgical treatment of dense congenital bilateral cataracts. J AAPOS.2009 Feb;13(1):67-71.
Kim DH, Kim JH, Kim SJ, Yu YS. Longterm results of bilateral congenital cataract treated with early cataract surgery, aphakic glasses and secondary IOL implantation. Acta Ophthalmol.
2012 May;90(3):231-6.
Plager DA, Lynn MJ, Buckley EG, Wilson ME, Lambert SR; Infant Aphakia Treatment Study Group. Complications,
adverse events, and additional intraocular surgery 1 year after cataract surgery in the infant Aphakia Treatment Study. Ophthalmology. 2011
Dec;118(12):2330-4.
Beck AD, Freedman SF, Lynn MJ, Bothun E, Neely DE, Lambert SR; Infant Aphakia Treatment Study Group. Glaucomarelated adverse events in the Infant Aphakia Treatment Study: 1-year results. Arch Ophthalmol. 2012 Mar;130(3):300-5.
Long-Term Cumulative Incidence of Glaucoma after Congenital Cataract Surgery
Scott R Lambert; Amitabh Purohit; Hillary M Superak; Micheal J Lynn; Allen D Beck
Emory Eye Center, Atlanta, GA
Introduction: Glaucoma is one of the greatest threats to vision following congenital
cataract surgery. The odds of developing glaucoma have been reported to be directly
related to the age of surgery after short-term follow-up.1 We report the long-term cumulative incidence of glaucoma in a consecutive series of children undergoing congenital
cataract surgery
Methods: We reviewed the medical record of a consecutive series of children who
underwent congenital cataract surgery by one surgeon. Inclusion criteria included cataract surgery <7 months of age and a minimum follow-up of 12 months. Glaucoma was
defined as IOP >21 mmHg coupled with glaucomatous optic neuropathy or pressureinduced ocular enlargement. Glaucoma suspect was defined as IOP >21mmHg without
any other associated signs of glaucoma. A Kaplan-Meier analysis was used to calculate
the cumulative incidence of glaucoma.
Results: A total of 65 eyes in 41 children who underwent congenital cataract surgery at
a median age of 2.0 months were reviewed. The median follow-up after cataract surgery
was 5.5 years (range, 1.3 to 21.8 years). Six eyes (9.2%) developed glaucoma a median
of 2.7 months after cataract surgery. An additional 15 eyes (23.1%) were diagnosed as
glaucoma suspects a median of 9.7 years after cataract surgery. The cumulative incidence of glaucoma was projected to be 9.6% 5 years after congenital cataract surgery
(95% CI: 4.4% - 20.1%).
Discussion: Nearly one-quarter of the eyes in our series were glaucoma suspects,
but they have not yet developed glaucoma. Long-term monitoring of these eyes will be
important since they are at increased risk of developing glaucoma.
Conclusion: We projected the cumulative incidence of glaucoma to be about 10% 5
years after congenital cataract surgery.
References: 1.
Beck AD, Freedman SF, Lynn MJ, Bothun E, Neely DE, Lambert SR. Glaucoma-related adverse events in the Infant
Aphakia Treatment Study: 1-year results. Arch Ophthalmol. 2012;130:300-5.
59
Poster 22
Thursday
9:55 - 10:55 am
JAAPOS Abstract #069
Poster 23
Thursday
9:55 - 10:55 am
JAAPOS Abstract #050
The Role of Goniotomy in the Management of
Aphakic Glaucoma - extended follow up
Eva Gajdosova MD, PhD; William Moore FRCOphth; Ken K Nischal FRCOphth
Department of Academic and Clinical Ophthalmology,
Great Ormond St Hospital for Children
London, United Kingdom
Introduction: We wished to determine the role of goniotomy in cases with aphakic glaucoma after congenital cataract surgery.
Methods: Retrospective case note review of patients (pts.) with aphakic glaucoma undergoing goniotomy between Sept 1999 and Sept 2008.
Results: We identified 6 pts. (8 eyes) who underwent 12 goniotomies (10 temporal
approach goniotomies (TAG), 2 nasal approach goniotomies (NAG)). All patients underwent lensectomy without intraocular lens implant. All 8 eyes had anomalous angle on
gonioscopy. Median age at cataract surgery was 2 months (range 0.75-3 months). There
were 4 pts. (4 eyes) with unilateral cataract with persistent fetal vasculature (PFV), 2 pts.
(4 eyes) with bilateral cataract. Median age at presentation of glaucoma was 4 months
(range 1.5-20 months). Median time of follow up after last goniotomy was 68.5 months
(range 23-114 months). 4/8 eyes (all with PFV) underwent 1-3 cyclodiode treatments
before TAG or NAG. 6 of 8 eyes (75%) were controlled with no sign of glaucoma progression with/without topical treatment by 1 or 3 goniotomies. 2 of 8 eyes required multiple
cyclodiode lasers after last goniotomy was performed to control glaucoma. 1 of 8 eyes
had developed rhegmatogenous retinal detachment 23 months after NAG. No eye developed hyphaema that needed evacuation.
Discussion: In this small series 75% of eyes had controlled glaucoma with/without
drops by goniotomy/-ies and were spared from filtration/seton surgery.
Conclusion: Goniotomy should be considered as a treatment option in cases of aphakic
glaucoma when gonioscopy shows an abnormality of the angle, especially in cases of
PFV.
Poster 24
Thursday
9:55 - 10:55 am
JAAPOS Abstract #064
Ocular and systemic findings in Peters’ anomaly
Darakhshanda Khurram; Jayaprakash Patil; Eva Gajdosova; Will Moore; Samer Hamada
Great Ormond Street Children Hospital
London, United Kingdom
Dexamethasone Intravitreal Implant (Ozurdex) in the Treatment of Pediatric Uveitis
Monica L Bratton MD; Yu Guang He MD; David Weakley MD
University of Texas Southwestern Medical Center
Dallas, Texas
Introduction: The dexamethasone (Ozurdex) implant (Allergan Inc. Irvine Ca.) is an implantable biodegradable polymer containing of 0.7 mg of dexamethasone. It is approved
for the treatment of non-infectious uveitis in adults.
Methods: A retrospective chart review of all pediatric patients at our institution with noninfectious posterior uveitis unresponsive to standard treatment that received the Ozurdex
implant.
Results: Thirteen eyes of 10 patients (mean age 9.5 years range 4-12 years) underwent
one to three Ozurdex implants (total 18 implants) in 2011-2012. Seven patients (10 eyes)
had idiopathic intermediate or posterior uveitis. The remaining 3 patients had sympathetic
ophthalmia, juvenile idiopathic arthritis and sarcoidosis. All patients were uncontrolled
with standard treatments including topical corticosteroids, subtenon’s corticosteroid
injections and systemic corticosteroid and/or immune-modulation. Improvement was
noted initially in all patients, and implantation allowed for reduction of topical treatment in
most eyes. Four eyes (31%) underwent 2 or 3 implantations for recurrent inflammation.
Complications included implant migration into the anterior chamber in aphakic eyes (5
implants), increased IOP (> 10 mm/hg from baseline) in 3 eyes, and progression of a preexisting cataract (1 eye).
Discussion: The Ozurdex implant should be considered in pediatric patients with refractory uveitis. The adverse events identified in our study are similar to those identified in
adult studies.
Conclusion: The dexamethasone intravitreal implant can be used safely and effectively
in the pediatric population as an adjunctive treatment for intraocular inflammation in noninfectious intermediate and posterior uveitis.
Natural history of retinal hemorrhage in children with abusive
or accidental head trauma
Wendy S Chen MD PhD; Brian Forbes MD PhD; Gui-shuang Ying PhD;
Jiayan Huang MS; Gil Binenbaum MD MSCE
The Children’s Hospital of Philadelphia and Scheie Eye Institute, Perelman School of
Medicine at the University of Pennsylvania, Philadelphia, PA
Introduction: Retinal hemorrhage (RH) is an important sign of abusive head trauma.
Ophthalmologists are commonly asked to infer injury timing with limited data to guide
them. We sought to describe the natural history of RH in children with head trauma and
identify patterns that might suggest chronicity.
Methods: A retrospective case notes study was conducted in all the patients with anterior segment developmental anomaly who were either treated surgically or medically
in the Paediatric Ophthalmology Department of Great Ormond Street Children Hospital
between January 2000 and Dec 2011. No exclusion criteria were defined for this study.
Methods: Retrospective cohort study of children age <2 years at the Children’s Hosptial
of Philadelphia during 2001-2009 with abusive or accidental head trauma, RH on initial
fundus exam within 72 hours of presentation, and one or more follow-up exams. Each
RH type was graded as none, mild, moderate, severe.
Results: A total of 200 procedures were performed on 72 eyes of 35 patients. The
procedures included 31 PKPs and 90 glaucoma procedures. The median follow-up was 9
years (11 years to 8 months from the time of first procedure.) VA greater than 1.0 logmar
was achieved in12 patients, less than 1.0 logmar to hand movement in 14 patients, light
perception in 4 and no light perception in 7 patients. Post operative complications were
graft failure(8.33%), cataract(8.57%), glaucoma in 4 eyes, phthisis in 5 eyes. 68% of patients had systemic involvement including cardiac anomalies and developmental delay.
Results: 104 eyes of 52 children qualified. Intra-RH was present in 91 eyes (62 toonumerous-to-count). At 1 week, intra-RH resolved to none or mild (<10 hemorrhages) in
99%. The longest an isolated intra-RH persisted was 32 days. Pre-RH was present in 68
eyes, persisting 5-111 days. Upon initial exam, 22% eyes had only intra-RH, 66% both
pre and intra, 0% only pre; at 2 weeks, 3% intra, 18% both, 45% pre. In no cases did RH
worsen. 10 eyes had folds, 19 retinoschisis.
Conclusion: Long term visual outcomes of Peters’ anomaly differ according to the disease severity.
60
JAAPOS Abstract #037
References: Lowder, C., et al., Dexamethasone Intravitreal Implant for Noninfectious Intermediate or Posterior Uveitis. Arch Ophthalmol, 2011.
129(5): p. 545-553.
Introduction: Peters’ anomaly is a congenital anterior segment anomaly of the eye,
characterized by central corneal opacity and the corresponding posterior stromal defect.
The purpose of the study was to document the frequency of systemic disease in patients
with Peter’s anomaly, investigate the long term clinical course and to determine the final
visual outcomes in unilateral and bilateral disease.
Discussion: Children born with Peters’ anomaly require thorough clinical examination,
including UBM. These patients should be screened for any associated systemic anomalies in case of bilateral disease.
Poster 25
Thursday
9:55 - 10:55 am
Discussion: The time course observed matches birth-related RH studies. Traumatic
pre-RH did not occur without intra-RH, suggesting a spectrum relating to increasing
trauma severity (intra-RH, then coincident pre-RH, then folds/retinoschisis).
Conclusion: In young children, most intra-RH clear quickly, within a week, while preRH may persist for many weeks. The presence of pre-RH with no or only mild intra-RH
indicates that head trauma occurred days or more prior to the eye exam.
61
Poster 26
Thursday
9:55 - 10:55 am
JAAPOS Abstract #039
Poster 27
Thursday
9:55 - 10:55 am
JAAPOS Abstract #100
Retinal vasoproliferative tumors in patients with neurofibromatosis.
An analysis of 6 patients
Jerry A Shields MD; Marco Pellegrini MD; Swathi Kaliki MD; Carol L Shields MD
Wills Eye Institute, Philadelphia, PA
Introduction: Most patients with neurofibromatosis type 1 (NF1) have no major fundus manifestations. However, rare findings include multiple choroidal nevi, myelinated nerve fibers,
combined hamartoma, choroidal schwannoma and choroidal melanoma. Another fundus
lesion, retinal vasoproliferative tumor, (RVPT) has recently been recognized with NF1.
Methods: The authors reviewed the fundus findings and management of 6 patients with NF1
who developed RVPT.
Results: The mean patient age at recognition of RVPT was 18 years (median 12; range
9-36). There were 3 females and 3 males. Other ocular findings of NF1 included multiple
Lisch nodules in 2 and optic nerve glioma in 1. The VPT was located between the equator
and ora serrata in 5 cases and posterior to equator in 1 case The mean basal diameter of
VPT was 11 mm, with a mean thickness of 4 mm. Associated features included retinal detachment (n=6), yellow exudation (n=6) epiretinal membrane (n=3),), retinal hemorrhage (n=2),
retinal neovascularization (n=1) cystoid macular edema (n=1). The primary treatment included
cryotherapy (n=1), cryotherapy with intravitreal Bevacizumab (n=2), subtenon’s Triamcinolone
(n=1), plaque radiotherapy (n=1), and enucleation (n=1).
Discussion: RVPTs have been classified into primary and secondary types. Secondary
RVPTs have been observed with an increasing number of pediatric fundus conditions including intermediate uveitis, retinitis pigmentosa, Coats’ disease, retinopathy of prematurity,
familial exudative vitreoretinopathy, and others.
Conclusion: RVPT should be added to the list of conditions that can occur with NF1 and
children with NF1 should be monitored for RVPTs. This tumor can lead to severe visual loss
may require vigorous treatment.
Selected references: 1. Shields JA, Decker WL, Sanborn GE, et al. Presumed acquired retinal hemangiomas. Ophthalmology 1983;90:1292-300.
2. Shields CL, Shields JA, Barrett J, DePotter P. Vasoproliferative tumors of the ocular fundus. Classification and clinical manifestations in 103
patients. Arch Ophthalmol 1995;113:615-23.
3. Shields JA, Reichstein D, Mashayekhi A, Shields CL. Retinal vasoproliferative tumors in ocular conditions of childhood. J AAPOS 2012;16:6-9.
4. Shields CL, Kaliki S, Al-Dahmash SA, Rojanaporn D, Shukla SY, Reilly B, Shields JA, Vasoproliferative tumors of the ocular fundus. Comparative
clinical features of primary versus secondary tumors in 334 cases. Arch Ophthalmol in press.
Poster 28
Thursday
9:55 - 10:55 am
JAAPOS Abstract #098
Incidence of Pineal Gland Cyst and Pineoblastoma in Children with Retinoblastoma during the Chemoreduction Era
Aparna Ramasubramanian; Christina Kytasty; Jerry A Shields; Anna T Meadows;
Ann Leahey; Carol L Shields
Drexel University College of Medicine/Hahnemann, Wills Eye Institute,
Childrens Hospital of Philadelphia, Philadelphia
References: 1. De Potter P, Shields CL, Shields JA. Clinical variations of trilateral retinoblastoma. A report of 13 cases. J Pediatr Ophthalmol
Strabismus 1994; 31:26-31.
Incidence of Retinopathy of Prematurity (ROP) in Infants Greater Than 31 Weeks
Gestational Age Undergoing Screening Examinations for ROP
MASSIMILIANO SERAFINO MD; FRANCESCO PICHI MD; GIAN PAOLO GIULIARI MD;
CAROL L SHIELDS MD; ANTONIO P CIARDELLA MD; PAOLO NUCCI MD
San Giuseppe Hospital, University Eye Clinic, University of Milan, Milan, Italy
Jennifer L Hsu, MD; Stefan Sillau, MS; Rebecca S Braverman, MD;
Robert E Enzenauer, MD
University of Colorado, Denver, Colorado
References: 1. Pichi F, Serafino M, Sacchi M, Lembo A, Nucci P. A spectral domain optical coherence tomography and autofluorescence classification of retinal astrocytic hamartomas: Old and new frontiers. Journal of AAPOS 16 (1), e25-e25
2. Shields JA, Shields CL. Glial tumors of the
retina and optic disc. In: Atlas of Intraocular Tumors. Philadelphia: Lippincott, Williams & Wilkins; 1999: 272-283.
62
JAAPOS Abstract #093
Introduction: Pineoblastoma is an important cause of mortality in retinoblastoma patients
during the first 5 years of life. In the pre-chemoreduction era, pineoblastoma was found in 8%
of all bilateral familial retinoblastoma and 5% of all bilateral sporadic retinoblastoma (1)
Methods: Magnetic resonance imaging (MRI) features of the pineal gland were evaluated in
408 patients with retinoblastoma.
Results: Of 408 patients, treatment included systemic chemoreduction in 252 (62%) and
non-chemoreduction methods in 156 (38%). Overall, 34 patients (8%) manifested pineal gland
cyst and 4 (1%) showed pineoblastoma. Of all 408 patients, comparison (chemoreduction vs
non-chemoreduction) revealed pineal cyst (20/252 vs 14/156, p = 0.7) and pineoblastoma
(1/252 vs 3/156, p=0.1). The pineal cyst (n=34) (mean diameter - 4 mm) was asymptomatic,
and followed conservatively (n=34) and 5 cases (15%) showed minimal enlargement but without progression to pineoblastoma. The cyst was found in 22 germline and 12 non-germline
patients (p=0.15). Among the 4 patients with pineoblastoma, 2 had family history of retinoblastoma (50%). Among all patients with family history of retinoblastoma (n = 45), 4% developed
pineoblastoma. The pineoblastoma was detected on routine screening in 2 patients and 2
patients presented with vomiting and headache. Management included surgery, aggressive
chemotherapy and radiotherapy with 2 survivors.
Discussion: Pineal gland cyst was incidentally detected in 8% of retinoblastoma patients
screened by MRI and none showed progression to pineoblastoma. Compared to historic
reports, fewer cases of pineoblastoma are currently diagnosed.
Conclusion: Fewer patients who received systemic chemotherapy developed pineoblastoma
possibly indicating a protective effect.
Retinal Astrocytic Hamartoma: Spectral-Domain Optical Coherence Tomography
Classification and Correlation with Tuberous Sclerosis Complex
Introduction: Retinal astrocytic hamartoma (RAH) is the best-known ocular manifestation
of tuberous sclerosis complex (TSC). We classified RAHs using spectral-domain OCT in 86
eyes and correlate each class with systemic manifestations of TSC.
Methods: Systemic features of TSC of 47 patients with RAHs were recorded. The examiners
classified the RAHs using SD-OCT into one of 4 groups1. The association between class of
RAH and systemic manifestations of TSC was studied using univariate analysis on one-way
ANOVA test and multiple linear regression analysis.
Results: Logistic regression showed that type III RAHs (20.4%) are the only independent
significant factor strictly associated with subependymal giant-cell astrocytoma (SEGAs) of the
brain (70% of type III; odds ratio = 0,995; 95% CI; P < 0,001); type IV RAHs (12.2%) seem
to be found only in patients with pulmonary lymphangiomyomatosis (100% of type IV; odds
ratio = 1); finally type II RAHs (25.5%) are an independent significant factor associated with
forehead plaques (92% of type II; odds ratio = 0,997; 92% CI; P < 0,001). Analysis with paired
t test showed no significant correlation between the four types and all others systemic manifestations (P = 0,26 for type I, P = 0,12 for type II, P = 0,19 for type III, P = 0,24 for type IV).
Discussion: The statistical correspondence between type III RAHs and SEGAs emphasizes
the histological similarities of the two lesions, composed of elongated fibrous astrocytes with
interlacing cytoplasmic processes2. We found a statistical association between the cavitary
type IV RAHs and pulmonary lymphangiomyomatosis which is characterized by cystic destruction of lung parenchyma.
Conclusion: A non-invasive technique such as SD-OCT could become a fundamental tool in
screening patient and referring them to the specialist.
Poster 29
Thursday
9:55 - 10:55 am
Introduction: There is some discrepancy regarding what gestational age should be
used as the criterion for retinopathy of prematurity (ROP) screening examinations (1,2).
The purpose of this study is to determine whether screening infants born at 30 weeks or
less gestational age results in failure to diagnose Type 1 ROP compared to screening
infants at 32 weeks or less gestational age.
Methods: An Institutional Review Board (IRB) approved retrospective chart review of
premature infants born at 31 weeks gestational age or later who underwent ROP screening examinations between June 2008 and December 2011 was performed.
Results: 101 infants met the inclusion the criteria. Four infants developed Type 2 ROP
and none developed Type 1 ROP. Of the infants with Type 2 ROP, two had a birthweight
of less than 1500g, one had a birthweight of 1545g, and one infant had a complicated
clinical course.
Discussion: 4% of infants in our study developed Type 2 ROP and none required treatment. The infants that developed ROP had a lower birthweight and additional co-morbidities.
Conclusion: Our findings suggest that it may be feasible to reduce the recommended
gestational age criterion for retinopathy of prematurity screening examinations from 32
weeks to 30 weeks or less gestational age. These findings are consistent with published
recommendations (1,2). Eliminating unnecessary examinations would be cost effective.
References: 1. Section on Ophthalmology. Screening Examination of Premature Infants for Retinopathy of Prematurity. PEDIATRICS. 2006 Feb
1;117(2):572-6.
2. ERRATA. PEDIATRICS. 2006 Sep 1;118(3):1324-1324.
63
Poster 30
Thursday
9:55 - 10:55 am
JAAPOS Abstract #060
Poster 31
Thursday
9:55 - 10:55 am
JAAPOS Abstract #092
Evaluation of an Indirect Ophthalmoscopic Digital Photographic System (Keeler)
as a Retinopathy of Prematurity (ROP) screening tool
Sasapin G Prakalapakorn MD, MPH; Sharon F Freedman MD; Yuliya Lokhnygina Ph.D.;
David K Wallace MD, MPH
Duke University, Durham, NC 27710, USA
Introduction: While retinopathy of prematurity (ROP) remains an important cause of
blindness, there is a paucity of trained screeners, especially in the developing world(1).
The purpose of this study was to determine whether digital retinal images obtained using
an indirect ophthalmoscopic imaging system (Keeler) could be accurately graded for preplus or plus disease by masked experts and potentially be used for telemedicine.
Methods: We performed a retrospective chart review of infants screened for ROP
(11/2009-11/2011), who had posterior pole images acquired using the Keeler system during routine ROP examinations. Masked to the clinical exam findings, two ROP experts
reviewed and graded these images as normal, pre-plus or plus. We compared the experts’ grades of Keeler digital retinal images for a given eye on a given exam against the
clinical examination results from the same session.
Results: Included were 253 infants (average gestational age = 27 weeks (range: 23-34),
birth weight = 961 grams (range: 450-2300), post-menstrual age at examination = 35
weeks (range: 30-42)). Of those infants with plus disease on clinical exam, graders 1
and 2 had a sensitivity of 100% and 94% and specificity of 86% and 89%, respectively,
for grading pre-plus or plus disease.
Discussion: Digital retinal images obtained by the Keeler system can be read with a
high sensitivity and specificity to screen for clinically important ROP.
Conclusion: The Keeler system may be a valuable tool for ROP screening at a distance
(i.e. via telemedicine).
References: 1. Gilbert C. Retinopathy of prematurity: a global perspective of the epidemics, population of babies at risk and implications for control.
Early human development 2008;84:77-82.
Poster 32
Thursday
9:55 - 10:55 am
JAAPOS Abstract #112
Improved Speed and Accuracy of Plus Disease Quantification
Using Image Fusion Methodology
Laura A Vickers MD; David K Wallace MD, MPH; Sharon F Freedman MD;
Rolando Estrada PhD; Sina Farsiu PhD; Grace Prakalapakorn MD, MPH
Duke University Eye Center, Durham, North Carolina
Introduction: The diagnosis of plus disease in Retinopathy of Prematurity (ROP) largely
determines the need for treatment; however, this diagnosis is subjective and prone to error. [1] ROPtool is a semi-automated computer program that quantifies vascular tortuosity
and dilation. A previous study showed that more than half of video indirect ophthalmoscopy still images had insufficient quality to permit analysis by RopTool. [2] We evaluated
the ability of an image fusion methodology (robust mosaicing) to increase traceability and
improve efficiency of posterior pole disease analysis using RopTool.
Methods: We reviewed video indirect ophthalmoscopy images from routine ROP examinations of 39 right eyes of 39 infants (September 2010-March 2011). We selected the
best unenhanced still image from the video for each infant. Robust mosaicing, a multiframe image fusion algorithm, created an enhanced still image from the same video for
each eye. We evaluated the time required and ROPtool’s ability to analyze two major
vessels per quadrant on the enhanced vs. unenhanced still images.
Results: Mean(range) gestational age was 27 weeks(24-35); birthweight 885
grams(540-1660). Of 156 quadrants available for analysis, 10(6%) had plus and 11(7%)
had pre-plus disease. ROPtool analysis was faster (124 vs 153 seconds; p=0.017) and
able to trace more quadrants (143/156, 92% vs 115/156, 74%; p<0.0001) using enhanced vs. unenhanced still images, respectively.
Discussion: Enhancing images with robust mosaicing increases traceability and decreases time to analyze posterior pole vessels by ROPtool.
Conclusion: Retinal image enhancement using robust mosaicing advances efforts to
automate the grading of posterior pole disease in ROP.
References: 1. Wallace DK, Quinn GE, Freedman SF, Chiang MF. Agreement among pediatric ophthalmologists in diagnosing plus and pre-plus
disease in retinopathy of prematurity. J AAPOS 2008;12(4):352-6.
2. Ahmad S, Wallace DK, Freedman SF, Zhao Z. Computer-assisted assessment of plus disease in retinopathy of prematurity using video indirect ophthalmoscopy images. Retina 2008;28(10):1458-62.
64
Factors influencing rates of Retinopathy of Prematurity (ROP) in Argentina: a case
study of policy, legislation and international collaboration
Luxme Hariharan MD MPH; Graham E Quinn MD MSCE; Clare Gilbert MD MSc ;
Juan E Silva MD MPH; Alicia Benitiz MD, Celia Lomuto MD; Ana Quiroga RN
University of Pennsylvania Scheie Eye Institute
Philadelphia, Pennsylvania
Poster 33
Thursday
9:55 - 10:55 am
JAAPOS Abstract #056
Introduction: The purpose of this study is to describe the key processes and stakeholders, including the Ministry of Health (MOH) and UNICEF, involved in the recognition of
an epidemic of ROP blindness in Argentina to the development of national guidelines,
policies and legislation for its control.
Methods: Data on the incidence of ROP was collected from 13 NICUS from 1999 until
2012, as well as the percent of children blind from ROP in 9 blind schools throughout 7
provinces in Argentina. Additionally, document reviews, focus group discussions and key
informant interviews were conducted with neonatologists, ophthalmologists, neonatal
nurses, MOH officials, clinical societies, legislators and UNICEF staff in the 7 provinces.
Results: In the late 1990’s over 80% of children under 5 years old in schools for the
blind were blind from ROP. Recognition of this led to the formation of a National ROP
group through the MOH in 2003, a targeted intervention of workshops and capacity building with UNICEF from 2004-2008 and the development of a national ROP screening law
in 2007. By 2012, the rates of ROP as a cause of blindness in children in blind schools
and the rates of severe ROP needing treatment in the NICUs visited had decreased
significantly.
Discussion: The combination of a national ROP program, collaboration with UNICEF
and national legislation, played a role in decreasing ROP in 7 provinces throughout Argentina.
Conclusion: The lessons learned and successes experienced in Argentina can hopefully be replicated in other countries in Latin America and beyond.
References: 1) Gilbert C. Retinopathy of Prematurity: A Global Perspective of the epidemics, population of babies at risk and implications for
control. Early Human Development, 2008: 84; 77-82
2) Gilbert C, Fielder A, Gordillo L, Quinn G, Semiglia R et al, Characteristics of infants with
severe ROP in countries with low, moderate and high levels of development: implications for screening programs. Pediatrics, 2005; 115: e518-25
3) Zin A. The Increasing problem of ROP Community Eye Health 2001: 14:58-9
Comparison of Serum VEGF Levels, Vision and Neurological Development in Laser
and Bevacizumab Treated ROP Patients
Lingkun Kong MD, Ph.D, David K Coats MD, Kimberly L. Dinh, Pharm.D2,
Robert Voigt, MD, Sid Schechet, MS, Paul G Steinkuller MD
Dept. of Ophthalmology, Baylor College of Medicine, Houston TX 77030
Introduction: To measure serum levels of Bevacizumab and VEGF in infants who were
treated with intravitreal injection of Bevacizumab or laser for type 1 ROP, and to observe
the effects on vision and neurological development.
Methods: Infants with type 1 ROP were treated with either 0.625 mg intravitreal injection
of Bevacizumab or laser. Blood samples were collected before treatment and on posttreatment day 2, 14, 42 and 60. Serum levels of Bevacizumab and VEGF were measured
on each sample. Ocular and neuro-developmental outcomes were assessed and compared, as were systemic complications.
Results: 1) The serum level of Bevacizumab was detected at 2 days after intravitreal
injection, peaked at 14 days, and last at least for 60 days. 2) The serum level of VEGF
decreased in both groups 2 days after the treatment. 3) There were no significant differences in the systemic complications. 4) Refractive errors at age 1 year in the Bevacizumab treated group were significantly lower than in the laser treated group. 4) Neurological
development (developmental quotient, DQ) at last visit before age 1year was not significantly different.
Discussion: This is a preliminary outcome study. Long- term follows up and large group
studies are continuing.
Conclusion: Bevacizumab escapes into systemic circulation after intravitreal injection
and persists more than 2 months. Serum VEGF level decreased after both laser and
Bevacizumab treatment, but it was more significant in the Bevacizumab treated group.
The Bevacizumab treated group had lower refractive errors. There were no significant
neurodevelopmental differences between these two groups.
65
Poster 34
Thursday
9:55 - 10:55 am
JAAPOS Abstract #067
Poster 35
Thursday
9:55 - 10:55 am
JAAPOS Abstract #053
Computer-assisted Quantification of Plus Disease after Treatment of Retinopathy
of Prematurity with Intravitreal Bevacizumab
Kevin R Gertsch MD; David Wallace MD, MPH; J. Niklas Ulrich MD; Laura Enyedi MD;
Michelle Cabrera MD
University of North Carolina Department of Ophthalmology, Chapel Hill, NC
The Association of Prematurity and Nonglaucomatous Optic Disc Cupping
in Children
Introduction: Treatment for Type 1 retinopathy of prematurity (ROP) includes laser and,
more recently, intravitreal injection of bevacizumab [1]. This study uses ROPtool, a photoanalyzer, to objectively measure changes in retinal vascular dilation and tortuosity (plus disease)
following intravitreal bevacizumab.[2]
Methods: Fundus images from 6 newborns treated with intravitreal bevacizumab for ROP
were analyzed using ROPtool to assess for changes in tortuosity, dilation and a calculation
of overall plus disease. Measurements were obtained at baseline (n=6), 1 week (n=6), and 2
weeks (n=1) after treatment.
Results: Average vessel tortuosity decreased by 49%, dilation decreased by 9% and overall
plus disease decreased by 17% in the first week after treatment with bevacizumab. One week
later, the average vessel tortuosity decreased by another 20%, dilation decreased by 1%, and
overall plus disease decreased by 14%.
Discussion: Few studies have shown objective changes in ROP after treatment with laser[3]
but no previous studies have shown similar objective findings after treatment with bevacizumab. This study demonstrates a larger decrease in tortuosity at 1 week post-bevacizumab
compared to a previous study of post-laser patients analyzed by Computer Assisted Image
Analysis Software (that study found only a 2% decrease in tortuosity and 20% decrease in
dilation at 1 week)[3].
Conclusion: Objective measurements of plus disease show greater changes in tortuosity 1
week after treatment with bevacizumab compared to a previous study of post-laser changes.
Understanding the expected pattern of change over time in retinal vascular dilation and tortuosity following bevacizumab guides clinicans’ expectations for ROP regression following this
new treatment.
Introduction: The purpose of our study was to examine the association of premature
birth and nonglaucomatous optic disc cupping in children and the neurologic correlates in
premature and nonpremature cohorts with nonglaucomatous optic disc cupping.
Methods: Within a comprehensive pediatric ophthalmology practice associated with a
children’s hospital, a computerized database search was conducted of all patients seen
over a four year period with nonglaucomatous optic disc cupping. Optic disc parameters
measured with digital photographs and history with regard to prematurity were evaluated
and compared to control groups from the same practice. Data regarding associated systemic or neurologic disease was tabulated and existing neuroimaging reviewed.
Results: Forty-five eyes (mean horizontal cup/disc 0.704 ± SD 0.021) with nonglaucomatous cupping had clinically larger discs than 31 eyes (mean horizontal cup/disc 0.407
± 0.095) without large cups (cupping eyes mean disc area 3.352 ± 0.176 mm squared
versus eyes without large cups mean disc area 2.370 ± 0.355 mm squared, P < 0.0001).
The nonglaucomatous cupping group showed 14 (31%) of 45 children premature (all had
gestational age at birth 32 weeks or less), and the control group showed 5 (3.9%) of 128
consecutive patients with gestational age at birth of 32 weeks or less (P < 0.001). Periventricular leukomalacia was not seen.
Discussion: We found a statistically and clinically significant increased prevalence of
prematurity in pediatric patients with nonglaucomatous cupping. The cupping was associated with large disc size but not with periventricular leukomalacia.
Conclusion: Prematurity should be considered in evaluating the etiology of optic disc
cupping in children.
References: 1. Mintz-Hittner HA, Kennedy KA, Chuang AZ for the BEAT-ROP Cooperative Group. Efficacy of Intravitreal Bevacizumab for Stage
3+ Retinopathy of Prematurity. N Engl J Med 2011; 364:603-615.
2. Wallace DK, Zhao Z, Freedman SF. A pilot study using “ROPtool” to quantify
plus disease in retinopathy of prematurity. J AAPOS 2007;11:381-7.
3. Kwon JY, Ghodasra DH, Karp KA, Quinn GE, et al. Retinal vessel changes
after laser treatment for retinopathy of prematurity.J AAPOS 2012;16:350-353.
Poster 36
Thursday
9:55 - 10:55 am
JAAPOS Abstract #096
Orbital Ultrasonography in Premature Babies with and without
Retinopathy of Prematurity
Yonina D Ron Kella; David Barash; Miri Erhenberg; Ronit Friling; Micky Osovsky;
Rita Ehrlich
Schneider Children’s Medical Center, Petach Tikva, Isreal
Introduction: Retinopathy of prematurity (ROP) is routinely assessed by direct visualization of the retina. The purpose of this study was to echographically assess the orbits of
premature babies including those with ROP.
Methods: A prospective study was designed in which the orbits of premature babies
have been echographically demonstrated using Cine Scan S (Quantel Medical), provided
with standardized A-scan and 10 MHz B-scan. Optic nerve diameter was measured using the standardized A-scan. The superior ophthalmic vein (SOV) was demonstrated in
cases of dilatation. The examiner was masked to the retinal findings obtained on routine
examinations.
Results: Twenty premature babies were included in this study. The average gestational
age was 27.3 (±2.3) weeks, average birth weight 1000.3 (±338.9) grams. Ten babies (20
out of 20 eyes) were diagnosed with ROP at the time of the examination, none of whom
required treatment. The SOV was found to be dilated in all (20 out of 20) eyes with ROP
and in only 1 out of 20 eyes in babies who were not diagnosed with ROP. The average
optic nerve diameter was 2.52 (±0.24) mm, no specific correlation was found between
ROP and optic nerve diameter.
Discussion: The SOV was found to be significantly dilated in babies diagnosed with
ROP. No specific difference was found in optic nerve diameter between premature babies.
Conclusion: SOV dilatation may be another sign for ROP and requires further investigation.
66
Alexander E. Pogrebniak, MD
The Nemours Children’s Clinic, Jacksonville, Florida
Poster 37
Thursday
9:55 - 10:55 am
JAAPOS Abstract #091
References: Pogrebniak AE, Wehrung B, Pogrebniak KL, Shetty RK, Crawford P. Violation of the ISNT rule in nonglaucomatous pediatric optic disc
cupping. Invest Ophthalmol Vis Sci. 2010;51(2):890-895.
The Role of Magnetic Resonance Imaging in Diagnosing Optic Nerve Hypoplasia
Phoebe D Lenhart; Nilesh K Desai; Beau B Bruce; Amy K Hutchinson; Scott R Lambert
Emory University School of Medicine
Atlanta, Georgia, USA
Introduction: Optic nerve hypoplasia (ONH), one of the most common congenital abnormalities of the ON, can be difficult to diagnose by ophthalmologic examination alone. Our
goal was to establish normal ON size in children based on high resolution orbital magnetic
resonance imaging (MRI).
Methods: Case control study of ONH vs. normal controls. A neuroradiologist made four
total measurements of each ON at two locations (5 mm posterior to the optic disc and just
posterior to the optic canal). These measures were averaged for each ON and random
intercept mixed multivariable linear modeling was applied.
Results: Twenty seven cases of clinically confirmed ONH and 21 controls were identified. Median age for cases was 1 year vs. 5.5 years for controls. Eleven (41%) cases
and 9 (43%) controls underwent high-resolution T2-weighted imaging of the orbits at
a field strength of 3.0T; the remainder were done at 1.5T. Based on modeling, mean
ON measurement was 1.54 mm (95%CI:1.12-2.07;p<0.001) smaller for clinically hypoplastic ONs than for controls. ON size increased by 0.065 mm per year (95%CI:0.030.09;p<0.001). A lower bound to the 95% prediction interval for normal ONs was 2.25 mm
- 0.065 x (age in years) mm and excluded all cases.
Discussion: Age was independently associated with normal ON size by MRI.
Conclusion: Patient age needs to be taken into consideration when evaluating ONH
based on MRI criteria. We have provided a formula to assist clinicians in objectively determining if ONH is present.
References: Brodsky MC, Glasier CM, Pollock SC, Angtuago EJC. Optic nerve hypoplasia: identification by magnetic resonance imaging. Arch
Ophthalmol 1990;108:1562-7.
Lambert SR, Hoyt CS, Narahara MH. Optic nerve hypoplasia. Surv Ophthalmol 1987;32:1-9.
Hellstrom A, Wiklund L, Svensson E. Diagnostic value of magnetic resonance imaging and planimetric measurement of optic disc size in confirming
optic nerve hypoplasia. J AAPOS 1999;3:104-8.
67
Poster 38
Thursday
9:55 - 10:55 am
JAAPOS Abstract #072
Poster 39
Thursday
9:55 - 10:55 am
JAAPOS Abstract #071
Anti-TNF Therapy for Childhood and Adolescent Uveitis
Janet D Leath; Breno da Rocha Lima; Nida Sen; Mohamad S Jaafar
Children’s National Medical Center
Washington, DC
Notes
Introduction: Childhood uveitis is the third most common cause of blindness in the pediatric population (1). Numerous side effects of chronic corticosteroid use have prompted
a quest for a viable steroid-sparing treatment. Our purpose is to describe the corticosteroid-sparing effect of anti-TNF therapy in chronic childhood and adolescent uveitis.
Methods: Retrospective longitudinal case series of patients started on anti-TNF therapy
for chronic uveitis. Major outcome measures were corticosteroid-sparing success, adverse events, inflammation control, need for and ability to taper concurrent treatments
assessed at 1-, 3-, 6-, 12-, 18-, and 24-month intervals.
Results: Nineteen eyes of 10 patients who used adalimumab or infliximab and followed
for an average of 12 months were identified. Three patients had anterior uveitis and 7
had posterior segment uveitis. All patients with posterior segment inflammation improved
significantly with anti-TNF therapy. 84% of eyes with anterior chamber inflammation
improved or remained stable. Four patients (40%) required two cycles of therapy due to
either relapse or failure. All patients were successfully weaned to systemic steroid dose
of less than 7 mg/day without relapse, but 33% required lowdose maintenance steroids.
Half of patients required at least one other non-biologic systemic immunosuppressive
after 6 months. One serious adverse event (anaphylactic reaction to infliximab) was
identified.
Discussion: This is the first study of its’ kind looking at outcomes for both anterior and
posterior uveitis after relatively long term treatment with anti-TNF therapy in children.
Conclusion: Anti-TNF antibody biologics improve inflammation control and offer a
steroid-sparing therapy in pediatric uveitis patients.
References: Smith JA, Mackensen F, Sen HN, et al. Epidemiology and course of disease in childhood uveitis. Ophthalmology. 2009;116:1544-1551.
Poster 40
Thursday
9:55 - 10:55 am
JAAPOS Abstract #070
Corneal anesthesia in childhood
Rosemary G Lambley FRCOphth; Naira Pereyra MD; Asim Ali MD, FRCSC;
Kamiar Mireskandari FRCSEd FRCOphth PhD
Hospital for Sick Children, Toronto, Canada
Introduction: Corneal anesthesia (CA) in childhood carries a poor prognosis and there
is little literature on its management. We present the largest reported series of children
with this rare disorder.
Methods: We performed a retrospective chart review of children with congenital or
acquired CA presenting to our institution over the last 15 years. Patients with concurrent
facial nerve or other cranial nerve palsies were included.
Results: 21 eyes of 16 children were identified with CA caused by posterior fossa
tumours (5), cerebellar hypoplasia (3), severe head trauma (3), familial dysautonomia (2)
and isolated CA (3). The range of follow-up was 1-244 months, median 47.5 months.
Six eyes in four children had final visual acuities (VA) of 20/40 or better. All eyes with VA
20/200 or worse at last follow-up had associated facial nerve palsy (CNVIIP) or isolated
CA. Complications included corneal scarring (81%), infectious keratitis (48%), corneal
neovascularization (48%) and perforation secondary to keratitis (5%). Four children
underwent corneal grafting for perforation or scarring. All grafts became hazy or opaque,
with VAs of 20/800 or worse.
The commonest surgical procedure was tarsorrhaphy (ten eyes). Seven were done on
eyes with VA already 20/200 or worse. The three eyes undergoing tarsorrhaphy with VA
better than 20/200 maintained vision of at least 20/200.
Discussion: Isolated CA, and CA with CNVIIP, are associated with visual outcomes
below 20/200. Earlier tarsorrhaphy may help preserve vision in these high-risk eyes.
Conclusion: We recommend that ophthalmologists suspect and test for CA in children
with painless epithelial defects and consider early tarsorrhaphy.
68
69
Notes
Notes
70
71
Notes
Poster Schedule
2nd Set of Posters (41-80) Displayed from Friday, April 5, 4:15 PM - Sunday, April 7, 10:45 AM,
Essex Ballroom Foyer
Interactive Poster Session - Author Presentation and Q/A - Saturday, April 6, 10:00 - 11:00 AM
AMBLYOPIA - VISION - VISION SCREENING
72
Poster #41
Visual Evoked Potential Latency Predicts Improvement in Amblyopia Following Occlusion Therapy
Sina Salehi Omran, MS3
Sean P. Donahue, MD, PhD
Poster #42
Interocular Suppression and Amblyopia
Vidhya Subramanian
Reed M. Jost; Sheridan Jost; Eileen E. Birch
Poster #43
Ocular Component Growth in Children with Persistent Hyperopia
Simone L. Li, PhD
Vidhya Subramanian, PhD; Reed M. Jost, MS; Donald O. Mutti, OD, PhD; Eileen E. Birch, PhD
Poster #44
Sweep Visual Evoked Potential and Visual Development in Optic Nerve Hypoplasia
Krista J. Stewart
Jim Ver Hoeve; Yasmin Bradfield
Poster #45
Parental Understanding of Amblyopia and Compliance with Follow Up after Vision Screening
Justin Y. Rheem, BS
Demitrio J. Camarena, BS, BA; Blen D. Eshete, MPH; Leila M. Khazaeni, MD; Jennifer A. Dunbar, MD
Poster #46
Incidence of Pathology Found in Pediatric Patients Referred for Ophthalmologic Assessment Following Abnormal
Vision Screening
Andrea K. Leung, MD
Helia Garcia, OC; Heather de Beaufort, MD
Poster #47
High Sensitivity and Specificity of the Pediatric Vision Scanner in Detecting Strabismus and Amblyopia in
Preschool Children
Reed M. Jost, MS
Susan E. Yanni, PhD; Cynthia L. Beauchamp, MD; David R. Stager, Sr., MD; David Stager, Jr., MD;
Lori Dao, MD; Molly Nolan; Eileen E. Birch, PhD
Poster #48
The Efficacy of the PlusoptiX S04 Photoscreener as a Vision Screening Tool in Children with Autism
Thomas C. McCurry, MS, MBA
Linda Lawrence, MD; Liliana Mayo, PhD
Poster #49
PPOC Vision Screening Analysis
Suzanne C. Johnston, MD, MPH
Louis Vernacchio, MD, MSc; Emily K. Trudell, MPH; Katherine Majzoub, RN, MBA;
Rashmi Dayalu, MPH; Bruce Moore, OD
Poster #50
Effectiveness of Plusoptix Vision Screening in a School Setting with Modified Referral Criteria
Jennifer D. Davidson, MD
Mae Millicent W. Peterseim, MD; Benjamin C. Kramer, MD; Rupal H. Trivedi, MD
Poster #51
Does Adding Stereo Testing to PlusoptiX Photoscreening Improve Sensitivity?
Noelle S. Matta, CO, CRC, COT
David I. Silbert, MD, FAAP
Poster #52
Change in Community-Based Preschool Vision Screening from Visual Charts to Retinomax
Eugene A. Lowry
Ryan Lui; Travis C. Porco; Alejandra De Alba Campomanes
Poster #53
Prospective Evaluation of the Spot (Pediavision) Vision Screener as Autorefractor and in the Detection of
Amblyogenic Risk Factors Compared to Plusoptix and a Comprehensive Pediatric Ophthalmology Examination
Mae Millicent Peterseim
Rupal H. Trivedi; Vera A. Ball; Carrie E. Papa; Maria E. Shtessel; M. Edward Wilson;
Jennifer D. Davidson
Poster #54
Validation of Spot Screening Device for Amblyopia Risk Factors in a Pediatric Ophthalmology Clinic Setting
Glynnis A. Garry
73
Poster #55
Poster #56
Real-Time Automatic Strabismus Screening Using Digital Image Analysis Techniques
Annegret H. Dahlmann-Noor, PhD
Ron Maor; Simon Barnard, PhD; Yuval Yashiv; Gill Adams
Poster #71
Asymptomatic Pediatric Idiopathic Intracranial Hypertension
Sarah Whitecross, OC(C)
Gena Heidary, MD, PhD
STRABISMUS
Poster #72
Ocular Findings in Children Who Underwent Expansion Cranioplasty with Distraction Osteogenesis for
Craniosynostosis
Seung Ah Chung
Soolienah Rhiu; Soo Han Yoon; Jong Bok Lee
Mood and Quality of Life in Adults with Strabismus
Kelly A. MacKenzie BSc (Hons)
Hayley McBain, MSc, BSc; Joanne C. Hancox, FRCOphth; Daniel G. Ezra, FRCOphth;
Gillian G. Adams, FRCOphth; Stanton Newman, MRCP (Hons), CPsychol
REFRACTIVE
Poster #57
A New Continuous Outcome Measure for Assessing Strabismus
Jonathan M. Holmes
David A. Leske; Sarah R. Hatt; Laura Liebermann
Poster #73
Long Term Efficacy and Safety of Photorefractive Keratectomy in the Pediatric Population
Evelyn A. Paysse, MD
Zaina Al-Mohtaseb, MD; Lingkun Kong, MD; Mitchell P. Weikert, MD; David K. Coats, MD
Poster #58
Responsiveness of a Diplopia Questionnaire Score to Strabismus Surgery
David A. Leske
Sarah R. Hatt; Laura Liebermann; Jonathan M. Holmes
Poster #74
Poster #59
Incidence of Strabismus in Preverbal Children with Hyperopia Previously Diagnosed with Pseudoesotropia
Ariel L. Silbert
Noelle S. Matta, CO, CRC, COT; David I. Silbert, MD, FAAP
The Long-Term Outcome of the Refractive Error in Hypermetropic Children
Eedy Mezer, MD
Tamara Wygnanski-Jaffe, MD; Ewy Meyer, MD; Yaacov Sahuly, MD; Wofgang Haase, MD;
Albert W. Biglan, MD
Poster #60
Diagnostic Ophthalmologic Findings in Moebius Syndrome
Sarah E. MacKinnon, MSc, OC(C), COMT
Darren T. Oystreck, MMedSci, OC(C); Caroline V. Andrews, MS; Elizabeth C. Engle, MD;
David G. Hunter, MD, PhD
Poster #61
Outcomes Including Stereoacuity Following Surgical Correction of the Non-Accommodative Component in
Accommodative Esotropia
Sudhi P. Kurup, MD
Heath W. Barto, CO; Gihyun Myung, MD; Marilyn B. Mets, MD
Poster #62
The Use of Pre-Operative Botulinum Toxin Injection in Large Angle Childhood Esotropia
Katerina C. Fragkou, Dr
Vinod Sharma, Dr; Chris I. Lloyd, Pr; Susmito Biswas, Dr; Jane L. Ashworth, Dr
Poster #63
Does Injection into the Dominant or Non-Dominant Eye Affect the Outcome of Botulinum Toxin Injection for
Recurrent Strabismus?
Marlo L. Galli, CO
Gregg T. Lueder, MD
Poster #64
Incidence and Clinical Characteristics of Adult-Onset Distance Esotropia
Genie M. Bang, MD
Jennifer Martinez, MD; Brian G. Mohney, MD
Poster #65
Hypertropia in Unilateral, Isolated Abducens Palsy (6NP)
Matthew S. Pihlblad, MD
Joseph L. Demer, MD, PhD
Poster #66
Is the Convergence Insufficiency Symptoms Survey Specific for Convergence Insufficiency?
Lindsay Horan, CO
Benjamin H. Ticho, MD; Megan Allen, OD
Poster #67
The Sensitivity of the Bielschowsky Head Tilt Test in Diagnosing Bilateral Superior Oblique Paresis
Brinda Muthusamy, FRCOphth
Kristina Irsch, PhD; Peggy Chang, MD; David L. Guyton, MD
GENETICS
Poster #75
The Optic Nerve and Retinal Vasculature in Albinism: Normal or Abnormal?
Julie A. Conley, MD
Alejandra Decanini Mancera, MD; Ann M. Holleschau, BA, CCRP; C. Gail Summers, MD
Poster #76
Ophthalmic Manifestations of the Glycoproteinoses
Ronald G. Teed
Poster #77
Lenticular Changes in Cerebrotendinous Xanthomatosis, A Treatable Metabolic Disorder that is Important to
Recognize
Arif O. Khan
Mohammed A. Aldahmesh; Jawaher Y. Mohamed; Fowzan S. Alkuraya
NASOLACRIMAL - OCULOPLASTICS
Poster #78
Timing of Dacryostenosis Resolution and the Development of Anisometropia
Ma Khin Pyi Son, BA
Brian G. Mohney, MD; David O. Hodge, MS
Poster #79
Outcome of Patients with Lacrimal Canalicular Atresia
Mohamed Soliman
Gregg Lueder, MD
Poster #80
The Activity and Damage of Blepharokeratoconjunctivitis in Children
Ken Nischal
Samer Hamada; Joanne Evans
NYSTAGMUS - NEURO-OPHTHALMOLOGY
Poster #68
Visual Acuity Deficits in Children with Nystagmus and Down Syndrome
Joost Felius, PhD
Cynthia L. Beauchamp, MD; David R. Stager, Sr., MD
Poster #69
Normative Data on Pupil Size and Anisocoria in Children
Jillian F. Silbert
Noelle S. Matta, CO, CRC, COT; Jing Tian, MS; Eric L. Singman, MD, PhD; David I. Silbert, MD, FAAP
Poster #70
Can Color Vision and Retinal Nerve Fibre Layer Thickness Serve as Suitable Biomarkers in Childhood
Demyelinating Disease?
Manca Tekavcic Pompe
Darko Perovsek; Branka Stirn Kranjc
74
75
Visual Evoked Potential Latency Predicts Improvement in Amblyopia
Following Occlusion Therapy
Sina Salehi Omran, MS3; Sean P Donahue, MD, PhD
Vanderbilt Eye Institute, Nashville, TN
Introduction: Visual evoked potentials (VEP) can be used to diagnose amblyopia in a
preverbal child. We sought to determine the relationship between characteristics of the
VEP and the eventual outcome of occlusion therapy.
Methods: Twenty-one amblyopic individuals (age 3-6 years) were tested shortly after the
initiation of monocular occlusion for amblyopia therapy. The Diopsys NOVA-TR system
produced a checkerboard pattern reversal visual evoked response at 2 Hz for 10 seconds (20 reversals) for each of 5 spatial frequencies in the amblyopic and fellow eye. Of
the twenty-one, nineteen presented for follow-up after 6 months of treatment or having
reached a final endpoint. The difference in logMAR VA between initial and endpoint acuities was compared to the P100 latency of the amblyopic eye for the two highest spatial
frequencies.
Results: Linear regression analysis for the relationship between the P100 latency in the
amblyopic eye and the logMAR improvement in the distance VA of that eye was statistically significant and negative (Pearson coefficient -0.66; n=11, p=0.027), suggesting that
children with longer P100 latencies when therapy is initiated have less improvement.
For seven patients with P100 latency less than 120 ms, the mean improvement was
0.20±0.11, while those having a more delayed P100 latency had no detectable improvement in acuity.
Discussion: The P100 latency time measured at the beginning of occlusion therapy in
the amblyopic eye correlates significantly and negatively with the eventual improvement
in distance visual acuity.
Conclusion: VEP P100 latency time in an amblyopic eye can predict how well a child
will respond to occlusion therapy.
Poster 41
Saturday
10:00 - 11:00 am
JAAPOS Abstract #097
References: Chung W, Hong S, Lee JB, Han SH. Pattern visual evoked potential as a predictor of occlusion therapy for amblyopia. Korean J
Ophthalmol. 2008;22(4):251-4.
Interocular Suppression and Amblyopia
Vidhya Subramanian; Reed M Jost; Sheridan Jost; Eileen E Birch
Retina Foundation of the Southwest
Dallas, TX
76
Introduction: Discordant monocular visual inputs that result from strabismus and/or
anisometropia are resolved by either alternation between monocular inputs or habitual
suppression of one eye’s input. The dominant theory is that amblyopia results from habitual suppression. Recently, we demonstrated and quantified suppression in amblyopic
children using dichoptic video game goggles (Subramanian et al. ARVO 2011). Here we
quantify suppression associated with amblyopia of different etiologies and ages of onset.
Methods: 43 amblyopic children ages 5-16 years participated (11 strabismic, 13 anisometropic, and 19 combined; 6 infantile, 26 pre-school and 11 school-age onset). Dichoptic goggles presented coherently moving dots to the amblyopic eye (AE) and noise
(randomly moving dots) to the fellow eye (FE) eye. AE coherent dot contrast was always
100%; FE noise dot contrast was reduced until the child experienced binocular vision.
The FE contrast required to experience binocular vision quantified severity of suppression.
Results: Children with strabismic and combined amblyopia only experienced binocular
vision when FE contrast was reduced to 12±3% and 17±5%, respectively. Children with
anisometropic amblyopia were able to tolerate significantly higher FE contrast (39±5%;
p≤0.005). Severity of suppression was not correlated with age of onset (r=-0.09; p>0.1)
but was correlated with AE logMAR visual acuity (r=0.40; p<0.05).
Discussion: Suppression was more severe in strabismic and combined amblyopia than
in anisometropic amblyopia. The association between severity and depth of amblyopia
supports the hypothesis that amblyopia results from interocular suppression.
Conclusion: The link between amblyopia and suppression suggests that binocular
therapy to reduce interocular suppression may be of benefit in the prevention or treatment of amblyopia.
77
Poster 42
Saturday
10:00 - 11:00 am
JAAPOS Abstract #107
Poster 43
Saturday
10:00 - 11:00 am
JAAPOS Abstract #075
Ocular Component Growth in Children with Persistent Hyperopia
Simone L. Li PhD1; Vidhya Subramanian PhD 1; Reed M. Jost MS1;
Donald O. Mutti OD, PhD2; Eileen E. Birch PhD 1,3
1Retina Foundation of the Southwest, 9600 North Central Expressway, Suite 100,
Dallas, TX 75231 2The Ohio State University College of Optometry, Columbus, OH
3Dept. of Ophthalmology, UT Southwestern Medical Center, Dallas, TX
JAAPOS Abstract #106
Justin Y Rheem BS; Demitrio J Camarena BS, BA; Blen D Eshete MPH;
Leila M Khazaeni MD; Jennifer A Dunbar MD
Loma Linda University Medical Center
11234 Anderson Street Loma Linda, California 92354
Introduction: Most infants born hyperopic undergo emmetropization. However, about 15%
retain hyperopia throughout the preschool years. We evaluated whether persistent hyperopia
reflects reduced/absent axial growth (1) or whether developmental changes in other ocular
components negate axial elongation (2) in a cohort of esotropic children with persistent hyperopia.
Methods: 60 children (3-8y) with persistent hyperopia (≤0.50 D decrease in spherical equivalent) and esotropia were enrolled; 26 had moderate hyperopia (+2.00 to +4.75D) and 34 had
high hyperopia (≥+5.00 D). In addition, 37 controls (4-8y) participated. A Lenstar LS 900 Optical Biometer was used to measure axial length (AL), lens thickness (LT), and corneal power
(K). Data from right eyes were used for ANCOVA analysis.
Results: In children with persistent moderate and high hyperopia, AL increased by 0.13
mm/y. At the same time, LT decreased by 0.1 mm/y for both groups. Neither the rate of
change of AL or LT differed from that observed in controls (P≥0.36 for all comparisons). There
was little change in K during years 3-8 in hyperopic children or controls.
Discussion: Axial length increases while the lens thins in esotropic children with persistent hyperopia during preschool and early school years at rates similar to those of controls.
Hyperopia persists because increasing axial length is negated by the concurrent thinning and
presumed power loss of the lens.
Conclusion: Hyperopia persists in esotropic children because the dioptric effects of axial
growth do not exceed the effects of losses in lens power. Interventions to reduce persistent
hyperopia must aim at changing the balance between axial growth and lens thinning.
Introduction: This study evaluates the influence of parental amblyopia education on compliance with photoscreening referral.
Methods: Children age 6 months to 6 years received photoscreening in the setting of parent
amblyopia education. Parents responded to Pre-education and Post-education test questions regarding the urgency of amblyopia follow-up. Children failing photoscreening received
referral for comprehensive examination and their compliance was recorded. Parental support
for follow-up included full-time social worker, gas cards, free clinic appointments, and free
glasses. Reasons for noncompliance were assessed via telephone survey. Results were
stratified for compliance and education and analyzed with Chi-square and logistic regression.
Results: Among 2,579 referred following photoscreening, 567 were compliant (22.4%). Participation in the educational session (n=420) did not increase compliance with follow-up (Chi
Square P=0.91). Compliance was not influenced by the difference between the pre- and posttest scores assessing understanding of urgency to follow up (LR P=0.38; Wald test P=0.35;
LR: P=0.27, Wald test P=0.25).
Survey results (n=109) for noncompliance reasons included: no time (36.7%), insurance matters (22.9%), hold from pediatricians (11.0%), no urgency (6.4%), personal matters (5.5%), no
money or transportation (5.5%), other life emergency (3.7%), and miscellaneous (0.9%).
Discussion: Although parents’ assessment scores improved after the educational session,
education did not significantly improve compliance with comprehensive exam. Lack of time
and insurance problems were the most frequent reasons given for noncompliance.
Conclusion: In this study, parental understanding of the urgency of amblyopia did not
improve compliance with vision screening recommendations. Further research into lowering
barriers to compliance with vision screening follow-up is needed in this population.
Sweep visual evoked potential and visual development in optic nerve hypoplasia
Incidence of Pathology found in Pediatric Patients referred for Ophthalmologic
Assessment following Abnormal Vision Screening
References: 1. Sorsby, A. & Leary, G.A. (1969). A longitudinal study of refraction and its components during growth. Spec Rep Ser Med Res Counc
(G B), 309, 1-41.
2. Mutti D. et al (2005). Axial growth and changes in lenticular and corneal power during emmetropization in infants. Invest
Ophthalmol Vis Sci, 46, 3074-80.
Poster 44
Saturday
10:00 - 11:00 am
Parental Understanding of Amblyopia and Compliance with
Follow-up after Vision Screening
Krista J Stewart; Jim Ver Hoeve; Yasmin Bradfield
University of Wisconsin, Madison, WI
Introduction: Optic nerve hypoplasia (ONH) remains a leading cause of childhood visual impairment. Visual development in infancy and preverbal age in patients with ONH
has not been well characterized to date. In this study, we assessed sweep visual evoked
potential (VEP) measurements as indicators of early visual development and predictors
of final recognition visual outcome in patients with ONH.
Methods: We retrospectively studied 38 patients with clinically diagnosed ONH who had
performed sweep VEP. Final recognition acuity was assessed with Snellen or HOTV letters, if patients were capable. Other factors assessed included presence of nystagmus,
CNS malformations, pituitary involvement, and optic nerve size.
Results: Most patients had subnormal sweep VEP acuities compared to age-matched
normals. VEP acuities reached a plateau by 20 months of age in patients with ONH
compared to a plateau at 12 months in normal children, correlating well with recognition
acuity performed at an older age. 59% of patients had acuity worse than 20/40, and 11%
had acuity 20/200 or worse after 20 months of age.
Discussion: Sweep VEP measurements in ONH suggest a significant delay in visual
development, but confirm that there is some improvement in vision until 20 months of
age. Final visual acuity correlates with sweep VEP measurements, suggesting that
sweep VEP may be used to predict outcomes at an early age.
Conclusion: Sweep VEP measurements may be used clinically to provide parents with
an accurate visual prognosis for children with optic nerve hypoplasia.
References: 1. McCulloch DL, Garcia-Filion P, Fink C, Chaplin CA, Borchert MS. Clinical electrophysiology and visual outcome in optic nerve
hypoplasia. Br J Ophthalmol. 2010; 94: 1017-1023.
2. Borchert M, McCulloch D, Rother C, Stout A. Clinical assessment, optic disk measurements, and visual evoked potential in optic nerve hypoplasia. Am J Ophthalmol. 1995; 120: 605-612.
78
Andrea K Leung, MD; Helia Garcia, OC; Heather de Beaufort, MD
Children’s National Medical Center, Washington, DC
Introduction: The purpose of this study is to review the incidence of pathology identified
on abnormal vision screening by primary care physicians and school systems, based on
the age of the patient at the time of screening. The secondary purposes of this study are
to describe the patient demographics associated with types of pathology found on ophthalmologic examination and to assess the accuracy of different methods used for vision
screening.
Methods: New-patient ophthalmology assessments at a tertiary-care pediatric hospital
over a two-year period were identified. A retrospective chart review was performed to determine the incidence and the types of pathology found in patients referred for abnormal
vision screening.
Results: Based on preliminary data, over 500 of 4635 new patients had abnormal vision
screening. The majority had been screened by their primary care physician and had vision better than 20/40. Fifty percent of patients had amblyopia, twenty percent were myopic, and thirty percent had no pathology. Pathology was equally distributed when patients
were grouped by ethnicity or by age.
Discussion: There is little literature discussing the incidence of pathology found in
children with abnormal vision screening. Our early data shows that the majority of these
patients have amblyopia or refractive errors, but thirty percent have no pathology.
Conclusion: Based on preliminary data, vision screening by primary care physicians
and schools primarily identify children with refractive error and amblyopia. There was no
significant difference between ethnicities or age groups in the types of refractive error or
pathology identified on ophthalmologic examination.
79
Poster 45
Saturday
10:00 - 11:00 am
JAAPOS Abstract #095
Poster 46
Saturday
10:00 - 11:00 am
JAAPOS Abstract #074
Poster 47
Saturday
10:00 - 11:00 am
JAAPOS Abstract #062
High Sensitivity and Specificity of the Pediatric Vision Scanner in Detecting
Strabismus and Amblyopia in Preschool Children
Reed M Jost MS1; Susan E Yanni PhD1; Cynthia L Beauchamp MD2; David R Stager, Sr. MD2;
David Stager, Jr. MD3; Lori Dao MD3; Molly Nolan1; Eileen E Birch PhD1,4
1
Retina Foundation of the Southwest; 2Pediatric Ophthalmology & the Center for Adult
Strabismus; 3Pediatric Ophthalmology & Adult Strabismus; 4Department of
Ophthalmology, UT Southwestern Medical Center, Dallas, TX
Introduction: The Pediatric Vision Scanner (PVS) directly detects strabismus and amblyopia by
analyzing binocular scans for the presence or absence of birefringence, which is characteristic of
steady, bifoveal fixation. In a preliminary study (AAPOS 2012), the PVS demonstrated 98% sensitivity and 88% specificity. Here we report the sensitivity and specificity for a large cohort, confidence
intervals, and analyses of screening errors.
Methods: 250 children (2-6y) were enrolled; 103 controls and 147 with strabismus and/or amblyopia. In addition to the PVS, children were tested with the SureSight™ Autorefractor and the Randot® Preschool Stereoacuity Test (RPST). Each test yielded a recommendation of ‘pass’ or ‘refer.’ A
comprehensive pediatric ophthalmic exam served as the gold-standard.
Results: The PVS correctly identified 144 of 147 children with strabismus and/or amblyopia; sensitivity = 98% (95%CI: 95-100%). The PVS correctly identified 90 of 102 control children; specificity =
88% (95%CI: 79-96%). The SureSight™ misclassified 81 children, failing to detect 49 children with
strabismus and/or amblyopia and over-referring 18 children with astigmatism. The RPST misclassified 51 children, including similar numbers of affected and control children. Misclassifications were
not consistent across tests. Using Bayesian analysis to estimate the performance of each test in a
preschool screening setting (assuming a prevalence of 4%1,2), accuracies of 89%, 69%, and 77%
were predicted for the PVS, SureSight™, and RPST tests, respectively.
Discussion: The PVS identifies children with strabismus and/or amblyopia with high sensitivity,
outperforming the SureSight™ and the RPST.
Conclusion: Preschool vision screening may be more efficient with a device that directly detects
strabismus and/or amblyopia.
References: 1. Multi-Ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months the multi-ethnic pediatric eye disease study. Ophthalmology 2008; 115: 1229-36 e1.
2. Friedman DS, Repka MX, Katz J, et al. Prevalence of amblyopia and strabismus in white and African American children aged 6 through 71 months
the Baltimore Pediatric Eye Disease Study. Ophthalmology 2009; 116: 2128-34 e1-2.
Poster 48
Saturday
10:00 - 11:00 am
JAAPOS Abstract #082
The efficacy of the plusoptiX S04 photoscreener as a vision screening tool
in children with autism
Thomas C McCurry MS, MBA; Linda Lawrence MD; Liliana Mayo PhD
Medical University of South Carolina, Charleston, SC
Introduction: Children with autism and related disorders reportedly have an increased
prevalence (40%) of ocular disorders. Comprehensive eye examinations by a pediatric
ophthalmologist are recommended for all children with autism and related disorders.1
Examinations can be very time consuming, expensive, and stressful for the child. A
photoscreener such as the plusoptiX SO4 may be a cost-effective, time-saving, and less
invasive method for examining patients with autism. The purpose of this study is to determine the efficacy of photoscreening with the plusoptiX SO4 in detecting treatable ocular
conditions in children with autism and related disorders.
Methods: Photoscreening and complete ophthalmologic examinations were performed
on 45 children with autism. Prevalence, sensitivity, specificity, positive predictive value,
and negative predictive value were calculated using ophthalmologic examination as the
gold standard.
Results: The plusoptiX S04 referred 29 (67%) of 43 children with autism. 15 (35%)
children had treatable eye disease upon examination. The plusoptiX SO4 had a sensitivity of 93% (CI: 0.68 to 0.99). The specificity, positive predictive value, and negative
predictive value were 46% (CI: 0.28-0.66), 48% (CI: 0.29-0.67), and 93% (CI: 0.66-0.99),
respectively.
Discussion: The plusoptiX SO4 is sensitive but less specific at detecting treatable ocular conditions in children with autism. The majority of children with autism and amblyogenic risk factors were detected on screening, however about half of all referrals had no
amblyogenic risk factors.
Conclusion: The use of the plusoptiX S04 photoscreener in children with autism is
effective and has the potential to save time and expense related to routine eye
examinations.
References: 1. Ikeda J, Bradley VD, Ultmann M, et al. Brief Report: Incidence of Ophthalmologic Disorders in Children with Autism. Epub February
21, 2012. J Autism Dev Disord.
80
PPOC Vision Screening Analysis
Suzanne C Johnston MD, MPH; Louis Vernacchio MD, MSc; Emily K Trudell MPH;
Katherine Majzoub RN, MBA; Rashmi Dayalu MPH; Bruce Moore OD
Boston Children’s Hospital, Boston, MA
Poster 49
Saturday
10:00 - 11:00 am
JAAPOS Abstract #061
Introduction: Vision testing is an important part of preventive care for children, particularly for pre-school age children at risk for amblyopia; few data exist describing the
proportion of children who undergo routine vision screening or have abnormal screens.
Methods: We evaluated vision screening among pre-school aged children who are
patients of the Pediatric Physicians’ Organization at Children’s, including 72 private pediatric practices in eastern Massachusetts affiliated with Boston Children’s Hospital. 450
well-child visits in 2010, 150 for three, four, and five year-olds, were randomly selected.
Charts were reviewed for evidence of visual acuity (VA) and stereo-vision (SV) testing.
Results: Evidence of VA screening was documented in 63.3% of visits while evidence of
SV testing was documented in 38.5% . The percentage of three, four, and five year-olds
undergoing VA testing was 42.2%, 70.5% and 77.2%, respectively (p<0.0001). VA testing varied by practice size with large practices (>/=6 physicians), medium-size practices
(3-5), and small practices (1-2) having rates of 76.8%, 60.5%, and 41.4%, respectively
(p<0.0001). VA testing did not differ by race. Of those with inadequate or missing testing,
11.3% had evidence of referral.
Discussion: Substantial deficiencies were found in preschool vision screening with
only 63.3% of children undergoing VA screening, and 38.5% SV screening. Rates were
significantly associated with age and practice size.
Conclusion: Improving our understanding of vision screening in area practices will help
direct policy decisions. Future research will focus on screening in patients with disabilities and in understanding follow-up patterns.
Effectiveness of Plusoptix Vision Screening in a School setting
with Modified Referral Criteria
Jennifer D Davidson MD; Mae Millicent W Peterseim MD; Benjamin C Kramer MD;
Rupal H Trivedi MD
Storm Eye Institute, Medical University of South Carolina, Charleston, SC
Introduction: Modifications to the Plusoptix SO8 photoscreener manufacturer’s referral criteria
(1) have been proposed to improve detection of amblyopia risk factors while minimizing overreferrals. These modifications are based on retrospective results from a pediatric ophthalmology patient
population. We describe our experience applying the modified referral criteria to assess for amblyopia risk factors compared with on-site examination by a pediatric ophthalmologist in the public
school setting.
Methods: Screening with the plusoptix S08 was performed on three to five-year-old children at
area Title 1 public schools using referral criteria set per Nathan and Donahue Arthur modification one. (1) Amblyopia risk factors were defined per AAO guidelines. (2) Examination including
cycloplegic retinoscopy was performed on-site by a pediatric ophthalmologist on all children who
met referral criteria and from whom parental consent was obtained. The referral rate and positive
predictive value were assessed. Refractions from the screener and cycloplegic retinoscopy were
compared.
Results: 894 children were screened, approximately 60 per hour, of whom 209 screened positive
(referral rate 23%). 103 patients underwent subsequent examination. The positive predictive value
(PPV) of plusoptix screening using the modified referral criteria was 46%. The photoscreener overestimated spherical equivalent by 0.60D ± 0.86D and cylinder by 1.06D ± 0.99. The mean absolute
difference in cylinder axis was 8.85 deg ± 17.49.
Discussion: Modification of the manufacturer’s referral criteria to that suggested by Nathan and
Donahue (1) yielded a PPV of 46% in the school setting, higher than had been predicted. As an
autorefractor, the device tended to overestimate both hyperopia and magnitude of astigmatism.
Cylinder axis measurements were similar.
Conclusion: Recently proposed modifications of referral criteria improve the performance of the
plusoptix photorefractor in school screening programs and are recommended. In addition, plusoptix
screening is quickly accomplished in the school setting and on-site exams provide an opportunity to
expand care.
References: 1.Nathan NR, Donahue SP. Modification of Plusoptix referral criteria to enhance sensitivity and specificity. J AAPOS 2009;14:e24.
2.Amblyopia. Preferred Practice Pattern Guidelines. American Academy of Ophthalmology 2007. Available at http://www.aao.org/ppp
81
Poster 50
Saturday
10:00 - 11:00 am
JAAPOS Abstract #045
Poster 51
Saturday
10:00 - 11:00 am
JAAPOS Abstract #080
Does Adding Stereo Testing to PlusoptiX Photoscreening Improve Sensitivity?
Noelle S Matta CO, CRC, COT; David I Silbert MD, FAAP
Family Eye Group, Lancaster Pennsylvania
Introduction: To determine if adding Lang stereoacuity to plusoptiX photoscreening
improves sensitivity.
Methods: Retrospective chart review of children who had a plusoptiX A09 photoscreening and Lang stereoacuity performed by a lay screener in our office. All children also
underwent a comprehensive pediatric ophthalmology examination including cycloplegic
refraction performed by one pediatric ophthalmologist. Children were determined to have
amblyopia risk factors based on the current AAPOS referral criteria. Children were considered to pass the Lang stereo test if they had any measurable stereoacuity.
Results: 92 patients ages 3-11 were included, 76% of children were found to have
amblyopia risk factors. The Lang Stereo test alone was found to have a sensitivity of 63%
and specificity of 64%. The plusoptiX alone was found to have a sensitivity of 93% and
specificity of 91%. Assuming that all children who were initially a pass on the plusoptiX
but were referred on the Lang stereo, the sensitivity increased to 97% but the specificity
decreased to 62%.
Discussion: While it is important to maximize sensitivity (reducing false negatives) programs must also ensure they are maximizing specificity (reducing false positives).
Conclusion: The Lang stereo test has a low sensitivity and specificity and should not be
used alone for pediatric vision screening. Adding this test to a plusoptiX photoscreening
program would improve sensitivity only minimally, while at the same time would decrease
specificity significantly. The Lang stereo-acuity test is not sensitive or specific enough to
be recommended as an adjunct to pediatric vision screening.
Poster 52
Saturday
10:00 - 11:00 am
JAAPOS Abstract #077
Change in Community-Based Preschool Vision Screening
from Visual Charts to Retinomax
Eugene A Lowry; Ryan Lui; Travis C Porco; Alejandra De Alba Campomanes
University of California, San Francisco, San Francisco
Introduction: To determine the difference in referral rate and positive predictive values
between a community-based vision screening program using eye charts against one using autorefraction.
Methods: 5,186 preschool children were screened in the 2010-2011 using vision charts,
motility, and cover-uncover testing. Follow-up on referred children was determined
through provider surveys. 1,773 preschool children were screened in 2011-2012 using
autorefraction with Retinomax (manufactured by Nikon, Tokyo, Japan), Hirschberg and
cover-uncover testing. Follow-up on referred children was provided on a mobile eyevan. Populations were compared for referral rates and positive predictive value. Positive
cases were defined as: refractive error treated with glasses, strabismus, cataracts, or
amblyopia.
Results: The visual charts screening program referred 4.3% of screened children. The
autorefraction screening program referred 16.5% of screened children. The difference
(12.2%) was significant (p<0.0001). The probability of a referred child meeting case definition at follow-up was 69.3% and 56.2% for vision charts and autorefraction, respectively
(p = 0.07).
Discussion: A significantly larger number of preschool children were referred for followup in a community-based screening program using autorefraction rather than vision
charts. There is a non-significant trend towards decreased positive-predictive value in
children referred based on Retinomax compared with visual eye chart.
Conclusion: Screening programs based on Retinomax are likely to refer a greater number of children that require glasses compared with vision charts. This will increase the
number of children appropriately treated with glasses as well as overall screening costs.
82
Prospective Evaluation of the Spot (Pediavision) Vision Screener as Autorefractor
and in the detection of Amblyogenic Risk Factors Compared to Plusoptix and a
Comprehensive Pediatric Ophthalmology Examination.
Mae Millicent Peterseim; Rupal H Trivedi; Vera A Ball; Carrie E Papa; Maria E Shtessel;
M Edward Wilson; Jennifer D Davidson
Medical University of South Carolina/Storm Eye Institute
Charleston, South Carolina, USA
Poster 53
Saturday
10:00 - 11:00 am
JAAPOS Abstract #089
Introduction: The Pediavision Spot photorefractor screener has been marketed over the last year
(1) without published validation. We report a prospective study of the Spot compared to the more
validated Plusoptix screener and to a comprehensive examination. We also report these evaluations utilizing modifications to photorefractor referral criteria that have been proposed to improve
specificity while maintaining sensitivity. (2)
Methods: After informed consent, patients underwent screening with the Spot and with the Plusoptix prior to their comprehensive examination by a pediatric ophthalmologist masked to the results.
Data including refractions, pass/refer, strabismus and any ocular pathology, were entered into a
Redcap database for statistical analysis.
Results: Currently, 161 patients have been enrolled (ave age 6 yo). The sensitivity and specifity
of the Spot for detection of proposed AAPOS amblyopia risk factors (3) are 0.98 and 0.49. With
proposed modifications to the manufacturers criteria the Spot sensitivity is 0.87 and specificity 0.72
and with the Plusoptix, sensitivity 0.91 and specificity 0.61. Compared to cycloplegic retinoscopy
(right eyes), the Spot showed a mean difference of -0.99D ± 1.15 for SE and 0.36D ± 0.63 for cylinder. Corresponding numbers for the Plusoptix were -0.37D ± 1.20 for SE and 0.31D ±0.63 cylinder.
Discussion: In this ongoing study, sensitivity for the Spot with manufacturer’s guidelines is excellent and is comparable to the more established Plusoptix. Proposed modifications to manufacturers
referral criteria improve specificity with acceptable sensitivity for both the Spot and the Plusoptix.
The Spot underestimates hyperopia more than does the Plusoptix.
Conclusion: The Spot is an effective pediatric vision screener comparable to the Plusoptix. Proposed modifications to the manufacturers criteria may be useful for the Spot and for the Plusoptix.
References: 1 http://www.spotvisionscreening.com/2011/
2 Modification of Plusoptix referral criteria to enhance sensitivity and specificity during
pediatric vision screening. Niraj R. Nathan, BA, and Sean P. Donahue, MD, PhD J AAPOS 2011;15:551-555
3 Clinical accuracy of the AAPOS
pediatric vision screening referral criteria. David I. Silbert, MD, FAAP,a Noelle S. Matta, CO, CRC, COT,a Douglas Burkholder, BS, Andrew Gehman,
BS,b and James Fenwick, PhD J AAPOS 2012;16:361-364.
Validation of Spot screening device for amblyopia risk factors
in a pediatric ophthalmology clinic setting
Glynnis A Garry
Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
Introduction: Early detection of amblyopia is critical to the prevention of permanent
visual impairment in children. The Spot Vision Screener is a handheld digital screening
device that evaluates children for the presence of amblyopia risk factors (ARFs). We attempted to validate this screening device in a controlled clinic setting.
Methods: During a 3-month period, 217 children (ages 2 to 9 years) were screened
using Spot in a Pediatric Ophthalmology clinic before receiving a comprehensive gold
standard eye exam. Gold standard examinations were evaluated using the new AAPOS
Vision Screening Committee guidelines and compared with results from the Spot Vision
Screener. Results from Spot were evaluated through two different manufacturer software
criterias; v1.0.3 and v1.1.51. The specificity and sensitivity for each software in detecting
ARFs were determined.
Results: 217 children were screened by Spot (n=80 had amblyopia, n=153 had ARFs);
157 children were referred, and 60 passed. Using the original software (v1.0.3), Spot
had a sensitivity of 91% and a specificity of 73% to detect ARFs. The updated software
(v1.1.51) was applied to 157 patient records in a masked manner, and specificity (83%)
improved substantially while sensitivity (84%) was minimally affected.
Discussion: Spot v1.0.3 had a high sensitivity to detect all types of ARFs but overreferred for myopia and strabismus. Spot v1.1.51 greatly improved the specificity, while
maintaining a high sensitivity of the device.
Conclusion: The original manufacturer’s software has demonstrated a very high sensitivity to detect ARFs, but a low specificty; the v1.1.51 software update has greatly increased the specificity with minimal impact on sensitivity.
83
Poster 54
Saturday
10:00 - 11:00 am
JAAPOS Abstract #052
Poster 55
Saturday
10:00 - 11:00 am
JAAPOS Abstract #044
Real-time automatic strabismus screening using digital image analysis techniques
A new continuous outcome measure for assessing strabismus
Annegret H Dahlmann-Noor PhD; Ron Maor; Simon Barnard PhD; Yuval Yashiv;
Gill Adams
NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of
Ophthalmology; IRISS Medical Technologies, London, UK
Jonathan M Holmes; David A Leske; Sarah R Hatt; Laura Liebermann
Mayo Clinic, Rochester MN, USA
Introduction: Strabismus is a risk factor for amblyopia and in pre-school children has a
prevalence of 3.9%.1 Alignment tests increase the sensitivity of preschool vision screening
to detect strabismus.1 The Hirschberg test of ocular alignment evaluates centricity of corneal
light reflections.2 IRISS Medical Technologies are developing a novel real-time strabismus
screening device, based on automated processing and analysis of high-resolution digital
photographs of the first Purkinje image. Advantages of this approach include portability, availability, low price, speed and ease of use of devices which can be used to acquire images.
This study aimed to deliver a first estimate of diagnostic test accuracy in a diagnostic and a
screening setting.
Methods: The Research and Ethics Committee of the UK Institute of Optometry approved
relevant parts of the study. We examined 331 individuals in primary schools (n=56) and an
optometry practice (n=275). Age: 179 </= 10 years, 152 >/= 11 years). We acquired three fullface photographs. All participants underwent unaided visual acuity (Logmar or crowded single
letters/pictures), cover/uncover test and Randot stereopsis by a study-accredited optometrist.
Results: Prevalence of manifest strabismus in the study sample was 6.34%. Sensitivity of
the IRISS device to detect strabismus was 95%, specificity 91%.
Discussion: Early results compare very favourably with other alignment tests.
Conclusion: In order to further test the technology we are currently acquiring photographs
from 500 strabismic children in a diagnostic setting. This data will be used to refine the technology to output a “pass/fail” recommendation. A diagnostic test accuracy study will evaluate
the final ‘Strabismus Screener’ in population-based screening of pre-school children.
References: 1. Does assessing eye alignment along with refractive error or visual acuity increase sensitivity for detection of strabismus in
preschool vision screening? Invest Ophthalmol Vis Sci. Jul 2007;48(7):3115-3125.
2. Hirschberg J. The Quantitative Analysis of Diplopic
Strabismus. Br Med J. Jan 1 1881;1(1044):5-9.
Poster 56
Saturday
10:00 - 11:00 am
JAAPOS Abstract #078
Mood and Quality of Life in Adults with Strabismus
Kelly A MacKenzie BSc (Hons); Hayley McBain MSc BSc; Joanne C Hancox FRCOphth;
Daniel G Erza FRCOphth; Gillian G Adams FRCOphth;
Stanton Newman MRCP(Hons), CPsychol
Moorfields Eye Hospital; School of Health Sciences, City University; UCL Institute of
Ophthalmology NIHR Biomedical Research Centre for Ophthalmology, London, UK
Introduction: To explore the demographic, clinical and psychosocial factors which are
associated with mood and quality of life in patients with strabismus.
Methods: Cross-sectional study at a tertiary referral centre. Participants were recruited
prior to strabismus surgery, between November 2011 and April 2012. Exclusion criteria
consisted of other co-morbidities, facial or ocular abnormalities, identifiable psychosis,
dementia, or other cognitive impairment. Those unable to read or understand English
were also excluded. All patients completed a series of psychosocial questionnaires, Hospital Anxiety and Depression scale (HADS) and AS-20 Quality of Life (QoL).
Results: Of 286 consented, 222 participants completed the questionnaires. Demographic data: 103 male (46%), overall age range 17 to 88 and 81% participants white. Average
deviation 34 dioptres and 125 (56%) patients experienced diplopia. Adopting the clinical
thresholds for anxiety and depression, the proportion of patients with clinical anxiety in
this sample was 23.87% and clinical depression 10.36%. Utilising previously described
norms 204 (92%) of participants scored below normal on overall, 151 (68%) in functional
and 185 (83%) in psychosocial QoL.
Discussion: Psychosocial rather than clinical and demographic characteristics were
consistently associated with QoL and mood. In this study population the levels of anxiety
and depression are 10x that of the normal population. These levels are more in line with
long-term chronic diseases such as arthritis and facial disfigurement.
Conclusion: Psychosocial factors rather than strabismic characteristics have more effect on patient distress. In the future, based on these variables we may be able to predict
which patients will not be satisfied, regardless of their surgical outcome.
References: Hatt SR, Leske DA, Bradley EA, et al. Development of a Quality-of-Life Questionnaire for Adults with Strabismus. Ophthalmology
2009;116:139-44.
84
Introduction: Previous outcome measures for strabismus surgery have categorized
patients dichotomously as either success or failure depending on motor alignment alone
or a combination of motor alignment and diplopia. We created a potentially more discriminatory outcome measure that is continuous (0 to 100, best to worst strabismus) and
studied its distribution, test-retest reliability, and responsiveness.
Poster 57
Saturday
10:00 - 11:00 am
JAAPOS Abstract #058
Methods: To calculate the diplopia-angle score (0 to 100), a diplopia score (0 to 100)
was first derived from a previously validated diplopia questionnaire, evaluating diplopia
as: always, often, sometimes, rarely or never in 7 gaze positions. The diplopia score was
then modified by the distance and near strabismus angles; angles of 10 pd or less were
set to have no effect on the score, whereas angles of 30 pd or more rendered the overall
score maximal, with a sliding scale between. We evaluated distribution of the diplopiaangle scores (n=158), test-retest reliability (n=58), and preoperative to 6-week postoperative change in scores (n=158).
Results: Diplopia-angle scores ranged from 0 (least severe strabismus) to 100 (most
severe), using the entire distribution. The diplopia-angle score had good test-retest
reliability (ICC= 0.88, 95% CI: 0.80-0.92) and excellent responsiveness after surgery
(improvement from 70 ± 31 preoperatively to 23 ± 30 postoperatively, p<0.0001).
Discussion: The new diplopia-angle score is implementable across the whole range
of adult strabismus, has good test-retest reliability, and has excellent responsiveness to
treatment.
Conclusion: The new diplopia-angle score is likely to be useful as an outcome measure
for future studies of strabismus.
Responsiveness of a diplopia questionnaire score to strabismus surgery
David A Leske; Sarah R Hatt; Laura Liebermann; Jonathan M Holmes
Mayo Clinic, Rochester, Minnesota
Introduction: We have previously described a patient-reported diplopia symptom
questionnaire that allows a patient to rate their diplopia on a 5-point scale (never, rarely,
sometimes, often, always), in specific positions of gaze (reading, straight ahead distance,
down, right, left, up, and other). We have also previously described a data-driven scoring
algorithm for this questionnaire to yield a score of 0 (no diplopia) to 100 (diplopia in all
gaze positions always). In the present study, we evaluated the responsiveness of the
diplopia questionnaire (DQ) score to strabismus surgery.
Methods: To first evaluate test-retest variability, we collected DQ data at 2 consecutive
visits (1-154 days apart) with no intervening treatment and no clinical change in 91 adults
with diplopic strabismus. In a subsequent cohort (87 surgeries for diplopia), we then
compared preoperative and 6-week postoperative scores (range 4 to 19 weeks). Types
of strabismus included paretic, restrictive, idiopathic, and childhood onset.
Results: Test-retest reliability was good (ICC=0.81, 95% CI: 0.73-0.87), with 95% limits
of agreement (LOA) of 39 points. Postoperative scores were markedly improved from
preoperative scores (66 ± 33 vs 28 ± 33, p<0.0001). Of 67 (87%) surgeries where the
preoperative score was able to improve greater than the 95% LOA, 42 (63%) improved
by exceeding this threshold.
Discussion: The new diplopia questionnaire score was responsive to surgery in adult
patients with diplopic strabismus.
Conclusion: The new patient-reported diplopia questionnaire score may be a useful
outcome measure for clinical applications and for research studies.
85
Poster 58
Saturday
10:00 - 11:00 am
JAAPOS Abstract #073
Poster 59
Saturday
10:00 - 11:00 am
JAAPOS Abstract #102
Incidence of strabismus in preverbal children with hyperopia previously
diagnosed with pseudoesotropia
Outcomes Including Stereoacuity Following Surgical Correction of the
Non-accommodative Component in Accommodative Esotropia
Ariel L Silbert; Noelle S Matta CO, CRC, COT; David I Silbert MD, FAAP
Family Eye Group, Lancaster Pennsylvania
Sudhi P Kurup MD; Heath W Barto CO; Gihyun Myung MD; Marilyn B Mets MD
Ann & Robert H. Lurie Children’s Hospital of Chicago
225 E. Chicago Avenue, Chicago, Illinois 60611
Introduction: We previously reported that 12% of children under age 3 diagnosed with
pseudoesotropia without significant refractive error later developed strabismus or mild
refractive amblyopia. Mohan and Sharma recently reported on 51 patients with pseudoesotropia and hyperopia and noted that esotropia developed in 53.9% of the children
with >1.50D of hypermetropia compared to 2.6% of those who had <=1.50D hypermetropia, implying a low risk of esotropia unless hyperopia was greater than1.50D on initial
exam. We reviewed our data to see if this association holds.
Methods: Records between 01/01/2001, and 02/26/2010, were reviewed retrospectively. 394 patients diagnosed with pseudoesotropia with an otherwise normal examination
were reviewed. 253 with follow-up were analyzed.
Results: 46 children were 36 months or older at initial presentation; none developed
strabismus. 207 children were <36 months at initial presentation; 22 (11%) were later
found to have strabismus. 78 of these children had hyperopia > 1.50 D; 8 (10%) later
developed strabismus. 129 children had hyperopia <=1.50 D; 14 (11%) developed strabismus.
Discussion: Our analysis shows an equal risk of strabismus developing in pseudoesotropes under age 3 with greater or less than 1.50D of hyperopia.
Conclusion: There is a significant risk of esotropia developing in children under three
diagnosed with pseudoesotropia. Hyperopia less than 1.50D, does not obviate the need
for careful follow-up.
Poster 60
Saturday
10:00 - 11:00 am
JAAPOS Abstract #079
Diagnostic ophthalmologic findings in Moebius Syndrome
Sarah E MacKinnon MSc, OC(C), COMT; Darren T Oystreck MMedSci, OC(C);
Caroline V Andrews MS; Elizabeth C Engle MD; David G Hunter MD, PhD
Boston Children’s Hospital, Boston, MA
Introduction: Moebius syndrome is defined as congenital facial nerve palsy combined
with abduction deficit. To precisely characterize the clinical phenotype beyond these
minimum diagnostic criteria, we evaluated participants at consecutive Moebius Syndrome Foundation conferences.
Methods: All attendees of Moebius Syndrome conferences held in the United States in
2008, 2010, and 2012 were invited to participate. Participants underwent standardized
ophthalmologic examination. Eye and facial movements were recorded and reviewed by
the study team, and diagnostic and associated findings were noted.
Results: Of the 113 participants enrolled, 16 did not qualify for diagnosis of Moebius
syndrome (typically facial palsy with full eye movements) and 9 had an atypical phenotype with complete upgaze limitation. The remaining 88 participants had a classic Moebius syndrome phenotype with either orthotropia or esotropia in primary position, and
no ptosis. Of these, 49 (83%) had limited adduction, of whom 33 (67%) had a motility
pattern simulating horizontal gaze palsy. Dysinnervation was observed in 24 participants
(35%), including anomalous eye or lid movements and crocodile tears. We noted 2 novel
findings: intorsion with re-fixation (16%), and a volitional Bell’s phenomenon to moisten
the cornea (45%).
Discussion: Only 4 of 5 patients believed to have Moebius syndrome have typical findings. The remainder either do not meet diagnostic criteria or have another condition. Adduction limitation may be profound, even with straight eyes. Dysinnervation is common,
and we describe two previously unreported clinical features.
Conclusion: Careful assessment of eye movements is essential for accurate diagnosis
of Moebius syndrome and related entities.
86
Poster 61
Saturday
10:00 - 11:00 am
JAAPOS Abstract #068
Introduction: Initial therapy for accommodative esotropia is spectacles, followed by surgical
management of any persistent, non-accommodative component. Previous studies have assessed
surgical alignment outcomes. We additionally evaluated binocularity by considering stereoacuity.
Methods: This is a retrospective review of consecutive patients over twenty years who underwent
bilateral medial rectus recession by one surgeon (n=695), with a diagnosis of accommodative esotropia and hypermetropia greater than or equal to +2.25D (n=93). Data extracted at the preoperative, 6-week, 1-year, and final postoperative visits included visual acuity, stereoacuity, cycloplegic
retinoscopy, and esodeviation at distance and near. Alignment was subdivided into group A (within
10 PD of orthophoria), group B (residual esotropia greater than 10 PD), or group C (consecutive
exotropia greater than 10 PD). Stereoacuity was measured as fine (40-100 arc-seconds) or gross
(101-3600 arc-seconds).
Results: At six weeks, 86% were in group A while 14% patients were in group B. At the final
postoperative visit, 64% were in group A while 27% were in group B and 8.6% were in group C.
30.4% of patients maintained stereoacuity despite increased misalignment. Better binocularity was
associated with a mean older age at time of surgery (4.75 years-old with stereoacuity versus 3.38
years-old without stereoacuity). Those with fine stereoacuity were the oldest (5.13 years-old).
Discussion: Better alignment outcomes correlated with better stereoacuity. Children who underwent surgery at an older age were also found to have better stereoacuity.
Conclusion: A favorable alignment correlates with good binocularity, which can persist in patients
who have a residual esotropia greater than 10 PD (group B).
References: 1. Wilson ME, Bluestein EC, Parks MM. Binocularity in accommodative esotropia. J Pediatr Ophthalmol Strabismus 1993;30:233-6.
2. Durnian JM, Owen ME, Marsh IB. The psychosocial aspects of strabismus: Correlation between the AS-20 and DAS59 quality-of-life questionnaires. J AAPOS 2009;13:477-80.
3. Archer SM, Musch DC, Wren PA, Guire KE, Del Monte MA. Social and emotional impact of strabismus
surgery on quality of life in children. J AAPOS 2005;9:148-51.
4. Kassem RR, Elhilali HM. Factors affecting sensory functions after successful
postoperative ocular alignment of acquired esotropia. J AAPOS 2006;10:112-6.
5. Demirkilinç Biler E, O. Uretmen O, Köse S. The effect of optical
correction on refractive development in children with accommodative esotropia. J AAPOS 2010;14:305-10.
6. Birch EE. Marshall Parks lecture.
Binocular sensory outcomes in accommodative ET. J AAPOS 2003;7:369-73.
7. Fawcett S, Leffler J, Birch EE. Factors influencing stereoacuity
in accommodative esotropia. J AAPOS 2000;4:15-20.
8. Ludwig IH, Imberman SP, Thompson HW, Parks MM. Long-term study of accommodative
esotropia. J AAPOS 2005;9:522-6.
9. Arnoldi K. Long-term surgical outcome of partially accommodative esotropia. Am Orthopt J 2002;52:75-84.
The use of pre-operative botulinum toxin injection in large angle
childhood esotropia.
Katerina C Fragkou Dr; Vinod Sharma Dr; Chris I Lloyd Pr; Susmito Biswas Dr;
Jane L Ashworth Dr
Manchester Royal Eye Hospital, UK
Introduction: This study aimed to assess the influence of pre-operative botulinum toxin
(BT) injection upon the surgical correction of large angle esotropia (ET) in children and
the stability of alignment following subsequent strabismus surgery.
Methods: A retrospective review of children younger than 14 who had received BT prior
to surgery for large angle ET (> 50 prism dioptres-∆) from January 2002 to April 2012 was
undertaken. 27 patients who met inclusion criteria and had been treated with BT to both
medial recti were identified. The angles for near and distance fixation, pre-BT, 3 months
post BT, at last follow-up prior to surgery and at last post-operative follow-up were analysed.
Results: 3 months post BT the mean angle of deviation had reduced from 60 ∆ to 38
∆. This stayed stable (42 ∆) after a mean follow up of 11.8 months. 20 of the 27 patients
(74%) had undergone or were awaiting 2-muscle surgery. Of those operated (n=15), 11
were satisfactorily aligned but 4 exhibited a residual post-operative esotropia of 20 ∆ or
more at final follow up (range 3 months to 3 years).
Discussion: The use of pre-operative BT reduced the angle of deviation in children
with large angle ET and enabled the use of less aggressive 2-muscle (instead of 3 or 4
muscle) strabismus surgery.
Conclusion: BT injection prior to planned surgery in large-angle ET is an effective
strategy for reducing the angle of esotropia to be surgically managed. We believe this is
beneficial for the long term management of these patients who may require further strabismus procedures in their lifetime.
References: 1. Campomanes A, Binenbaum G, Eguiarte G. Comparison of botulinum toxin with surgery as primary treatment for infantile esotropia.J
AAPOS 2010;14:111-6.discussion 558-560.
87
Poster 62
Saturday
10:00 - 11:00 am
JAAPOS Abstract #049
Poster 63
Saturday
10:00 - 11:00 am
JAAPOS Abstract #051
Does injection into the dominant or non-dominant eye affect the outcome
of botulinum toxin injection for recurrent strabismus?
Marlo L Galli CO, Gregg T. Lueder, MD
Washington University School of Medicine/ St. Louis Children’s Hospital
One Children’s Place 2S89, Saint Louis, MO 63110
Introduction: Botulinum toxin (Botox®) injections may be used for patients with recurrent strabismus. We hypothesized that injection into the dominant eye would be more
effective than injection into the non-dominant eye, because there would be a greater
stimulus to restore binocularity by inducing temporary misalignment of the preferred eye.
Methods: Retrospective review of 46 patients with moderate angle recurrent esotropia
following previous extraocular muscle surgery. Patients with deprivation amblyopia or
developmental delay were excluded. Injection into the dominant eye was usually recommended, but the injection was performed in the non-dominant eye if the parents preferred. The pre- and postoperative records were analyzed.
Results: Forty-six patients with recurrent esotropia of 14-25 PD (prism diopters) were
treated with Botox. The injection was performed in the non-dominant eye in 21 patients
(average deviation 19.6 PD; average age 4.9 years), and in the dominant eye in 25
patients (average deviation 18.9 PD; average age 5.6 years). Follow-up was greater
than one year in all patients (average 4.4 years)
Treatment was successful in 13/21 (61%) of patients in the non-dominant group and
14/25 (56%) of patients in the dominant group.
Discussion: There was no significant difference in the outcome of Botox injection for
recurrent esotropia between patients who received injections in the dominant or nondominant eye.
Conclusion: The efficacy of Botox for recurrent strabismus is not affected by ocular
dominance. Therefore, other factors may be considered when deciding which muscle to
inject.
Poster 64
Saturday
10:00 - 11:00 am
JAAPOS Abstract #036
Hypertropia In Unilateral, Isolated Abducens Palsy (6NP)
Matthew S Pihlblad MD; Joseph L Demer MD, PhD
Jules Stein Eye Institute, University of California, Los Angeles
100 Stein Plaza, Los Angeles, CA, 90095-7002
Introduction: If hypertropia is observed with 6NP, multiple cranial neuropathies or a skew deviation are often considered. Understanding of the association of hypertropia with 6NP would
facilitate etiologic evaluation.
Methods: We retrospectively reviewed binocular alignment in a consecutive series of 43
cases of unilateral, isolated, previously unoperated 6NP. Complete 6NP was defined as inability to abduct past midline, and incomplete palsy as lesser limitation.
Results: Etiologies of 6NP included: microvascular-15, trauma-5, meningioma-4, idiopathic-3,
nasopharyngeal carcinoma-2, meningitis-2, aneurysm-2, migraine-2, arteriovenous malformation-1, neovascular compression-1, retrobulbar block-1, abducens schwanomma-1, sarcoma-1, stroke-1, carotid-cavernous fistula-1, and Arnold-Chiari malformation-1. Hypertropia
in any gaze position was found on objective alternate cover or Krimsky testing in 30% (13/43),
and on subjective Hess screen testing in 63% (22/35) of 6NP cases. Hypertropia on objective or subjective testing were found in 50% (7/14) of patients with complete and 62% (18/29)
with partial 6NP. Mean (±SD) hypertropia was 5.3±2.2 prism diopters(PD), range 2-10PD on
clinical exam, and 4.7±2.1PD, range 2-10PD on Hess screen testing. The ipsilesional eye was
hypertropic in 64% (14/22), and hypotropic in 36% (8/22) of cases.
Discussion: Small angle hypertropia is frequently associated with 6NP, not necessarily implying another neurological lesion. Recent anatomical and physiological studies have demonstrated that the lateral rectus muscle has separately-innervated superior and inferior compartments. Some hypertropias associated with 6NP may result from pathology weakening one
lateral rectus compartment more than the other, thus inducing a vertical imbalance.
Conclusion: Measurable hypertropia is commonly seen in unilateral, isolated 6NP, whether
complete, or partial.
JAAPOS Abstract #090
References: 1. Clark RA, Demer JL. Differential lateral rectus compartmental contraction during ocular counter-rolling. Invest Ophthalmol Vis Sci
2012;53:287-2896.
2. Peng M, Poukens V, da Silva Costa RM, et al. Compartmentalized innervation of primate lateral rectus muscle. Invest
Ophthalmol Vis Sci 2010;51:4612-4617.
3. Wong AMF, Tweed D, Sharpe JA. Vertical misalignment is unilateral sixth nerve palsy. Ophthalmology
2002;109:1315-1325.
Incidence and Clinical Characteristics of Adult-Onset
Distance Esotropia
IS THE CONVERGENCE INSUFFICIENCY SYMPTOMS SURVEY SPECIFIC
FOR CONVERGENCE INSUFFICIENCY?
Genie M Bang MD; Jennifer Martinez MD; Brian G Mohney MD
Mayo Clinic, Rochester, MN
Lindsay Horan CO; Benjamin H Ticho MD; Megan Allen OD
The Eye Specialists Center
Chicago Ridge, IL
Introduction: The purpose of this study is to describe the incidence and clinical
characteristics of adult-onset distance esotropia in a population-based cohort.
Methods: The medical records of all adult (>19 years of age) residents of Olmsted
County, Minnesota diagnosed from January 1, 1985, through December 31, 2004, with a
symptomatic, comitant esodeviation greater at distance than near, were retrospectively
reviewed.
Results: Seventy-five cases of adult-onset distance esotropia were identified during
the 20-year period, yielding an annual incidence of 6.0 per 100,000 residents older than
19 years, and comprising 10% of all forms of adult-onset strabismus in this population.
The 75 cases were diagnosed at a mean age of 70 (range 19-91 years) and 49 patients
(p=0.008) were female. Twenty-three percent (17) were also already diagnosed with
age-related macular degeneration. The Kaplan-Meier rate of progression was 47% by
5 years after diagnosis. None of the following co-morbidities were statistically associated with progression: gender, age, refraction, treatment modality, macular disease or
vascular disease risk factors, such as diabetes mellitus, hypertension or coronary artery
disease.
Discussion: Although adult-onset distance esotropia is more prevalent among women
and commonly progresses over time, neither gender nor age, refractive error, modality of
treatment, or systemic vascular disease risk factors are associated with progression.
Conclusion: Adult-onset distance esotropia comprised 1 in 10 adults with new-onset
strabismus in this population and was significantly more common among women. Although almost half progressed within 5 years, there were no identifiable ocular or systemic comorbidities associated with progression.
Introduction: 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).
88
Poster 65
Saturday
10:00 - 11:00 am
Methods: 32 patients ages 8 to 18 were enrolled in a prospective, masked clinical trial.
CISS scores of patients with and without CI (as defined by CITS) who presented for a
routine eye examination were rcompared. Patients completed the CISS and then underwent a complete eye examination, including visual acuity, assessment of distance and
near ocular alignment, near point of convergence, convergence and divergence amplitudes, and monocular near point of accommodation.
Results: Preliminary results of the mean score on the CISS for the convergence insufficiency group (n=9) was 19.2 (SD=12.9) vs. 16.5 (SD=11.7) for the non-CI group (n=23).
There was no statistical difference between the two groups (p=0.7).
Discussion: Our results suggest that a high CISS score may be found in patients without clinical CI. A related question (relevant to CISS use as a measure of treatment effect
in clincal studies) is the test-retest variability over time.
Conclusion: There may be no reliable difference in the CISS score in pediatric patients
with and without convergence insufficiency.
89
Poster 66
Saturday
10:00 - 11:00 am
JAAPOS Abstract #059
Poster 67
Saturday
10:00 - 11:00 am
JAAPOS Abstract #085
The Sensitivity of the Bielschowsky Head Tilt Test in Diagnosing
Bilateral Superior Oblique Paresis
Brinda Muthusamy FRCOphth; Kristina Irsch Ph.D; Peggy Chang MD; David L Guyton MD
The Wilmer Eye Institute, The Johns Hopkins University School of Medicine
600 N Wolfe Street, Baltimore, MD 21287
Introduction: We want to determine the sensitivity of the Bielschowsky head tilt test (BHTT)
in distinguishing bilateral (BSOP) from unilateral superior oblique paresis (USOP).
Methods: A retrospective chart review was performed to identify patients seen by the senior
author between 1978 and 2009 who were diagnosed with BSOP. Inclusion criteria were a
confirmed history of head trauma or brain surgery with altered consciousness followed by
diplopia upon gaining consciousness. BSOP was diagnosed by the presence of greater extorsion in down gaze than upgaze on Lancaster red-green testing (LRGT), V-pattern strabismus, and bilateral fundus extorsion. Patients were excluded if they had previous strabismus
surgery. All patients subsequently had bilateral strabismus surgery. The results of the BHTT
were retrospectively analyzed to determine its sensitivity in diagnosing BSOP.
Results: 25 Patients were identified with the above diagnosis of BSOP. 10 (40%) patients
had a BHTT consistent with BSOP. In 15 (60%) patients, the BHTT was consistent with a
USOP despite all other parameters pointing to evidence of BSOP. 92% had a good post-operative outcome with 8% having symptomatic residual torsional diplopia on down gaze.
Discussion: What has previously been described as masked BSOP may simply be a reflection of the inherent poor sensitivity of the BHTT.
Conclusion: In our patients with BSOP, confirmed on LRGT, with bilateral fundus extorsion
and V-pattern strabismus, the BHTT had only a sensitivity of 40% in identifying bilaterality of
the superior oblique paresis and hence should not be relied upon to make this differentiation.
References: Kushner BJ. The diagnosis and treatment of bilateral masked superior oblique palsy. Am J Ophthalmol 1988;105:186.
Kraft SP, Scott W. Masked bilateral superior oblique palsy: clinical features and diagnosis. J Pediatr Ophthalmol Strabismus 1986;23: 264-72.
Ellis FJ, Leah AS, Guyton DL. Masked bilateral superior oblique muscle paresis. A simple overcorrection phenomenon? Ophthalmology
1998;105:544-51.
Poster 68
Saturday
10:00 - 11:00 am
JAAPOS Abstract #048
Visual acuity deficits in children with nystagmus and Down Syndrome
Joost Felius PhD; Cynthia L Beauchamp MD; David R Stager Sr. MD
Retina Foundation of the Southwest; Ophthalmology, UT Southwestern Medical Center;
Pediatric Ophthalmology and Center for Adult Strabismus
Dallas, Texas USA
Introduction: Visual function deficits in children with Down syndrome are caused by
refractive error, limited accommodation, nystagmus, and possibly by abnormal cortical
morphology. Here we determine to what extent nystagmus may explain visual acuity deficits in children with Down syndrome wearing refractive correction.
Methods: Eye movement recordings and Teller visual acuity were obtained under binocular viewing conditions in 15 children (age 1 - 16 years, median 3.7 years) with Down
syndrome and nystagmus wearing proper refractive correction. Fixation stability was
quantified using the Nystagmus Optimal Fixation Function (NOFF). An exponential model
based on results from 93 age-similar children with idiopathic infantile nystagmus (Felius
et al, IOVS 2011) was used to relate NOFF to age-corrected visual acuity deficits.
Results: Visual acuity ranged from 0.2 to 0.9 logMAR, resulting in 0.38±0.18 logMAR
(4 lines) age-corrected visual acuity deficit. NOFF ranged from -4.6 (poorest fixation,
1% foveation) to 1.3 (best, 79% foveation) with median -1.0 (27% foveation). Although
on average, visual acuity deficit was slightly but significantly larger (0.13 logMAR; t=2.7,
P=0.016) than expected based on the nystagmus model, most children (80%) had visual
acuity deficit within the model’s 95%-predictive interval.
Discussion: There was only a small mean difference between the measured visual acuity deficit and the deficit predicted by the nystagmus model. While other factors may also
contribute to visual acuity loss in Down syndrome, nystagmus alone could account for
visual acuity deficits in a majority of these children.
Conclusion: Therefore, nystagmus treatment may result in improved visual acuity in
children with Down syndrome.
90
Normative Data on Pupil Size and Anisocoria in Children
Jillian F Silbert; Noelle S Matta CO, CRC, COT; Jing Tian MS; Eric L Singman MD, PhD;
David I Silbert MD, FAAP
Family Eye Group, Lancaster Pennsylvania
Poster 69
Saturday
10:00 - 11:00 am
JAAPOS Abstract #103
Introduction: The plusoptiX photoscreener is able to measure noncycloplegic refraction
as well as pupil size and deviation. Both pupils are measured simultaneously, making it
an ideal instrument to measure the magnitude of anisocoria in children.
Methods: Retrospective chart review was performed on 516 children aged <1 to 17
years who had a plusoptiX performed as part of a pediatric ophthalmology examination.
plusoptiX was performed by an orthoptist or ophthalmic technician in dim illumination.
Data collected included size of left and right pupils by age and laterality and magnitude of
anisocoria.
Results: 88% of children had less than 0.5mm of anisocoria, 9% had 0.5-0.9mm of
anisocoria, 1% had 1.0-1.4mm of anisocoria, and 1% had 1.5+ mm of anisocoria. Pupil
size increased with age from an average 5.2mm for age less than 1, to 6.5mm for age
16-17, ANOVA test (P<0.0001). There is not a statistical difference in laterality of anisocoria (P=0.56).
Discussion: Although pupil size decreases in adults with increasing age, there has been
little reported on normative data for pupil size or anisocoria in children. Our data shows
that pupil size increases throughout childhood through age 17. Also of interest, nearly
11% of children had anisocoria of 0.5mm or greater, an asymmetry visible to parents and
casual observers.
Conclusion: Our study provides normative data useful to the clinician when discussing
anisocoria and pupil size with patients and families.
Can color vision and retinal nerve fibre layer thickness serve as suitable
biomarkers in childhood demyelinating disease?
Manca Tekavcic Pompe; Darko Perovsek; Branka Stirn Kranjc
University Eye Clinic, Ljubljana, Slovenia
Introduction: With OCT a better understanding of neurodegeneration in demyelinating
disease can be achieved by capturing thinning of the retinal nerve fibre layer (RNFL). On the
other hand it is well known that color vision is often affected in these patients. The purpose of
this study is to investigate whether there is any association between RNFL thinning and color
vision deficiency in children and young adults with demyelinating disease with or without a
history of optic neuritis (ON).
Methods: Thirty young patients (13-28y) participated in this study. They all had clinically and
neuroradiologically confirmed demyelinating disease (which was diagnosed before the age
of 16y) with or without a history of ON. After a thorough clinical examination, they underwent
OCT imaging using high-resolution spectral-domain OCT (SD-OCT; Spectralis, Heidelberg
Engineering, Germany), measuring RNFL thickness. In addition all patients had a monocular
psychophysical color vision evaluation using Ishihara test and Farnsworth-Munnsell hue 100
(FM 100) test. The FM 100 test error score (E.S.) was compared to SD-OCT parameters in
eyes with and without ON.
Results: All eyes of patients with demyelinating disease showed RNFL thinning compared to
normative data. Although thinning in eyes without a history of ON was much smaller, compared to RNFL thinning in eyes after one or more episodes of ON, where significant RNFL
thinning was found (p<0.01). Average E.S. of the whole group of patients was more than 90,
ranging from 28 to 584 and was much higher in ON eyes (range: 68-584) compared to eyes
without ON (28-56).
A strong correlation was found between color vision FM 100 error score and RNFL thickness
(p<0.001).
Discussion: Also other potentially useful biomarkers (such as ERG) need to be analyzed in
patients with demielinating disease.
Conclusion: Color vision loss and RNFL thinning measured with SD-OCT are in strong correlation in patients with demyelinating disease and can therefore serve as suitable biomarkers
of the disease.
91
Poster 70
Saturday
10:00 - 11:00 am
JAAPOS Abstract #110
Poster 71
Saturday
10:00 - 11:00 am
JAAPOS Abstract #113
Asymptomatic Pediatric Idiopathic Intracranial Hypertension
Sarah Whitecross, OC(C); Gena Heidary, MD, PhD
Boston Children’s Hospital, Harvard Medical School, Boston, MA
Introduction: Pediatric idiopathic intracranial hypertension (IIH) may be identified in
patients with clinical symptoms including headache and blurry vision and signs of papilledema on exam. Little is known about the clinical features and outcomes in asymptomatic IIH patients.1,2
Methods: Ten year retrospective chart review of all patients with a diagnosis of IIH
(ICD-9 348.2) at a single, tertiary care center. Data including clinical characteristics and
complete ophthalmic findings were recorded.
Results: We identified 13/68 (19%) patients with asymptomatic IIH, and 10/13 (77%) of
these patients were male. Asymptomatic patients on average were younger than symptomatic patients (9 yrs versus 13 yrs, P=0.05) and male gender was associated with the
absence of symptoms (P=0.002). Three patients were on a medication associated with
IIH and only two had a BMI > 25 kg/m2. Mean opening pressure did not differ significantly
between symptomatic and asymptomatic groups (37 cm H20 versus 34 cm H20, P=0.17).
Chronic optic nerve edema was noted in 54% (7/13) of asymptomatic patients and
permanent vision loss in one. One asymptomatic patient was treated with serial lumbar
punctures and two required definitive surgical intervention.
Discussion: Asymptomatic IIH can be associated with significant morbidity including vision loss, chronic optic nerve edema, and the need for surgical intervention.
Conclusion: Pediatric patients with asymptomatic IIH may be young and male. Often
they may be misdiagnosed as having pseudopapilledema without a formal work-up.
When optic nerve swelling is present, the clinician should have a high index of suspicion
for papilledema and pursue an evaluation for this diagnosis.
References: 1. Bassan H, Berkner L, Stolovitch C, Kesler A. Asymptomatic idiopathic intracranial hypertension in children. Acta Neurol Scan.
2008;118:251-5. Epub 2008 Mar 12.
2. Weig SG. Asymptomatic idiopathic intracranial hypertension in young children. J Child Neurol.
2002;17:239-41.
Poster 72
Saturday
10:00 - 11:00 am
JAAPOS Abstract #041
Long term Efficacy and Safety of Photorefractive Keratectomy
in the Pediatric Population
Evelyn A Paysse MD; Zaina Al-Mohtaseb MD; Lingkun Kong MD; Mitchell P Weikert MD;
David K. Coats, MD
Dept. of Ophthalmology, Baylor College of Mdicine, Texas Children’s Hospital
Houston, TX
Methods: In this prospective noncomparative interventional case series, 44 eyes of 22
patients with severe bilateral high refractive errors and 35 eyes of 35 patients with severe
anisometropia who failed traditional therapy were treated with PRK. Patients were examined preoperatively and then postoperatively at month 1 and 6, year 1, and then annually.
The main outcome measures were refractive stability, visual acuity, and corneal clarity.
Results: The average preoperative refractive error was -9.45 ± 4.16 diopters (D) for
the myopic patients and +6.32 ± 1.26D for the hyperopic patients. The mean spherical equivalent was -0.92 ± 1.64D and 1.48 ± 0.51D for the myopic and hyperopic group
respectively at year one. The mean corneal haze score and percentage of eyes with corneal haze decreased from 0.9 to 0.5 and 64% to 25% in the myopic patients over three
years of follow up. In the patients that had measurable uncorrected visual acuity (UCVA)
pre-operatively, the UCVA improved from logMar 1.32 ± 0.57 to logMar 0.58 ± 0.31. Refraction was stable for up to 5 years of follow up.
Discussion: PRK is an effective and stable surgical alternative in children with high
refractive errors who are cannot tolerate traditional therapy.
Conclusion: PRK is an effective and stable surgical alternative in children with amblyogenic high refractive errors who are unable to tolerate traditional therapy.
THE LONG-TERM OUTCOME OF THE REFRACTIVE ERROR
IN HYPERMETOPIC CHILDREN
Seung Ah Chung(1); Soolienah Rhiu(2); Soo Han Yoon(3); Jong Bok Lee(4)
Eedy Mezer MD; Tamara Wygnanski-Jaffe MD; Ewy Meyer MD; Yaacov Sahuly MD;
Wofgang Haase MD; Albert W Biglan MD
Introduction: To describe the prevalence and nature of ocular comorbidity in children with
craniosynostosis before and after expansion cranioplasty.
Methods: We retrospectively reviewed the medical records of 88 consecutive children who
underwent expansion cranioplasty with distraction osteogenesis for craniosynostosis. Recorded data included the following: patient demographics, ocular motility, cycloplegic refraction,
intraocular pressure measured with tonopen, examination of the anterior and posterior segment, intracranial pressure, and procedures for craniofacial correction. Ocular findings were
assessed before and 6 months after surgery.
Results: Children with a mean age of 24.4 months were treated for their craniosynostosis
(27 were coronal, and 61 were sagittal and/or lambdoid). Ocular motility test was available for
85 of 88 patients. Sixty three of 85 patients (74.1%) had strabismus: 36 had exodeviation, 22
had esodeviation, and 14 had vertical deviation. Ametropia was found in 46.5% of patients:
36.3% had hypermetropia of +2.00 diopters (D) or more and 10.2% had myopia of less than
-0.50 D. Astigmatism of 1.50 D or more was in 31 cases (35.2%). Anisometropia, astigmatism,
and head tilt occurred more frequently on the contralateral side to the fused suture (P=0.038
for head tilt). Procedures for craniofacial correction improved abnormal head posture, but not
refraction.
Discussion: Patients who needed expansion cranioplasty were at risk for strabismus, ametropia, and astigmatism, especially who with unilateral synostosis in the eye contralateral to
the synostosis. Neurosurgical correction did not show any effect on ocular findings other than
abnormal head posture.
Conclusion: Our findings support the importance of ocular evaluation and management in
these children.
92
JAAPOS Abstract #087
Introduction: To use photorefractive keratectomy (PRK) for the treatment of myopia and
hyperopia and to observe long term efficacy and safty in pediatric patients
Ocular findings in children who underwent expansion cranioplasty with distraction
osteogenesis for craniosynostosis
(1)Department of Ophthalmology, Ajou University School of Medicine Suwon, Republic of Korea
(2)Department of Ophthalmology, Dongtan Sacred Heart Hospital Hallym University College of Medicine
Hwaseong, Republic of Korea
(3)Department of Neurosurgery, Ajou University School of Medicine Suwon, Republic of Korea
(4)Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Republic of Korea
Poster 73
Saturday
10:00 - 11:00 am
Department of ophthalmology, Rambam health care campus, Haifa, Ruth and Baruch Rappaport
Faculty of Medicine, Technion - Israel institute of Technology, Goldschleger Eye Institute, Haim
Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel-Aviv University, University
of Pittsburgh School of Medicine, Hamburg University
Israel, USA, Germany
Introduction: The course of changes in high hypermetropic refractive errors occurring in
childhood is not well studied.
Methods: We retrospectively abstracted data from the clinical records of 131 children with
high spherical equivalent hypermetropic refractive errors in 3 medical centers collected over
29 years. Children with hypermetropic refractive errors between +1.00 and + 3.00 were classified as Mild Hypermetropia (MH), and those +5.00 or greater were classified as High Hypermetropia (HH).
Three variables were studied: age, refractive error and gender. The rate of reduction of the hypermetropic refractive error was calculated over time in years. We utilized 3 logistic regression
models for sub-group analysis.
Results: Eighty one children had HH refractive errors and 51 had MH refractive errors.
Children with HH refractive errors were detected at a mean age of 3.3 years, those with a MH
refractive error were detected at 4 years. The mean follow-up was 6.5 years.
Younger children, boys (45.2-93.9%) more than girls (15.7-75.3%), with MH refractive errors
tended to reduce the refractive error over time. Those with HH refractive errors tended to
remain highly hyperopic with no gender predisposition.
Discussion: Children with MH refractive errors reduce their hyperopia and most were able to
remove their glasses as they approach their teen age years. Those with HH refractive errors
did not reduce the refractive error, and all required glasses entering their teen age years.
Conclusion: This study provides information for parents on whether their hypermetropic child
may require glasses as they approach their teen age years.
93
Poster 74
Saturday
10:00 - 11:00 am
Poster 75
Saturday
10:00 - 11:00 am
JAAPOS Abstract #042
The optic nerve and retinal vasculature in albinism: normal or abnormal?
Julie A Conley, MD; Alejandra Decanini Mancera, MD; Ann M Holleschau, BA CCRP;
C. Gail Summers, MD
University of Minnesota, Minneapolis, MN
Introduction: Albinism, an inherited disorder resulting in reduced ocular melanin, is
usually associated with reduced best-corrected visual acuity (BCVA), nystagmus, foveal
hypoplasia and iris transillumination. The purpose of this study is to describe the optic
nerve (ON) anatomy and peripapillary retinal vasculature in albinism and to examine the
relationship to BCVA.
Methods: This IRB-approved study is a retrospective review of 34 patients with albinism
and 51 controls seen at the University of Minnesota. The ON and peripapillary vasculature were analyzed by fundus photos using Ophthavision.
Results: Our data indicate that the optic disc diameter (DD) and ON area are statistically smaller in albinism than controls (p <0.001; p=0.0008). Using DD to disc-macula
ratio, with ‘macula’ determined as center of foveal avascular zone, more patients with
albinism qualified as optic nerve hypoplasia. Significantly more patients with albinism had
a double ring sign, situs inversus and a nasally-directed artery (p at least <0.0148). There
was no significant difference between groups for ON color, vessel branching pattern,
cilioretinal artery, tortuosity or vessels crossing the ON margin. No correlation of BCVA to
DD or ON area was found.
Discussion: In this study, patients with albinism had smaller DD and ON area than controls, confirming the clinical impression of Spedick and Beauchamp (1986). The vasculature was heterogeneous within the albinism group. Reduced BCVA is not explained by
the smaller DD and ON area.
Conclusion: The ON in albinism is smaller than controls. Further studies are required to
elucidate the cause of the decreased BCVA in albinism.
References: 1. Spedick MJ, Beauchamp GR. Retinal vascular and optic nerve abnormalities in albinism. J Pediatr Ophthalmol Strabismus
1986;23:58-63.
Poster 76
Saturday
10:00 - 11:00 am
JAAPOS Abstract #109
Lenticular changes in cerebrotendinous xanthomatosis,
a treatable metabolic disorder that is important to recognize
Arif O Khan; Mohammed A Aldahmesh; Jawaher Y Mohamed; Fowzan S Alkuraya
King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
JAAPOS Abstract #063
Introduction: Cerebrotendinous xanthomatosis is a progressive neurodegenerative
storage disease characterized by abnormal deposition of cholestanol and cholesterol in
multiple tissues, including the lens and brain, and caused by recessive CYP27A1 mutations. Ophthalmologists have the unique potential to facilitate earlier diagnosis and
preventative treatment by recognizing the juvenile cataract phenotype. We highlight the
morphology of lens opacities in a family with genetically confirmed disease.
Methods: Retrospective case series.
Results: Two sisters, each visually symptomatic before ten years old, had a unique
pattern of bilateral fleck deposits throughout the lens with significant posterior capsular
cataract. When initially examined at eight years old, their then asymptomatic younger
brother had the same bilateral fleck deposits with minimal posterior capsular opacity;
one year later he developed anterior capsular opacity and became symptomatic. Both
asymptomatic parents had few but distinct similar flecks localized at the Y-suture while
an asymptomatic sister did not. Genetic analysis revealed homozygosity for a CYP27A1
mutation (c.1263+1G>A) in the three symptomatic siblings, heterozygosity for the mutation in the two parents, and no mutation in the asymptomatic sister. When specifically
questioned, the three affected children had had recurrent bouts of diarrhea since early
childhood, which is a common feature of the disease.
Discussion: An unusual pattern of fleck lenticular deposits was seen in affected children. With time posterior and/or anterior capsular opacity developed and caused visual
symptoms. Asymptomatic fleck-like opacities at the Y-suture may be a carrier sign.
Conclusion: Such juvenile lenticular findings should raise suspicion for this treatable
metabolic disorder.
Ophthalmic Manifestions of the Glycoproteinoses
Timing of Dacryostenosis Resolution and the Development of Anisometropia
Ronald G Teed
Children’s Eye Specialists, LLC, Ladson, SC
Ma Khin Pyi Son, BA; Brian G Mohney, MD; David O Hodge, MS
Mayo Clinic, Rochester, MN
Introduction: The glycoproteinoses comprise a group of rare and extremely rare lysosomal storage disorders. The ophthalmic manifestations of these disorders have been
sparsely documented. A better understanding of these findings may help with the diagnosis of each disorder and may provide improved ophthalmic prognosis.
Methods: Twenty-nine patients with glycoprotein storage disorders underwent ophthalmological examinations as part of a multi-specialty clinic at the Third International
Conference for Glycoproteinoses. Three patients had a diagnosis of mucolipidosis II; 8,
mucolipidosis III; 5, combined mucolipidosis II/III; 7, alpha-mannosidosis; 2, aspartylglucosaminuria; 2, fucosidosis; and 1, galactosialidosis. Near visual acuity, motility examination, slit lamp examination, dilated fundus examination, and cycloplegic refraction were
recorded for each patient.
Results: Age range was 3-41 years. Overall, near visual acuity was well preserved
in all patients, with at least J3 acuity in the better eye. Hypermetropia of at least +5.00
spherical equivalent was found in 20 of 58 eyes. 21 of 29 patients had strabismus. 19
patients had at least trace corneal haze, though no patient had corneal clouding that obscured the anterior segment examination. Most patients had a normal posterior segment
examination; however, 6 of 7 patients with alpha mannosidosis exhibited retinal vascular
tortuosity.
Discussion: Refractive error and strabismus are common findings in the glycoproteinoses. Corneal clouding is generally mild, and retinal and optic nerve findings are uncommon. Functional visual acuity is generally maintained.
Conclusion: These findings add to the sparse literature on ophthalmic findings in the
glycoproteinoses. This series represents the largest collection to date on these disorders.
Introduction: Anisometropia was recently shown to develop in ten percent of infants
diagnosed with dacryostenosis at a mean age of one year. The purpose of this study was
to determine whether earlier (<1 year) spontaneous resolution or probing decreases or
eliminates this risk.
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Poster 77
Saturday
10:00 - 11:00 am
Methods: The medical records of all patients diagnosed as an infant with dacryostenosis from January 1, 1988, through December 31, 1992 were retrospectively reviewed.
Anisometropia was defined as > 1 diopter of refractive error between the two eyes.
Results: Among 662 consecutive infants, 244 (36.9%) subsequently underwent a complete ophthalmic examination: 189 (77.5 %) spontaneously resolved at a mean age of 4.5
months (range, 0.3-35 months), and 55 (22.5 %) underwent probing at a mean age of 16
months (range, 0-53 months). Anisometropia was diagnosed in 17 (9.0%) of the 189 who
spontaneously resolved and in two (3.6%) of the 55 operated children (p=0.19). There
was a tendency, although not statistically significant, for earlier resolution to be associated with higher rates of anisometropia.
Discussion: Although dacryostenosis is associated with the development of anisometropia, especially among those with early spontaneous resolution, it remains unknown
whether this relationship is causal or merely an association and whether early surgical
intervention can modify or eliminate this risk.
Conclusion: Early spontaneous resolution of dacryostenosis was more likely to have
a higher, not lower, rate of anisometropia than late spontaneous or surgical resolution.
Further studies are warranted to clarify the relationship between age at resolution and the
development of anisometropia in infants with dacryostenosis.
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Poster 78
Saturday
10:00 - 11:00 am
JAAPOS Abstract #083
Poster 79
Saturday
10:00 - 11:00 am
JAAPOS Abstract #104
Outcome of patients with lacrimal canalicular atresia
Mohamed Soliman; Gregg Lueder MD
Washington University in St. Louis
St. Louis, MO
Notes
Introduction: Canalicular atresia (CA) is an uncommon anomaly. This study evaluated
the treatment and outcome of patients with CA.
Methods: This was a retrospective study of 25 eyes of 16 otherwise normal patients
with history of nasolacrimal duct obstruction (NLDO) found to have CA at the time of
nasolacrimal duct probing (NLDP).
Results: Eleven eyes had lower atresia, 12 had upper atresia, and 2 had both upper
and lower atresia. NLDP was performed through the patent canaliculi in all patients except the two who had both upper and lower atresia.
Of the 12 patients with upper CA, 10 improved after NLDP and 2 improved after subsequent balloon catheter dilation (BCD). Of the 11 patients with lower CA, 1 improved after
NLDP and 10 required additional surgeries (BCD, lacrimal stents, and/or dacryocystorhinostomy). Patients with upper and lower canalicular atresia were treated with Jones tube
placement.
Discussion: Canalicular atresia is an unusual lacrimal anomaly that is sometimes found
at the time of NLDP. The outcome of NLDP is much better for patients with upper CA
compared to lower CA. NLDP through the lower canaliculi has a success rate similar to
that for children without CA. Patients with lower CA have much poorer outcomes following simple NLDP.
Conclusion: NLDO associated with upper CA can be successfully treated in most patients by simple NLDP through the lower canaliculi. For patients with lower CA, additional
procedures (BCD or stent placement through the upper canaliculi) should be considered
at the time of initial surgery.
References: LaPiana FG. Management of occult atretic lacrimal puncta. Am J Ophthalmol. 1972;74(2):332-3.
Lyons CJ, Rosser PM, Welham
RA. The management of punctal agenesis. Ophthalmology. 1993 ;100(12):1851-5.
Putterman AM. Treatment of Epiphora With Absent Lacrimal
Puncta. Arch Ophthalmol. 1973;89(2):125-127
Poster 80
Saturday
10:00 - 11:00 am
JAAPOS Abstract #055
The Activity and Damage of Blepharokeratoconjunctivitis in Children
Ken Nischal; Samer Hamada; Joanne Evans
UPMC Children’s Hospital of Pittsburgh Eye Center, Pittsburgh, PA
Introduction: The syndrome of childhood blepharokeratoconjunctivits (BKC) is frequently underestimated.
Total control of the disease is not possible in many cases. Measuring success has been based on clinical
experience only. We are implementing a new classification of BKC to define the degree of activity and damage
at any stage of the disease and hence measuring success of disease management. It will objectively measure
success of our BKC management protocol.
Methods: A retrospective review of all children with BKC over the last 10 years at tertiary referral centre.
Children with significant systemic disorders, atopy, vernal keratoconjunctivitis, or perennial allergic conjunctivitis were excluded. Activity/damage score of the worst affected eye at initial presentation and at last follow up
were included in the statistical analysis. Clinical features were graded, before and after instituting a hierarchical
therapeutic protocol comprising lid hygiene, topical/systemic antibiotics, intensive topical glucocorticoids, topical
lubricants, and nutritional supplement. Activity (A0-A3) and damage (D0-D3) scoring was applied to grade BKC.
Complete success was defined as ability to fully control disease activity i.e. from any grade to A0. Partial success meant reduction in activity scoring but not reaching A0 grade. Failure indicates no change or worsening of
disease activity.
Results: We identified a cohort of 42 patients (84 eyes) with BKC; mean age at onset of symptoms was 4.6
years (0.4 to 14 years) and at presentation to our centre 7 (1-15) years. The median duration of symptoms prior
to presentation was 2.22 years [range 0.01-10] years. 17 Asian and 25 Caucasian patients were followed up for
3.2 years (3months - 10 years). The protocol was followed in 90% of children. All cases where scored as per
activity and damage scoring system. All risk factors were analysed. Complete success was achieved in 50%,
partial success in 38%, and failure in 12% of children). Recurrences ranged from 0-7 times (mean 2.1).
Discussion: BKC is underestimated in Caucasian children. Total control of the disease is not always possible.
A protocol based on topical steroids and following a strict regime of treatment is vital for disease control. A
classification of BKC based on activity and damage score is an appropriate method to describe the disease and
classify it. It allows measuring success of treatment and to compare various modalities of treatments.
Younger age and longer duration of symptoms were common in the failure group. Those with acne rosacea had
the worst prognosis and this was statistically significant. Our protocol resulted in full control of the disease in
50% of patients but failed in 12% of cases. White Caucasians with BKC were at risk of severe phenotype that is
resistant to treatment.
Conclusion: The management of BKC in children is very challenging. Suboptimal treatment of BKC in children may permit a progressively destructive sight-threatening phenotype, which may last into adulthood and
cause visual disability. Aggressive topical steroids and following a strict regime of treatment are vital for disease
remission. A novel scoring system, which takes into consideration both activity and damage of BKC, will allow
appropriate disease description and classification, measuring success of treatment, and comparing various
treatment protocols.
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Notes
Workshop Schedule
Thursday, April 4, 2013
2:00 PM - 4:00 PM
Workshop #1
Simulated Strabismus Surgery - A Practical and Interactive Demonstration of
Novel Simulation Technique
John D. Ferris; Anthony J. Vivian
St. George A & B
2:15 PM - 3:15 PM
Workshop #2
Fiscal Benchmarking Workshop
America Ballroom
Deborah S. Lenahan, MD; Daniel Laby, MD; Nils Mungan, MD; Robert Gold, MD; Merrill Stass-Isern, MD; Theodore Curtis, MD; Jorie Jackson, CO
3:30 PM - 5:30 PM
Workshop #3
Pediatric Coding 2013
Robert S. Gold, MD; Robert Wiggins, MD, MHA;
Elizabeth Cottle, CSC, OCS
America Ballroom
Friday, April 5, 2013
100
7:00 AM - 8:15 AM
Workshop Session A
Workshop #4
AOC Workshop: DVD - A Conceptual, Clinical and Surgical Overview
Alex Christoff, CO, COT; Edward L. Raab, MD, JD;
Erick Bothun, MD; Michael C. Brodsky, MD; Kathy Fray, CO; David L. Guyton, MD; Claire C. Hennessey, CO; Kim Merrill, CO; David Morrison, MD
America North
Workshop #5
Oculoplastic Surgery of Interest to the Pediatric Ophthalmologist
Linda R. Dagi, MD; Alexandra T. Elliott, MD;
Suzanne K. Freitag, MD
America Center
Workshop #6
Genetic and Metabolic Cases You Don’t Want to Miss!
Sylvia R. Kodsi; Gail Summers; Deborah Alcorn; Jane Edmond; Sharon Lehman
St. George
Workshop #7
Pediatric Cataract - International Perspectives
I. Christopher Lloyd, FRCS, FRCOphth;
Graeme C. Black, DPhil, FRCOphth;
Cecilia Fenerty, MD, FRCOphth; Lola Solebo, PhD, MRCOphth; Jane L. Ashworth, PhD, FRCOphth
America South
8:30 AM - 9:45 AM
Workshop Session B
Workshop #8
The New Age of Medical Management of Pediatric Non-Infectious Uveitis
Rebecca Braverman, MD; C. Stephen Foster, MD;
Nasrin Tehrani, MD; John Ainsworth, MD: Mark Dacey, MD
America Center
Workshop #9
Apt Lecture Workshop: Cutting No Slack for the Sagging Eye Syndrome
Joseph L. Demer, MD, PhD; Zia Chaudhuri, MS, FRCS (Glasg);
Robert A. Clark, MD
America North
Workshop #10
Video Demonstrations of Classical or Rare Signs in Pediatric Ophthalmology
and Strabismus
Ken K. Nischal, FRCOphth; Edward Buckley, MD;
David Plager, MD; Edward Wilson, MD; David Granet, MD;
Jane C. Edmond, MD
America South
Workshop #11
Rehabilitation of Children with Low Vision: Controversies and Consensus
Terry L. Schwartz; Rebeccca Coakley; Kelly Lusk
St. George
101
Saturday, April 6, 2013
10:30 AM - 11:45 AM
Workshop Session C
Workshop #12
Should Your Patients get Whole Genome Sequencing? Should You?
Arlene V. Drack, MD
St. George
Workshop #13
Elder Wise: Pearls from Pediatric Greats
K. David Epley, MD; Alan B. Scott, MD; Marilyn Miller, MD;
Eugene Helveston, MD; John O’Neill, MD; William Scott, MD
America South
Rapid Fire Cases in Pediatric Ophthalmology (Non Strabismus) That Will
Change Your Practice
Aparna Ramasubramanian; Carol L. Shields; Alex V. Levin;
Bruce Schnall; Jerry A. Shields
America North
Workshop #15
Optical Coherence Tomography - Pearls for the Pediatric Ophthalmologist
Daniel J. Salchow; Cynthia A. Toth; Veit Sturm
America Center
7:30 AM - 9:00 AM
Workshop #27
America Ballroom
1:15 PM - 2:30 PM
Workshop Session D
Difficult Problems Non Strabismus Workshop
Ken K. Nischal, MD; Elias Traboulsi, MD; Lea Ann Lope, MD;
Federico Velez, MD; Mary O’Hara, MD
Workshop #16
Through the Eyes of Autism: Eye Care for these Special Patients
Joseph L. Demer; Eugenie E. Hartman; M. Edward Wilson;
Stuart R. Dankner
America Center
9:15 AM - 10:45 AM
Workshop #28
Difficult Problems Strabismus Workshop
Sean P. Donahue, MD, PhD; Edward G. Buckley, MD;
Oscar A. Cruz, MD; David G. Hunter, MD; Evelyn A. Paysse, MD
America Ballroom
Workshop #17
No CME
Protecting Your Online Image
K. David Epley, MD; Andrew Doan, MD, PhD
St. George
Workshop #18
Sticky Situations in Pediatric Glaucoma and What They Taught Us - Lessons
Learned the Hard Way
Sharon F. Freedman, MD; Allen D. Beck, MD; Alex V. Levin, MD;
David S. Walton, MD
America North
Workshop #19
Adult Strabismus
America South
David Stager, Jr; Steven M. Archer; Edward G. Buckley, MD;
Forrest J. Ellis; David B. Granet; David L. Guyton; David G. Hunter
2:45 PM - 4:00 PM
Workshop Session E
Workshop #20
Developing an Integrated System for Children’s Vision Care - Report on the
Work of the National Center for Children’s Vision and Eye Health
Mary Louise Z. Collins, MD; Jean E. Ramsey, MD, MPH;
Eugenie Hartman, PhD; Joseph M. Miller, MD, MPH;
Michael X. Repka, MD; Kira Baldonado
Workshop #21
AAP/AAPOS Pediatric Neuro-Ophthalmology Workshop - Avoiding Disaster: America South
Lessons Learned from Difficult Cases
Daniel J. Karr, MD; Edward G. Buckley, MD; Jane C. Edmond, MD;
Gena Heidary, MD, PhD; John MacDonald, MD;
R. Michael Siatkowski, MD
Workshop #22
Management Issues in Non-Cataractous Lenticular Disorders in Children
Ramesh Kekunnaya; Arif O. Khan; Alex V. Levin; Ken Nischal;
David A. Plager
America North
Workshop #23
New Concepts on Visual Cortical Plasticity: Multiple Critical Periods and
Implications for Amblyopia
Agnes Wong, MD, PhD, FRCSC; Terri Lewis, PhD;
Takao Hensch, PhD
St. George
4:30 PM - 6:00 PM
Workshop #24
Special Symposium: The Child with Developmental Delay: Multispecialty
Perspectives on Improving Care
K. David Epley, MD; Linda Lawrence, MD; Cheryl McCarus, CO;
Shirley Anderson, OTR/L, SCLV, CLVT; Sharon Lehman, MD;
Jorie Jackson, CO
America Ballroom
Workshop #14
102
7:00 AM - 8:15 AM
Workshop #25
Symposium - Update on Ocular Anti-Infectives for the Pediatric
Ophthalmology
M. Edward Wilson, MD; Steven J. Lichtenstein, MD;
Rudolph S. Wagner, MD; Peter D’Arienzo, MD
America Ballroom
2:00 PM - 3:15 PM
Workshop #26
OMIC Workshop: Lessons Learned From 25 Years of Pediatric Ophthalmology America Ballroom
& Strabismus Claims
Anne M. Menke, RN, PhD; Robert Wiggins, MD, MHA
Sunday, April 7, 2013
America Center
103
Simulated Strabismus Surgery - a practical and interactive demonstration of
novel simulation techniques.
John D Ferris Mr; Anthony J Vivian Mr
Gloucestershire Eye Unit and Addenbrooke’s Hospital, Cambridge
Workshop 1
Thursday
2:00 - 4:00 pm
JAAPOS Abstract #127
Purpose/Relevance: To demonstrate how the safety of strabismus surgical training can
be enhanced by the use of novel simulation techniques, using life-like silicone model eyes.
Target Audience: Ophthalmologists involved with teaching strabismus surgery and surgical trainees.
Current Practice: Patient safety should be our principle concern when teaching any form
of surgery. However, very few training programs provide any form of strabismus surgery
simulation. This means surgical trainees may not have developed core surgical skills, such
as rectus muscle and scleral suturing techniques, before operating on patients.
Best Practice: A simulation program, using life-like silicone eyes, to teach basic suturing techniques before moving on to performing recession / resection techniques, inferior
oblique surgery and then the use of adjustable sutures.
|Trainees are required to have performed at least 5 complete rectus muscle procedures
satisfactorily, before being allowed to operate on patients.
Expected Outcomes: All delegates will be aware of the potential benefits of simulation
training for patients, trainees and trainers and will have observed live demonstrations of
rectus muscle and oblique muscle surgery on the model eyes. They will also have learnt
how to incorporate surgical simulation into their training programs or practices.
Format: Introductory lectures (40 minutes); Live strabismus surgery demonstration, by
leading surgeons from the USA and UK (20 minutes); Q&A session (15 minutes).
Summary: This workshop will demonstrate how strabismus surgical simulation, using
life-like model eyes, can enhance patient safety and the quality of surgical training. The
combination of lectures, live surgical demonstrations, followed by a Q&A session, will we
hope be conducive to an educational and interactive workshop.
References: Surgical Techniques in Ophthalmology Series: Strabismus Surgery. John D Ferris Peter J Davies Elsevier 2007
Fiscal Benchmarking Workshop - Data From FY 2011
AAPOS Socioeconomic Committee
Deborah S Lenahan MD; Daniel Laby MD; Nils Mungan MD; Robert Gold, MD;
Merrill Stass-Isern, MD; Theodore Curtis, MD; Jorie Jackson, CO
Pediatric Eyecare of Western Colorado, Grand Junction, CO
Purpose/Relevance: The purpose of this presentation is to present financial data
gathered by a survey of AAPOS members. This will be the third consecutive year that
key metrics for a successful pediatric ophthalmology practice have been evaluated
and discussed. Each year, the survey continues to be refined and new metrics added.
Target Audience: The target audience is pediatric ophthalmologists and their practice.
Current Practice: Financial benchmarks have not been available for pediatric ophthalmology until the advent of the SEC Fiscal Benchmarks Project in 2010.
Best Practice: The ongoing survey discussed at this workshop allows AAPOS members to establish norms specific to pediatric ophthalmology, thus enabling participants
to identify potential problem areas in their practice, whether private or academic.
Expected Outcomes: At the conclusion of the session, the attendees will be able to
understand key financial metrics in their practices and have norms available for comparison. Additionally, they will gain a better understanding of how practice patterns
can be modified to enhance practice profitability.
Format: Panel discussion/open question and answer forum.
Summary: The data from the just completed FY 2011 survey will be presented. This
information will be discussed, with a panel discussion of each of the benchmarks and
questions from the audience.
References: References: AAPOS Benchmarking Presentations, 2011 and 2012 meetings.
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Workshop 2
Thursday
2:15 - 3:15 pm
JAAPOS Abstract #133
Workshop 3
Thursday
3:30 - 5:30 pm
JAAPOS Abstract #129
Pediatric Coding 2013
Robert S Gold MD; Robert Wiggins MD,MHA; Elizabeth Cottle CSC,OCS
Purpose/Relevance: To have an interactive discussion regarding the proper coding of pediatric eye examinations, specialized testing, and surgical procedures in order to perform these tasks for proper compliance.
The panel has expertise in coding being involved in the review of the Pediatric Coding Companion for the
American Academy of Ophthalmology, AAOE participants, and a certified coding specialist who is part of the
AAO Coding specialists group.
Target Audience: Pediatric ophthalmologists, orthoptists, administrators, and technicians.
Current Practice: In pediatric ophthalmology practices today, proper coding of exams and procedures is
essential for compliance. Proper documentation is essential for proper coding and continued education
and practice experience is expanded at this session. Specific topics and examples will include Retinopathy
of Prematurity documentation and coding, Sensorimotor Exam documentation and coding, and vision vs.
medical coding examples. Statistics show that 8.4% of E/M payments were billed at the wrong code level
(http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network
MLN/MLNProducts/downloads/Evaluation_Management_Fact_Sheet_ICN905363.pdf). Between phone,
email, etalk and ecode nearly 4,000 inquiries a year are received. The examples below provide a strong
indication of the current level of knowledge and what will be among the questions addressed in this course.
1. I performed strabismus surgery on a patient with bilateral A-pattern exotropia. The report indicates that
retinal bent spacers were used. What is the correct way to report this part of the procedure?
2. Would CPT code 30300 be appropriate to code for a tube removal?
3. How do I code for right medial rectus advancement?
4. When a pateint returns to follow-up on nasolacrimal duct obstruction and the baby’s eyes are clear, what
is the appropriate diagnosis code?
5. How do you code for inferior oblique myectomy?
6. Patient has bilateral lateral rectus resections and the inferior obliques explored. How do I code for the
exploration of the obliques?
Best Practice: The ideal situation to coding properly is education, continually asking questions to get to
the proper answer, and put both into real practice examples.
Expected Outcomes: Once this course is completed, the attendees should have a better understanding of
the coding situations presented and be able to take this back to their practice and make the proper coding
decisions.
Format: Panel discussion with discussion of submitted questions and open question and answer format.
Summary: The material presented at this workshop will be driven by questions submitted in advance by
the AAPOS members, their orthoptists, administrators, or technicians to the panel, so that interactive discussion can occur for many coding situations submitted. Questions will also be taken “live” at the session.
References: References: Pediatric Coding Companion, American Academy of Ophthalmology
Workshop 4
Friday
7:00 - 8:15 am
JAAPOS Abstract #117
DVD - A Conceptual, Clinical and Surgical Overview
Alex Christoff CO, COT, Co-Moderator; Edward L Raab MD,JD Co-Moderator;
Erick Bothun, MD; Michael C. Brodsky, MD; Kathy Fray, CO; David L. Guyton, MD;
Claire C Hennessey CO; Kim Merrill CO; David Morrison, MD
Johns Hopkins Medical Institutions
600 North Wolf Street, Baltimore, MD 21287
Purpose/Relevance: Dissociated vertical deviation is recognized by clinicians as a slow, dissociated hypertropic deviation of a non-fixating eye. It is usually bilateral, asymmetrical, and often associated with congenital esotropia. The deviating eye elevates, abducts, and excyclotorts.
There is no unanimous agreement on the mechanism and pathophysiology of DVD.
Target Audience: All clinicians with an interest in pediatric ophthalmology and adult strabismus. Additionally, neuro-physiologists with an interest in dissociated strabismus.
Current Practice: This type of strabismus is often asymmetric and variable, making measurement and clinical quantification difficult. This workshop will also explore current methods for
assessing and quantifying DVD.
Best Practice: DVD requires a specific knowledge of the mechanisms and characteristics
of the dissociated deviation in order to assess it properly and effectively. This workshop will
explore those characteristics and techniques.
Expected Outcomes: Understanding the potential etiology, clinical characteristics, and indications for surgical intervention should help all who attend gain a better insight into the proper way
to assess and treat, both surgically and non-surgically, dissociated deviations.
Format: Didactic lecture, open question and answer forum, panel discussion, case presentation, audience quiz or polling, video analysis.
Summary: The workshop begins with two of the most widely known concepts of the etiology of
DVD, given by their respective proponents.
Three certified orthoptists from the American Association of Certified Orthoptists (AACO) will
discuss measurement techniques, non-surgical treatment, and provide a case presentation.
Based on personal experience, two board-certified pediatric ophthalmologists who routinely
perform surgery for dissociated strabismus will present their surgical views on the procedures
that they have found most effective in the surgical management of DVD and/or DHD.
15-25 minutes allotted for questions from the panel (AC and ER), and audience Q&A.
References: 1.Brodsky MC. Dissociated Vertical Divergence: A Righting Reflex Gone Wrong. Arch Ophthalmol. 1999;117(9):1216-1222.
|2.Guyton, DL. Dissociated vertical deviation: Etiology, mechanism, and associated phenomena. Costenbader Lecture. J AAPOS 2000;4(3):131144.
106
Oculoplastic Surgery of Interest to the Pediatric Ophthalmologist
Linda R Dagi MD; Alexandra T Elliott MD; Suzanne K Freitag MD
Boston Children’s Hospital / Massachusetts Eye and Ear Infirmary /
Harvard Medical School
Boston MA
Workshop 5
Friday
7:00 - 8:15 am
JAAPOS Abstract #119
Purpose/Relevance: Management of oculoplastic disorders encountered in the pediatric
population
Target Audience: For the pediatric ophthalmologist
Current Practice: Surgical management of congenital ptosis, masses in the lid and brow,
coloboma of the eyelids, epiblepharon, and blow-out fractures in children falls in the grey zone
between the subspecialty training of pediatric ophthalmologists and the purview of oculoplastic
surgeons. Many pediatric ophthalmologists do not feel equipped to manage these disorders following fellowship training. In some locations, oculoplastic surgeons are not readily available, or
would prefer to defer to the pediatric subspecialist for care of infants and children.
Best Practice: Pediatric ophthalmologists should have in depth knowledge of the surgical considerations and approach relevant to each condition, in order to manage or co-manage these
conditions.
Expected Outcomes: This workshop will provide attendees already performing these procedures with enhanced technical knowledge. Those not currently performing relevant procedures
will have the opportunity to review anatomical considerations, surgical approaches and optimal
care of each condition. Surgical procedures performed will be described in depth, fostering skill
acquisition by all attendees.
Format: Didactic lectures emphasizing case presentations.
Summary: Workshop will include surgical treatment of congenital ptosis, third nerve palsy,
Horner’s syndrome or ptosis in association with craniosynostosis. Surgical management of
eyelid coloboma, epiblepharon and blepharophimosis will be addressed. Excision of orbital
dermoids or other masses through the natural lid crease will be demonstrated. Finally, surgical
management of the child with orbital blow-out fracture will be included.
References: Karsloglu, S, Serin, D, Ziylan, S.Simple alternative to the Wright needle in frontalis surgery.Ophthalmic Plastic & Reconstructive
Surgery.2007. 23(3):231-232.
Burroughs, JR, Soparkar, CN. et al. Periocular Dog Bite Injuries and Responsible Care.Ophthalmic Plastic &
Reconstructive Surgery. 2002. 18(6)416-420.
Pediatric Oculoplastic Surgery. James A Katowitz (Editor)
Genetic and metabolic cases you don’t want to miss!
Sylvia R Kodsi; Gail Summers; Deborah Alcorn; Jane Edmond; Sharon Lehman
Purpose/Relevance: Genetic and metabolic disorders of childhood may initially present to the pediatric ophthalmologist. It is essential for the pediatric ophthalmologist to
recognize ocular abnormalities that may signal the presence of a genetic or metabolic
disorder, particularly those with serious systemic manifestations.
Target Audience: Pediatric Ophthalmologist
Current Practice: Pediatric ophthalmologist may not be able to identify genetic or
metabolic cases and appropriately refer the child when needed.
Best Practice: Pediatric Ophthalmologist should be able to identify ocular abnormalities that indicate a genetic or metabolic disease such as nystagmus and refer the child
when needed to other appropriate physicians.
Expected Outcomes: At the conclusion of this workshop, the physician will be better
able to recognize and treat the ocular manifestations of more unusual inborn errors of
metabolism and genetic disorders that involve the eye.
Format: This workshop will consist of a panel that will present interesting cases of
hereditary eye disorders including inborn errors of metabolism and structural abnormalities of the eye. To make this workshop more thought provoking, the diagnosis will
not be initially given, but the workshop will use case presentations to develop a differential diagnosis. At the end of each case there will be opportunity for questions from
the audience to be answered by the panel.
Summary: Children with various abnormalities including ocular motility disorders,
optic nerve changes, retinal changes and anterior segment abnormalities will be presented. After the case presentation a differential diagnosis will be formulated, followed
by a discussion of the etiology, genetics and management of the condition.
References: 1. The infant with nystagmus, normal appearing fundi, but an abnormal ERG. Lambert SR, Taylor D, Kriss A. Surv Ophthalmol.
1989 Nov-Dec;34(3):173-86.
2. Value of the ERG in congenital nystagmus. Good PA, Searle AE, Campbell S, Crews SJ. Br J Ophthalmol. 1989 Jul;73(7):512-5.
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Workshop 6
Friday
7:00 - 8:15 am
JAAPOS Abstract #132
Workshop 7
Friday
7:00 - 8:15 am
JAAPOS Abstract #134
Pediatric Cataract - international perspectives
I Christopher Lloyd FRCS FRCOphth; Graeme C Black DPhil FRCOphth;
Cecilia Fenerty MD FRCOphth; Lola Solebo PhD MRCOphth; Jane L Ashworth PhD FRCOphth
JAAPOS Abstract #116
Joseph L Demer MD, PhD; Zia Chaudhuri MS, FRCS (Glasg); Robert A Clark MD
Manchester Royal Eye Hospital, Manchester Academic Health Sciences Centre
Manchester, UK
Purpose/Relevance: This workshop will cover developments in important areas of congenital and childhood cataract
management - genetics, aphakic/pseudophakic glaucoma and the surgical management of children under 2 years of age.
Target Audience: Pediatric Ophthalmologists, Orthoptists, interested geneticists and vision scientists.
Current Practice: The Genetics of Congenital Cataract - Congenital cataract has a large and heterogeneous genetic
aetiology. This heterogeneity delays diagnosis and precludes a detailed understanding of the impact of genotype on phenotypic outcomes.
Management of Aphakic and Pseudophakic Glaucoma - Surgery for congenital cataract in the neonate and infant carries
significant risk for the development of secondary glaucoma. The risk factors associated with development of glaucoma and
the pathophysiological mechanisms will be discussed.
Update on the IOLu2 study - Primary intraocular lens (IOL) implantation is the most important recent innovation in the
management of childhood cataract, despite unanswered questions regarding best practice, visual benefits and adverse
outcomes. A bi-national European epidemiological study of outcomes in children undergoing cataract surgery in the first two
years of life is being undertaken through systematic, standardised data collection. Early outcome data will be presented.
Best Practice: The Genetics of Congenital Cataract - New high throughput molecular technologies, including microarray
technologies for autozygosity mapping and next generation sequencing promise to shed light on the breadth of the genetic
causes, both syndromic and nonsyndromic. This will be illustrated using cases and examples.
Management of Aphakic and Pseudophakic Glaucoma - The rationale for different treatment modalities, their relative risks
and benefits will be presented together with results from a UK tertiary hospital.
IOLu2 study - 256 children under 2 years old undergoing surgery for congenital or infantile cataract have been recruited.
IOL implantation was undertaken in the majority of children over 6 months old, but aphakia was the preferred option for
younger children, due in part to the high frequency of other ocular anomalies. Overall primary IOL implantation conferred
no visual benefit for those with unilateral cataract, but may be associated with better visual outcome following bilateral cataract surgery. 16% developed glaucoma during the first postoperative year. Age at surgery was the most significant factor.
Refractive outcomes suggest there is a need for standardisation of refractive planning.
Expected Outcomes: The Genetics of Congenital Cataract - Molecular analysis for congenital cataract facilitates the
development of individualised care pathways and enables improved determination of diagnosis, familial risk and clinical
outcomes.
Management of Aphakic and Pseudophakic Glaucoma - Earlier intervention with surgical treatment modalities improves
outcomes in aphakic and pseudophakic glaucoma.
IOLu2 study - This unique inception cohort will provide information on longer term outcomes and their impact on the educational and personal development of children born with cataract.
Format: Didactic lectures followed by panel discussion and audience participation. The workshop will close with case
presentations illustrating management of challenging clinical scenarios.
Summary: This workshop will provide a comprehensive update of recent advances in 3 important themes of congenital
and childhood cataract management - genetics, aphakic/pseudophakic glaucoma and the epidemiology and surgical management of children under 2 years of age.
Purpose/Relevance: Adult acquired horizontal and cyclovertical strabismus are increasingly prevalent as the population ages. This workshop elaborates the Apt lecture’s contention that much age-related distance esotropia (ARDE, commonly called divergence
paralysis esotropia) and cyclovertical strabismus (CVS) is due to an orbital connective
tissue degeneration termed the “sagging eye syndrome” (SES), and will detail approaches
to diagnosis and treatment.
Target Audience: Pediatric ophthalmologists and orthoptists.
Current Practice: ARDE and CVS are typically regarded as being exclusively neurological, while connective tissue degeneration is seldom included in the differential diagnosis.
Best Practice: Attendees should recognize clinical findings typical of SES, versus findings suggesting neurological strabismus. Typical findings include: older age and history
of blepharoplasty; adnexal laxity with blepharoptosis, superior sulcus defect, and floppy
eyelids; limited sursumversion; and full abduction with normal saccadic velocity. Although
orbital imaging is clinically unnecessary in typical SES, attendees should recognize its
magnetic resonance imaging signs including lateral rectus sag, LR-SR ligament degeneration, and rectus muscle elongation. Attendees should understand non-surgical and surgical treatments, including augmented medial rectus recession, lateral rectus myopexy, and
partial vertical rectus tenotomy.
Expected Outcomes: Attendees will understand how to diagnose and treat strabismus
due to SES.
Format: Didactic format will introduce features of SES and treatment alternatives. Interactive cases with question/answers will be emphasize clinical scenarios.
Summary: Diagnostic and pathophysiological features of adult acquired strabismus due
to SES will be defined, and practical treatments described.
The new age of medical management of pediatric non-infectious uveitis.
Video Demonstrations of Classical or Rare Signs in Pediatric Ophthalmology
and Strabismus
References: 1. Congenital and infantile cataract - aetiology and management. Chan WH, Ashworth JL, Biswas S, Lloyd IC. Eur J Pediatr
(2012) 171:625-630
Workshop 8
Friday
8:30 - 9:45 am
Apt Lecture Workshop: Cutting No Slack for the Sagging Eye Syndrome
Rebecca Braverman MD; C. Stephen Foster MD; Nasrin Tehrani MD;
John Ainsworth MD; Mark Dacey MD
University of Colorado School of Medicine Department of Ophthalmology, Aurora, CO
Purpose/Relevance: Pediatric non-infectious uveitis is one of the most challenging conditions
ophthalmologists must treat. The myriad of medications now available can make selection of
the appropriate treatment regimen daunting but can improve the ultimate outcome. 1-4
Target Audience: The target audience will be pediatric and comprehensive ophthalmologists.
Current Practice: Successful medical management of pediatric non-infectious uveitis depends
on the appropriate medication selection and duration of treatment. Corticosteroids, anti-metabolites and biologic agents are among the choices available. Ophthalmologists must be aware of
possible adverse effects of individual agents.5
Best Practice: Steroid sparing agents including antimetabolites and biologics can reduce
the complications associated with long term steroid use when treating pediatric non-infectious
uveitis.
Expected Outcomes: Ophthalmologists may reduce the risk of permanent vision loss and
sequelae from uncontrolled uveitis in their pediatric patients by appropriate medical regimen
selection and implementation.
Format: Corticosteroids, anti-metabolites and biologic agents will be presented in a didactic review and their application will be illustrated in case presentations. Important aspects of medication selection, duration of treatment and the adverse effects will be discussed. Tips for counseling parents on the risks of individual agents will serve to conclude the workshop.
Summary: Medications available to treat pediatric non-infectious uveitis will be reviewed. Case
presentations will illustrate appropriate medication selection and duration of treatment. The risks
and benefits of immunomodulation will be discussed to aid the ophthalmologist in counseling
families appropriately.
References: 1. Tomkins-Netzer O, Taylor SR, Lightman S. Corticosteroid-sparing agents: new treatment options. Dev Ophthalmol. 2012;51:4756.
2. Kruh J, Foster CS. Corticosteroid-sparing agents: conventional systemic immunosuppressants. Dev Ophthalmol. 2012;51:29-46.
3. Kruh J, Foster CS. The philosophy of treatment of uveitis: past, present and future. Dev Ophthalmol. 2012;51:1-6.
4. Durrani K, Zakka
FR, Ahmed M, Memon M, Siddique SS, Foster CS. Systemic therapy with conventional and novel immunomodulatory agents for ocular
inflammatory disease. Surv Ophthalmol. 2011;56:474-510.
5. 25. Kempen JH, Gangaputra S, Daniel E, Levy-Clarke GA, Nussenblatt RB,
Rosenbaum JT, Suhler EB, Thorne JE, Foster CS, Jabs DA, Helzlsouer KJ. Long-term risk of malignancy among patients treated with immunosuppressive agents for ocular inflammation: a critical assessment of the evidence. Am J Ophthalmol. 2008;146:802-12.
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Workshop 9
Friday
8:30 - 9:45 am
JAAPOS Abstract #121
References: 1. Rutar, T. and Demer, J. L. “Heavy eye syndrome” in the absence of high myopia: A connective tissue degeneration in elderly
strabismic patients. JAAPOS 13:36-44, 2009.
2. Chaudhuri, Z. and Demer, J. L. Medial rectus recession is as effective as lateral rectus resection in divergence paralysis esotropia. Arch. Ophthalmol. 130:1280-1284, 2012. 3. Chaudhuri, Z. and Demer, J. L. Sagging eye syndrome:
Connective tissue involution causes horizontal and vertical strabismus in older patients. Arch. Ophthalmol. (in press), 2013.
Ken K Nischal FRCOphth; Edward Buckley MD; David Plager MD;
Edward Wilson MD; David Granet MD; Jane C Edmond MD
Childrens Eye Center , Childrens Hospital of Pittsburgh of UPMC, Pittsburgh PA
Purpose/Relevance: To demonstrate using high quality video, rare or classical clinical or surgical signs in pediatric ophthalmology and strabismus.
Target Audience: Pediatric ophthalmologists, orthoptists and training ophthalmologists.
Current Practice: Many rare or classical signs are often described in textbooks but not always
recorded in busy clinics. Equally some surgical signs are so rare that very few people get to see
them. This workshop allows the audience to see videos of such signs with an explanation from
the ophthalmologist who had recorded them.
Best Practice: Many of the conditions shown in the video demonstartions are usually seen in
tertiary and quarternary settings but may well present in the primary or secondary setting. Ideally all physicians would have access to such videos for contued medical education but these
are not currently available at any one site.
Expected Outcomes: This workshop should make the audience more confident in making
diagnoses based on the signs shown. It should allow them to better formulate treatment plans
based on the clinical signs . The surgical videos will allow the audience to see unusual procedures or signs so they are more familiar with them.
Format: Six experienced authors will have 12 minutes each to present videos of surgical, and
clinical signs of classical ,or rare conditions. Each presenter will be quizzed by other panel
members about differential diagnoses for clinical signs or alternative techniques for surgical videos. Some of these will be videos of oculo-palatal myoclonus, signs in pediatric myasthenia gravis, endoscopic evaluation of a failed Ahmed Tube, forced duction test of a lax superior oblique
tendon, floppy iris syndrome in a child,eyemovents in a child diagnosed with neurological tics
which were due to dry eye syndrome, goniotomy in aniridia,nystagmus of benign paroxysmal
hemiplegia of childhood, paradoxical pupils, forced duction test to cure Brown syndrome and
rupture of an inferior rectus muscle during strabismus surgery.
Summary: Demonstration of classical or rare clincial signs and surgical techniques using high
quality video and inter-panel debate.
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Workshop 10
Friday
8:30 - 9:45 am
JAAPOS Abstract #136
Workshop 11
Friday
8:30 - 9:45 am
JAAPOS Abstract #140
Rehabilitation of Children with Low Vision: Controversies and Consensus
Elder Wise: Pearls from Pediatric Greats
Terry L Schwartz; Rebecca Coakley; Kelly Lusk
Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Oh
K. David Epley MD; Alan B Scott MD; Marilyn Miller MD; Eugene Helveston MD;
John O’Neill MD; William Scott MD
Purpose/Relevance: It is not uncommon for pediatric ophthalmologists to be asked to
share opinions about learning braille, obtaining large print, or the possibility of driving for
their patients with low vision. These recommendations can be incorporated into educational plans with significant impact on future visual function and independence.
Target Audience: pediatric ophthalmologists
Current Practice: Recommendations regarding the use of educational media are often
based on minimal data, availability of free large print materials, and a reluctance to teach
braille. Low vision driving is a controversial and poorly understood topic for most ophthalmologists, complicated by issues associated with teen driving.
Best Practice: To optimize literacy skills in children, this course will define literacy, present data regarding literacy instruction (braille, print, and optical devices) and offer strategies for making appropriate recommendations. Viewed by many as a means to become
more independent and increase options for employment, low vision driving issues (qualifications, safety data, and controversies) will be presented.
Expected Outcomes: Understanding requisites for literacy and familiarity with assessment of literacy will help the pediatric ophthalmologist become a partner in educational
planning. Knowledge of low vision driving will help the doctor anticipate questions and
provide current information for teenages who might qualify for a low vision driving program.
Format: didactic lecture
Summary: This workshop will present data to better understand decisions surrounding
literacy skills and controversies in visually impaired children. Topics will include braille versus print, large print versus the use of optical devices, and timing of interventions. Driving
for teens with low vision will be explored through reviewing studies of low vision driving,
current status of training programs, and legal regulations.
References: Huss, C., & Corn, A. L. (2004). Low vision driving with bioptics: An Overview. Journal of Visual Impairment and Blindness. 98,
641-653.
Lusk, K. E., & Corn, A. L. (2006a). Learning and using print and braille - A study of dual-media learners: Part 1. Journal of Visual
Impairment and Blindness, 100, 606-619.
Lusk, K. E., & Corn, A. L. (2006b). Learning and using print and braille - A study of dual-media
learners: Part 2. Journal of Visual Impairment and Blindness, 100, 653-665.
Workshop 12
Friday
10:30 - 11:45 am
JAAPOS Abstract #123
Should your patients get whole genome sequencing? Should you?
Arlene V Drack MD
University of Iowa, Iowa City, IA
Purpose/Relevance: Whole genome DNA sequencing is a reality and the price
keeps coming down. Direct-to-consumer companies sequence genomes, exomes,
SNPS or genes for a fee. How do direct-to-consumer tests differ from genetic testing
ordered by an M.D.? Is whole genome sequencing the gateway to personalized medicine, or not quite ready for prime time? Can a person really learn about their ancestry,
their medical risks and their dog’s breed from DNA testing? Physicians need to know
these answers for their patients, and for themselves.
Target Audience: Ophthalmologists, Orthoptists, anyone interested in what genetic
testing tells us about ourselves in 2013.
Current Practice: Patients are now able to get their own genetic results through
direct-to-consumer testing, but they look to physicians to interpret it and to advise
them about what testing to order. The genetic revolution is new, and physicians may
not be knowledgeable about all aspects of genetic testing available.
Best Practice: Physicians should be conversant about different types of genetic testing, and when to refer a patient to a geneticist. They should be aware of pharmacogenetics. They should understand the AAO position statement on genetic testing.
Expected Outcomes: At the conclusion of this presentation, participants will have a
working knowledge of the utility of various types of genetic testing. They will be familiar with the recent AAO position paper.
Format: Didactic lecture with audience participation.
Summary: Examples of single gene testing, exome and genome sequencing, pharmacogenetics and direct-to-consumer genetic testing will be presented. What these
tests can and cannot tell us will be explored. The AAO genetic testing position paper
will be discussed.
References: Offitt, K. Personalized medicine; old genomics, new lessons. Hum Genet 2011; 130:3-14. Stone EM, Aldave AJ, Drack AV, et
al. Recommendations for Genetic Testing of Inherited Eye Diseases: Report of the American Academy of Ophthalmology Task Force on Genetic
Testing. Ophthalmol 2012 Aug 31. [Epub ahead of print]
110
Purpose/Relevance: Things we learn in residency and fellowship give us a foundation for practicing pediatric ophthalmology. But every good clinician and surgeon
realizes that there are many things that go to making an oustanding physician. This
workshop will assemble 5 oustanding pediatric ophthalmologists who are pioneers in
our field to discuss pearls of wisdom they have learned through years of practice.
Target Audience: Pediatric ophthalmologists, history buffs, orthoptists, anyone who
interacts with patients in a healthcare setting.
Current Practice: Pediatric ophthalmologists are often challenged to make the correct diagnosis when symptoms and science don’t fit the classic diagnostic picture.
Best Practice: The panel with 150 years of combined experience in pediatric ophthalmology and strabismus will present their best and most complex cases in order to
relay pearls of knowledge to help participants better practice their clinical and surgical
skills.
Expected Outcomes: Every physician who attends this workshop will leave with at
least 10 pearls of wisdom to help in their medical and surgical practice.
Format: Panel presentations and discussion with audience participation (ideally with
polling).
Summary: 5 reknowned pediatric ophthalmologists will present pearls of wisdom in
a variety of formats that will engage the audience as well as convey knowledge that
otherwise takes years to acquire independently.
References: There are no references for this workshop.
Workshop 13
Friday
10:30 - 11:45 am
JAAPOS Abstract #126
A large number of AAPOS members have asked for a workshop involving elder high
profile pediatric ophthalmologists.
Rapid Fire Cases in Pediatric Ophthalmology (Non Strabismus) That Will
Change Your Practice
Aparna Ramasubramanian; Carol L Shields; Alex V Levin;
Bruce Schnall; Jerry A Shields
Drexel University College of Medicine, Wills Eye Institute, Philadelphia, PA
Purpose/Relevance: There are a multitude of pediatric eye diseases that can present
with a single feature or an atypical manifestation and cause diagnostic dilemmas. Furthermore, they could represent an underlying systemic disease, syndrome, or even a malignant process. This workshop will provide an overview of key features that help to diagnose
and treat a spectrum of pediatric conditions with ophthalmic manifestations.
Target Audience: Pediatric Ophthalmologists & General Ophthalmologists
Current Practice: Pediatric ophthalmologists often encounter atypical clinical presentations such as a common ocular tumor that presents in an uncommon way or rare clinical
diseases that need prompt attention and diagnosis. In the field of pediatric ophthalmology
it is not always possible to run a battery of ancillary testing and hence clinical acumen is
essential.
Best Practice: Recognition of key clinical features for ophthalmic conditions and systemic
diseases for prompt work up and management. Attendees will gain an understanding of
key clinical features for ophthalmic conditions for atypical presentations of common diseases that require further workup.
Expected Outcomes: At the conclusion of this presentation, attendees would be able to
recognize and treat or appropriately refer patients with (1) eye manifestations of a systemic
disease or (2) eye features that suggest a benign or malignant process.
Format: Case Presentation
Summary: With the use of multiple short non strabismus cases, a spectrum of challenging and interesting pediatric ophthalmic features of syndromes, diseases, and neoplastic
processes will be provided. An emphasis on the key clinical points will be highlighted.
References: 1. Shields CL, Schoenfeld E, Kocher K, Shukla SY, Kaliki S, Shields JA. Lesions simulating retinoblastoma (pseudoretinoblastoma) in 604 cases. Ophthalmology 2012; In press.
111
Workshop 14
Friday
10:30 - 11:45 am
JAAPOS Abstract #138
Workshop 15
Friday
10:30 - 11:45 am
JAAPOS Abstract #139
Optical Coherence Tomography - Pearls for the Pediatric Ophthalmologist
Daniel J Salchow; Cynthia A Toth; Veit Sturm
Charité University Medicine, Berlin, Germany
Purpose/Relevance: Optical Coherence Tomography (OCT) allows insights in pediatric ophthalmology. In order to interpret OCT findings, one must be familiar with its
basic concepts as well as well as with findings of recent studies.
Target Audience: Pediatric ophthalmologists, general ophthalmologists, vision researchers.
Current Practice: Physicians may be uncertain about the feasibility of the OCT in
children, and - since normative data for children are not always readily available - interpretation of OCT results can be difficult.
Best Practice: Normative data have been established for peripapillary nerve-fiber
layer thickness, macular thickness and optic disc parameters in children. These help
the physician interpret OCT results in children. New insights into many disorders including retinopathy of prematurity, pediatric glaucoma and optic nerve disorders, and
into retinal disorders of childhood have altered our way of practicing.
Expected Outcomes: When familiar with the OCT findings in certain pediatric
ophthalmic conditions, the clinician will be better able to interpret these findings in the
clinical context and use the data to better care for the young patient.
Format: The first part consists of a didactic lecture, presenting the use of OCT in different aspects of pediatric ophthalmology. In the second part, cases will be presented
and the value of the OCT in managing these cases will be discussed.
Summary: The capacity and limitation of the OCT in pediatric ophthalmology is
discussed. By better understanding the role of the OCT in managing children with eye
problems, the clinician will be able to better care for his or her patients.
References: 1. Salchow DJ, Hutcheson KA. Optical coherence tomography applications in pediatric ophthalmology. J Pediatr Ophthalmol
Strabismus 2007;44:335-349
2. Maldonado RS, O’Connell R, Ascher SB, Sarin N, Freedman SF, Wallace DK, Chiu SJ, Farsiu S, Cotten M, Toth CA. Spectral-domain optical
coherence tomographic assessment of severity of cystoid macular edema in retinopathy of prematurity. Arch Ophthalmol 2012;130:569-578
3. Sturm V, Landau K, Menke MN. Optical coherence tomography findings in Shaken Baby syndrome. Am J Ophthalmol. 2008;146:363-368
Workshop 16
Friday
1:15 - 2:30 pm
JAAPOS Abstract #120
Through the Eyes of Autism: Eye Care for these Special Patients
Joseph L Demer; Eugenie E Hartman; M. Edward Wilson; Stuart R Dankner
Jules Stein Eye Institute, UCLA; Univ. of Alabama Birmingham;
Med. Univ. South Carolina; Danker-Fiergang Eye Assoc.
Los Angeles, CA; Birmingham, AL; Charleston, SC; Baltimore, MD
Purpose/Relevance: Autism Spectrum Disorder (ASD) is a lifetime neurodevelopmental disability characterized by impairments in social interaction and communication, and a restricted
range of behaviors and/or interests. ASD prevalence has exploded to 1% by 2010, probably
due both to increased awareness and a real increase in ASD. ASD is frequently co-morbid with
strabismus, amblyopia, infantile cataract, and glaucoma. Ability of pediatric ophthalmologists
to detect subtle signs of undiagnosed ASD and work effectively with ASD children is critical to
ophthalmic care.
Target Audience: Pediatric ophthalmologists, and ancillary staff, particularly orthoptists.
Current Practice: Untrained intuition typically suggests counterproductive approaches to
children with ASD, reinforcing anxiety and phobic reactions, diminishing examination cooperation, and reducing compliance. Behavior modification techniques, particularly those directing
attention and reward to appropriate behavior, are highly effective but must be clinically tailored.
No systematic training has heretofore been offered to pediatric ophthalmic ophthalmologists to
enable them to work with ASD.
Best Practice: Attendees should identify the impairments in ASD, know resources available for
diagnosis and intervention for children with ASD, recognize subtle autistic behaviors, understand effective eye examinations of children with ASD, and how to discuss ASD with patients’
parents. Vide infra references.
Expected Outcomes: Knowledge will provide attendees with insight to do the foregoing.
Format: Didactic format will introduce features of ASD. Instructors will share clinical suggestions for working with ASD children, and personal experiences as parent of children with special
needs.
Summary: ASD will be defined in public health context. Approaches will be presented for ASD
behaviors common in pediatric ophthalmology.
References: Warren Z, Veenstra-VanderWeele J, Stone W, Bruzek JL, Nahmias AS, Foss-Feig JH, Jerome RN, Krishnaswami S, Sathe NA,
Glasser AM, Surawicz T, McPheeters ML. Therapies for Children With Autism Spectrum Disorders. Rockville (MD): Agency for Healthcare
Research and Quality (US); 2011 Apr.
Johnson, CP, Myers, SM, and the Council on Children with Disabilities. (2007). Identification and
evaluation of children with autism spectrum disorders. Pediatrics, 120 (5), 1183 - 1215.
112
Protecting Your Online Image
K. David Epley MD; Andrew Doan MD, PhD
Purpose/Relevance: The purpose of this workshop is to enable the attendee to understand
and identify critical issues in building an online presence free of harmful information that can
help build the provider’s practice and protect it against harmful or fraudulent claims.
Target Audience: Pediatric ophthalmologists, practice administrators, anyone who does anything online
Current Practice: Many doctors and practices have a website, but few are actively managing
their online persona and presence. Services like Yelp, Health Grades, AVVO, Health Tap, Facebook, Twitter and many more can help your practice or hurt it. Often the physician feels helpless
to manage this aspect of practice, yet never has it been more important as a first impression to
your new patients and in interaction with your current patients.
Best Practice: Currently, physicians are not doing a good job, or in many cases, any job of
monitoring their online reviews and reputation. This workshop will help the attendee to understand how online media can help build their practice and protect against bad reviews or
negative comments. Participants will be taught how to edit their personas on the websites most
commonly used by parents and patients. Strategies for protecting the participant’s online identity will be given.
Expected Outcomes: Attendees will be able to immediately change how the person and the
practice are perceived online, and how to build a positive presence. The participant will also
have an armamentarium to combat negative reviews and help protect his or her online reputation.
Format: Interactive didactic lecture with audience polling/quiz, presentation by experienced
physicians who have successfully built online reputations. Specific examples will be used.
Participants will be encouraged to bring their laptops/tablets to directly apply the didactic knowledge to better their own online image.
Summary: Physicians are frequently reviewed at websites such as healthgrades.com, vitals.
com, angieslist.com, avvo.com, facebook.com, twitter.com and many more. Most physicians
are not doing enough to protect their online identity, some are doing nothing at all. Online media
will be reviewed with emphasis on how to develop and uphold your online persona and how to
protect your reputation.
Workshop 17
Friday
1:15 - 2:30 pm
JAAPOS Abstract #125
No CME for this workshop
References: http://www.kevinmd.com/blog/2011/05/dealing-negative-online-review-physician-rating-site.html
|http://www.credentialprotection.com/news/23-online-reputation-management-for-doctors-katie-courik-reports.html
Sticky situations in pediatric glaucoma and what they taught us lessons learned the hard way
Sharon F Freedman MD; Allen D Beck MD; Alex V Levin MD; David S Walton MD
Duke Eye Center, Durham, NC, USA
Purpose/Relevance: Most pediatric ophthalmologists in practice will encounter the infant/child with known or suspected glaucoma. Diagnosis and management of pediatric glaucoma cases often poses uncommon challenges to the
clinician, from those cases that are hard to call ‘glaucoma’ to those with definite glaucoma whose management is tough
to decide upon, or whose course becomes rocky and difficult.
Target Audience: Pediatric Ophthalmologists.
Current Practice: The problem is that pediatric glaucoma is rare enough that everyday clinical practice does not lend
itself to facility with current diagnostic and management algorithms for this potentially blinding condition. The key issues
are: 1) recognizing the disease when it does present, especially when subtle; 2) experience with the techniques of diagnosis; 3) experience with or access to surgical interventions in an appropriate sequence; 4) dealing with the sequelae of
the disease and its treatment short- and long-term. Outcomes studies are limited to clinical series in most cases, since
the disease is so uncommon.
Best Practice: In the ideal situation the practitioner will suspect pediatric glaucoma due to thorough understanding
of clinical features, and apply tonometry in all suspected cases, as well as thorough anterior segment and optic nerve
head examination and imaging when appropriate. Treatment algorithms will be evidence-based and collaborative with
experts where appropriate. Ethical issues will be considered at each step, as well as quality of life and family support
issues, and a team approach applied.
Expected Outcomes: At the conclusion of this workshop, attendees will be able to: 1) recognize the major factors
to be considered when making a diagnosis of glaucoma in children; 2) choose appropriate treatment for children with
glaucoma who require medication and/or surgery; 3) consider the ethical implications of off-label medical and unproven
surgical interventions as treatment for childhood glaucoma.
Format: case-based with panel, including photographs and video (see below under Summary please).
Summary: In this case-based workshop, the moderator will present cases to an expert panel, from diagnostic dilemmas to surgical challenges, and the experts will share triumphs as well as humbling lessons with the attendees. Photographic and video-documentation will be included. Ethical dilemmas will be highlighted in relevant cases throughout
the workshop. Audience participation will be encouraged. Cases to be included will highlight issues including (but not
limited to): tonometry and diagnostic dilemmas, including the use of OCT and ultrasound, angle surgery and related
mishaps, filtration and glaucoma drainage implant surgery and its challenges, cycloablation and its place in surgical
management.
References: 1. Freedman SF: Childhood Glaucomas: Classification and Examination. Medical and Surgical Treatments for Childhood
Glaucoma. Clinical Presentation. In: Shield’s Textbook of Glaucoma, Sixth Edition, Eds. R. Rand Allingham and M. Bruce Shields. Lippincott
Williams & Wilkins, 2011.
2. Papadopoulos M, Cable N, Rahi J, Khaw PT; BIG Eye Study Investigators. The British Infantile and Childhood
Glaucoma (BIG) Eye Study. Invest Ophthalmol Vis Sci. 2007 Sep;48(9):4100-6.
3. Howard F, McKneally MF, Upshur RE, Levin AV. The
formal and informal surgical ethics curriculum: views of resident and staff surgeons in Toronto. Am J Surg. 2012 Feb;203(2):258-65. Epub 2011
Jun 29.
4. Beck AD, Lynn MJ, Crandall J, Mobin-Uddin O. Surgical outcomes with 360-degree suture trabeculotomy in poor-prognosis
primary congenital glaucoma and glaucoma associated with congenital anomalies or cataract surgery. JAAPOS 2011 Feb;15(1):54-8.
5. Yeung HH, Walton DS. Clinical classification of childhood glaucomas. Arch Ophthalmol. 2010 Jun;128(6):680-4. Erratum in: Arch Ophthalmol. 2010 Sep;128(9):1225. PMID:20547943
6. Morad Y, Donaldson CE, Kim YM, Abdolell M, Levin AV: The Ahmed seton in the treatment
of pediatric glaucoma. Am J Ophthalmol 2003; 135(6):821-829
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Workshop 18
Friday
1:15 - 2:30 pm
JAAPOS Abstract #128
Workshop 19
Friday
1:15 - 2:30 pm
JAAPOS Abstract #141
Adult Strabismus
David Stager Jr; Steven M Archer; Edward G Buckley; Forrest J Ellis;
David B Granet; David L Guyton; David G. Hunter
Pediatric Ophthalmology and Adult Strabismus, Plano, Texas
Purpose/Relevance: The surgical treatment of the adult with strabismus comprises
a significant portion of the clinical and surgical volume of many pediatric ophthalmologists. This workshop is designed to educate attendees regarding surgical treatment of
adults with strabismus.
Target Audience: Pediatric ophthalmologists interestested in treating adults with
strabismus.
Current Practice: Pediatric ophthalmologists are often intimidated by adults with
complicated forms of strabismus. Because they represent huge challenges for therapeutic armamentarium, restrictive motility disorders are often not amenable to routin
strabismus approaches.
Best Practice: Clinicians will gain a more thorough understanding of the surgical approaches and techniques which yield better outcomes in adults with strabismus.
Expected Outcomes: At the conclusion of the workshop, attendees will have a better understanding of effective strategies for managing adults with complicated forms of
strabismus.
Format: The workshop will include discussions and presentations by a panel of
experts. In addition, time for audience participation with questions of the panelists is
planned. Throughout the discussions, pertinent scientific literature will be presented
and reviewed.
Summary: Topics will include challenging cases of adults with strabismus, congenital
cranial dysinnervation disorders (CCDDs), restrictive strabismus, and surgical pearls
related to adults.
References: Tischfield MA et al. Cell. 2010;140:74.
Workshop 20
Friday
2:45 - 4:00 pm
JAAPOS Abstract #118
Developing an Integrated System for Children’s Vision Care - Report on the
Work of the National Center for Children’s Vision and Eye Health
Mary Louise Z Collins MD; Jean E Ramsey MD, MPH; Eugenie Hartman PhD;
Joseph M Miller MD, MPH; Michael X Repka MD, Kira Baldonado
Greater Baltimore Medical Center, Baltimore, MD
Purpose/Relevance: The National Center for Children’s Vision and Eye Health (NCCVEH) was established by Prevent Blindness America with support from the Maternal and Child Health Bureau. The mission
of the NCCVEH is to improve children’s vision through strong partnerships, sound science, and targeted
public policy This session will outline the work of the NCCVEH, recommendations to enhance the system
of vision care for children and the future role of pediatric ophthalmologists in the continuum of eye care.
Target Audience: Pediatric ophthalmologists, general ophthalmologists, vision scientists and others interested in public health policy and programs for pediatric vision care.
Current Practice: System fragmentation has limited the success of current approaches to pediatric vision
care.
Best Practice: This workshop will address recommendations of the National Expert Panel (NEP) on
development of an integrated system for children’s vision care. The discussion will include best practices for
vision screening methods, performance measures, and data collection and reporting, and will also provide
some examples of these integrated systems.
Expected Outcomes: Attendees will gain knowledge regarding the present barriers to effective pediatric
vision care programs and the role for vision in strategic planning of the Maternal and Child Health Bureau.
The work of the NCCVEH and the NEP will be presented, including the recommendations of the workgroups
and some examples of integrated systems. Based on this information, attendees will understand how to
more effectively work to establish integrated pediatric vision care systems.
Format: The format used will be a combination of several short didactic lectures followed by open question
and answer forum.
Summary: In summary, the workshop will provide attendees with information regarding the limitations in
current pediatric vision screening programs and introduce the work of the National Center for Children’s
Vision and Eye Health (NCCVEH) and the National Expert Panel (NEP). Information and recommendations
from the work groups of the NEP, including the Vision Screening, Performance Measures, and Data Collection and Reporting work groups will be presented. Finally, several examples of integrated vision screening
systems will be discussed as well as plans for future work of the NCCVEH.
References: Nelson H, Nygren P, Huffman L, Wheeler D, Hamilton A. Screening for Visual Impairment in Children Younger than Age 5 Years:
Update of the Evidence from Randomized Controlled Trails, 1999-2003, for the U.S. Preventive Services Task Force. May 2004. Agency for
Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/visionscr/vischup.htm.
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AAP/AAPOS Pediatric Neuro-Ophthalmology Workshop. Avoiding Disaster:
Lessons Learned from Difficult Cases
Daniel J Karr M.D., Edward G Buckley M.D., Jane C Edmond M.D.,
Gena Heidary M.D., PhD, John MacDonald M.D., Michael R Siatkowski M.D.
Workshop 21
Friday
2:45 - 4:00 pm
JAAPOS Abstract #130
Purpose/Relevance: Difficult Cases, those patients we remember most vividly because
of great success or tragic failure, frequently produce a disproportionately intense learning
experience. This workshop will present pediatric neuro-ophthalmology case examples that
significantly influenced each expert’s approach to a specific problem. The panel members
will responds with ideas, differential diagnoses, diagnostic testing and treatment considerations at each stage of the presentations from history to conclusion. Each presenter will
provide a short final summary statement with their personal ‘clinical pearls’.
Target Audience: Pediatric ophthalmologists, general ophthalmologists, fellows and
residents
Current Practice: Neuro-ophthalmology conditions are typically complex, frequently confusing and often require additional testing (MRI, CT, visual fields, VEP etc.) for diagnosis
and treatment direction. Incorrect or missed diagnoses can result in significant morbidity
and mortality.
Best Practice: Case presentations by experts in the field provide the closest learning
experience to hands on management of a patient. Neuro-ophthalmology is a subspecialty
area that lends itself to require frequent review and reinforcement of acquired information.
Expected Outcomes: The audience will learn an in depth approach to the understanding,
diagnosis and treatment of a limited number of neuro-ophthalmology conditions. They will
learn how to reduce misdiagnosis by working through the clinical problems with experts.
Format: Progressive case presentation with panel discussion/interaction at each stage
of the case presentation from history to conclusion. Audience participation with questionand-answer and commentary will follow each case presentation.
Summary: Difficult pediatric neurology cases will be presented. Diagnostic and treatment
pitfalls will be examined. Strategies to prevent future mistakes will be highlighted.
References: Brodsky MC. Pediatric Neuro-Ophthalmology.2nd ed. New York:Springer;2010
Management issues in non-cataractous lenticular disorders in children
Ramesh Kekunnaya; Arif O Khan; Alex V Levin; Ken Nischal; David A Plager
L V Prasad Eye Institute, Hyderabad; King Khaled Eye Specialist Hospital, Riyadh;
Wills Eye Institute, Philadelphia; UPMC Eye Center, Children’s Hospital of Pittsburgh;
Glick Eye Institute, Indiana University Medical Center
Purpose/Relevance: Patients with non-cataractous lenticular disorders present
unique challenges in terms of evaluation for systemic association and treatment. This
workshop contains a panel of experienced surgeons who will provide practical approach to manage the above cases.
Target Audience: Pediatric ophthalmologist; general ophthalmologist.
Current Practice: Non-cataractous lenticular disorders are rarely discussed. When a
surgeon encounters such a case he/she only has limited and often anecdotal literature
for guidance.
Best Practice: The ophthalmologist should be able to arrive at proper diagnosis
of these conditions, recognize potential systemic association, and offer appropriate
advice in terms of treatment.
Expected Outcomes: The topics include 1) Evaluation of a case of ectopia lentis
and 2) its optical/surgical management; 3) Congenital aphakia; 4) Accommodative
spasm; 5) Microspherophakia; 6) Interesting cases. At the conclusion of the presentation, attendees will be able to appropriately diagnose the lenticular condition, perform
appropriate investigations, rule out possible systemic associations and select appropriate surgical/optical or medical treatment for a particular patient.
Format: Didactic lecture/open question and answer forum/case presentation.
Summary: The presentation by the experts in the field will provide practical tips for
the comprehensive care, appropriate investigations and recent advances in the management of these conditions.
References: 1: Neely DE, Plager DA. Management of ectopia lentis in children. Ophthalmol Clin North Am. 2001 Sep;14(3):493-9. Review.
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Workshop 22
Friday
2:45 - 4:00 pm
JAAPOS Abstract #131
Workshop 23
Friday
2:45 - 4:00 pm
JAAPOS Abstract #144
New Concepts on Visual Cortical Plasticity:
Multiple Critical Periods and Implications for Amblyopia
Agnes Wong, MD, PhD, FRCSC; Terri Lewis, PhD; Takao Hensch, PhD
Purpose/Relevance: To review the most recent developments in amblyopia research, including the biological constraints that establish the critical periods of visual development, new evidence of different critical periods for damaging as opposed to rehabilitating the visual system,
and new therapeutic strategies that can improve visual functions even in adults.
Target Audience: Pediatric ophthalmologists, general ophthalmologists, researchers
Current Practice: Traditionally, treatment has been considered ineffective after closure of critical periods because of a lack of visual cortical plasticity.
Best Practice: We will first summarize results from animal models that shed new insight into
the opening (excitatory-inhibitory circuit balance), execution (structural rewiring), and closure of
plasticity (molecular ‘brakes’) in the visual cortex. Next, we will look at data from children treated
for dense bilateral cataracts showing that the closure of the critical period for damage varies
from 6 months to 10-14 years of age (depending on the aspect of vision measured). Finally, we
will examine data indicating that even after the closure of the critical period, playing an action
video game for 40 hours over 4 weeks can improve many aspects of vision in adults. Taken
together, this evidence suggests that the biology of the brain is heavily invested in the optimal
timing and duration of plasticity, and opens new ways for potential therapies for amblyopia.
Expected Outcomes: The attendees will gain new knowledge on how the impact of early
visual experience is actively maintained throughout life, offering potentially novel strategies for
the reactivation of visual cortical plasticity and amelioration from amblyopia even in adulthood.
Format: Didactic Lecture
Summary: We will present evidence on: (1) biological constraints that establish the critical periods of development; (2) different critical periods for damaging as opposed to rehabilitating the
visual system; and (3) improvements in many aspects of vision in adults after playing an action
video game for 40 hours over 4 weeks.
References: 1. Bavelier D, Levi DM, Li RW, Dan Y, Hensch TK. Removing brakes on adult brain plasticity: from molecular to behavioral interventions. J Neurosci. 2010 Nov 10;30(45):14964-71.
2. Wong AM. New concepts concerning the neural mechanisms of amblyopia and their
clinical implications. Can J Ophthalmol. 2012 Oct;47(5):399-409.
3. Maurer, D., & Lewis, T.L. (2012). Sensitive Periods in Development. In P.
Zelazo (Ed.) Oxford Handbook of Developmental Psychology, Oxford University Press, pp 201 - 234.
Workshop 24
Friday
4:30 - 6:00 pm
JAAPOS Abstract #124
The Child with Developmental Delay:
Multispecialty Perspectives on Improving Care
David Epley MD; Linda Lawrence MD; Cheryl McCarus CO;
Shirley Anderson OTR/L, SCLV, CLVT; Sharon Lehman MD; Jorie Jackson CO
Purpose/Relevance: To further knowledge of coordinated care and available resources for
children with developmental delay and disability amongst pediatric ophthalmologists, orthoptists
and other attendees.
Target Audience: Pediatric ophthalmologists, orthoptists, allied health care workers, school
nurses
Current Practice: There is a lack of uniform formal education in the coordination of care for
children with developmental delay and disability. Knowledge about the resources, types of care,
and school-related services is sporadic and largely driven by independent physician interest,
yet most pediatric ophthalmologists and orthoptists see these children on a daily basis. A better
understanding of how to coordinate care and what services are available would help each member of our target audience better treat these patients.
Best Practice: Current best practices across the spectrum of providers of care aren’t well
documented. This symposium attempts to collate this information in a singular location to crosseducate these various disciplines about available services and care needs for children with
developmental delay and disability.
Expected Outcomes: Expanded knowledge base and better understanding of the needs of
children with developmental delay and disability will allow for better overall care, improved communication with parents and caregivers, and enhanced ability to provide access to appropriate
resources.
Format: Panel discussion with moderator.
Summary: We have a panel of 2 school nurses, an occupational therapist, a pediatric ophthalmologist with special interest in this topic area, and 2 orthoptists to discuss basic care types,
access to care, what is needed by these children, how to coordinate care, when referrals are
appropriate, what school resources are available, and much more.
References: Child Health Care. 1984 Winter;12(3):148-50. Children’s health care: brief report. ECI: a study in health care coordination.
Visual processing and learning disorders. Koller HP. Curr Opin Ophthalmol. 2012 Sep;23(5):377-83.
Assessing the communication skills of
carers working with multiple learning disabilities: a case study. Koski K, Launonen K. Int J Lang Commun Disord. 2012 Nov;47(6):685-95. doi:
10.1111/j.1460-6984.2012.00175.x. Epub 2012 Jul 18.
Expert group devises tool to evaluate learning disabilities care outcomes. Parish C.
Nurs Manag (Harrow). 2012 Sep;19(5):7.
Relation between early motor delay and later communication delay in infants at risk for autism.
Bhat AN, Galloway JC, Landa RJ. Infant Behav Dev. 2012 Sep 12;35(4):838-846. doi: 10.1016/j.infbeh.2012.07.019. [Epub ahead of print]
Pediatric Ophthalmology: Current Thought and A Practical Guide. Wilson, Edward M.; Saunders, Richard; Rupal, Trivedi (Eds.)2009
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Update on Ocular Anti-Infectives for the Pediatric Ophthalmologist
M. Edward Wilson, MD, Moderator
Steven J. Lichtenstein, MD, FAAP; Rudolph S. Wagner, MD; Peter A. D’Arienzo, MD, FACS
Target Audience: Pediatric ophthalmologists, general ophthalmologists, other physicians, allied health professionals
Format: Didactic Lecture, Open Question and Answer Forum, Panel Discussion
New Anti-Infectives: How they work and when we should use them
Purpose: Anti-infectives for ocular use, especially for use in pediatrics, are constantly changing. This presentation will bring the attendees up
to date on the new anti-infectives available for use, along with on-label as well as off-label uses.
Current Practice: Anti-infectives are being used in inappropriate situations as well as not being used in potentially beneficial situations
because of “on label” directives
Best Practice: Utilizing the available medications to their utmost and safe potential. Many physicians will stay strictly within the “FDA approved” uses of an anti-infective. They need to realize that these available medications have uses that are safe and effective, even though they
do not carry “FDA approval.”
Expected Outcomes: The participants will have an understanding of the available anti-infectives as well as treatment options that can safely
be used in their patients to obtain the best outcome potential available
Summary: Inform participants of new anti-infectives available for ocular use; discuss the differences of these anti-infectives compared to those
already commonly used in pediatric patients; describe treatment parameters for these anti-infectives that are not necessarily approved by the
FDA but are proving to be safe and beneficial
Anti-microbial resistance in ophthalmology: Is it a problem?
Purpose: Recent surveillance studies show that a significant fraction of ocular isolates are becoming resistant to one or more commonly used
antibiotics for the treatment of acute bacterial conjunctivitis.
Current Practice: A Key issue is selecting an effective topical antibiotic, which rapidly eradicates the organisms and shortens the course of
bacterial conjunctivitis in children, covers resistant organisms and does not promote the growth of new resistant organisms.
Best Practice: Physicians should use potent antibiotics (newer generation fluoroquinolones) for the treatment of pediatric bacterial conjunctivitis since they can shorten the course of the disease and not produce resistant organisms. These should be prescribed as directed for the
recommended duration and not tapered to prevent the development of resistance.
Expected Outcomes: Physicians will understand that the use of appropriate antibiotics will not promote resistance and will understand proper
dosing frequency and duration. They will be better able to understand how and why resistance occurs and that appropriate topical antibiotics
do not select for resistant organisms when used properly with bacterial conjunctivitis.
Summary: Resistance of ocular isolates to commonly used antibiotics is on the increase. Most resistance comes from the inappropriate use
of systemic antibiotics. The use of potent topical antibiotics including newer fluoroquinolones in the treatment of bacterial conjunctivitis does not
promote resistance.
Viral infections and allergy: How can we update our approach to these common problems
Purpose: These conditions are easily diagnosed however our treatment options continue to improve with the development of new drugs and
diagnostic equipment.
Current Practice: Pediatricians tend to treat viral conjunctivitis with topical antibiotics and some ophthalmologists use topical steroids for treatment. Physicians are unsure when children with conjunctivitis can safely return to school. Allergic conjunctivitis is often under-diagnosed and
patients typically self-medicate. Oral antihistamines can dry the eye and exacerbate ocular allergy.
Best Practice: Viral conjunctivitis should be treated supportively ie cool compresses and artificial tears. Allergic conjunctivitis should be
treated topically and oral antihistamines should be avoided.
Expected Outcomes: Attendees will have a better understanding of the available treatment options for these conditions. Case studies will be
utilized to demonstrate this including cases of complications resulting from errors in treatment choice. The attendee will also gain knowledge of
the latest Phase III and IV studies in these conditions.
Summary: Viral and allergic conjunctivitis are commonly encountered in the pediatrician’s office however many physicians are utilizing older
forms of treatment or over-prescribing topical antibiotics. There are many FDA-approved ocular medications available for the treatment of allergic conjunctivitis. Topical steroids should not be used for the treatment of viral conjunctivitis, unless in special cases, due to the possibility of
causing vision-threatening complications.
References available upon request
Lessons Learned From 25 Years of Pediatric Ophthalmology & Strabismus
Claims
Anne M Menke RN, PhD; Robert Wiggins MD, MHA
OMIC (Ophthalmic Mutual Insurance Company)
655 Beach Street, San Francisco, CA 94109
Purpose/Relevance: Physicians who provide care for pediatric ophthalmic conditions and strabismus are concerned about the risk of medical malpractice lawsuits.
Target Audience: Eye surgeons who practice pediatric ophthalmology and perform
strabismus surgery.
Current Practice: While eager to implement loss prevention measures, these eye
surgeons face multiple demands from regulatory, legal, and professional societies and
may not know how best to focus their efforts on improving the quality of their care.
Best Practice: This assessment of closed claims will identify practices that could
lead to harm or liability and ways to decrease those risks.
Expected Outcomes: Physicians who participate in this workshop will be able to assess their risk and choose loss prevention measures geared toward them.
Format: Didactic lecture featuring claims data and case studies followed by question
and answer period.
Summary: Summarize material to be presented at the workshop : This workshop
will present an analysis of 25 years of claims related to pediatric opthalmology and
strabismus. Frequency, severity (money paid to settle), causes, and trends will be
explained. Key lessons on how to improve patient safety and reduce the likelihood of
successful claims will be shared.
References: Retinopathy of prematurity malpractice claims: the Ophthalmic Mutual Insurance Company experience. 2009: Shelley Day; Anne
M. Menke; Richard L. Abbott; Archives of Ophthalmology 2009;127(6):794-8.
Menke AM, Weber P. ROP Case Defines Legal Duty of Care to Patients. http://www.omic.com/new/digest/Summer_05.pdf
Menke AM. Pediatric Sedation for Office-Based Procedures. http://www.omic.com/new/digest/Digest_SummerFall_04_v9.pdf
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Workshop 25
Saturday
7:00 - 8:15 am
Workshop 26
Saturday
2:00 - 3:15 pm
JAAPOS Abstract #135
Workshop 27
Sunday
7:30 - 9:00 am
JAAPOS Abstract #137
Difficult Problems - Non-Strabismus
Ken K Nischal MD, FRCOphth; Elias Traboulsi MD; Lea Ann Lope MD;
Federico Velez MD; Mary O’Hara MD
UPMC Children’s Eye Center of Children’s Hospital of Pittsburgh, Pittsburgh, PA
Notes
Purpose/Relevance: The clinical range of what we as practitioners see is so varied that it
is impossible for one person to have seen all the atypical presentations of common conditions and the typical presentations of rare conditions. This workshop allows us to share
some of these cases with the audience.
Target Audience: Pediatric ophthalmologists , orthoptists, vision scientists and trainees
Current Practice: Current practice for each individual is comprised of a bulk of secondary
clinical cases. Exposure to tertiary and quarternary cases is limited to those working in a
few academic centers across the USA. Managing or recoginising rarely presenting scenarios or diseases can be difficult.
Best Practice: Ideally one day we will all have time in our schedules to have tele-medicine
style case conferences with other centers to discuss unusual cases. To an extent this is
done now with the pediatric listserve but real time diagnosis with videos of cases would be
an improvement.
Expected Outcomes: At the conclusion of the workshop the audience and the panel will
have shared their experiences and strategies for rare and unusual clinical scenarios. It is
the exchange in strategies and approach that should encourage the attendees to consider
alternative diagnoses when faced with similarly challenging cases in their own practices.
Format: Each member of the panel will present one clincial scenario and the panel will
discuss their approaches to diagnosis and tretment. At the end of each case the audience
will be allowed to ask questions. The Moderator may ask the audience for opinions during
the case presentation also.
Summary: Five clinical cases with appropriate audio-viual material will be presented for
discussion.
Workshop 28
Sunday
9:15 - 10:45 am
JAAPOS Abstract #122
Difficult Problems: Strabismus
Sean P Donahue MD, PhD; Edward G. Buckley, MD; Oscar A. Cruz, MD;
David G. Hunter, MD; Evelyn A. Paysse, MD
Vanderbilt University Medical Center, Nashville, TN
Purpose/Relevance: The most common ICD-9 codes used by pediatric ophthalmologists
concerned strabismus. Patients that present with straight-forward unoperated strabismus do not
present a challenge to most pediatric ophthalmologists. However, patients may also present with
very complex strabismus that pose diagnostic and therapeutic challenges: strabismus secondary to
brain injury, brain tumors, cranial nerve palsies, orbital disease or anomalies, and status post multiple extraocular muscle surgeries. This workshop will specifically deal with rarer and more atypical
presentations of strabismus that present a knowledge gap to the practicing pediatric ophthalmologist.
Target Audience: Pediatric ophthalmologists in practice and fellowship training, Orthoptists, Opthalmology Residents
Current Practice: They are reading medical journals, attending CME meetings, talking among
their colleagues.
Best Practice: Participants will gain new perspective from the review of cases by pediatric
ophthalmologist experts who deal with complex strabismus. New insights will inform clinical and
surgical approach when confronted complex strabismus.
Expected Outcomes: At the conclusion of the symposium the attendees will have been taught
new skills and refine previous skills in the diagnosis of complex and diverse strabismus conditions,
the salient exam features to perform, tests to order, and new surgical skills in the treatment of
complicated strabismus
Format: The symposium will consist of expert panel discussion and subsequent open question
and answer forum with the audience’s participation. Actual patient vignettes will be presented. The
presenter will provide a differential diagnosis, a treatment plan, shedding insight on the disease
process, the etiology of the strabismus, and the rationale behind the treatment, and treatment outcome. Also discussed will be the potential reasons for the treatment success or failure
Summary: The panel participants are all internationally recognized experts in the field of strabismus and strabismus surgery. They will each present a difficult case that will be discussed by the
other experts, and the results of the treatment will be presented and discussed. Approximately 6
cases will be presented.
References: Strabismus Surgery Basic and Advanced Strategies, Ophthalmology Monographs 17, The American Academy of Ophthalmology,
Oxford University Press, 2004
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119
Notes
AAPOS Committees – 2012-13
Audit
Mary A. O’Hara, MD, Chair
Eric A. Lichtenstein, MD, Vice Chair
Allan M. Eisenbaum, MD
Laurie Hahn-Parrot, CO, COT, MBA
William P. Madigan, Jr., MD, FACS
Aaron M. Miller, MD, MBA
Bylaws and Rules
John D. Roarty, MD, Chair
Richard Alan Lewis, MD, MS
Robert D. Gross, MBA, MD
Amber A. Sturges, MD
Steven C. Thornquist, MD
Constance E. West, MD
Christopher Gappy, MD
Corporate Relations
M. Edward Wilson, Jr., MD, Chair
Garima Lal, MD, Vice Chair
Lisa S. Abrams, MD
Nikki Noopur Agarwal-Batra, CO
Deborah M. Alcorn, MD
Rebecca S. Braverman, MD
Brian N. Campolattaro, MD
John W. Simon, MD
Robert B. North, Jr., DO, FACS
Gregory Ostrow, MD
Laura S. Plummer, MD
David I. Silbert, MD
Barry N. Wasserman, MD
Erin D. Stahl, MD
Constance E. West, MD
Paul J. Rychwalski, MD
Kamiar Mireskandari, MBChB, FRCSEd, FRCO
A. Melinda Rainey, MD
Costenbader Lecture
Gregg T. Lueder, MD, Chair
Susan H. Day, MD, Vice Chair
Daniel E. Neely, MD, Consultant
Willaim P. Madigan, Jr., MD, FACS
David Stager, Jr., MD
Benjamin H. Ticho, MD
Fellowship Training Compliance
Daniel J. Karr, MD, Chair
Alex V. Levin, MD, Vice Chair
William Anninger, MD
Sylvia R. Kodsi, MD
Hee-Jung Park, MD, MPH
Kamiar Mireskandari, MD
Shira L. Robbins, MD
Mohamad S. Jaafar, MD
Erin P. Herlihy, MD
Deborah K. VanderVeen, MD
David R. Weakley, MD
Bradley V. Davvitt, MD, Membership Representative
Brian J. Forbes, MD, PhD, Consultant
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Finance
Robert E. Wiggins, Jr., MD, Chair
Mary O’Hara, MD, Vice Chair
Walter W. Merriam, MD
Monte D. Mills, MD
M. Edward Wilson, Jr., MD
David A. Plager, MD
Sherwin J. Isenberg, MD
Sharon F. Freedman, MD
Steven E. Rubin, MD
Christie L. Morse, MD, EVP
K. David Epley, MD
International Affairs
David Robbins Tien, MD, Chair
Erick Bothun, MD, Vice Chair
Daniel E. Neely, MD
Kara M. Cavuoto, MD
Robert O. Hoffman, MD
Federico G. Velez, MD
Kyle Arnoldi, CO
Rudolph G. Wagner, MD
Stephen B. Prepas, MD
Kimberly A. Beaudet, CO, COMT
Samir B. El-Mulki, MD
Rosane C. Ferreira, MD
Miquel Paciuc, MD
Iason S. Mantagos, MD
Alejandra G. de Alba Campomanes, MD
David R. Weakley, Jr., MD
Ashish M. Mehta, MD
Bruce A. Furr, CO
Almutez M. Gharaibeh, MD
Eugene M. Helveston, MD
Mohamad S. Jaafar, MD
Scott R. Lambert, MD
Daniel T. Weaver, MD
Sobi Pandey, MD
Marilyn T. Miller, MD, Consultant
Andrea Molinari, MD, Consultant
Michael X. Repka, MD, International Meeting Coordinator
Interorganizational Relations
Mary Louise Z. Collins, MD, Chair
Jean E. Ramsey, MD, MPH, Vice Chair
Bob Palmer, AAO, State Affairs
Brandan Marr, AAO, State Affairs
Bradley C. Black, MD, Member at Large
Daniel J. Briceland, MD, AAO Secretariat
Denise R. Chamblee, MD, CEF Representative
Jane C. Edmond, MD, Member at Large
David A. Plager, MD, Councilor to AAO
Linda M. Lawrence, MD, Member at Large
Katherine A. Lee, MD, PhD, Member at Large
Noelle Matta, CO, COT, AACO
Jitka L. Zobal Ratner, MD, Chair, Professional Education
Jennifer Hull, SF-AMS
Michael X. Repka, MD, Member at Large
David Rogers, MD, Chair, Public Information
Faruk H. Orge, MD, Chair, Online Media
Steven E. Rubin, MD, Past President
Sharon S. Lehman, MD, AAP-SOOP Member
K. David Epley, MD, President
Christie L. Morse, MD, EVP
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Legislative Committee
Jean E. Ramsey, MD, MPH, Chair
Kenneth P. Cheng, MD, Vice Chair
Donald P. Sauberan, MD
Iris S. Kassem, MD, PhD
Stacey J. Kruger, MD
Jeffery S. Hunter, MD
Oscar A. Cruz, MD
Garima Lal, MD
Geoffrey E. Bradford, MD
Rebecca S. Braverman, MD
William T. Lawhon, MD
Jill Thalacker Clark, CO
Evelyn A. Paysse, MD
Ronald GW Teed, MD
Michael X. Repka, MD, Consultant
Program
Stephen P. Christiansen, MD, Chair
Katherine A. Lee, MD
David K. Wallace, MD
Yasmin S. Bradfield, MD
Graham E. Quinn, MD
Ann U. Stout, MD
C. Gail Summers, MD
Membership
Bradley V. Davvitt, M.D., Chair
Pamela Erskine Williams, M.D., Vice Chair
Kathryn M. Haider, M.D.
Denise A. Hug, M.D.
Dean J. Bonsall, MD, MS, FACS
Michael C. Struck, MD
Donny Won Suh, M.D.
Public Information
David Rogers, MD, Chair
Richard P. Golden, MD, Vice Chair
Darron A. Bacal, MD
Amr A. ElKamshoushy, MD
Jay M. Rosin, MPH, MD
Robert S. Lowery, MD
Pamela H. Berg, CO
Kathryn Camille Dimicelli, MD
Amber A. Sturges, MD
Faruk H. Orge, MD
Leah Reznick, MD
Adam J. Rovit, MD
Omondi Nyong’o, MD
Alejandro Leon, MD
Rick Whitehead, MD
Carlos Gonzales, MD
Katheryn S. Klein, MD, MPH
Gavin J. Roberts, MD
Amy R. Wexler, MD
Erick Bothun, MD, Consultant
Research
Kristina Tarczy-Hornoch, MD, Chair
Gil Binenbaum, MD, Vice Chair
Brian P. Brooks, MD, PhD
Patrick J. Droste, MD
Suqin Guo, MD
Sudha Nallasamy, MD
Stacy L. Pineles, MD
Sylvia R. Kodsi, MD
David G. Morrison, MD
Danielle M. Ledoux, MD
Francine Maria Baran, MD
Joost Felius, PhD
Mays A. El Dairi, MD
Robert W. Arnold, MD
Graham E. Quinn, MD, Consultant
Nominating
Steven E. Rubin, MD, Chair
Susan H. Day, MD
Michael X. Repka, MD
Lisa S. Abrams, MD
Michael F. Chiang, MD
Online Media
Faruk Orge, MD, Chair
Scott A. Larson, MD, Vice Chair
Barry Oppenheim, MD
Mitchell B. Strominger, MD
Rahul Bhola, MD
Tara G. Missoi, MD
Gordon H. Smith, MD
James L. Plotnik, MD, FACS
Mays A. El Dairi, MD
Herbert D. Goldman, MD
Stephanie L. Davidson, MD
Professional Education
Jitka Zobal-Ratner, MD, Chair
Darron A. Bacal, MD, Vice Chair
Tina Rutar, MD
Nisha Krishan Dave, MD
Stacy L. Pineles, MD
William Walker Motley, MD
Katherine A. Hare, MD
Terry L. Young, MD
Majida A. Gaffar, MD
Melanie A. Kazlas, MD
Linda R. Dagi, MD
Jennifer A. Kozak, MD
Christopher M. Feccarotta, MD
C. Corina Gerontis, MD
Sergul Erzurum, MD
Arlene V. Drack, MD
Patrick J. Droste, MD
David K. Wallace, MD
Ramesh Kekunnaya, MD, FRCS
Subday Program
Stephen P. Christiansen, MD, Chair
David A. Plager, MD
Jane C. Edmond, MD
Daniel E. Neely, MD
Kaniel J. Karr, MD
Laura B. Enyedi, MD
122
Socioeconomic
Robert S. Gold, MD, Chair
Michael J. Bartiss, OD, MD Vice Chair
Eric A. Lichtenstein, MD
Derek B. Hess, MD
Marc F. Greenberg, MD
Lisa S. Abrams, MD
Robert W. Arnold, MD
Lisa P. Rovick, MHSc, CO, COMT
A. Melinda Rainey, MD
Irene H. Ludwig, MD
John E. Bishop, MD
Theodore H. Curtis, MD
Laura B. Enyedi, MD
Rebecca S. Leenheer, MD
Kathryn M. Haider, MD
Saiyid Jafar Hasan, MD
Steven Howell, MD
Jorie L. Jackson, CO
Daniel M. Laby, MD
Deborah S. Lenahan, MD
Nils K. Mungan, MD, FRCSC
Maria Portellos Patterson, MD
Merrill L. Stass-Isern, MD
Michael X. Repka, MD, Consultant
Lance Siegel, MD, Consultant
Sheryl M. Handler, MD, Consultant
Vision Screening
Daniel E. Neely, MD, Chair
Mae Millicent W. Peterseim, MD, Vice Chair
Geoffrey E. Bradford, MD
Robert W. Enzenauer, MD
Daniel J. Karr, MD
James William O’Neil, MD
Natario L. Couser, MD
Deborah R. Fishman, MD
Andrew C. Black, MD
David I. Silbert, MD
Linda M. Lawrence, MD
Jeffrey D. Colburn, MD
Robert W. Hered, MD
Deborah S. Lenahan, MD
Noelle S. Matta, CO, COT
Iris S. Kassem, MD, PhD
Amy K. Hutchinson, MD
Todd J. Murdock, MD
Kimberly Merrill, CO
Bonita R. Schweinler, CO, COMT
Joel M. Weinstein, MD
Jennifer A. Dunbar, MD
Kurt Simons, PhD, Consultant
Thomas Rogers, CEF Consultant
Learning Disabilities and Vision Therapy Task Force
Sheryl M. Handler, MD, Chair
Walter M. Fierson, MD, Vice Chair
Gregory I. Ostrow, MD
William O. Young, MD
Jorie L. Jackson, CO
Sharon S. Lehman, MD
A. Melinda Rainey, MD
Alfred J. Cossari, MD
Mark Cascairo, DO
Lisa S. Abrams, MD
Mae Millicent Peterseim, MD
LInda M. Lawrence, MD
Krista A. Heidar, MD
Jane C. Edmond, MD
Laura Kirkeby, Consultant
Michael J. Bartiss, OD, MD, Consultant
Long Range Planning Task Force
David A. Plager, MD, Chair
C. Gail Summers, MD, Vice Chair
Sherwin J. Isenberg, MD
M. Edward Wilson, Jr, MD
Christie L. Morse, MD
Jennifer Hull - SF AMS
Children’s Eye Foundation Board of Directors
George R. Beauchamp, MD; Chairman of the Board
William E. Gibson, PhD, President
Denise R. Chamblee, MD, Director
Sean P. Donahue, MD, PhD; Director
Thomas Rogers, MBA, Executive Director
Grace Parks Mitchell, Director
John D. Baker, MD, Director
Sheryl J. Menacker, MD, Director
Sidney Silver, Esq; Director
Mohamad S. Jaafar, MD, AAPOS Representative
Robert D. Gross, MD, FAAP; Director
Michael Abrams, MD, Director
Colleen Kuzmich - Director
Sarah Buckmeier, Office Administrator
Marshall M. Parks, MD, Founder
123
Index of Authors
KEY
NOTE: Numbers represent the abstract number, NOT the page number.
Paper abstract: number only / Poster abstract: number plus “p” / Workshop abstract: number plus “w”
Acera, Erika 4p
Adams, Gillian 55p,56p
Ainsworth, John 8w
Alcorn, Deborah 6w
Aldahmesh, Mohammed 77p
Ali, Asim 40p
Alkuraya, Fowzan 77p
Allen, Megan 66p
Al-Mohtaseb, Zaina 73p
Anderson, Shirley 24w
Andrews, Caroline 60p
Apkarian, Alexandra 10
Archer, Steven 10, 17, 19w
Areaux, Raymond 6
Armitage, Mary 27
Arnold, Robert 27
Ashworth, Jane 62p, 7w
Astudillo, Paulita Pamela 2p
Bahl, Reecha 17
Baldonado, Kira 20w
Ball, Vera 53p
Bang, Genie 64p
Barash, David 36p
Barnard, Simon 55p
Barto, Heath 61p
Beauchamp, Cynthia 47p, 68
Beauchamp, George presentation, CEF update
Beaudet, Kimberly 24
Beck, Allen 22p, 18w
Beck, Roy 25
Benitiz, Alicia 33p
Berrocal, Audina 33
Biglan, Albert 74p
Binenbaum, Gil 6, 26p
Biousse, Valerie 9p
Birch, Eileen 20, 42p, 43p, 47p
Biswas, Susmito 62p
Black, Graeme 7w
Black, Trevor 5p
Bonaparte, Leah 21p
Bothun, Erick 4w
Bradfield, Yasmin poster tour, 22p,
44p
Bratton, Monica 25p
Braverman, Rebecca 30p, 8w
Breidenstein, Brenda 4p
Brodsky, Michael 4w
Bruce, Beau 9p, 38p
Buckley, Edward intro to
Costenbader, update,10w, 19w, 21w, 28w
Cabrera, Michelle 35p
Camarena, Demitrio 45p
124
Capo, Hilda 33
Cavouto, Kara 33
Chan, Jeffrey 32
Chang, Peggy 67p
Chaudhuri, Zia 15, 9w
Chen, Angela 25
Chen, Wendy 26p
Cheng, Kenneth update
Chiang, Michael 24
Christiansen, Stephen welcome, moderator
Christoff, Alex 4w
Chuang, Alice 32
Chun, Bo Young 10p
Chung, Seung Ah 72p
Ciardella, Antonio 28p
Clark, Robert 9, 9w
Clarke, Michael 25
Coakley, Rebecca 11w
Coats, David 30, 34p, 73p
Coleman, Anne 14p
Collins, Mary Louise moderator, 20w
Conley, Julie 75p
Copenhagen, David 29
Cotter, Susan 25
Cottle, Elizabeth 3w
Cox, Kyle 19p
Cruz, Oscar 28w
Curtis, Theodore 2w
D’Arienzo, Peter 25w
da Rocha Lima, Breno 39p
Dacey, Mark 8w
Dagi, Linda 5w
Dahlmann-Noor, Annegret 55p
Dankner, Stuart 16w
Dao, Lori 47p
Davidson, Jennifer 50p, 53p
Davies, Brett 17p
Dayalu, Rashmi 49p
De Alba Campomanes, Alejandra 52p
de Beaufort, Heather 46p
Deacon, Brita 11p
Dean, William 18p
Decanini Mancera, Alejandra 75p
Del Monte, Monte 10, 17
Demer, Joseph 9, 11, 13,15, 19, 20, 7p, 13p, 65p, 9w, 16w
Desai, Nilesh 38p
Diab, Mohamed Mostafa 5
Dinh, Kimberley 34p
Doan, Andrew 17w
125
Donahue, Sean disc of 27, 41p, 28w
Dosunmu, Eniolami 7
Drack, Arlene 12w
Droll, Lilly 15p
Dubis, Adam 31
Dunbar, Jennifer 45p
Edmond, Jane 6w, 10w, 21w
Eggers, Howard 12
Ehrlich, Rita 36p
El Essawy, Rania 18
El-Dairi, Mays 8
Elliott, Alexandra 5w
Ellis, Forrest 19w
Elner, Victor 17
Engle, Elizabeth 60p
Enyedi, Laura 35p
Enzenauer, Robert 30p
Epley, K. David President’s
remarks, awards, intro of Parke, moderator, 13w, 17w, 24w
Erhenberg, Miri 36p
Eshete, Blen 45p
Essaa, Shrief 5
Estrada, Rolando 32p
Evans, Joanne 80p
Ezra, Daniel 56p
Faron, Nicholas 4, 21
Farsiu, Sina 8, 32p
Farzavandi, Sonal update
Felius, Joost 5p, 68p
Fenerty, Cecilia 7w
Fenoglio, Zachary 20
Ferris, John 1w
Fielder, Alistair disc of 25
Folgar, Francisco 31
Forbes, Brian 26p
Foster, C. Stephen 8w
Fragkou, Katerina 62p
Fray, Katherine disc of 23, 11p, 4w
Freedman, Sharon moderator, 7, 8, 31, 31p, 32p, 18w
Freitag, Suzanne 5w
Friedman, David 16p
Friling, Ronit 36p
Furuta, Minoru 28
Gajdosova, Eva 23p, 24p
Galli, Marlo 63p
Gamm, David 34
Gappy, Christopher 17
Garcia, Helia 46p
Garry, Glynnis 54p
Geloneck, Megan 32
Gertsch, Kevin 35p
KEY
NOTE: Numbers represent the abstract number, NOT the page number.
Paper abstract: number only / Poster abstract: number plus “p” / Workshop abstract: number plus “w”
KEY
NOTE: Numbers represent the abstract number, NOT the page number.
Paper abstract: number only / Poster abstract: number plus “p” / Workshop abstract: number plus “w”
Gilbert, Clare 33p
Giuliari, Gian Paolo 28p
Goff, Mitchell 1p
Gold, Robert 2w, 3w
Graeber, Carolyn 6p
Granet, David presentation,
update, 4p, 10w, 19w
Grigorian, A. Paula 11p
Gurland, Judith 15p
Guyton, David 67p, 4w, 19w
Haase, Wofgang 74p
Hamada, Samer 24p, 80p
Hancox, Joanne 56p
Hariharan, Luxme 33p
Hartman, Eugenie 16w, 20w
Hatt, Sarah 57p, 58p
He, Yu Guang 25p
Heidary, Gena 71p, 21w
Helveston, Eugene 13w
Hendler, Karen 7p
Hennessey, Claire 4w
Hensch, Takao 23w
Hodge, David 78p
Hoehn, Mary Ellen 19p
Hoekel, James 21
Holleschau, Ann 75p
Holmes, Jonathan 25, 57p, 58p
Horan, Lindsay 66p
Horwood, Anna 23
Hsu, Jennifer 30p
Huang, Jiayan 6, 26p
Hunter, David 14, 6p, 60p, 19w, 28w
Hussein, Mohamed 30
Hutchinson, Amy 9p, 38p
Irsch, Kristina 67p
Isenberg, Sherwin moderator, 20
Itty, Sujit 8
Jaafar, Mohamad 39p
Jackson, Jorie 2w, 24w
Jerkins, Brian 19p
Johnston, Suzanne 49p
Jost, Reed 42p, 43p, 47p
Jost, Sheridan 42p
Kaliki, Swathi 28, 27p
Kang, Kyung Min 10p
Karo, Jason 1p
Karr, Daniel 21w
Katz, Joanne 16p
Kazlas, Melanie 14
Kekunnaya, Ramesh 16, 8p, 22w
Kerr, Natalie 19p
Ketner, Scott 15p
Khan, Arif 77p, 22w
Khazaeni, Leila 45p
Pereyra, Naira 40p
Perovsek, Darko 70p
Peterseim, Mae Millicent 50p, 53p
Petersen, David 25
Phillips, Paul 11p
Pichi, Francesco 28p
Pihlblad, Matthew 65p
Pineles, Stacy 20, 7p
Plager, David 10w, 22w
Pogrebniak, Alexander 37p
Porco, Travis 52p
Prakalapakorn, Grace 32p
Prakalapakorn, Sasapin 31p
Purohit, Amitabh 22p
Pyi Son, Ma Khin 78p
Quinn, Graham disc of 29, 33p
Quiroga, Ana 33p
Qureshi, Hanya 11p
Raab, Edward 4w
Rabinovich Ronen 13
Ramasubramanian, Aparna 29p, 14w
Ramsey, Jean 20w
Rao, Sujata 29
Read-Brown, Sarah 24
Repka, Michael 25, 14p, 16p, 20w
Rheem, Justin 45p
Rhiu, Soolienah 72p
Riddell, Patricia 23
Robbins, Shira 4p
Roberts, Joan 25
Ron Kella, Yonina 36p
Sachdeva, Virender 16
Sadiq, Sardar Mohammad Ali 14
Sahuly, Yaacov 74p
Salchow, Daniel 15w
Salehi Omran, Sina 41p
Schechet, Sid 34p
Schnall, Bruce 14w
Schofield, Jennifer 2p
Schwartz, Terry 11w
Scott, Alan 13w
Scott, William 13w
Scribbick, Frank 1p
Sen, Nida 39p
Serafino, Massimiliano 28p
Shah, Shaival 20p
Sharma, Vinod 62p
Shelton, Julie 17
Shenoy, Hariprasad 16
Shields, Carol 28, 27p, 28p, 29p, 14w
Shields, Jerry 28, 27p, 29p, 14w
Shin, Andrew 13p
Shtessel, Maria 53p
Khurram, Darakhshanda 24p
Kim, Seong-Joon 12p
Kipp, Michael 26
Kipp, Michael Jr 26
Klein, Kathryn 16p
Kodsi, Sylvia 6w
Kong, Lingkun 30, 34p, 73p
Kothari, Kinneri 6
Kozak, Jennifer 17
Kraft, Stephen 2p
Kraker, Raymond 25
Kramer, Benjamin 50p
Kranjc, Branka Stirn 70p
Kundnani, Aneela 15p
Kurup, Sudhi 61p
Kushner, Burton disc of 12
Kytasty, Christina 29p
Laby, Daniel 2w
Lambert, Scott 2, 3, 9p, 22p, 38p
Lambley, Rosemary 40p
Lang, Richard 29
Lawrence, Linda 48p, 24w
Lazar, Elizabeth 25
Leahey, Ann 29p
Leath, Janet 39p
Lee, Jason 3
Lee, Jong Bok 72p
Lee, Katherine poster tour
Lehman, Sharon 6w, 24w
Lenahan, Deborah 2w
Lenhart, Phoebe 9p, 38p
Leske, David 57p, 58p
Leung, Andrea 46p
Levin, Alex 14w, 18w, 22w
Lewis, Terri 23w
Li, Simone 43p
Lichtenstein, Steven 25w
Liebermann, Laura 57p, 58p
Lindquist, Timothy 3p
Lloyd, I Christopher 62p, 7w
Lokhnygina, Yuliya 31p
Lomuto, Celia 33p
Lope, Lea Ann 27w
Lorenzana, Ingryd 25
Lowry, Eugene 52p
Lueder, Gregg 63p, 79p
Lui, Ryan 52p
Lum, Flora 14p
Lusk, Kelly 11w
Lynn, Michael 2, 3, 22p
MacDonald, John 21w
MacKenzie, Kelly 56p
MacKinnon, Sarah 60p
Maharshak, Idit 8
Majzoub, Katherine 49p
126
Maldonado, Ramiro 31
Manchandia, Ajay 11
Maor, Ron 55p
Marcus, Inna 7
Martinez, Jennifer 64p
Mashayekhi, Arman 28
Matta, Noelle 51p, 59p, 69p
Mayo, Liliana 48p
McBain, Hayley 56p
McCarus, Cheryl 24w
McCourt, Emily 17p
McCurry, Thomas 48p
McNeer, Keith 22
Meadows, Anna 29p
Melissa, Cotesta 2p
Menke, Anne 26w
Merrill, Kim 4w
Mets, Marilyn 61p
Meyer, Ewy 74p
Mezer, Eedy 74p
Miller, Joseph 20w
Miller, Marilyn 13w
Mintz-Hittner, Helen 32
Mireskandari, Kamiar 2p, 40p
Mohamed, Jawaher 77p
Mohney, Brian 64p, 78p
Moore, Bruce 49p
Moore, William 23p, 24p
Morad, Yair 8p
Morrison, David 4w
Mungan, Nils 2w
Muthusamy, Brinda 67p
Mutti, Donald 43p
Myung, Gihyun 61p
Nallasamy, Sudha 17
Newman, Nancy 9p
Newman, Stanton 56p
Nie, Qing 8
Nischal, Ken 23p, 80p, 10w, 22w,
27w
Nolan, Molly 47p
Nucci, Paolo 28p
Nusinowitz, Steven 20
O’Hara, Mary 1p, 27w
O’Neill, John 13w
Olitsky, Scott 3p
Orlin, Stephen 6
Osovsky, Micky 36p
Oystreck, Darren 60p
Papa, Carrie 53p
Parke, David address
Patil, Jayaprakash 24p
Paysse, Evelyn 30, 73p, 28w
Pellagrini, Marco 27p
Peragallo, Jason 9p
Siatkowski, R. Michael moderator, 21w
Silbert, Ariel 59p
Silbert, David 51p, 59p, 69p
Silbert, Jillian 69p
Sillau, Stefan 30p
Silva, Juan 33p
Singman, Eric 69p
Sloper, John disc of 20
Solebo, Lola 7w
Soliman, Mohamed 79p
Spencer, Horace 11p
Stager, David Jr 47p, 19w
Stager, David Sr 5p, 47p, 68p
Stass-Isern, Merrill 2w
Steinkuller, Paul 30, 34p
Stephens, Derek 2p
Stewart, Krista 44p
Stout, Ann poster tour
Struck, Michael 20p
Struthers, William 26
Sturm, Veit 15w
Subramanian, Vidhya 42p, 43p
Suh, Donny 25
Suh, Soh-youn 12p
Summers, C. Gail 75p, 6w
Superak, Hillary 22p
Tarczy-Hornoch, Kristina intro of young investigator
Teed, Ronald 76p
Tehrani, Nasrin 8w
Tekavcic Pompe, Manca 70p
Thiamthat, Warakorn 7
Tian, Jing 69p
Ticho, Benjamin 66p
Tielsch, James 16p
Toor, Sonia 23
Toth, Cynthia 31, 15w
Traboulsi, Elias 3, 27w
Tran-Viet, Du 31
Trivedi, Rupal 2, 21p, 50p, 53p
Trudell, Emily 49p
Tu, Daniel 24
Tucker, Mary 22
Tung, Irene 7
Tychsen, Lawrence intro of Apt, 4, 21
Ulrich, Niklas 35p
VanderVeen, Deborah 18p
Velez, Federico 20, 7p, 27w
Ver Hoeve, Jim 44p
Vernacchio, Louis 49p
Vickers, Laura 32p
Villegas, Victor 33
Vivian, Anthony 1w
127
Voigt, Robert 34p
Wagner, Rudolph 25w
Wall, Palak 3
Wallace, David disc of 32,
poster tour, 25, 31p, 32p, 35p
Walton, David 18w
Weakley, David 25p
Weikert, Mitchell 73p
Whitecross, Sarah 71p
Whitman, Mary 12
Wiggins, Robert moderator, 3w, 26w
Wilson, Lorri 6
Wilson, M. Edward 1, 2, 21p, 53p, 10w, 16w, 25w
Wong, Agnes 23w
Woods, David 1p
Wygnanski-Jaffe, Tamara 74p
Yackel, Thomas 24
Yang, Michael 29
Yanni, Susan 47p
Yashiv, Yuval 55p
Yeates, Scott 21p
Ying, Gui-shuang 6, 26p
Yoo, Lawrence 13p
Yoo, Wonsuk 19p
Yoon, Soo Han 72p
Yu, Fei 14p
Yu, Young Suk 12p
Yuan, Eric 31
Zabeneh, Alexander 3p
Zaidman, Gerald 6
Westin Copley Place Floor Plans
Westin Copley Place
Function Space
128
Room
Sq. Ft
Ceiling Height
Rockport
470
11'11"
Ipswich
680
Harbor
Turner Private Dining
Rounds
Hollow
Theater
Reception
Classroom
U-Shape
30
30
50
16
20
8
11'10"
50
50
102
20
30
20
711
11'11"
50
55
106
22
30
22
1,861
11'11"
130
-
278
-
-
-
Room
Sq. Ft
Ceiling Height
Gloucester
506
12'
of 10
Rounds
of 10
48
Theater
Reception
Classroom
U-Shape
48
48
16
23
129
Square
Hollow
Square
14
Westin Copley Place
Function
Space
Westin Copley Place Floor
Plans
Notes
Westin Copley Place
Function Space
Room
Sq. Ft
America
4,685
North
America
4,701
Center
America
5,890
South
America
Ceiling
Rounds
Height
of 10
16'4"
18'4"
16'4"
18'4"
16'4"
18'4"
6,530
Foyer
America
Ballroom
15,337
16'4"
18'4"
Hollow
Exhibit
Square
Booths 8 x 10
70
80
30
250
70
80
30
600
300
78
90
30
-
600
-
-
-
15
1800
2000
970
-
-
80
Theater
Reception
Classroom
U-Shape
360
450
500
250
320
450
500
450
500
-
1300
Room
Sq. Ft
Rounds of 10
Theater
Reception
Conference
Classroom
U-Shape
Hollow Square
Courier
622
41
41
41
20
26
20
22
-
-
-
130
Mastiff
646
43
-
-
14
131
Notes
132