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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.

Background: This study identifies the clinical and ocular motility characteristics of the periodic and aperiodic forms of infantile alternating nystagmus (IAPAN) and establishes the range of electrophysiological and clinical characteristics while providing clues to its presence and pathophysiology., Methods: Seventy-eight patients with ocular oscillations consistent with IAPAN were reported. Outcome variables were: age, follow-up in months, vision, strabismus, other eye and systemic abnormalities, head position, periodicity, cycle and null period duration, foveation time, waveforms, and cycle symmetry., Results: Age range was 1 to 67 years, 50% had pure periodic and aperiodic forms, 46% had albinism, 26% had binocular acuity of 20/40 or greater, 72% had strabismus, 35% had amblyopia, 31% had other eye disease, 14% had systemic disease, 87% had an anomalous head posture, and 65% had binocular directional asymmetry. The periodic cycle averaged 224 seconds and the aperiodic cycle ranged from 2 to more than 300 seconds. One in three patients with strabismus and nystagmus periodicity had a static head posture., Conclusion: Fifteen percent of the infantile nystagmus syndrome population had either the periodic or aperiodic form. A changing null period is often clinically missed because of long or irregular cycles, decreased acuity, associated strabismus, and either a nonexistent or inconsistent head posture. The changing null period is easier to recognize using eye movement recordings or if the non-preferred eye is occluded and the preferred eye is examined with the head straight and gaze in primary position for at least 5 to 7 minutes. The recognition of this variant has profound treatment implications.

Objective: To compare patching with atropine eyedrops in the treatment of moderate amblyopia (visual acuity, 20/40-20/100) in children aged 7 to 12 years., Methods: In a randomized, multicenter clinical trial, 193 children with amblyopia were assigned to receive weekend atropine or patching of the sound eye 2 hours per day. Main Outcome Measure Masked assessment of visual acuity in the amblyopic eye using the electronic Early Treatment Diabetic Retinopathy Study testing protocol at 17 weeks., Results: At 17 weeks, visual acuity had improved from baseline by an average of 7.6 letters in the atropine group and 8.6 letters in the patching group. The mean difference between groups (patching - atropine) adjusted for baseline acuity was 1.2 letters (ends of complementary 1-sided 95% confidence intervals for noninferiority, -0.7, 3.1 letters). This difference met the prespecified definition for equivalence (confidence interval <5 letters). Visual acuity in the amblyopic eye was 20/25 or better in 15 participants in the atropine group (17%) and 20 in the patching group (24%; difference, 7%; 95% confidence interval, -3% to 17%)., Conclusions: Treatment with atropine or patching led to similar degrees of improvement among 7- to 12-year-olds with moderate amblyopia. About 1 in 5 achieved visual acuity of 20/25 or better in the amblyopic eye., Clinical Relevance: Atropine and patching achieve similar results among older children with unilateral amblyopia., Trial Registration: (clinicaltrials.gov) Identifier: NCT00315328.

We used ground-plane motion stimuli displayed on a computer monitor positioned below eye level to induce involuntary version-vergence nystagmus (VVN). The VVN was recorded with a search coil system. It was shown that the VVN had both vertical versional and horizontal vergence components. The VVN induced by backward motion (toward subjects) had upward versional and divergence quick phases, whereas those induced by forward motion (away from subjects) had downward and biphasic divergence-convergence quick phases. The versional and vergence components of the VVN quick phases were analyzed. A temporal dissociation of about 20 ms between version velocity peak and convergence velocity peak was revealed, which supported a modified saccade-related vergence burst neuron (SVBN) model. We suggest that the temporal dissociation may be partly because of a lower-level OKN control mechanism. Vergence peak time was dependent on version peak time. Linear relationships between vergence peak velocity and versional saccadic peak velocity were demonstrated, which was in line with the new multiplicative model. Our data support the hypothesis that the vergence system and the saccadic system can act separately but interact with each other whenever their movements occur simultaneously.

The only Confederate president, Jefferson Davis, led a long and eventful life. He was a Mississippi planter, a husband, a father, West Point graduate, war hero, congressman, senator, secretary of war, and finally President of the Confederate States of America. In many ways he was a study of contrast with his northern counterpart Abraham Lincoln. Davis was personally courageous and a rich, educated, southern aristocrat who did not deeply understand the political process or have the refined personal skills necessary to work well with others. Prior to his Presidency he served with distinction in two wars, but as a result of his confederate activity and pro-slavery philosophy he is one of the least discussed famous Americans. Davis's health was a constant problem and he suffered an almost fatal attack of 'malaria' in 1836. In the winter of 1857-1858, he again was seriously ill and by the end of February 1858, a chronic, relapsing, ocular inflammatory condition began. Using historical evidence from multiple sources, this paper will propose a diagnosis of the Confederate President's ocular condition and consider how this could have influenced his military and political decisions.

Purpose: To perform ocular motility recordings of infantile nystagmus (IN) in RPE65-deficient canines and determine whether they can be used as a motor indicator of restored retinal function to investigate the effects of gene therapy., Methods: Treated and untreated canines were comfortably suspended in a custom-built sling and encouraged to fixate on distant targets at gaze angles varying between +/-15 degrees horizontally and +/-10 degrees vertically. Ocular motility recordings were made, using two distinct methods-infrared reflection and high-speed video. The resultant recordings from three untreated, four treated, and three pre- and post-treatment dogs were analyzed for using the eXpanded Nystagmus Acuity Function (NAFX), which yields an objective assessment of best potential visual acuity, based on the duration and repeatable accuracy of foveation and centralisation., Results: During fixation, the untreated dogs exhibited large-amplitude, classic IN waveforms, including pendular and jerk in both the horizontal and vertical planes, which prevented them from keeping the targets within the area centralis (the region of highest receptor density, spanning +/-3 degrees horizontally by +/-1.5 degrees vertically, analogous to the fovea). Some untreated dogs also had small-amplitude (0.5-1 degrees), high-frequency (6-9 Hz) oscillations. Under the same conditions, successfully treated canines no longer exhibited clinically detectable IN. Their IN was converted to waveforms with very low amplitudes that yielded higher NAFX values and allowed target images to remain well within the area centralis. Of note, uniocular treatment appeared to damp the IN in both eyes. Behaviorally, the treated dogs were able to successfully navigate through obstacles more easily without inadvertent contact, a task beyond the untreated dogs' ability., Conclusions: Gene therapy that successfully restored retinal function also reduced the accompanying IN to such a great extent that it was not clinically detectable approximately 90% of the time in many of the dogs. IN improvement, as quantified by the NAFX, is an objective motor indicator of visual improvement due to gene therapy.

Objective: To evaluate the effectiveness of treatment of amblyopia in children aged 7 to 17 years., Methods: At 49 clinical sites, 507 patients with amblyopic eye visual acuity ranging from 20/40 to 20/400 were provided with optimal optical correction and then randomized to a treatment group (2-6 hours per day of prescribed patching combined with near visual activities for all patients plus atropine sulfate for children aged 7 to 12 years) or an optical correction group (optical correction alone). Patients whose amblyopic eye acuity improved 10 or more letters (> or =2 lines) by 24 weeks were considered responders., Results: In the 7- to 12-year-olds (n = 404), 53% of the treatment group were responders compared with 25% of the optical correction group (P<.001). In the 13- to 17-year-olds (n = 103), the responder rates were 25% and 23%, respectively, overall (adjusted P = .22) but 47% and 20%, respectively, among patients not previously treated with patching and/or atropine for amblyopia (adjusted P = .03). Most patients, including responders, were left with a residual visual acuity deficit., Conclusions: Amblyopia improves with optical correction alone in about one fourth of patients aged 7 to 17 years, although most patients who are initially treated with optical correction alone will require additional treatment for amblyopia. For patients aged 7 to 12 years, prescribing 2 to 6 hours per day of patching with near visual activities and atropine can improve visual acuity even if the amblyopia has been previously treated. For patients 13 to 17 years, prescribing patching 2 to 6 hours per day with near visual activities may improve visual acuity when amblyopia has not been previously treated but appears to be of little benefit if amblyopia was previously treated with patching. We do not yet know whether visual acuity improvement will be sustained once treatment is discontinued; therefore, conclusions regarding the long-term benefit of treatment and the development of treatment recommendations for amblyopia in children 7 years and older await the results of a follow-up study we are conducting on the patients who responded to treatment.

Purpose: We wished to determine the effectiveness of horizontal rectus tenotomy in changing the nystagmus of children with infantile nystagmus syndrome., Design: This was a prospective, noncomparative, interventional case series in five children with varied sensory and oculographic subtypes of congenital nystagmus (including asymmetric (a)periodic alternating nystagmus) and no nystagmus treatment options. Simple tenotomy of all four horizontal recti with reattachment at the original insertion was accomplished. Search-coil and infrared eye movement recordings and clinical examinations were performed before and 1, 6, 26, and 52 weeks after surgery. Outcome measures included masked pre- and postoperative expanded nystagmus acuity function (NAFX), foveation time obtained directly from ocular motility recordings, and masked measures of visual acuity., Results: At 1 year after tenotomy and under binocular conditions, two of the three patients for whom the NAFX could be measured had persistent, significant postoperative increases in the NAFX of their fixating eye. Average foveation times increased in these patients' fixating eyes. Measured binocular visual acuity increased in four patients; the remaining patient had retinal dystrophy. There were no adverse events due to surgery., Conclusions: In the two children who could fixate the targets for several seconds and for whom we could obtain accurate measurements of their infantile nystagmus, tenotomy resulted in significant improvements in nystagmus foveation measures. In those patients plus two others (four of five), measured visual function improved.

Objective: To compare daily atropine to weekend atropine as prescribed treatments for moderate amblyopia in children younger than 7 years., Design: Prospective, randomized multicenter clinical trial (30 sites)., Participants: One hundred sixty-eight children younger than 7 years with amblyopia in the range of 20/40 to 20/80 associated with strabismus, anisometropia, or both., Intervention: Randomization either to daily atropine or to weekend atropine for 4 months. Partial responders were continued on the randomized treatment until no further improvement was noted., Main Outcome Measure: Visual acuity (VA) in the amblyopic eye after 4 months., Results: The improvement in VA of the amblyopic eye from baseline to 4 months averaged 2.3 lines in each group. The VA of the amblyopic eye at study completion was either (1) at least 20/25 or (2) better than or equal to that of the sound eye in 39 children (47%) in the daily group and 45 children (53%) in the weekend group. The VA of the sound eye at the end of follow-up was reduced by 2 lines in one patient in each group. Stereoacuity outcomes were similar in the 2 groups., Conclusions: Weekend atropine provides an improvement in VA of a magnitude similar to that of the improvement provided by daily atropine in treating moderate amblyopia in children 3 to 7 years old. This article contains additional online-only material available at http://www.ophsource.com/periodicals/ophtha.

Background: Although amblyopia can be successfully treated with patching or atropine, there have been few prospective studies of amblyopia recurrence once treatment is discontinued., Methods: We enrolled 156 children with successfully treated anisometropic or strabismic amblyopia (145 completed follow-up), who were younger than 8 years of age and who received continuous amblyopia treatment for the previous 3 months (prescribed at least 2 hours of daily patching or prescribed at least one drop of atropine per week) and who had improved at least 3 logMAR levels during the period of continuous treatment. Patients were followed off treatment for 52 weeks to assess recurrence of amblyopia, defined as a 2 or more logMAR level reduction of visual acuity from enrollment, confirmed by a second examination. Recurrence was also considered to have occurred if treatment was restarted because of a nonreplicated 2 or more logMAR level reduction of visual acuity., Results: Recurrence occurred in 35 (24%) of 145 cases (95% confidence interval 17% to 32%) and was similar in patients who stopped patching (25%) and in patients who stopped atropine (21%). In patients treated with moderately intense patching (6 to 8 hours per day), recurrence was more common (11 of 26; 42%) when treatment was not reduced prior to cessation than when treatment was reduced to 2 hours per day prior to cessation (3 of 22; 14%, odds ratio 4.4, 95% confidence interval 1.0 to 18.7)., Conclusions: Approximately one fourth of successfully treated amblyopic children experience a recurrence within the first year off treatment. For patients treated with 6 or more hours of daily patching, our data suggest that the risk of recurrence is greater when patching is stopped abruptly rather than when it is reduced to 2 hours per day prior to cessation. A randomized clinical trial of no weaning versus weaning in successfully-treated amblyopia is warranted to confirm these observational findings.

Objective: To compare full-time patching (all hours or all but 1 hour per day) to 6 hours of patching per day, as prescribed treatments for severe amblyopia in children younger than 7 years., Design: Prospective, randomized multicenter clinical trial (32 sites)., Participants: One hundred seventy-five children younger than 7 years with amblyopia in the range of 20/100 to 20/400., Intervention: Randomization either to full-time patching or to 6 hours of patching per day, each combined with at least 1 hour of near-visual activities during patching., Main Outcome Measure: Visual acuity in the amblyopic eye after 4 months., Results: Visual acuity in the amblyopic eye improved a similar amount in both groups. The improvement in the amblyopic eye acuity from baseline to 4 months averaged 4.8 lines in the 6-hour group and 4.7 lines in the full-time group (P = 0.45)., Conclusion: Six hours of prescribed daily patching produces an improvement in visual acuity that is of similar magnitude to the improvement produced by prescribed full-time patching in treating severe amblyopia in children 3 to less than 7 years of age.

The goal of office testing of the child remains the same as it is for the adult--to gather as much information as efficiently as possible. Clinical testing of the child requires familiarity with the limitations available tests. Perhaps most important is the ability choose the proper test to use at every development stage. Cooperation may be surprisingly good in to hands of experienced examiners, though very young children can be unpredictable. The general ophthalmologist should not fear having young patients but rather take joy in the interaction with them. Armed with as many tools as possible, the challenge of testing children can be converted to the reward of helping families.

Objective: To compare 2 hours vs 6 hours of daily patching as treatments for moderate amblyopia in children younger than 7 years., Methods: In a randomized multicenter (35 sites) clinical trial, 189 children younger than 7 years with amblyopia in the range of 20/40 to 20/80 were assigned to receive either 2 hours or 6 hours of daily patching combined with at least 1 hour per day of near visual activities during patching.Main Outcome Measure Visual acuity in the amblyopic eye after 4 months., Results: Visual acuity in the amblyopic eye improved a similar amount in both groups. The improvement in the visual acuity of the amblyopic eye from baseline to 4 months averaged 2.40 lines in each group (P =.98). The 4-month visual acuity was at least 20/32 and/or improved from baseline by 3 or more lines in 62% of patients in each group (P>.99)., Conclusion: When combined with prescribing 1 hour of near visual activities, 2 hours of daily patching produces an improvement in visual acuity that is of similar magnitude to the improvement produced by 6 hours of daily patching in treating moderate amblyopia in children aged 3 to 7 years.

The purpose of this paper is to outline the clinical benefits and electrophysiological changes after extraocular muscle surgery for acquired nystagmus and strabismus in an adult patient. a 41-year-old Caucasian female suffered from oscillopsia, bilateral cranial nerve IV palsies, and vertical nystagmus. Medical therapy was ineffective. She underwent bilateral, eight muscle surgical procedure which included: tenectomies of the superior oblique OU, myectomies of the inferior oblique OU, recessions of the medial rectus muscles OU (with OD on a post-operatively adjustable suture), and differential recessions of the superior rectus muscles OU. This provided marked improvement in her symptoms. These results suggest that surgery for acquired nystagmus can affect an improvement in the characteristics of the nystagmus that result in visual complaints. Combining "nystagmus surgery" plus strabismus surgery may be a viable option in some adult patients with acquired nystagmus who are unresponsive to medical therapy.

Purpose: To search for the presence of, and qualitatively characterize the microscopic anatomy of, nerve terminals in the tendino-scleral (enthesial) area of the extraocular muscle tendon., Methods: Extraocular rectus muscle tendino-scleralspecimens from a macaque monkey, a normal human, cadavers, and patients with congenital nystagmus were obtained and studied with transmission electron microscopy., Results: Enthesial neurovascular structures were identified in all specimens. The enthesial area showed structures consisting of myelinated and unmyelinated nerve fibers with associated supporting vascular capillaries. Qualitative analysis showed anomalous neurovascular structures were in the enthesis of patients with congenital nystagmus., Conclusions: This study confirms the presence of normal and abnormal neural anatomy in the enthesial area of the extraocular muscle tendon. Neurovascular abnormalities in the enthesial part of the extraocular muscle tendon may be a result of, or contribute to, disease pathogenesis. If these structures are related to afferent central nervous system input, then disruption of them during surgery might influence postoperative outcome.