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Purpose: To test the hypothesis that eye muscle surgery in treatment of patients with acquired downbeat nystagmus results in improvement measures of visual and ocular motor function., Methods: This is a prospective, interventional case series analysis of clinical and electrophyisological data before and after eye muscle surgery in 17 patients with acquired downbeat nystagmus who did not respond to medical treatments. Outcome measures included: 1) routine demography and clinical characteristics, 2) subjective oscillopsia (SO), 3) binocular best-corrected visual acuity in the null position (BVA), 3) primary position strabismic deviation (SD), 5) anomalous head posture (AHP), 6) contrast sensitivity function (CS), and 7) nystagmus slow phase velocity (SPV). All patients were followed at least 12 months. Parametric and non-parametric statistical analysis of outcome measure data above pre- and post-treatment were perfomed using standard software on grouped data using computerized software., Results: Patients' age ranged from 5 to 85 years (average 27 years). About 59% were male. Follow up ranged from 1-10 years (average 2.0 years). Around 70% had an associated central nervous systemic diagnosis, 100% had an AHP, oscillopsia and decreased CS, 53% had other eye disease, and 59% had strabismus. There were no complications from surgery. There were signficant post-treatment improvements in mean/median group BVA, SO, SD, AHP, CS, and SPV., Conclusion: This study supports the hypothesis that eye muscle surgery as treatments for patients with acquired downbeat nystagmus can result in improvements in multiple aspects of ocular motor and visual functions., Competing Interests: None

Visual electrodiagnostics and eye movement recording are important additional clinical tools in evaluation, diagnosing and management of ophthalmic and neurological disorders. Due to their objectiveness and non-invasiveness they can play an important role in pediatric ophthalmology. The WSPOS (World Society of Pediatric Ophthalmology and Strabismus) consensus statement gives insight into basic principles and highlights the clinical application of both visual electrodiagnostic tests and eye movement recording., Competing Interests: None

Purpose: This study presents test-retest reliability of optotype visual acuity (OVA) across 60° of horizontal gaze position in patients with infantile nystagmus syndrome (INS). Also, the validity of the metric gaze-dependent functional vision space (GDFVS) is shown in patients with INS., Methods: In experiment 1, OVA was measured twice in seven horizontal gaze positions from 30° left to right in 10° steps in 20 subjects with INS and 14 without INS. Test-retest reliability was assessed using intraclass correlation coefficient (ICC) in each gaze. OVA area under the curve (AUC) was calculated with horizontal eye position on the x-axis, and logMAR visual acuity on the y-axis and then converted to GDFVS. In experiment 2, validity of GDFVS was determined over 40° horizontal gaze by applying the 95% limits of agreement from experiment 1 to pre- and post-treatment GDFVS values from 85 patients with INS., Results: In experiment 1, test-retest reliability for OVA was high (ICC ≥ 0.88) as the difference in test-retest was on average less than 0.1 logMAR in each gaze position. In experiment 2, as a group, INS subjects had a significant increase (P < 0.001) in the size of their GDFVS that exceeded the 95% limits of agreement found during test-retest., Conclusions: OVA is a reliable measure in INS patients across 60° of horizontal gaze position. GDFVS is a valid clinical method to be used to quantify OVA as a function of eye position in INS patients. This method captures the dynamic nature of OVA in INS patients and may be a valuable measure to quantify visual function patients with INS, particularly in quantifying change as part of clinical studies.

Purpose: Nystagmus eye movement data from infants and young children are often not suitable for advanced quantitative analysis. A method was developed to capture useful information from noisy data and validate the technique by showing meaningful relationships with visual functioning., Methods: Horizontal eye movements from patients (age 5 months-8 years) with idiopathic infantile nystagmus syndrome (INS) were used to develop a quantitative outcome measure that allowed for head and body movement during the recording. The validity of this outcome was assessed by evaluating its relation to visual acuity deficit in 130 subjects, its relation to actual fixation as assessed under simultaneous fundus imaging, its correlation with the established expanded nystagmus acuity function (NAFX), and its test-retest variability., Results: The nystagmus optimal fixation function (NOFF) was defined as the logit transform of the fraction of data points meeting position and velocity criteria within a moving window. A decreasing exponential relationship was found between visual acuity deficit and the NOFF, yielding a 0.75 logMAR deficit for the poorest NOFF and diminishing deficits with improving foveation. As much as 96% of the points identified as foveation events fell within 0.25° of the actual target. Good correlation (r = 0.96) was found between NOFF and NAFX. Test-retest variability was 0.49 logit units., Conclusions: The NOFF is a feasible method to quantify noisy nystagmus eye movement data. Its validation makes it a promising outcome measure for the progression and treatment of nystagmus during early childhood.

Objective: To determine whether age at initiation of treatment for amblyopia influences the response among children 3 to less than 13 years of age with unilateral amblyopia who have 20/40 to 20/400 amblyopic eye visual acuity., Methods: A meta-analysis of individual subject data from 4 recently completed randomized amblyopia treatment trials was performed to evaluate the relationship between age and improvement in logMAR amblyopic eye visual acuity. Analyses were adjusted for baseline amblyopic eye visual acuity, spherical equivalent refractive error in the amblyopic eye, type of amblyopia, prior amblyopia treatment, study treatment, and protocol. Age was categorized (3 to <5 years, 5 to <7 years, and 7 to <13 years) because there was a nonlinear relationship between age and improvement in amblyopic eye visual acuity., Results: Children from 7 to less than 13 years of age were significantly less responsive to treatment than were younger age groups (children from 3 to <5 years of age or children from 5 to <7 years of age) for moderate and severe amblyopia (P < .04 for all 4 comparisons). There was no difference in treatment response between children 3 to less than 5 years of age and children 5 to less than 7 years of age for moderate amblyopia (P = .67), but there was a suggestion of greater responsiveness in children 3 to less than 5 years of age compared with children 5 to less than 7 years of age for severe amblyopia (P = .09)., Conclusions: Amblyopia is more responsive to treatment among children younger than 7 years of age. Although the average treatment response is smaller in children 7 to less than 13 years of age, some children show a marked response to treatment.

Purpose: To report the effect of the abnormal head posture (AHP) correcting procedures on the visual acuity improvement in patients with infantile nystagmus syndrome (INS) and the visual acuity improvement outcomes in different AHP correcting surgeries in INS., Methods: This was a prospective, non-randomized, interventional study. Twenty-eight patients underwent the Anderson-Kestenbaum procedure or the modified Anderson procedure with or without tenotomy of at least one horizontal recti for correction of AHP. Best-corrected binocular null zone acuity and degree of AHP was recorded preoperatively and compared with those done 1 month postoperatively., Results: The average null zone logarithm of the minimum angle of resolution acuity was 0.42 preoperatively, which improved significantly to 0.33 postoperatively (P = .002). The AHP ranged from 10° to 40° (mean: 20.89°), which improved significantly to a mean of 3.21° (P = .000). No significant difference (P = .65) was found in the visual acuity improvement among patients who underwent the Anderson-Kestenbaum procedure or the modified Anderson procedure with or without tenotomy. No significant difference in the visual acuity improvement was seen in patients who underwent tenotomy of at least one horizontal rectus muscle along with the modified Anderson procedure compared to those who underwent the modified Anderson procedure alone (P = .28)., Conclusion: The procedures used mainly for correction of AHP in INS do yield significant improvement in the visual acuity. This improvement is seen in patients undergoing surgery for both horizontal and vertical AHP., (Copyright 2011, SLACK Incorporated.)

Aims: We developed a new data analysis algorithm called the automated nystagmus acuity function (ANAF) to automatically assess nystagmus acuity function. We compared results from the ANAF with those of the well-known expanded nystagmus acuity function (NAFX)., Methods: Using the ANAF and NAFX, we analysed 60 segments of nystagmus data collected with a video-based eye tracking system (EyeLink 1000) from 30 patients with infantile or mal-development fusional nystagmus. The ANAF algorithm used the best-foveation positions (not true foveation positions) and all data points in each nystagmus cycle to calculate a nystagmus acuity function., Results: The ANAF automatically produced a nystagmus acuity function in a few seconds because manual identification of foveation eye positions is not required. A structural equation model was used to compare the ANAF and NAFX. Both ANAF and NAFX have similar measurement imprecision and relatively little bias. The estimated bias was not statistically significant for either methods or replicates., Conclusions: We conclude that the ANAF is a valid and efficient algorithm for determining a nystagmus acuity function.

Purpose: Infantile nystagmus syndrome (INS) can be idiopathic or associated with ocular or systemic disease. The ocular oscillation of INS directly contributes to loss of visual acuity. In this study, visual acuity development in patients with INS was examined., Methods: Children with INS were classified as having idiopathic INS (n = 84) or INS with an associated sensory deficit: INS and albinism (n = 71), bilateral optic nerve hypoplasia (ONH; n = 23), or congenital retinal disorder (n = 36). Visual acuity was assessed with Teller cards and/or optotypes, and the data were analyzed for three age groups (<24 months, 24-48 months, and >48 months)., Results: Patients with idiopathic INS showed mildly reduced visual acuity early in life and gradual maturation with age that paralleled a normative curve. Patients with albinism also showed a mild visual deficit early in life but failed to keep pace with the normative curve, showing a gradual increase in visual acuity deficit. Patients with ONH and congenital retinal disorders exhibited more severe visual acuity deficits during infancy. The ONH group displayed slow improvement of visual acuity with a plateau at 24 months through >48 months, with a small increase in visual acuity deficit. The congenital retinal disorder group had no significant change in visual acuity across age and had a rapid increase in visual acuity deficit., Conclusions: The pattern of visual acuity development differs among children with INS, depending on the presence or absence of associated sensory system deficits. Careful characterization of visual system differences in patients with INS is important if visual acuity is an outcome in clinical trials.

Purpose: To determine the effectiveness of weekend atropine for severe amblyopia from strabismus, anisometropia, or both combined among children 3 to 12 years of age., Methods: We enrolled children into 2 prospective, randomized multicenter clinical trials of amblyopia therapy. Herein we report the results for severe amblyopia, 20/125 to 20/400. In Trial 1, 60 children 3 to 6 years of age (mean, 4.4 years) were randomized to weekend atropine plus a plano lens or weekend atropine plus full spectacle correction for the sound eye. In Trial 2, 40 children 7 to 12 years of age (mean, 9.3 years) were randomized to weekend atropine or 2 hours of daily patching. The visual acuity outcome was assessed at 18 weeks in Trial 1 and 17 weeks in Trial 2., Results: In Trial 1, visual acuity improved by an average of 4.5 lines in the atropine plus correction group (95% CI, 3.2-5.8 lines) and 5.1 lines in the atropine plus plano lens group (95% CI, 3.7-6.4 lines). In Trial 2, visual acuity improved by an average of 1.5 lines in the atropine group (95% CI, 0.5-2.5 lines) and 1.8 lines in the patching group (95% CI, 1.1-2.6 lines)., Conclusions: Weekend atropine can improve visual acuity in children 3 to 12 years of age with severe amblyopia. Improvement may be greater in younger children.

Objective: To assess the stability of visual acuity improvement during the first year after cessation of amblyopia treatment other than spectacle wear in children aged 7 to 12 years., Methods: At the completion of a multicenter randomized trial during which amblyopia treated with patching and atropine improved by at least 2 lines on the electronic Early Treatment of Diabetic Retinopathy Study testing protocol, 80 patients aged 7 to 12 years were followed up while not receiving treatment (other than spectacle wear) for 1 year., Main Outcome Measure: Ten letters or more (> or =2 lines) worsening of visual acuity (measured using the electronic Early Treatment of Diabetic Retinopathy Study testing protocol) during the year following treatment discontinuation., Results: During the year following cessation of treatment, the cumulative probability of worsening visual acuity (> or =2 lines) was 7% (95% confidence interval, 3%-17%); 82% of patients maintained an increase in visual acuity of 10 letters or more compared with their visual acuity before starting treatment., Conclusion: Visual acuity improvement occurring during amblyopia treatment is sustained in most children aged 7 to 12 years for at least 1 year after discontinuing treatment other than spectacle wear., Trial Registration: ClinicalTrials.gov identifier: NCT00094692.

Purpose: We report a new method of measuring visual function in patients with INS by demonstrating the effects of eccentric gaze and forced time restriction on optotype recognition., Design: Cross-sectional, comparative case-series., Methods: No-time-restricted acuity (NTRA) and time-restricted acuity (TRA) for 19 patients and 18 controls were measured at multiple horizontal gaze angles., Results: INS patients showed a significant lower visual acuity than controls (P < 0.0001). The TRA were significantly decreased in most gaze positions relative to NTRA in INS patients (P = 0.03) while there were no difference among controls. About half of the INS patients showed that their best visual acuity was gaze dependent, matching the preferred head posture in both NRTA and TRA paradigms., Conclusions: Gaze-dependent visual acuity tested with and without time restriction may be a useful measure of visual function in INS patients and could be used in interventional clinical trials.

Purpose: To assess the test-retest reliability of the electronic Early Treatment Diabetic Retinopathy Study (E-ETDRS) visual acuity algorithm using the computerized Electronic Visual Acuity (EVA) tester in children 7 to <13 years old., Design: Test-retest reliability study., Methods: This multicenter study involved 245 subjects at four clinical sites. As the main outcome measure, visual acuity was measured twice using the E-ETDRS testing protocol on the EVA system, which uses a programmed handheld device to communicate with a personal computer and a 17-inch monitor at a 3-m test distance., Results: Test-retest reliability was high (r =.94 for right eyes and 0.96 for left eyes) and for both right and left eyes, 89% of retest scores were within 0.1 logarithm of the minimal angle of resolution (logMAR) (five letters) of the initial test score and 99% of retests were within 0.2 logMAR (10 letters). Reliability was high across the age range of 7 to <13 years. Based on 95% confidence level estimates, a change in visual acuity of 0.2 logMAR (10 letters) from a previous acuity measure is unlikely to result from measurement variability., Conclusions: The E-ETDRS protocol using the EVA has high test-retest reliability in children 7 to <13 years of age. Potential advantages include better standardization across multiple sites, the ability to directly capture data electronically with an automatic acuity score calculation, the reduction of potential bias by limiting the tester's role, and the requirement of only a single testing distance for measurements from 20/800 to 20/12. This computerized testing method should be considered when visual acuity is used as an outcome measure in eye research involving children 7 to <13 years old.

Purpose: To determine whether patients with congenital nystagmus and an anomalous head posture have better binocular visual acuity than such patients without an anomalous head posture., Patients and Methods: This was an observational case series of prospectively collected data for 125 patients with clinical and oculographically confirmed congenital nystagmus. Clinical data were tabulated using computer software. Statistical analyses compared binocular visual acuity with and without the presence of a clinically evident anomalous head posture and visual acuity with and without associated sensory disease., Results: The mean visual acuity was 20/42 (log of the minimal angle of resolution [MAR], 0.32) in patients with an anomalous head posture and 20/83 (logMAR, 0.62) in patients with no anomalous head posture (P < .001). Among patients with disease of the sensory system, those with an anomalous head posture had a mean visual acuity of 20/55 (logMAR, 0.44) and those without an anomalous head posture had a mean visual acuity of 20/108 (logMAR, 0.73; P < .001)., Conclusions: Visual acuity was found to be significantly better in patients with congenital nystagmus who had an anomalous head posture versus those without such a head posture. Our findings indicate that the presence of an anomalous head posture in a patient with congenital nystagmus correlates with good vision and thus may be considered a positive prognostic sign in a preverbal child.

Purpose To test the hypothesis that the topical carbonic anhydrase inhibitor brinzolamide (Azopt) has beneficial effects versus placebo on measures of nystagmus and visual acuity in adult subjects with infantile nystagmus syndrome (INS). Design Prospective, cross-over, double masked clinical trial. Methods Setting: Single centre. Study population: Five subjects ≥18 years old with typical INS and bestbinocular visual acuity in their primary position null zone ETDRS 55 letters to 85 letters (20/200 to 20/50) and had no previous treatment for nystagmus. Intervention: In a randomised order, each subject received one drop of Azopt or placebo in both eyes three times a day separated by a washout period of at least a week followed by Azopt or placebo in both eyes three times a day; thus each subject got the drug and placebo, each acting as his or her own control. Outcome measures: The nystagmus acuity function and INS waveforms obtained from eye movement recordings, binocular optotype visual acuity, using the ETDRS protocol analysed individually and as a group before and after Azopt and placebo. Results Versus placebo and baseline measures, topical Azopt significantly improved; INS waveform characteristics in the primary position null zone, group mean values of the nystagmus acuity function across gaze ( p<0.01) and group mean ETDRS binocular letter visual acuity ( p<0.05). There was a predictable decrease in intraocular pressure (IOP) without any systemic or ocular adverse events. Conclusions Although a prospective large-scale clinical trial is needed to prove effectiveness, an eye-drop-based therapy for INS may emerge as a viable addition to optical, surgical, behavioural and systemic drug therapies for INS. [ABSTRACT FROM AUTHOR]

The study of the clinical and electrophysiological effects of eye muscle surgery on patients with infantile nystagmus has broadened our knowledge of the disease and its interventions. Prospective, comparative, interventional case series. Twenty-four patients with a vertical head posture because of electrophysiologically diagnosed infantile nystagmus syndrome. The ages ranged from 2.5 to 38 years and follow up averaged 14.0 months. Thirteen patients with a chin-down posture had a bilateral superior rectus recession, inferior oblique myectomy and a horizontal rectus recession or tenotomy. Those 11 with a chin-up posture had a bilateral superior oblique tenectomy, inferior rectus recession and a horizontal rectus recession or tenotomy. Outcome measures included: demography, eye/systemic conditions and preoperative and postoperative; binocular, best optically corrected, null zone acuity, head posture, null zone foveation time and nystagmus waveform changes. Associated conditions were strabismus in 66%, ametropia in 96%, amblyopia in 46% and optic nerve, foveal dysplasia or albinism in 54%. Null zone acuity increased at least 0.1 logMAR in 20 patients ( P < 0.05 group mean change). Patients had significant ( P < 0.05) improvements in degrees of head posture, average foveation time in milliseconds and infantile nystagmus syndrome waveform improvements. This study illustrates a successful surgical approach to treatment and provides expectations of ocular motor and visual results after vertical head posture surgery because of an eccentric gaze null in patients with infantile nystagmus syndrome. [ABSTRACT FROM AUTHOR]

Presents a panel discussion on extraocular muscle surgery for nystagmus led by Monte Del Monte and Richard Hertle with Rudolph S. Wagner. Medical history of a boy with tyrosinase-positive oculocutaneous albinism; Approach that Del Monte would use to inform the parents about their boy's condition; Concepts of the expanded nystagmus acuity function and foveation times discussed by Hertle.

The purpose of this report is to summarize clinical and electrophysiological effects of extraocular muscle surgery in patients with INS. Our hypothesis is that surgery on the extraocular muscles of patients with INS changes their nystagmus resulting in improved vision and visual functions. All patients had all four virgin horizontal recti operated on, either for strabismus alone, nystagmus alone, for a head posture due to an eccentric null zone alone or for a head posture due to an eccentric null zone plus strabismus. All patients have been followed for at least 12 months. Subjective outcome measures include the pre- and post-operative binocular best optically corrected null zone acuity (NZA) in 75 patients and gaze dependent acuity (GDA) in 12 patients. Objective outcome measure included null zone width (NZW) in 75 patients. The results are summarized as follows: NZA increased .1 LogMar or greater in 75% with those patients ≤8 years significantly better. Subjective GDA and NZW measured from eye movement recordings showed persistent, significant increases. This report adds to the evidence that surgery on the extraocular muscles in patients with INS has independent neurological and visual results, from simply reposition the head, eye(s) or visual axis. [ABSTRACT FROM AUTHOR]

Objective To compare patching and atropine sulfate as treatments for moderate amblyopia in children 18 months after completion of a 6-month randomized trial. Methods In a randomized, multicenter (47 sites) clinical trial, 419 children younger than 7 years with amblyopia (20/40 to 20/100 in the affected eye) were assigned to receive either patching or atropine eye drops for 6 months. Between 6 months and 2 years, treatment was at the discretion of the investigator. Main Outcome Measure Visual acuity in the amblyopic eye and sound eye after 2 years. Results At 2 years, visual acuity in the amblyopic eye improved from baseline a mean of 3.7 lines in the patching group and 3.6 lines in the atropine group. The difference in visual acuity between treatment groups was small: 0.01 logMAR (95% confidence interval, -0.02 to 0.04). In both treatment groups, the mean amblyopic eye acuity was approximately 20/32, 1.8 lines worse than the mean sound eye acuity, which was approximately 20/20. Conclusions Atropine or patching for 6 months followed by best clinical care until 2 years produced similar improvement of moderate amblyopia in children between 3 and 7 years of age at enrollment. However, on average the amblyopic eye acuity was still approximately 2 lines worse than the sound eye. [ABSTRACT FROM AUTHOR]

Congenital nystagmus (CN) is an aperiodic oscillatory eye movement disorder. Horizontal rectus tenotomy with simple re-attachment has been proposed as a therapy for CN. This therapy might affect vision and/or eye movements. Another paper deals with improvements in visual acuity. This and the companion paper examine changes in eye movements. In this study, we examined the effect of tenotomy on nystagmus waveforms using wavelet spectral analysis. No common effect was found across the patients on the wavelet spectra of the CN beat, suggesting that tenotomy surgery has no effect, or only a quite small effect, on the waveform structure of CN. [Copyright &y& Elsevier]

Objective: To evaluate the reliability of a new visual acuity testing protocol for children using isolated surrounded HOTV optotypes. Methods: After initial pilot testing and modification, the protocol was evaluated using the Baylor-Video Acuity Tester (BVAT) to present isolated surrounded HOTV optotypes. At 6 sites, the protocol was evaluated for testability in 178 children aged 2 to 7 years and for reliability in a subset of 88 children. Twenty-eight percent of the 178 children were classified as having amblyopia. Results: Using the modified protocol, testability ranged from 24% in 2-year-olds to 96% in 5- to 7-year-olds. Test-retest reliability was high (r=0.82), with 93% of retest scores within 0.1 logMAR unit of the initial test score. The 95% confidence interval for an acuity score was calculated to be the score ±0.125 logMAR unit. For a change between 2 acuity scores, the 95% confidence interval was the difference ±0.18 logMAR unit. Conclusions: The visual acuity protocol had a high level of testability in 3- to 7-year-olds and excellent testretest reliability. The protocol has been incorporated into the multicenter Amblyopia Treatment Study and has wide potential application for standardizing visual acuity testing in children. [ABSTRACT FROM AUTHOR]

To investigate anomalous head posturing in patients with INS. This was a prospective, cohort analysis of clinical and anomalous head posture (AHP) data in 34 patients with INS and an AHP. Particular outcome measures included measurement of AHP in three dimensions of pitch (anterior posterior flexion/extension), yaw (lateral rotation), and roll (lateral flexion) during best-corrected binocular acuity testing and during their subjective sense of straight. Patients were also queried as to their subjective sense of head posture in forced straight position and in their preferred AHP. The paired t test was used to determine significance in differences between measures. A total of 34 patients (19 males [56%]) 9-56 years of age (mean, 16.5 ± 6) were included. Associated systemic or ocular system deficits were present in 30 patients (88%). AHP during best-corrected visual acuity testing averaged 16.5° ± 8.20° (range, 10°-51°), which was significantly different from the mean voluntary "comfortable" position only in the pitch and roll directions (P < 0.001). There was a significant noncongruous response during subjective response to head posturing with most sensing their head as "crooked" (76.5%) when manually straightened (P = 0.001). The clinical AHP of patients with INS exists in all three spatial dimensions of pitch, yaw, and roll. Although the visual system may be causally related to the onset, amount, and direction of a compensatory AHP in patients with INS, its persistence over time or after surgical intervention is likely due to a combination of visual system (eg, nystagmus, strabismus) and nonvisual system (egocentric and musculo-skeletal) factors. [ABSTRACT FROM AUTHOR]

Purpose: To compare contrast sensitivity using a commercially available technique between patients with infantile nystagmus syndrome (INS) and controls. Design: Prospective, comparative case series. Methods: The functional acuity contrast test (FACT) was used binocularly in patients with INS and aged-matched controls with best acuity under normal lighting using a progression of high-quality sine wave grating size changes with increasing spatial frequencies. Results: Nine INS patients aged 5 to 11 years and 25 controls were tested. The INS patients’ best binocular acuity ranged from 20/125 to 20/30, and that of the controls was 20/25 or better. When compared with age-matched controls, INS patients displayed deficiencies in contrast sensitivity syndrome using the FACT test. Conclusions: The FACT or a similar testing system may have potential as a commercially available outcome measure in clinical trials in patients with INS. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

: PurposeTo report a case of inadvertent intraocular injection of botulinum toxin A (Botox, BTA) resulting in a retinal tear and bullous retinal detachment. The retinal detachment resolved spontaneously, and the tear was treated with laser demarcation with good visual outcome.: DesignInterventional case report.: MethodsA 36-year-old woman underwent Botox injections for paralytic esotropia and developed ocular perforation. Dilated fundus examination showed a slit-like retinal tear infranasally with a bullous retinal detachment nasally.: ResultsThe retinal detachment spontaneously resolved, and the patient was treated with laser demarcation on the following day. After 2 more days, her vision returned to baseline.: ConclusionsBotox did not appear toxic to human intraocular tissues. Close observation may be indicated in the event of an inadvertent intraocular Botox injection. [Copyright &y& Elsevier]