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Access to pediatric eye care is critical in diagnosing and treating eye disease promptly to prevent visual impairment. The demand for pediatric ophthalmology is high, even in developed countries, and significant socioeconomic disparities exist in access to care. The purpose of this article is to summarize the current literature on the use of telemedicine in pediatric ophthalmology in the underserved population and to identify areas of opportunity. A detailed literature review was performed in PubMed and Google Scholar on October 1, 2021. All articles in English that described the use of telemedicine in pediatric ophthalmology, with particular attention to the underserved pediatric population, were included. There is a paucity of literature on the visual outcomes from pediatric teleophthalmology alone, and even less in underserved populations specifically. Literature supports its use in subacute to chronic eye disease, return and postoperative visits, and screening for retinopathy in prematurity in particular. Collaboration between pediatric optometrists and pediatric ophthalmologists for both asynchronous and synchronous care delivery models has shown promise in several studies. It is essential to operate within the limits of pediatric teleophthalmology and utilize this valuable service for its strengths. Telemedicine may expand access to pediatric ophthalmologists in underserved populations and may reduce the burden of eye disease.

PURPOSE To evaluate outcomes of botulinum toxin (BTX) injection of the inferior oblique (IO) muscle. DESIGN Retrospective case series. METHODS Setting: Single center, ophthalmology department at Boston Children's Hospital. STUDY POPULATION All patients treated with IO muscle injection of BTX (onabotulinumtoxinA) between 2010 and 2020. OBSERVATION PROCEDURE Sensorimotor evaluations at short-term (

To analyze the top 100 cited papers on ophthalmic trauma.A literature search of Ophthalmology journals within the ISI Web of Science database for the most cited papers related to ophthalmic trauma.The most cited articles were published between 1943 and 2013, the greatest number being published in 2000. Ophthalmology (45), Archives of Ophthalmology (17), and the American Journal of Ophthalmology (15) published most of the articles. The institutions with the highest number of publications were Wilmer Eye Institute (10) and Massachusetts Eye and Ear Infirmary (7). Sixty-seven percent of the articles originated from the USA. The most common type of trauma studied was non-open-globe injuries and the most frequent topic studied were pathological conditions secondary to trauma (34), particularly endophthalmitis (8), and optic neuropathy (6). Articles presenting a standardized classification system for eye injury received the highest average of citations per publication. Types of research most frequently cited were observational clinical studies (62) and epidemiological studies (30); the least frequent were clinical trials (2).This bibliographic study provides a historical perspective of the literature and identifies trends within the most highly influential papers on ophthalmic trauma. Many of these articles emerged within the past three decades and came from Ophthalmology journals that remain high impact to this day. Clinical trials have been difficult to conduct and are lacking, reflecting a critical need in ophthalmic trauma research, as most of our understanding of ophthalmic trauma comes from observational and epidemiological studies.

Sarah C Miller,1 Prajna Meeralakshmi,2 Michael J Fliotsos,3 Grant A Justin,4 Yoshihiro Yonekawa,5 Ariel Chen,1 Annette K Hoskin,6,7 Richard J Blanch,8– 10 Kara M Cavuoto,11 Rebecca Low,12 Ximin Li,1,13 Matthew Gardiner,14 TY Alvin Liu,1 Ankoor S Shah,14 James D Auran,15 Rupesh Agrawal,12,16– 18 Fasika A Woreta1 On behalf of The International Globe and Adnexal Trauma Epidemiology Study (IGATES)1Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 2Aravind Eye Hospital, Madurai, India; 3Department of Ophthalmology, Yale New Haven Hospital, New Haven, CT, USA; 4Vitreoretinal Surgery Service, Duke Eye Center, Durham, NC, USA; 5Wills Eye Hospital, Mid Atlantic Retina, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA; 6Save Sight Institute, University of Sydney, Sydney, Australia; 7Lions Eye Institute, University of Western Australia, Perth, Australia; 8Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, England; 9University Hospitals Birmingham, NHS Foundation Trust, Birmingham, England; 10Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, England; 11Bascom Palmer Eye Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA; 12Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, Singapore; 13Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; 14Massachusetts Eye and Ear Infirmary, Boston, MA, USA; 15Columbia University Irving Medical Center, New York City, NY, USA; 16Singapore Eye Research Institute, Singapore; 17Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; 18Duke NUS Medical School, SingaporeCorrespondence: Fasika A Woreta, The Wilmer Eye Institute, Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21205, USA, Tel +410-961-2868, Fax +410-614-9632, Email fworeta1@jhmi.edu Rupesh Agrawal, Department of Ophthalmology, Tan Tock Seng Hospital, Singapore Eye Research Institute, Lee Kong Chian School of Medicine, Nanyang Technological University, Duke NUS Medical School, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore, Tel +6563571000, Email Rupesh_agrawal@ttsh.com.sgPurpose: Hyphema is a sequela of ocular trauma and can be associated with significant morbidity. Management of this condition is variable and can depend on individual institutional guidelines. We aimed to summarize current practices in hyphema management across ophthalmological institutions worldwide.Methods: A cross-sectional online survey was conducted across North America, Asia, South America, Africa, Europe, and Australia from August 2020 to January 2021. The survey assessed the existing practices in the management of hyphema at each institution.Results: For layered hyphema, topical steroids were routinely administered by 34 (of 36 respondents, 94.4%) institutions, of which prednisolone was the preferred choice (n = 32, 88.9%). Topical cycloplegics were used at 34 (94.4%) institutions. No institution reported routine use of antifibrinolytics. Head elevation was the most deployed procedure to promote hyphema reabsorption (n = 31, 86.3%), followed by partial bed rest (n = 21, 58.3%). The majority of institutions (n = 25, 69.4%) did not routinely pursue admission for hyphema patients, although 75.0% of institutions (n = 27) scheduled follow-up visits within 48 hours of presentation. Additionally, few institutions performed routine sickle cell trait testing for patients presenting with hyphema (n = 6, 16.7%). The decision to perform anterior chamber washout varied and was often based on intraocular pressure and the speed of hyphema resolution.Conclusion: Unanimity of international institutions on hyphema management is lacking. As it stands, many current interventions have unconvincing evidence supporting their use. Evidence-based guidelines would be beneficial in guiding decision-making on hyphema management. Additionally, areas of consensus can be used as foundations for future standard of care investigations.Keywords: current practices, hyphema, trauma, sickle cell, anterior segment

To identify periodic trends in internet searches for ocular symptoms and to determine the seasonal peaks and troughs.This cross-sectional study examined publicly available Google Trends data from the United States (01/01/2015 to 12/31/2019). A list of common ocular symptoms was compiled from the American Academy of Ophthalmology Eye Health website and Wills Eye Manual. Ocular symptoms were stratified into categories involving vision change, eye pain, or eye redness. The search volume over time for each term was modeled using periodic regression functions and the goodness-of-fit was reported. Fisher's exact tests were used to compare the characteristics of periodic vs. non-periodic query terms.Seasonal trends were demonstrated by 45% (48/106) of the ocular symptoms included in this investigation. Search terms with best fit to the periodic model included stye (rOcular symptom queries directly reflect seasonal trends for allergic eye disease and ocular trauma. Search query analyses can serve as accurate epidemiological tools with research and real-world clinical applications.

To quantify changes in ductions following nasal transposition of the split lateral rectus muscle (NTSLR) for treating third nerve palsy.Retrospective cohort study.A single eye from each patient with third nerve palsy treated with NTSLR with ocular motility measurements.Observation of changes in pre- and postoperative ductions. Outcome measures including patient demographic and surgical factors associated with the ability to adduct beyond the midline after NTSLR were evaluated using multivariable logistic regression.A total of 116 patients met the inclusion criteria for this study. The NTSLR significantly decreased abduction (median of 0 limitation [interquartile range (IQR), 0-0] prior to surgery to -4 [IQR, -4 to -3] after NTSLR; p0.001), with a corresponding improvement in adduction (median, -5 [IQR, -5 to -4] prior to surgery to -4 [IQR, -4 to -3] after NTSLR; p0.001). There was no change in median supraduction or infraduction after NRSLR (p0.05). The ability to adduct beyond the midline after NTSLR was demonstrated in 42% of patients. Although not statistically significant, a trend toward a postoperative ability to adduct beyond the midline was seen in patients who had concurrent superior oblique muscle tenotomy (odds ratio [OR] = 5.08; 95% CI, 0.91-40.9) or who were designated with partial rather than complete third nerve palsy (OR = 2.29; 95% CI, 0.82-6.70).NTSLR improves the horizontal midline positioning of eyes with third nerve palsy. Most eyes lose the ability to abduct, but some regain a modest ability to adduct while vertical ductions remain unchanged.

Many patients with concussion experience visual symptoms following injury that lead to a diagnosis of convergence insufficiency, accommodative insufficiency, or saccadic dysfunction. However, these diagnostic categories are based on aggregates of clinical tests developed from a non-concussed population and therefore may not accurately describe visual deficits in the concussed population. Thus, we sought to understand individual metrics of visual dysfunction in chronically symptomatic post-concussion patients. This retrospective cross-sectional study included patients examined at the multidisciplinary concussion clinic (MDCC) at Boston Children’s Hospital over four years. Patients aged 5–21 years who had a complete assessment of eye alignment, vergence, accommodation, and visual tracking, and had visual acuity better than or equal to 20/30 in each eye were included. Patients with history of amblyopia, strabismus, or ocular pathology were excluded. Chart review yielded 116 patients who met inclusion criteria (median age 15 years, 64% female). The majority of patients (52%) experienced a single concussion and most were sports-related (50%). Clinical data show vergence, accommodation, or visual tracking deficits in 95% of patients. A receded near point of convergence (NPC, 70/116) and reduced accommodative amplitude (63/116) were the most common deficits. Both NPC and accommodative amplitude were significantly correlated with one another (r = −0.5) and with measures of visual tracking (r = −0.34). Patients with chronic post-concussion symptoms show deficits in individual metrics of vergence, accommodation and visual tracking. The high incidence of these deficits, specifically NPC and accommodative amplitude, highlights the need for a detailed sensorimotor evaluation to guide personalized treatment following concussion.

To create and validate a citywide pediatric Asthma Registry to improve the care and outcomes of children and adolescents in Washington, DC through data-driven quality improvement (QI).All available electronic health record data from inpatient and outpatient domains of Children's National Hospital were aggregated from an existing enterprise data warehouse. Inclusion criteria included asthma relevant ICD-10 codes over the prior 24 months. Available Asthma Registry measures include patient demographics, ambulatory visits, hospital admissions, persistent asthma diagnoses, and prescription of controller medications. Data capture was validated using US Census data and current asthma prevalence estimate of the Behavioral Risk Factor Surveillance System (BRFSS).The registry identified 15,991 DC children and adolescents with asthma aged 0-17 years, inclusive, at the end of 2020. This was 14.2% higher than the estimate of 14,001 children derived from BRFSS. Characteristics of those in the registry included: mean age of 9.5 (1.4) years, 57.9% male, 72.3% Black, and 66.7% publicly insured. Over the prior 24 months, 30.3% had ≥1 emergency department visit, and 10.5% had ≥1 hospital admission. Controller medications were prescribed for 59.6% of children with persistent asthma. Rates varied by sampled primary care practice sites.A population-level pediatric asthma registry captures more children and adolescents with asthma in DC then a BRFSS-derived estimate, and provides city-wide measures of asthma-related utilization. The registry allows for stratification by primary care practice locations and asthma characteristics, supporting the design, implementation, and evaluation of QI projects at the practice, health system, and population levels.Supplemental data for this article can be accessed at publisher's website.

Summary Community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) in the United States on February 26, 2020, and the rapid spread that followed forced patients, providers, payors, and policy makers to adapt to an unprecedented, nearly instant, and enormous demand for virtual care. Although few US ophthalmology practices incorporated telemedicine prior to COVID-19, its use has now become the norm. Regarding the use of synchronous patient-to-provider virtual visits (SPPVV) in pediatric ophthalmology, we have pooled our collective experience at three academic practices across the country to describe initial workflows, technology solutions, use cases, and barriers to care.

Shwachman-Diamond syndrome (SDS) is an autosomal recessive multisystem disorder characterized by exocrine pancreatic dysfunction, bone marrow failure, and leukemia predisposition. Approximately 90% of cases are due to biallelic mutations in the Shwachman-Bodian-Diamond (SBDS) gene. Additional phenotypic features variably associated with SDS include skeletal, neurologic, hepatic, cardiac, endocrine, and dental abnormalities. We report five subjects with SDS who developed a range of inflammatory manifestations. Three patients developed inflammatory eye conditions. Single cases of juvenile idiopathic arthritis, chronic recurrent multifocal osteomyelitis, and scleroderma were also noted. Clinical presentation and treatment responses are described. Proteomic analysis revealed increased inflammatory signatures in SDS subjects as compared to controls. Treatment of inflammatory manifestations in patients with SDS may be complicated by potential myelosuppressive toxicities of anti-rheumatic medications. Further research is needed to better understand the potential link between inflammatory disorders and SDS to inform effective treatment strategies.

Carmel L Mercado,1,2 Colin P Froines,3 Eric D Gaier,4– 7 Qinyun Wang,8 Maanasa Indaram,8 Michael J Wan,9 Ankoor S Shah,4– 6 Euna B Koo10 1Department of Ophthalmology, University of Washington, Seattle, WA, USA; 2Department of Ophthalmology, Seattle Children’s Hospital, Seattle, WA, USA; 3School of Medicine, University of Washington, Seattle, WA, USA; 4Department of Ophthalmology, Boston Children’s Hospital, Boston, MA, USA; 5Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA; 6Department of Ophthalmology, Harvard Medical School, Boston, MA, USA; 7Picower Institute for Learning and Memory, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA; 8Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA; 9Department of Ophthalmology and Vision Sciences, SickKids, Toronto, ON, Canada; 10Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA, USACorrespondence: Euna B Koo, Department of Ophthalmology, Stanford University School of Medicine, 2452 Watson Ct, Palo Alto, CA, 94303, USA, Tel +1 650-723-6995, Email eunakoo@stanford.eduPurpose: The objective of this study was to identify the prevalence of CMV ocular disease in children and to identify associated risk factors for ocular involvement.Design: Retrospective multicenter, cross-sectional study.Methods: Setting: Hospitalized patients screened for CMV viremia by PCR between 2005 and 2018 at four pediatric referral centers. Participants: Seven-hundred and ninety-three children showed CMV viremia (> 135 copies/mL by polymerase chain reaction; PCR). Main Outcomes and Measures: (1) Occurrence of ophthalmologic examination. (2) Presence of CMV ocular disease, defined as retinitis, vasculitis, hemorrhage, optic nerve atrophy, or anterior uveitis in the setting of CMV viremia without other identifiable causes.Results: A total of 296/793 (37%) underwent ophthalmologic examination following CMV viremia. A total of23/296 patients (8%) had ocular symptoms prompting evaluation while the rest had eye exams for baseline screening unrelated to CMV viremia. Of these, 13 cases (4% of those with an eye exam) with ocular disease were identified (three congenital CMV, five severe combined immunodeficiency disorder (SCID) status post-stem cell transplantation, three hematologic malignancy status post-stem cell transplantation for two of them, one Evans syndrome status post-stem cell transplantation, and one medulloblastoma status post-bone marrow transplantation). No patients with solid organ transplantation developed CMV ocular disease in our cohort.Conclusion: CMV ocular disease was a rare occurrence in this cohort without an identifiable pattern across sub-groups. Excluding the three congenital CMV cases, nine out of ten patients with CMV ocular disease were status post-stem cell transplantation. We provide integrated screening guidelines based on the best available evidence for this rare condition.Keywords: cytomegalovirus, retinitis, CMV, screening guidelines, pediatrics

There is a nationwide shortage of pediatric ophthalmologists, with trends in fellowship applicants foreshadowing a continued reduction in the number of active pediatric ophthalmologists in the years ahead. In this study, we investigated whether similar fellowship applicant shortages exist in other pediatric surgical subspecialties. We compared the match statistics of six pediatric surgical fellowships from 2015 to 2020. During the 6-year interval, a median of 12.2 pediatric ophthalmology fellowship positions (IQR, 12.1-12.4) were offered per 100 graduating residents, 8.7% of ophthalmology residents (IQR, 8.3%-9.3%) pursued pediatric subspecialty training, and 72% of available pediatric fellowship positions (IQR, 69%-74%) were filled. Pediatric general surgery had the highest percentage of available fellowship positions filled, 99% (IQR, 98%-100%), which was significantly higher than for pediatric ophthalmology (P = 0.024). None of the other subspecialties had a significant difference in available positions filled compared to pediatric ophthalmology (P0.05).

Concussion is a common injury in childhood and has the potential for substantial impact on quality of life. Visual issues have been increasingly recognized as a common problem after concussion. Many children initially seek care for concussion with their pediatrician, making it even more important for pediatricians to recognize, evaluate, and refer children with visual issues after concussion. This clinical report is intended to support the recommendations in the companion policy statement on vision and concussion and provides definitions of some of the physiologic aspects of the visual system as they relate to concussion. A description of clinically feasible testing methodologies is provided in more detail to aid the clinician in assessing the visual system in a focused fashion after concussion. This guidance helps direct clinical management, including support for return to school, sports, and other activities, as well as potential referral for subspecialty care for the subset of those with persistent symptoms.

Visual symptoms are common after concussion in children and adolescents, making it essential for clinicians to understand how to screen, identify, and initiate clinical management of visual symptoms in pediatric patients after this common childhood injury. Although most children and adolescents with visual symptoms after concussion will recover on their own by 4 weeks, for a subset who do not have spontaneous recovery, referral to a specialist with experience in comprehensive concussion management (eg, sports medicine, neurology, neuropsychology, physiatry, ophthalmology, otorhinolaryngology) for additional assessment and treatment may be necessary. A vision-specific history and a thorough visual system examination are warranted, including an assessment of visual acuity, ocular alignment in all positions of gaze, smooth pursuit (visual tracking of a moving object), saccades (visual fixation shifting between stationary targets), vestibulo-ocular reflex (maintaining image focus during movement), near point of convergence (focusing with both eyes at near and accommodation (focusing with one eye at near because any of these functions may be disturbed after concussion. These deficits may contribute to difficulty with returning to both play and the learning setting at school, making the identification of these problems early after injury important for the clinician to provide relevant learning accommodations, such as larger font, preprinted notes, and temporary use of audio books. Early identification and appropriate management of visual symptoms, such as convergence insufficiency or accommodative insufficiency, may mitigate the negative effects of concussion on children and adolescents and their quality of life.

We hypothesized that children with low socioeconomic status (SES) had disproportionately fewer eye care visits during the early COVID-19 pandemic and that these children would be less likely to use synchronous provider-to-patient telemedicine eye care visits. This study investigated changes in patient demographics at a large, academic pediatric eye center before and after the pandemic. A retrospective review of all visits from March 18, 2019, to May 31, 2019 (pre-COVID period) and of the same date range in 2020 (COVID period) was performed. Patient addresses were used to calculate the Area Deprivation Index (ADI), a validated measure of a neighborhood's SES. Patients who identified as non-White, and those requiring an interpreter had relatively fewer visits during the COVID period compared to the pre-COVID period. In addition, relatively fewer telemedicine visits were performed with patients who lived in a neighborhood classified as at or above the 50th ADI percentile (more disadvantaged).

To describe the clinical course and outcomes of aggressive retinal astrocytic hamartoma (RAH) treated with oral mechanistic target of rapamycin inhibitors (mTORis).A retrospective clinical case series.Five patients with genetically confirmed tuberous sclerosis complex and visually significant RAH due to tumor growth or exudation.In this retrospective clinical case series, a review of electronic medical records was performed to determine baseline and follow-up ophthalmic examination characteristics, along with ancillary imaging findings, in patients receiving off-label treatment with either oral sirolimus or everolimus for symptomatic RAH.Visual acuity, change in tumor size, degree of exudation, and adverse effects of the mTORis were evaluated.The 5 patients in this series ranged in age from 8 months to 54 years. Four were treated with sirolimus, and 1 received everolimus. In all the cases, the tumor height was stable or decreased after the treatment (median follow-up duration, 39 months; range, 11-73 months). Exudation improved after the treatment in all the cases. In an 8-month-old infant, frequent upper respiratory tract infections prompted the cessation of treatment. In 1 patient, the mTORi was temporarily withheld because of elevated liver enzyme levels. No other significant adverse effects were noted.Sirolimus and everolimus should be considered in the management of vision-threatening RAH, particularly in the setting of exudative and rapidly growing tumors. Four of the 5 patients in this series tolerated the oral mTORi and continued with the therapy. There were no serious complications.

PURPOSE To examine the association between Post-Concussion Symptom Scale (PCSS) scores, Convergence Insufficiency Symptom Survey (CISS) scores, and oculomotor deficits post-concussion. METHODS Records of adolescent patients examined in a multidisciplinary concussion clinic between July 2014 and May 2019 were reviewed. PCSS and CISS scores, results of eye examination and oculomotor assessment, concussion history, and demographics were abstracted. RESULTS One hundred and forty patient records (median age, 15.3 years; 52 males, presented 109 days (median) from their most recent concussion) met inclusion criteria. Mean total scores on PCSS and CISS were 46.67 ± 25.89 and 27.13 ± 13.22, respectively, and were moderately correlated with each other (r = 0.53, p

Purpose To determine the frequency of occurrence of receded near point of convergence (NPC) in patients with chronic concussion-related symptoms and in those with receded NPC to enumerate the frequency of convergence insufficiency and other oculomotor disorders. Design Retrospective cross-sectional study. Methods Clinic charts were retrospectively reviewed for the prior 3.5 years to identify all patients 28 days postconcussion, had chronic concussion-related symptoms, had normal visual acuity, and had received a comprehensive sensorimotor examination. The frequency of receded NPC and oculomotor diagnoses were determined. Results Of the 83 eligible patients, 74 (89%) had receded NPC. Of these, 70 (95%) had oculomotor disorders; 30 (41%) had disorders of accommodation only; 21 (28%) had convergence insufficiency and accommodation deficits; and 6 (8%) had convergence insufficiency only. Six (8%) had a convergence deficit other than convergence insufficiency (all with concurrent accommodative disorders); 4 (5%) had both a nonspecific vergence dysfunction and accommodation deficits; 2 (3%) had convergence excess only; and 1 (1%) had both convergence excess and accommodative deficits. Conclusion A receded NPC was present in the majority of young patients with chronic postconcussion symptoms. Associated with numerous underlying oculomotor dysfunctions, the clinical finding of a receded NPC is not synonymous with the diagnosis of convergence insufficiency. Because treatment options for the various oculomotor dysfunctions differ, it is prudent that these patients undergo a thorough examination of their vergence and accommodative systems so that an accurate diagnosis can be made and appropriate treatment prescribed.

Purpose To compare the rates of infectious endophthalmitis following intravitreal injection of ranibizumab using prefilled syringes vs conventional preparation. Design Multicenter retrospective cohort study. Methods All eyes receiving intravitreal injection of 0.5 mg ranibizumab for retinal vascular diseases at 10 retina practices across the United States (2016 to 2017) and Japan (2009 to 2017) were included. The total numbers of eyes and injections were determined from billing codes. Endophthalmitis cases were determined from billing records and evaluated with chart review. Primary outcome was the rate of postinjection acute endophthalmitis. Secondary outcomes were visual acuity and microbial spectrum. Results A total of 243 754 intravitreal 0.5 mg ranibizumab injections (165 347 conventional and 78 407 prefilled) were administered to 43 132 unique patients during the study period. In the conventional ranibizumab group, a total of 43 cases of suspected endophthalmitis occurred (0.026%; 1 in 3845 injections) and 22 cases of culture-positive endophthalmitis occurred (0.013%; 1 in 7516 injections). In the prefilled ranibizumab group, 12 cases of suspected endophthalmitis occurred (0.015%; 1 in 6534 injections) and 2 cases of culture-positive endophthalmitis occurred (0.0026%; 1 in 39 204 injections). Prefilled syringes were associated with a trend toward decreased risk of suspected endophthalmitis (odds ratio 0.59; 95% confidence interval 0.31-1.12; P = .10) and a statistically significant decreased risk of culture-positive endophthalmitis (odds ratio 0.19; 95% confidence interval 0.045-0.82; P = .025). Average logMAR vision loss at final follow-up was significantly worse for eyes that developed endophthalmitis from the conventional ranibizumab preparation compared to the prefilled syringe group (4.45 lines lost from baseline acuity vs 0.38 lines lost; P = .0062). Oral-associated flora was found in 27.3% (6/22) of conventional ranibizumab culture-positive endophthalmitis cases (3 cases of Streptococcus viridans, 3 cases of Enterococcus faecalis) compared to 0 cases in the prefilled ranibizumab group. Conclusion In a large, multicenter, retrospective study the use of prefilled syringes during intravitreal injection of ranibizumab was associated with a reduced rate of culture-positive endophthalmitis, including from oral flora, as well as with improved visual acuity outcomes.

Background/aimsTo determine success rate and complications associated with nasal transposition of the split lateral rectus muscle (NTSLR) for treating strabismus from 3rd-nerve palsy.MethodsAn international, multicentre, registry of patients with unilateral 3rd-nerve palsy treated with NTSLR was created. Patients with concurrent surgery on the contralateral eye were excluded. Primary outcome was horizontal alignment within 15 prism dioptres (PD) of orthotropia. Incidence of technical difficulties and vision-threatening complications by 6 months post-procedure were reported.ResultsNinety-eight patients met inclusion criteria. Median age was 33.5 years (IQR 10.75–46). Aetiologies included congenital (31%), neoplastic (16%) and traumatic (15%). Twenty-five per cent of patients had prior ipsilateral strabismus surgery. Median exotropia decreased from 70PD preoperatively (IQR 50–90) to 1PD postoperatively (IQR 0–15.5), with a success rate of 69%. Performing concurrent superior oblique muscle tenotomy (SOT) was independently associated with success (p=0.001). Technical challenges occurred in 30% of cases, independently associated with a history of ipsilateral strabismus surgery (p=0.01). Eleven per cent of patients had vision-threatening complications, independently associated with more posterior placement of the split lateral rectus (LR) muscle (preducedthis risk.ConclusionNTSLR significantly improved primary position alignment altered by 3rd-nerve palsy. Concurrent SOT and placement of the split LR muscle ≤4.25 mm posterior to the MR muscle insertion optimised outcomes. NTSLR proved technically challenging when prior ipsilateral strabismus surgery had been performed.

A 9-year-old boy with partial third nerve palsy underwent medial transposition of the left lateral rectus muscle and left inferior oblique myectomy. He developed optic nerve compression, which improved after a superior oblique tenotomy. A primary superior oblique tenotomy or a maximum lateral rectus muscle split may help avoid this complication. [ J Pediatr Ophthalmol Strabismus . 2021;58(3):e12–e15.]

BACKGROUND Bedside manner describes how clinicians relate to patients in person. Telemedicine allows clinicians to connect virtually with patients using digital tools. Effective virtual communication or webside manner may require modifications to traditional bedside manner. OBJECTIVE This study aims to understand the experiences of telemedicine providers with patient-to-provider virtual visits and communication with families at a single large-volume children’s hospital to inform program development and training for future clinicians. METHODS A total of 2 focus groups of pediatric clinicians (N=11) performing virtual visits before the COVID-19 pandemic, with a range of experiences and specialties, were engaged to discuss experiential, implementation, and practice-related issues. Focus groups were facilitated using a semistructured guide covering general experience, preparedness, rapport strategies, and suggestions. Sessions were digitally recorded, and the corresponding transcripts were reviewed for data analysis. The transcripts were coded based on the identified main themes and subthemes. On the basis of a higher-level analysis of these codes, the study authors generated a final set of key themes to describe the collected data. RESULTS Theme consistency was identified across diverse participants, although individual clinician experiences were influenced by their specialties and practices. A total of 3 key themes emerged regarding the development of best practices, barriers to scalability, and establishing patient rapport. Issues and concerns related to privacy were salient across all themes. Clinicians felt that telemedicine required new skills for patient interaction, and not all were comfortable with their training. CONCLUSIONS Telemedicine provides benefits as well as challenges to health care delivery. In interprofessional focus groups, pediatric clinicians emphasized the importance of considering safety and privacy to promote rapport and webside manner when conducting virtual visits. The inclusion of webside manner instructions within training curricula is crucial as telemedicine becomes an established modality for providing health care.

Evidence for hematopoietic stem cell transplantation (HCT) in autoimmune disease has been building since the 1990s; however, many clinicians may not yet be aware of its applications to autoimmune disease. We review the basic tenets of HCT and evidence for autologous HCT in multiple sclerosis (MS), systemic sclerosis (SSc), and lupus with an emphasis on recent advanced phase trials. In MS, the phase 3 randomized MIST trial and the phase 2 randomized ASTIMS trial demonstrated the efficacy of autologous HCT in refractory MS over disease-modifying therapies and mitoxantrone, respectively. In SSc, the phase 3 randomized ASTIS trial and the phase 2 randomized SCOT trial demonstrated the efficacy of autologous HCT in advanced SSc compared to cyclophosphamide. The evidence for HCT in autoimmune diseases continues to grow, particularly in MS and SSc. In lupus, large, comparative trials are still needed. Across autoimmune diseases, questions that still remain to be answered include optimizing patient selection to limit TRM, the appropriate use of MAC, and the necessity for graft manipulation. Furthermore, collaboration between disease-specific and transplant physicians is imperative to expand the appropriate use of HCT in routine clinical practice.

To describe the etiology, clinical features, and outcomes for a large contemporary cohort of children presenting with glaucoma at a tertiary referral center.The medical records of patients presenting to Boston Children's Hospital from January 2014 to July 2019 with a diagnosis of childhood glaucoma were retrospectively reviewed. Data regarding etiology, treatment, and visual and anatomic outcomes were collected; visual acuity outcomes were analyzed by laterality and diagnosis categories, using the Childhood Glaucoma Research Network (CGRN) classifications.A total of 373 eyes of 246 patients (51% males) diagnosed with glaucoma before 18 years of age were identified. Mean follow-up was 7.04 ± 5.61 years; 137 cases were bilateral. The mean age at diagnosis was 4.55 ± 5.20 years. The most common diagnoses were glaucoma following cataract surgery (GFCS, 36.5%) and primary congenital glaucoma (PCG, 29.0%). Overall, 164 eyes (44.0%) underwent at least one glaucoma surgery. Intraocular pressure (IOP) was ≤21 mm Hg with or without glaucoma medications in 300 eyes (80.4%) at the last follow-up visit. Poor final best-corrected visual acuity (≤20/200) was found in 110 eyes; patients with poor final visual acuity tended to have poor visual acuity at presentation. The most common reason for poor vision was amblyopia. Uncontrolled IOP was an uncommon cause for vision loss.Childhood glaucoma can be challenging to manage, but poor vision usually results from amblyopia or presence of other ocular abnormalities or syndromes rather than glaucomatous optic neuropathy.

Systemic sclerosis is a chronic autoimmune disease with a poor prognosis, particularly when a patient has rapidly progressive skin or pulmonary involvement. Autologous hematopoietic stem cell transplant is an emerging treatment for this condition, that has been demonstrated to be more effective than immunosuppressants. Careful selection of patients has reduced the transplant-related mortality and maximized the likelihood of benefit. In this report, we present three cases of successful autologous hematopoietic stem cell transplant in patients who would not have met inclusion criteria for entrance into the completed hematopoietic stem cell transplant. After >18 months of follow-up, three patients had clinically significant benefit in terms of skin tightening and pulmonary function tests. Future studies of hematopoietic stem cell transplant in systemic sclerosis may aim to carefully liberalize inclusion criteria to include patients who may not have otherwise been treated while still maintaining an acceptable safety profile.

The authors declare that there are no disclosures or conflicts of interest regarding the publication of this manuscript. We did not receive any financial support and have no financial interests which could create a potential conflict of interest or the appearance of a conflict of interest with regard to the work.

Virtual visits (VVs) are necessitated due to the public health crisis and social distancing mandates due to COVID-19. However, these have been rare in ophthalmology. Over 3.5 years of conducting >350 ophthalmological VVs, our group has gained numerous insights into best practices. This communication shares these experiences with the medical community to support patient care during this difficult time and beyond. We highlight that mastering the technological platform of choice, optimizing lighting, camera positioning, and "eye contact," being thoughtful and creative with the virtual eye examination, and ensuring good documenting and billing will make a successful and efficient VV. Moreover, we think these ideas will stimulate further VV creativity and expertise to be developed in ophthalmology and across medicine. This approach, holds promise for increasing its adoption after the crisis has passed.

Purpose To evaluate the timing of ocular hypertension (OHT) after pediatric closed-globe injury (CGI) and traumatic hyphema. We hypothesize that OHT will occur at different times based on injury characteristics. Design Retrospective, cohort study. Methods Setting: Single-center, tertiary-care, pediatric hospital. Participants: Subjects included patients ≤18 years of age at the time of injury who suffered CGI and traumatic hyphema between 2002 and 2019. Observation Procedure(s): Intraocular pressure and injury demographics were abstracted for every visit after injury. OHT was defined as >21 mm Hg at presentation or after a reading of ≤21 mm Hg at a prior visit. Main Outcome Measures: The primary outcome measure was the timing of OHT categorized into 4 periods: presentation, acute (days 1-7), subacute (days 8-28), or late (day >28). Secondary outcome measures were identification of risks factors for OHT by multivariable logistic regression. Results OHT occurred in 119 of the 305 (39%) subject eyes. OHT occurred in 35 patients at presentation, 69 times acutely, 35 times subacutely, and 36 times late. Pupil damage predicted acute-period OHT (P = .004). OHT at presentation predicted subacute period OHT (P = .004). Iridodialysis and cataract predicted late-period OHT (P = .007 and P Conclusions OHT after CGI and traumatic hyphema in pediatric patients is common. Injury demographics predict this complication. Integration of these risk factors with current literature allows proposal of a risk-stratification tool to guide efficient surveillance for OHT.

Rasmussen encephalitis (RE) is a disorder characterized by drug-resistant seizures and progressive unihemispheric atrophy, hemiparesis, and varying degrees of cognitive decline. The pathophysiology of RE remains elusive, with hypotheses suggesting underlying autoimmune- and T cell-mediated processes. In this case report, we describe a single patient's clinical course from the first day of presentation until definitive treatment for atypical Rasmussen encephalitis at a tertiary care pediatric center. The patient exhibited several atypical features of Rasmussen encephalitis, including a posterior predominance of initial seizure onset with the development of severe choreoathetosis and ipsilateral cerebellar atrophy. He subsequently developed coexistent autoimmune disorders in the form of psoriasis and uveitis, and underwent multiple forms of immunotherapy with limited benefit. This patient shows an association of RE with other autoimmune conditions supporting an autoimmune mechanism of disease while exhibiting several atypical features of RE. Rarely, occipital lobe seizures have been documented as the presenting semiology of this syndrome. This case highlights the need to be mindful of atypical features that may delay hemispherectomy, which remains the definitive treatment. It also suggests that children may be predisposed to the development of autoimmune disorders in later stages of the disease., Highlights • Occipital seizure localization and semiology should not dissuade the diagnosis of Rasmussen's encephalitis • Movement disorders, can accompany Rasmussen's encephalitis • Ipsilateral cerebellar atrophy has been described in Rasmussen's encephalitis • Children with Rasmussen's encephalitis may be predisposed to autoimmune disorders in the later stages of the disease

OBJECTIVE To describe the collaborative findings across a broad array of subspecialties in children and adolescents with postconcussion syndrome (PCS) in a pediatric multidisciplinary concussion clinic (MDCC) setting. DESIGN Retrospective analysis. SETTING Multidisciplinary concussion clinic at a pediatric tertiary-level hospital. PATIENTS Fifty-seven patients seen in MDCC for evaluation and management of PCS between June 2014 and January 2016. INTERVENTIONS Clinical evaluation by neurology, sports medicine, otolaryngology, optometry, ophthalmology, physical therapy, and psychology. MAIN OUTCOME MEASURES Specialty-specific clinical findings and specific, treatable diagnoses relevant to PCS symptoms. RESULTS A wide variety of treatable, specialty-specific diagnoses were identified as potential contributing factors to patients' postconcussion symptoms. The most common treatable diagnoses included binocular vision dysfunction (76%), anxiety, (57.7%), depression (44.2%), new or change in refractive error (21.7%), myofascial pain syndrome (19.2%), and benign paroxysmal positional vertigo (17.5%). CONCLUSIONS Patients seen in a MDCC setting receive a high number of treatable diagnoses that are potentially related to patients' PCS symptoms. The MDCC approach may (1) increase access to interventions for PCS-related impairments, such as visual rehabilitation, physical therapy, and psychological counseling; (2) provide patients with coordinated medical care across specialties; and (3) hasten recovery from PCS.

Purpose: Chromosome 22q11.2 micro-duplication syndrome (MDS), is a rare autosomal dominant condition, with a highly variable phenotype that ranges from unremarkable and asymptomatic, to fatal due to cardiovascular defects. Hypertelorism, downslanting palpebral fissures, superior displacement of the eyebrows, and ptosis are the most commonly reported ocular manifestations. Here, we report a newborn with bilateral exposure, entropion, and corneal ulceration related to 22q11.2 MDS. Observation: A newborn girl presented with bilateral upper eyelid entropion, bilateral lower eyelid ectropion, and lagophthalmos. She subsequently developed bilateral corneal ulcers. Topical antibacterial drops, bandage contact lenses, medroxyprogesterone 1%, and fluorometholone 0.1%, together with partial tarsorrhaphy and correction of eyelid malposition, were used to treat the ulcers and address the underlying issues of exposure and entropion. Genetic testing revealed chromosome 22q11.2.MDS; further evaluation revealed systemic manifestations of this syndrome. The ocular surface healed well with gradual improvement of corneal opacification as well as bilateral partial tarsorrhaphy. Conclusion and importance: This report is the first that describes a newborn with 22q11.2 MDS presenting with sight-threatening corneal ulceration. Entropion, ectropion, and lagophthalmos were identified and treated, allowing for healing of the corneal surface. Genetic testing revealed a syndrome not known to be associated with eyelid abnormalities and corneal ulceration, but with other important systemic and ocular implications. Bilateral partial tarsorrhaphy should not be excluded as a treatment option for infants who fail more conservative measures for the treatment of exposure. Keywords: Chromosome 22q11.2 duplication syndrome, Corneal ulcer, Congenital entropion, Lagophthalmos, Partial tarsorrhaphy

BACKGROUND AND OBJECTIVE: To investigate predictors of visual outcomes in patients who underwent vitrectomy for full-thickness macular hole (FTMH) with at least 1 year of follow-up. PATIENTS AND METHODS: Retrospective, noncomparative, consecutive case series of 132 eyes of 122 patients who underwent surgical repair of idiopathic FTMH with at least 1 year of follow-up. Predictors of visual acuity (VA) outcomes were analyzed using linear regression. RESULTS: Mean follow-up time was 22.2 months. Twenty-three eyes (17.4%) had age-related macular degeneration (AMD), of which 17 (73.9%) cases were mild and nonexudative. At final follow-up, poor preoperative VA ( P < .001), perioperative complications ( P < .001), AMD ( P < .001), and delay from preoperative evaluation to surgery ( P = .037) were significant predictors of final VA. In multiple regression, these variables remained significant ( P < .001, P = .011, P < .001, and P = .002, respectively). CONCLUSION: Poor preoperative VA, perioperative complications, AMD, and delay to surgery were significant predictors of final VA following FTMH repair. [ Ophthalmic Surg Lasers Imaging Retina . 2018;49:566–570.]

Background Posterior ischemic optic neuropathy results from ischemia of the retrobulbar aspect of the optic nerve. It presents as acute loss of vision without optic disc swelling. This is rare in children, with only seven cases reported to date. Neuroimaging is frequently used to aid in the diagnosis of acute visual complaints in children; however, none of the cases described to date delineate the neuroimaging findings of this entity in children. Methods We retrospectively reviewed the electronic medical record. Results We describe the MRI findings in a 10-month-old boy with posterior ischemic optic neuropathy after intraophthalmic artery injection of chemotherapy for retinoblastoma. Conclusions As targeted therapies for retinoblastoma and other diseases amenable to intravascular treatment delivery are more frequently used, the risk of grave vision-related side effects increases. Posterior ischemic optic neuropathy should be considered in the differential diagnosis of any child presenting with acute loss of vision. Dedicated imaging of the orbits can elucidate specific findings that may aid in the diagnosis of this entity in children.

Aims Diabetic retinopathy (DR) and diabetic macular edema (DME) can be evaluated using telemedicine systems, such as the Intelligent Retinal Imaging Systems (IRIS), in patients with Diabetes Mellitus (DM). In an endocrinology-based population utilizing IRIS we determine prevalence rates of DR and DME, and identify associated epidemiologic correlations. Methods This is a multicenter, retrospective chart review using screening data from IRIS. Centers for Disease Control and Prevention (CDC) data on epidemiologic variables (by county) namely, prevalence of DM, incidence of DM, obesity, and time of physical inactivity, were compared against prevalence rates of DR found at screening. Results A total of 10,223 eyes of 5,242 patients with DM were imaged. DR and DME were noted in 1781 (33.98%) and 226 imaging studies (4.31%) respectively. The coefficient of determination was greatest for incidence of DM (R2 = 0.92), followed by DM prevalence (R2 = 0.79), obesity, (R2 = 0.67), and physical inactivity (R2 = 0.34). The presence of DR during screening varied significantly by county (p Conclusions Screening in counties with a higher incidence of DM led to a higher prevalence of identified DR at time of screening. The current work suggests that telemedicine screening in areas known to have a higher incidence of DM may be worthwhile.

Purpose To report the long-term surgical outcomes for a cohort of children with large-angle infantile esotropia. Design Multicenter, nonrandomized clinical study. Methods Setting: Two tertiary-care pediatric hospitals. Study Population: Children with large-angle (≥55 prism diopters) infantile esotropia. Intervention: Surgical treatment of infantile esotropia. Main Outcome Measure: Success rate at final follow-up (postoperative deviation ≤ 10 prism diopters and no need for retreatment). Results A total of 88 patients with large-angle infantile esotropia were treated during the 13-year study period. Treatment was bilateral medial rectus muscle recessions in 70 patients, botulinum toxin–augmented surgery in 15 patients, and 3-muscle surgery in 3 patients. After a mean follow-up of 40 months, 20 patients (23%) had a successful outcome compared to 68 treatment failures (77%). Of the 68 treatment failures, 59 had residual or recurrent esotropia and 9 had sequential exotropia. On multivariate logistic regression, treatment modality was the only factor significantly associated with a successful outcome. Specifically, patients treated with botulinum toxin–augmented surgery were more likely to have a successful outcome compared to patients treated with bilateral medial rectus muscle recessions. For the 26 patients (30%) who underwent retreatment, the mean number of procedures was 2.1, and 7 (27%) had a deviation of ≤10 prism diopters at final follow-up. Conclusions The overall success rate for treatment of large-angle infantile esotropia was poor in this cohort, with most failures owing to recurrent or residual esotropia. Botulinum toxin–augmented surgery was associated with a higher success rate at final follow-up.

BACKGROUND AND OBJECTIVE: The authors evaluated long-term postoperative visual outcomes and recurrence rates following surgery for symptomatic epiretinal membrane (ERM) ± internal limiting membrane (ILM) peeling. PATIENTS AND METHODS: This was a retrospective, consecutive case series of 78 patients undergoing vitrectomy for symptomatic ERM between 1/2010 and 4/2012 with follow-up through at least postoperative year 5 (POY5). Outcomes included visual acuity (VA) (Snellen VA converted to logMAR), central retinal thickness (CRT; μm), and ERM recurrence. Subgroup analysis evaluated outcomes related to ILM peeling. RESULTS: Subgroup analysis based on ILM peeling did not find VA (20/50 [0.430 logMAR ± 0.061 logMAR; mean ± SD] vs. 20/60 [0.518 logMAR ± 0.128 logMAR] for ILM vs. non-ILM peeling respectively; P = .513) nor macular thickness (355 μm ± 13 μm vs. 360 μm ± 42 μm; P = .410) to be significantly different at POY5. Recurrence requiring surgery with and without ILM peeling was not statistically significantly different at POY5 (1.6% and 11.8%; P = .118). CONCLUSION: Vitrectomy for symptomatic ERM led to improved visual and anatomic outcomes with sustained benefit through 5 years. ILM peeling was was associated with reduced ERM recurrence, but this benefit was not statistically significant at POY5. [ Ophthalmic Surg Lasers Imaging Retina . 2018;49:296–302.]

Background Bedside manner describes how clinicians relate to patients in person. Telemedicine allows clinicians to connect virtually with patients using digital tools. Effective virtual communication or webside manner may require modifications to traditional bedside manner. Objective This study aims to understand the experiences of telemedicine providers with patient-to-provider virtual visits and communication with families at a single large-volume children’s hospital to inform program development and training for future clinicians. Methods A total of 2 focus groups of pediatric clinicians (N=11) performing virtual visits before the COVID-19 pandemic, with a range of experiences and specialties, were engaged to discuss experiential, implementation, and practice-related issues. Focus groups were facilitated using a semistructured guide covering general experience, preparedness, rapport strategies, and suggestions. Sessions were digitally recorded, and the corresponding transcripts were reviewed for data analysis. The transcripts were coded based on the identified main themes and subthemes. On the basis of a higher-level analysis of these codes, the study authors generated a final set of key themes to describe the collected data. Results Theme consistency was identified across diverse participants, although individual clinician experiences were influenced by their specialties and practices. A total of 3 key themes emerged regarding the development of best practices, barriers to scalability, and establishing patient rapport. Issues and concerns related to privacy were salient across all themes. Clinicians felt that telemedicine required new skills for patient interaction, and not all were comfortable with their training. Conclusions Telemedicine provides benefits as well as challenges to health care delivery. In interprofessional focus groups, pediatric clinicians emphasized the importance of considering safety and privacy to promote rapport and webside manner when conducting virtual visits. The inclusion of webside manner instructions within training curricula is crucial as telemedicine becomes an established modality for providing health care.