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Purpose: To compare the effectiveness and efficiency of supervised dichoptic action-videogame play to occlusion therapy in children with amblyopia. Methods: Newly diagnosed children with amblyopia aged 4–12 years were recruited, excluding strabismus >30PD. After 16 weeks of refractive adaptation children were randomized to gaming 1 h/week supervised by the researcher, or electronically monitored occlusion 2 h/day. The gaming group played a dichoptic action-videogame using virtual reality goggles, which included the task of catching a snowflake presented intermittently to the amblyopic eye. Contrast for the fellow eye was self-adjusted until 2 identical images were perceived. The primary outcome was visual acuity (VA) change from baseline to 24 weeks. Results: We recruited 96 children, 29 declined and 2 were excluded for language or legal issues. After refractive adaptation, 24 of the remaining 65 no longer met the inclusion criteria for amblyopia, and 8 dropped out. Of 16 children treated with gaming, 7 (6.7 years) completed treatment, whereas 9 younger children (5.3 years) did not. Of 17 treated with occlusion, 14 (5.1 years) completed treatment and 3 (4.5 years) did not. Of 5 children with small-angle strabismus, 3 treated with occlusion completed treatment and 2 treated with gaming did not. Median VA improved by 0.30 logMAR (IQR 0.20–0.40) after gaming, 0.20 logMAR (0.00–0.30) after occlusion (p = 0.823). Treatment efficiency was 1.25 logMAR/100 h (range 0.42–2.08) with gaming, 0.08 (−0.19–0.68) with occlusion (p < 0.001). Conclusion: Dichoptic gaming seems a viable alternative for older children with refractive amblyopia after glasses adaptation. Treatment efficiency with gaming under continuous supervision was 15 times higher than with occlusion at home.

Objective: The EUSCREEN project concerns the study of European vision and hearing screening programmes. Part of the project was the development of a cost-effectiveness model to analyse such programmes. We describe the development and usability of an online tool to enable stakeholders to design, analyse or modify a newborn hearing screening (NHS) programme. Design: Data from literature, from existing NHS programmes, and observations by users were used to develop and refine the tool. Required inputs include prevalence of the hearing impairment, test sequence and its timing, attendance, sensitivity, and specificity of each screening step. Outputs include the number of cases detected and the costs of screening and diagnostics. Study sample: Eleven NHS programmes with reliable data. Results: Three analyses are presented, exploring the effect of low attendance, number of screening steps, testing in the maternity ward, or screening at a later age, on the benefits and costs of the programme. Knowledge of the epidemiology of a staged screening programme is crucial when using the tool. Conclusions: This study presents a tool intended to aid stakeholders to design a new or analyse an existing hearing screening programme in terms of benefits and costs.

Purpose In an ongoing randomised clinical trial comparing dichoptic VR video games with patching for amblyopia, we evaluated any potential barriers to successful use of this novel amblyopia treatment method. Methods From December 2017, all newly diagnosed amblyopic children were recruited. Excluded were children under age 4 and patients with strabismus exceeding 30PD. The video game was played for 1 h per week at the outpatient clinic under direct supervision. Records were kept of difficulties encountered during treatment and categorised into domains. Factors influencing the successful completion of this treatment were identified and related to patient characteristics. Results Ninety-one children were recruited for the trial, 20 parents refused participation before randomisation, because of the logistical challenges the outpatient dichoptic treatment would cause them. Of the 17 children who commenced dichoptic treatment (median age 6.2 years; IQR 4.9–8.4 years), 10 did not complete treatment. Children under age 5.5 years were unable to comprehend the game settings or the game itself. Older children (N = 7; 41%) were less willing to comply with the video game. Loss of interest in the game (N = 8; 47%) was found to be a limiting factor at all ages. Conclusion Half of the children failed to complete VR dichoptic treatment, mainly due to young age. In countries with nationwide screening where amblyopia is detected before age 6, the applicability of such dichoptic treatment is limited.

Objective: To inventory provision and features of childhood hearing screening after the newborn period (CHS), primarily in Europe. Design: From each participating country or region, experts provided information through an extensive questionnaire: implementation year, age at screening, test method, pass criteria, screening location, screener profession, and quality indicators: coverage, referral, follow-up and detection rates, supplemented by literature sources. Study sample: Forty-two European countries or regions, plus Russia, Malawi, Rwanda, India, and China. Results: CHS was performed universally with pure-tone audiometry screening (PTS) in 17 countries or regions, whereas non-universal CHS was performed in eight with PTS or whisper tests. All participating countries with universal PTS had newborn hearing screening. Coverage rate was provided from three countries, detection rate from one, and referral and follow-up rate from two. In four countries, universal PTS was performed at two ages. Earliest universal PTS was performed in a (pre)school setting by nurses (n = 9, median age: 5 years, range: 3–7), in a healthcare setting by doctors and nurses (n = 7, median age: 4.5 years, range: 4–7), or in both (n = 1). Conclusions: Within universal CHS, PTS was mostly performed at 4–6 years by nurses. Insufficient collection of data and monitoring with quality indicators impedes evaluation of screening.

Contains fulltext : 235444.pdf (Publisher’s version ) (Open Access) PURPOSE: Compare patients treated for Retinopathy of Prematurity (ROP) in two consecutive periods. METHODS: Retrospective inventory of anonymized neonatal and ophthalmological data of all patients treated for ROP from 2010 to 2017 in the Netherlands, subdivided in period (P)1: 1-1-2010 to 31-3-2013 and P2: 1-4-2013 to 31-12-2016. Treatment characteristics, adherence to early treatment for ROP (ETROP) criteria, outcome of treatment and changes in neonatal parameters and policy of care were compared. RESULTS: Overall 196 infants were included, 57 infants (113 eyes) in P1 and 139 (275 eyes) in P2, indicating a 2.1-fold increase in ROP treatment. No differences were found in mean gestational age (GA) (25.9 ± 1.7 versus 26.0 ± 1.7 weeks, p = 0.711), mean birth weight (791 ± 311 versus 764 ± 204 grams, p = 0.967) and other neonatal risk factors for ROP. In P2, the number of premature infants born

Purpose: To determine change in visual acuity (VA) in the population of a previous amblyopia treatment study (Loudon 2006) and assess risk factors for VA decrease. Methods: Subjects treated between 2001 and 2003 were contacted between December 2015 and July 2017. Orthoptic examination was conducted under controlled circumstances and included subjective refraction, best corrected VA, reading acuity, binocular vision, retinal fixation, cover-uncover and alternating cover test. As a measure for degree of amblyopia, InterOcular VA Difference (IOD) at the end of occlusion therapy was compared with IOD at the follow-up examination using Wilcoxon’s signed-rank test. Regression analysis was conducted to determine the influence of clinical and socio-economic factors on changes in IOD. Results: Out of 303 subjects from the original study, 208 were contacted successfully, 59 refused and 15 were excluded because of non-amblyopic cause of visual impairment. Mean IOD at end of therapy (mean age 6.4 years) was 0.11 ± 0.16 logMAR, and IOD at follow-up examination (mean age 18.3 years) was 0.09 ± 0.21 logMAR; this difference was not significant (p = 0.054). Degree of anisometropia (p = 0.008; univariable analysis), increasing anisometropia (p = 0.009; multivariable), eccentric fixation (p

Amblyopia screening can target reduced visual acuity (VA), its refractive risk factors, or both. VA testing is imprecise under 4 years of age, so automated risk-factor photoscreening appears an attractive option. This review considers photoscreening used in community services, focusing on costs, cost-effectiveness and scope of use, compared with EUSCREEN project Country Reports describing how photo- and automated screening is used internationally.A systematic narrative review was carried out of all English language photoscreening literature to September 10th 2018, using publicly available search terms. Where costs were considered, a CASP economic evaluation checklist was used to assess data quality.Of 370 abstracts reviewed, 55 reported large-scale community photoscreening projects. Five addressed cost-effectiveness specifically, without original data. Photoscreening was a stand-alone, single, test event in 71% of projects. In contrast, 25 of 45 EUSCREEN Country Reports showed that if adopted, photoscreening often supplements other tests in established programmes and is rarely used as a stand-alone test. Reported costs varied widely and evidence of cost-effectiveness was sparse in the literature, or in international practice. Only eight (13%) papers compared the diagnostic accuracy or cost-effectiveness of photoscreening and VA testing, and when they did, cost-effectiveness of photoscreening compared unfavourably.Evidence that photoscreening reduces amblyopia or strabismus prevalence or improves overall outcomes is weak, as is evidence of cost-effectiveness, compared to later VA screening. Currently, the most cost-effective option seems to be a later, expert VA screening with the opportunity for a re-test before referral.摘要: 针对视力降低 (VA) 、屈光危险因素或两者可进行弱视筛查。 VA测试在4岁以下是不精确的, 因此自动风险因素照片的筛选似乎是一个可行的选择。与EUSCREEN项目ʻ国别报告’ (该报告描述了国际上如何使用光筛和自动筛查) 相比, 本评论考虑了社区服务中使用的图像筛查方法, 重点关注成本, 成本效益和使用范围。 方法: 截至2018年9月10日, 我们使用搜索词在公众平台对所有英文文献进行了系统性回顾。在考虑成本的情况下, 使用了CASP经济评估清单来评估数据质量。 结果: 在370个摘要中, 有55个报告了大型社区图像筛选项目。没有原始数据的情况下, 有五个考虑了成本效益问题。在71% 的项目中, 图像筛选是一个独立的, 唯一的测试项目。相比之下, EUSCREEN 45个国家报告中的25个表明, 图像筛查通常只对既定程序中的其他测试进行补充, 并且很少将其用作独立测试的项目。成本差异很大, 在文献或国际惯例中, 成本效益的证据很少。只有八篇 (13%) 论文比较了图像筛查和VA测试的诊断准确性或成本效益, 而这样做时, 图像筛查的成本效益却不佳。 讨论: 与后者VA筛查相比, 图像筛查在降低弱视或斜视患病率或改善总体预后的证据方面 薄弱, 成本效益的证据也很少。目前, 最具成本效益的选择似乎是专家VA筛查, 并有机会在转诊前进行重新测试。.

Purpose Identify risk factors for endophthalmitis after strabismus surgery (EASS) and relate these to incidence and outcome. Methods Ophthalmologists, who had operated, diagnosed or treated EASS, completed a case record form with 71 questions in six domains: Preoperative, Surgery, Perforation, Postoperative, Outcome and Experts' opinion. To estimate the age-specific incidence per number of strabismus operations in the Netherlands during 1994-2013, the age distribution of Dutch cases was compared with the age-specific rates of strabismus surgery in the Dutch Registry of Strabismus Operations and with population data. Exploratory data analysis was performed. The immune state was evaluated in six patients. Five enucleated eyes were studied histopathologically. Results None of the 26 patients (27 eyes with EASS) were between 9 and 65 years old, except for one patient with retinal haemorrhage followed by endophthalmitis. In the Netherlands during 1994-2013, the rate of EASS was approximately one per 11 000 strabismus operations, but one per 4300 for children aged 0-3 and one per 1000 for patients 65 and older. Endophthalmitis was diagnosed on postoperative day 1-4 in children aged 0-3. In all 15 children aged 0-5, the 16 affected eyes were phthisical, eviscerated or enucleated. The involved eye muscle had been recessed in 25 of 27 cases. It was a medial rectus in 15 of 16 children aged 0-6. It was a lateral (6), inferior (2) or medial (1) rectus in elderly. Scleral perforation went unnoticed in all children (no record in three) and in two of seven elderly (no record in two). Histopathology showed transscleral scarring compatible with scleral perforation in four patients but, in a two-year-old girl who had EASS together with a transient medial rectus palsy, the sclera underneath the former suture tract was not perforated but did contain the long posterior ciliary artery. Conclusions Endophthalmitis after strabismus surgery (EASS) affects children and elderly, with a grave outcome in young children. It occurs after recession of the medial rectus muscle in children, and it may occur without scleral perforation. Age and perforation are key determinants that interact with other factors that determine the occurrence and fulminance of EASS.

Extraocular muscle pulley bands were described by Tenon in 1805 as "faisceaux tendineux" acting as "poulies de renvoi." The Passive and Active Pulley Hypotheses propose that these connective-tissue bands between muscle and bony orbital rim limit vertical shift of the horizontal rectus muscle belly in up- and downgaze, caused by the muscle's tendency to assume the shortest path from origin to insertion. The band's attachment to the muscle moves 20 mm sagittally when the eye looks from 50° left to 50° right, however, impeding vertical muscle stabilization. Sliding of the muscle in a sleeve would permit sagittal movement, but four anatomical studies could not confirm that. The band would have to be elastic: We measured it after orbital exenteration and found it to be slack, however, and once extended, very stiff. Our research group in Amsterdam suggested in 1984 that the retrobulbar fat and its enveloping connective-tissue sheets including the intermuscular membrane keep muscle bellies in place. We compared horizontal-rectus-muscle positions in up- and down-gaze using frontal CTs through the posterior pole of the eye. The bellies stayed in place while, anteriorly, the tendons bent up- and downward. We also found that the paths of horizontal rectus muscles were curved outwards in horizontal CTs. We surmised that retrobulbar pressure in the fat, resulting from four rectus muscles pulling the eyeball into the orbit, is contained by rectus muscles and connective-tissue sheets and that the resulting tension in the sheets keeps the muscles in place. Years later we repeated the CT study in a Crouzon patient whose bony orbital rim was displaced 2cm posteriorly, preventing pulley-band fixation to the bone: No vertical shift of horizontal rectus muscle bellies occurred in up- and down-gaze. Finally, we developed a mathematical finite-element model of orbit, muscles, fat and eyeball to study whether fat with enveloping connective-tissue sheets could keep eye muscles in place. In simulated eye movements, the retrobulbar fat, with low elasticity as found in vivo, not only kept the eyeball in place but also horizontal rectus muscle bellies in up- and down-gaze and vertical recti in left- and right-gaze.

Objective: To investigate the variance in reported prevalence rates of permanent neonatal hearing impairment (HI) worldwide.Design: A systematic review and meta-analysis was performed on reported p...

After the rapid spread of strabismus surgery by total tenotomy, which had been proposed by the orthopedist Louis Stromeyer from Gottingen in 1838 and performed by the plastic surgeon Johann Friedrich Dieffenbach on October 26th and by the ophthalmologist Florent Cunier on October 29th, 1839, brilliant researchers studied the physiology of eye movements, resulting in the laws by Franciscus Cornelis Donders on pseudotorsion in tertiary positions of gaze and by Johann Benedict Listing that each eye position can be reached by rotation about an axis perpendicular to the primary and the new position of gaze. John Hunter had first described ocular counterrolling (OCR) with head tilt in 1786. The anatomist Alexander Friedrich von Hueck inferred from anatomical studies, however, that up to 28.6° OCR would be possible onhead-tilt to right or left shoulder in 1838, and estimated his own OCR seen in a mirror at approximately 25°. Donders, Christian Georg Theodor Ruete, Alfred Wilhelm Volkmann, Albrecht von Graefe and Hermann von Helmholtz subsequently denied the existence of OCR for many years and thought that only pseudotorsion existed. Louis Emile Javal had myopia and astigmatism, and he re-established the existence of OCR in 1867 when he noticed that, on head tilt to either shoulder, the axis of astigmatism of his eyes no longer coincided with the axis of astigmatism of his glasses.

Objectives: To assess the performance of newborn hearing screening (NHS) programmes, through selected quality measures and their relationship to protocol design. Design: NHS coverage, referral, follow-up and detection rates were aggregated. Referral rates were compared to age at screening step 1, number of steps, and test method: OAE or aABR. Study sample: A questionnaire on existing hearing screening was completed by experts from countries in Europe, plus Russia, Malawi, Rwanda, India and China. Results: Out of 47 countries or regions, NHS coverage rates were reported from 26, referral rates from 23, follow up from 12 and detection rates from 13. Median coverage rate for step 1 was 96%. Referral rate from step 1 was 6–22% where screening may be performed 24 h, and 4% for >72 h. Referral rates to diagnostic assessment averaged 2.1% after one to two steps using OAE only, 1.7% after two steps including aABR, and 0.8% after three to four steps including aABR. Median detection rate for bilateral permanent hearing impairment ≥40dB was 1 per 1000 infants. Conclusion: Referral rates were related to age, test method and number of screening steps. Quality measures were not available for many NHS programmes.

On June 28th and 29th, 2021, the Final Dissemination Meeting of the EUSCREEN Study took place in Zaandam. As a hybrid event, the meeting was streamed live to a worldwide audience. Fortunately, the ...

Newborn hearing screening (NHS) varies regarding number and type of tests, location, age, professionals and funding. We compared the provision of existing screening programmes.A questionnaire containing nine domains: demography, administration, existing screening, coverage, tests, diagnosis, treatment, cost and adverse effects, was presented to hearing screening experts. Responses were verified. Clusters were identified based on number of screening steps and use of OAE or aABR, either for all infants or for well and high-risk infants (dual-protocol).Fifty-two experts completed the questionnaire sufficiently: 40 European countries, Russia, Malawi, Rwanda, India and China.It took considerable effort to find experts for all countries with sufficient time and knowledge. Data essential for evaluation are often not collected. Infants are first screened in maternity wards in most countries. Human development index and health expenditure were high among countries with dual protocols, three screening steps, including aABR, and low among countries without NHS and countries using OAE for all infants. Nationwide implementation of NHS took 6 years, on average.The extent and complexity of NHS programmes are primarily related to health expenditure and HDI. Data collection should be improved to facilitate comparison of NHS programmes across borders.

Purpose\ud Photoscreening assesses risk factors for amblyopia, as an alternative to measurement of visual acuity (VA) to detect amblyopia, on the premise that its early correction could prevent development of amblyopia. We studied implementations of Plusoptix photoscreening in existing population-based screening in Flanders and Iran. \ud \ud Methods\ud In Flanders, VA is measured at age 3, 4 and 6, photoscreening was added to existing screening at age 1 and 2.5 years in 2013. In Iran, VA is measured at ages 3-6 years, photoscreening was added at ages 3-6 years between 2011-2016. \ud Plusoptix use was analyzed in the literature for detection of risk factors for amblyopia and amblyopia itself, for ages 0-3 and for 4-6. A questionnaire, containing seven domains: existing vision screening, addition of photoscreening, implementation in screening program, training, attendance, diagnosis and treatment, and costs was distributed. In Iran, screening procedures were observed on site. \ud \ud Results\ud Implementation of Plusoptix photoscreening was mainly analyzed from questionnaires and interviews, its effectiveness from literature data. In Flanders, of 56,759 children photoscreened at age one (81% of children born in 2013), 9.2% had been referred,13% of these were treated, mostly with glasses, resulting in an increase of 4-year old children wearing glasses from 4.7% to 6.4%. In Iran, 90% of children aged 3-6 years participated in vision screening in 2016, but only those who failed the vision test were subjected to photoscreening. \ud \ud Conclusions\ud In Flanders, the use of Plusoptix photoscreening at ages 1 and 2.5 resulted in an increase of children wearing glasses, but it remains unknown how many cases of amblyopia have been prevented. \ud Studies are needed to determine the relation between size and sort of refractive error and strabismus, and the increased chance to develop amblyopia.

Objectives The EUSCREEN study compares the cost-effectiveness of paediatric hearing screening programmes and aims to develop a cost-effectiveness model for this purpose. Alongside and informed by the development of the model, neonatal hearing screening (NHS) is implemented in Albania. We report on the first year. Methods An implementation plan was made addressing objectives, target population, screening protocol, screener training, screening devices, care pathways and follow up. NHS started January 1st, 2018 in four maternity hospitals: two in Tirana, one in Pogradec and one in Kukes, representing both urban and rural areas. OAE-OAE-aABR was used to screen well infants in maternity hospitals, whereas aABR-aABR was used in neonatal intensive care units and in mountainous Kukes for all infants. Screeners’ uptake and attitudes towards screening and quality of screening were assessed by distributing questionnaires and visiting the maternity hospitals. The result of screening, diagnostics, follow up and entry into early intervention were registered in a database and monitored. Results Screeners were keen to improve their skills in screening and considered NHS valuable for Albanian health care. The number of “fail” outcomes after the first screen was high initially but decreased to less than 10% after eight months. In 2018, 11,507 infants were born in the four participating maternity hospitals, 10,925 (94.9%) of whom were screened in the first step. For 486 infants the result of screening was not registered. For the first screen, ten parents declined, eight infants died and one infant was discharged before screening could be performed. In 1115 (10.2%) infants the test either could not be performed or the threshold was not reached; 361 (32,4%) of these did not attend the second screen. For the third screen 31 (34.4%) out of 90 did not attend. Reasons given were: parents declined (124), lived too far from screening location (95), their infant died (11), had other health issues (7), or was screened in private clinic (17), no reason given (138). Conclusions Implementation of NHS in Albania is feasible despite continuing challenges. Acceptance was high for the first screen. However, 32.4% of 1115 infants did not attend the second screen, after a “fail” outcome for the first test.

In the Netherlands, youth-healthcare (YHC) physicians screen children 7 times for vision disorders between the ages of 1 and 60 months. Examination consists of inspection of the external structures of the eye, fundus red reflex, Hirschberg test, pupillary reflexes, cover-uncover test, alternating-cover test, eye motility, monocular pursuit, and, from 36 months onwards, visual acuity (VA). We observed how well these tests are done.Screening test performance was assessed with semistructured observations. Two orthoptic students developed a semistructured observation form. In addition to extensive instructions from an orthoptist and YHC-physicians instructor, they attended 2 one-day courses for YHC physicians. Tests were assessed using criteria based on the Dutch Child Vision Screening Guideline version 2010 and the Dutch Manual for Orthoptic Examination. Type of chart, testing distance, and starting eye were recorded for VA measurements. The observations in the first week were done simultaneously by the two observers and checked for concordance.Concordance between the two observers was good. Twenty-five YHC physicians were observed during 100 days in total. Two physicians were excluded because they examined few children. The remaining 23 physicians examined 329 children, of whom 82 were aged 1-4 months, 157 aged 6-24 months, and 90 aged 36-45 months of age. Fundus red reflex was performed in 89% of children, Hirschberg test in 88%, pupillary reflexes in 14%, cover-uncover test in 65%, alternating-cover test in 62%, eye motility in 68%, monocular pursuit in 23%, and VA at 36-45 months in 94%. Forty-eight percent of cover-uncover tests, 36% of alternating-cover tests, and 7% of eye motility tests were performed correctly. VA was measured at 3 meters in 2%, others at 5 meters in accordance with the guideline. A picture chart was used instead of the Landolt-C at the age of 45 months in 23%. VA measurements were performed correctly in 89%, fundus red reflex in 89%, and Hirschberg test in 87%.Hirschberg test, fundus red reflex, and VA were adequately tested in most cases. Cover-uncover test, alternating-cover test, and eye motility were often performed inadequately. Pupillary reflexes were skipped often as room lights could not be dimmed.

Congenital nystagmus, involuntary oscillating small eye movements, is commonly thought to originate from aberrant interactions between brainstem nuclei and foveal cortical pathways. Here we investigated whether nystagmus associated with congenital stationary nightblindness (CSNB) can result from primary deficits in the retina. We found that CSNB patients as well as an animal model (nob mice), both of which lack functional nyctalopin protein (NYX, nyx) in ON bipolar cells (ON-BC) at their synapse with photoreceptors, showed oscillating eye movements at a frequency of 4-7Hz. nob ON direction selective ganglion cells (ON-DSGC), which detect global motion and project to the accessory optic system (AOS), oscillated with the same frequency as their eyes. In the dark, individual ganglion cells (GC) oscillated asynchronously, but their oscillations became synchronized by light stimulation. Likewise, both patient and nob mice oscillating eye movements were only present in the light. Retinal pharmacological manipulations that blocked nob ON-DSGC oscillations also eliminated their oscillating eye movements, and retinal pharmacological manipulations that reduced oscillation frequency of nob ON-DSGCs also reduced oscillation frequency of their eye movements. We conclude that, in nob mice, oscillations of retinal ON-DSGCs cause nystagmus with properties similar to those associated with CSNB in humans. These results show that the nob mouse is the first animal model for a form of congenital nystagmus paving the way for development of therapeutic strategies.

Congenital nystagmus, involuntary oscillating small eye movements, is commonly thought to originate from aberrant interactions between brainstem nuclei and foveal cortical pathways. Here, we investigated whether nystagmus associated with congenital stationary night blindness (CSNB) results from primary deficits in the retina. We found that CSNB patients as well as an animal model (nob mice), both of which lacked functional nyctalopin protein (NYX, nyx) in ON bipolar cells (BCs) at their synapse with photoreceptors, showed oscillating eye movements at a frequency of 4–7 Hz. nob ON direction-selective ganglion cells (DSGCs), which detect global motion and project to the accessory optic system (AOS), oscillated with the same frequency as their eyes. In the dark, individual ganglion cells (GCs) oscillated asynchronously, but their oscillations became synchronized by light stimulation. Likewise, both patient and nob mice oscillating eye movements were only present in the light when contrast was present. Retinal pharmacological and genetic manipulations that blocked nob GC oscillations also eliminated their oscillating eye movements, and retinal pharmacological manipulations that reduced the oscillation frequency of nob GCs also reduced the oscillation frequency of their eye movements. We conclude that, in nob mice, synchronized oscillations of retinal GCs, most likely the ON-DCGCs, cause nystagmus with properties similar to those associated with CSNB in humans. These results show that the nob mouse is the first animal model for a form of congenital nystagmus, paving the way for development of therapeutic strategies., Nystagmus (involuntary eye movements) in cases of congenital stationary night blindness arises from light-induced synchronization of oscillating retinal ganglion cells, revealing that some forms of nystagmus can have a retinal origin, rather than originating from aberrant interactions between brainstem nuclei and foveal cortical pathways, as commonly thought.

Purpose The Adult Strabismus Quality of Life Questionnaire (AS-20) and the Amblyopia & Strabismus Questionnaire (A&SQ) both measure health-related quality of life in strabismus patients. We evaluated to what extent these instruments cover similar domains by identifying the underlying quality-of-life factors of the combined questionnaires. Methods Participants were adults from a historic cohort with available orthoptic childhood data documenting strabismus and/or amblyopia. They had previously completed the A&SQ and were now asked to complete the AS-20. Factor analysis was performed on the correlation-matrix of the combined AS-20 and A&SQ data to identify common underlying factors. The identified factors were correlated with the clinical variables of angle of strabismus, degree of binocular vision, and visual acuity of the worse eye. Results One hundred ten patients completed both questionnaires (mean age, 44 years; range, 38–51 years). Six factors were found that together explained 78% of the total variance. The factor structure was dominated by the first four factors. One factor contained psychosocial and social-contact items, and another factor depth-perception items from both questionnaires. A third factor contained seven items—only from the AS-20—on eye strain, stress, and difficulties with reading and with concentrating. A fourth factor contained seven items—only from the A&SQ—on fear of losing the better eye and visual disorientation, specific for amblyopia. Current visual acuity of the worse eye correlated with depth-perception items and vision-related items, whereas current binocular vision correlated with psychosocial and social-contact items, in 93 patients. Conclusions Factor analysis suggests that the AS-20 and A&SQ measure a similar psychosocial quality-of-life domain. However, functional problems like avoidance of reading, difficulty in concentrating, eye stress, reading problems, inability to enjoy hobbies, and need for frequent breaks when reading are represented only in the AS-20. During the development of the A&SQ, asthenopia items were considered insufficiently specific for strabismus and were excluded a priori. The patients who generated the items for the AS-20 had, in majority, adulthood-onset strabismus and diplopia and were, hence, more likely to develop such complaints than our adult patients with childhood-onset strabismus and/or amblyopia.

We present the Delft Assessment Instrument for Strabismus in Young children (DAISY) a device designed to measure angles of strabismus in young children fast and accurately. DAISY allows for unrestrained head movements by the mean of a triple camera vision system that simultaneously estimates the head rotation and the eye pose. The device combines two different methods to record bilateral eye position: corneal reflections (Purkinje images) and pupillary images. Detailed results are provided on three orthotropic subjects (age 25-27). Three different conditions were tested: 1) gaze ahead, 2) gaze ahead with different head rotations, and 3) fixed head with different eye positions. Systematic errors occurred between subjects that need further study. The system reached sufficient accuracy to be applied for the measurement of angles of strabismus, almost independent from the head pose.

Objective To establish whether the current vision screening practice in the Netherlands is effective in preventing permanent visual loss and to estimate the sensitivity of the programme. Settings In the Netherlands, all children are invited for preverbal (1, 3, 6–9 and 14–24 months) and preschool (36, 45, and 60–72 months) vision screening. Screening attendance is high, but the effectiveness in reducing amblyopia is unknown. Methods In a 7-year cohort study, 4624 children born in the city of Rotterdam between 16 September 1996 and 15 May 1997 were followed through all routine vision screening examinations. At age seven, visual acuity (VA) of children still living in Rotterdam was assessed by study orthoptists. In case of VA > 0.1 logMAR in one or both eyes, two or more logMAR lines of interocular difference or eye disorders like strabismus, children underwent a more intensive eye examination. Results Attendance at the 9-month screening was 89%, decreasing to about 75% at later examinations. Of preverbal tests, 2.5% were positive, and of preschool tests, 10%. In total, 19% of children had a positive vision screening test at least once. Amblyopia prevalence was 3.4%. Sensitivity of the vision screening programme was 73% and specificity 83%. At age seven, 0.7–1.2% (confirmed vs final exam) of the children had a VA > 0.3 logMAR in the worse eye compared with 2–3.9% (in literature) reported prevalence in non-screening situations. Children who were less frequently screened had a higher chance of poor vision (>0.3 logMAR) at age seven. Conclusion The Dutch child vision screening programme may reduce the risk of persistent amblyopia (VA > 0.3 logMAR) at age seven by more than half.

Purpose: We showed previously that an educational cartoon that explains without words why amblyopic children should wear their eye patch improves compliance, especially in children of immigrant parents who speak Dutch poorly. We now implemented this cartoon in clinics in low socioeconomic status (SES) areas with a large proportion of immigrants and clinics elsewhere in the Netherlands. Design: Clinical, prospective, nonrandomized, preimplementation, and postimplementation study. Participants: Amblyopic children aged 3 to 6 years who started occlusion therapy. Methods: Preimplementation, children received standard orthoptic care. Postimplementation, children starting occlusion therapy received the cartoon in addition. At implementation, treating orthoptists followed a course on compliance. In low SES areas, compliance was measured electronically during 1 week. Main Outcome Measures: The clinical effects of the cartoon— electronically measured compliance, outpatient attendance rate, and speed of reduction in interocular-acuity difference (SRIAD)—averaged over 15 months of observation. Results: In low SES areas, 114 children were included preimplementation versus 65 children postimplementation; elsewhere in the Netherlands, 335 versus 249 children were included. In low SES areas, mean electronically measured compliance was 52.0% preimplementation versus 62.3% postimplementation (P0.146); 41.8% versus 21.6% (P0.043) of children occluded less than 30% of prescribed occlusion time. Attendance rates in low SES areas were 60.3% preimplementation versus 76.0% postimplementation (P0.141), and 82.7% versus 84.5%, respectively, elsewhere in the Netherlands. In low SES areas, the SRIAD was 0.215 log/year preimplementation versus 0.316 log/year postimplementation (P0.025), whereas elsewhere in the Netherlands, these were 0.244 versus 0.292 log/year, respectively (P0.005; the SRIAD’s improvement was significantly better in low SES areas than elsewhere, P0.0203). This advantage remained after adjustment for confounding factors. Overall, 25.1% versus 30.1% (P0.038) had completed occlusion therapy after 15 months. Conclusions: After implementation of the cartoon, electronically measured compliance improved, attendance improved, acuity increased more rapidly, and treatment was shorter. This may be due, in part, to additional measures such as the course on compliance. However, that these advantages were especially pronounced in children in low SES areas with a large proportion of immigrants who spoke Dutch poorly supports its use in such areas. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Ophthalmology 2012;119:2393–2401 © 2012 by the American Academy of Ophthalmology.

Purpose: Little is known about the way orbital fat slides and/or deforms during eye movements. We compared two deformation algorithms from a sequence of MRI volumes to visualize this complex behavior. Methods: Time-dependent deformation data were derived from motion-MRI volumes using Lucas and Kanade Optical Flow (LK3D) and nonrigid registration (B-splines) deformation algorithms. We compared how these two algorithms performed regarding sliding and deformation in three critical areas: the sclera-fat interface, how the optic nerve moves through the fat, and how the fat is squeezed out under the tendon of a relaxing rectus muscle. The efficacy was validated using identified tissue markers such as the lens and blood vessels in the fat. Results: Fat immediately behind the eye followed eye rotation by approximately one-half. This was best visualized using the B-splines technique as it showed less ripping of tissue and less distortion. Orbital fat flowed around the optic nerve during eye rotation. In this case, LK3D provided better visualization as it allowed orbital fat tissue to split. The resolution was insufficient to visualize fat being squeezed out between tendon and sclera. Conclusion: B-splines performs better in tracking structures such as the lens, while LK3D allows fat tissue to split as should happen as the optic nerve slides through the fat. Orbital fat follows eye rotation by one-half and flows around the optic nerve during eye rotation. Translational Relevance: Visualizing orbital fat deformation and sliding offers the opportunity to accurately locate a region of cicatrization and permit an individualized surgical plan.

Occlusion therapy for amblyopia has been the mainstay of treatment for centuries, however, acceptance of the patch is often lacking. This study evaluated comfort of wear of the eye patch and assessed the mechanical properties in order to achieve a more individualized prescription.For 8 consecutive days, parents used each of the four main brands of patches for 2 consecutive days in a randomized fashion. After 2 days a 21-item questionnaire was completed to evaluate comfort of wear for each patch. Compliance was measured electronically using the Occlusion Dose Monitor (ODM). In addition, breathing capacity at 23°C and 33°C, resistance to water penetration, opacity, and strength of adhesion to the skin were measured.Twenty-four children participated. Overall, satisfaction was moderate: large differences in discomfort when removing the patch, skin reaction, and cosmetic appearance were found. In the material measurements large differences were found in opacity and strength of adhesion to the skin. In all brands breathing capability was minimal. Answers given by the parents matched the physical properties of the eye patch. There was no difference in electronically measured compliance between patches.We found large differences in comfort of wear and mechanical properties. Therefore, when prescribing a certain brand of patch, the wide variety needs to be taken into account. Further study into these properties seems warranted; especially breathing capability requires improvement since children often wear the patch for a longer period of time. This could contribute to increasing satisfaction and consequently may improve compliance.

Aim: To quantify manual fraction of inspired oxygen (FiO2) adjustments performed by caregivers in extremely low birth weight (ELBW; ≤1000 g) infants, in relation to oxygen saturation (SpO) and bedside care. Methods: In a single-centre study, FiO, SpO and alarm limits of ELBW infants were collected for 3 days continuously, while caregivers were filmed. A descriptive analysis, focused on manual FiO adjustments, was performed. Results: Twelve ELWB infants were included. Total recording time was 726 h. FiO was increased 851 times and decreased 1309 times; median (range) step size was 5% (1% to 65%) and -3% (-1% to -65%), respectively. Wide variation of FiO adjustments for equal levels of SpO was observed in all included infants. One hundred and twenty-six of 136 FiO adjustments with a step size âyen 15% and 111 of 171 desaturations 21%, alarm limits for SpO were set according to protocol (88-94%) in 64% of the time. Within these periods, SpO was >94% for 30% and

Purpose: The efficacy of population-based vision screening is hampered by unsuccessful referral after a positive screening test. We studied the nature and causes of unsuccessful referral in a 7-year birth cohort study of vision screening in Rotterdam, the Netherlands. Methods: All parents of children who had been unsuccessfully referred were asked whether they recalled the referral. Reasons for noncompliance, if any, were identified using semi-structured interviews. Screening records were checked for written evidence of the referral. The parents' fluency in Dutch and their socioeconomic status were also assessed. Results: Of the 561 screen-positive children, 129 (23%) had not been referred successfully. For the current study, 97 parents were successfully contacted. Of these, 14 parents had been willingly noncompliant and 83 said they were unaware of the referral, with 47% having poor to moderate fluency in Dutch. In 53 cases, the screening charts contained no written evidence of any referral. Amblyopia was identified in 3 of the unsuccessful referrals. Conclusions: In this population-based screening program, 1 of 4 positively screened children was not successfully referred. Apart from parental noncompliance, the unsuccessful referrals can be explained by miscommunication, deficient documentation, and physician noncompliance with screening guidelines. An effective monitoring feedback system may improve the efficacy of child vision screening. © 2011 by the American Association for Pediatric Ophthalmology and Strabismus.

Background Compliance with occlusion therapy for amblyopia in children is low when their parents have a low level of education, speak Dutch poorly, or originate from another country. We determined how sociocultural and psychological determinants affect compliance. Methods Included were amblyopic children between the ages of 3 and 6, living in low socio-economic status (SES) areas. Compliance with occlusion therapy was measured electronically. Their parents completed an oral questionnaire, based on the “Social Position & Use of Social Services by Migrants and Natives” questionnaire that included demographics and questions on issues like education, employment, religion and social contacts. Parental fluency in Dutch was rated on a five-point scale. Regression analysis was used to describe the relationship between the level of compliance and sociocultural and psychological determinants. Results Data from 45 children and their parents were analyzed. Mean electronically measured compliance was 56 ± 44 percent. Children whose parents had close contact with their neighbors or who were highly dependent on their family demonstrated low levels of compliance. Children of parents who were members of a club and who had positive conceptualizations of Dutch society showed high levels of compliance. Poor compliance was also associated with low income, depression, and when patching interfered with the child’s outdoor activity. Religion was not associated with compliance. Conclusions Poor compliance with occlusion therapy seems correlated with indicators of social cohesion. High social cohesion at micro level, i.e., family, neighbors and friends, and low social cohesion on macro level, i.e., Dutch society, are associated with noncompliance. However, such parents tend to speak Dutch poorly, so it is difficult to determine its actual cause. Electronic supplementary material The online version of this article (doi:10.1007/s00417-011-1637-5) contains supplementary material, which is available to authorized users.

Purpose: To determine the existence of a correlation between the vertical angle of strabismus and the vertical angle between the orbital axes in nonsyndromic plagiocephaly in childhood. Methods: Patients were included when diagnosed with plagiocephaly. Orthoptic measurements showed a vertical strabismus and three-dimensional computed tomographic (CT) imaging of the skull was available. Patients were excluded if plagiocephaly was part of a syndrome or if any surgical intervention had taken place before our measurements. Three-dimensional CT imaging was used to calculate the vertical angle between the orbital axes in 3 reference planes (VAO) perpendicular to a line of reference through the lower borders of the maxilla (VAOmax), both auditory canals (VAOaud), and the lower points of the external occipital protuberances (VAOocc). Results: Fourteen patients were included (mean age, 14 mo). Three-dimensional CT measurements showed a mean (SD) VAOmax of 1.70 (2.31) degrees, VAOaud of -1.54 (1.46) degrees, and VAOocc of -2.06 (4.29) degrees (a negative value indicates that the eye on the affected side was situated lower in the head). The mean vertical angle of strabismus was -2.39 (4.69) degrees in gaze toward the affected side, 3.66 (3.77) degrees in gaze ahead, and 8.14 (5.63) degrees in gaze toward the nonaffected side. The Pearson test showed no significant correlations. Conclusions: The clinical observation that vertical strabismus in adult plagiocephaly is correlated with the vertical angle of the orbital axes could not be confirmed in young children. Copyright

Purpose To investigate omission of population-based eye screening at age 6–9 months in the Netherlands. Methods Prospective population-based consecutive birth cohort study was used. In two consecutive birth cohorts, children were eye screened at 1–2 and 3–4 months, but at general-health screening at 6–9 months, the second cohort was not eye screened, unless anything conspicuous was noted or in case of positive family history. Data were collected from screening records and anonymous questionnaires. Semi-structured daylong observations were made of physicians examining children aged 0–4 years, including children from the cohorts, by two orthoptic students. Results 58 of 6059 children (0.96%), in the screened, and 48 of 5482 children (0.88%) in the unscreened group were referred to orthoptist or ophthalmologist, mostly for observed strabismus. Amblyopia, all combined with strabismus, was diagnosed in ten screened (0.17%) versus six unscreened children (0.11%). Most physicians found preverbal examinations and decisions to refer difficult. The observations by orthoptic students revealed that cover test, pupillary reflexes, pursuit movements and eye motility were frequently performed inadequately, contrary to the Hirschberg test, at this age. Conclusion The screened and unscreened group differed little regarding the number of children referred and found to have amblyopia. Referral was mostly based on observed strabismus.

textabstractPURPOSE. Noncompliance is one of the limiting factors in the success of occlusion therapy for amblyopia. Electronic monitoring was used to investigate predictors of noncompliance, and, in a prospective randomized clinical trial, determined the effectiveness of an educational program. METHODS. Compliance was measured electronically during 1 week every 3 months in 310 newly diagnosed amblyopic children. The family's demographic parameters and the child's clinical parameters were assessed for their influence on the level of compliance. In addition to standard orthoptic care, children were randomized to receive an educational cartoon story, reward stickers, and an information sheet for the parents (intervention group), or a picture to color (reference group). These and the electronic device were distributed during home visits by researchers. The primary outcome measure was the percentage of compliance (actual/prescribed occlusion time) in the two groups. The secondary outcome measure was the influence of demographic and clinical factors on compliance. RESULTS. Compliance was associated with parental fluency in the national language, country of origin, level of education, and initial visual acuity of the child. During the first 1-week measurement period children in the intervention group had better compliance than the reference group had (78% ± 32% vs. 57% ± 40%; P < 0.0001), and fewer children were not occluded at all (3 vs. 23 in the reference group; P < 0.0001). This difference remained throughout the study period. CONCLUSIONS. Poor parental fluency in the national language, a low level of education, and poor acuity at the start of treatment were predictors of low compliance. An educational program primarily aimed at the child improved compliance and reduced the number of children who did not comply with occlusion at all. Copyright

Approximately one third of all amblyopic eyes do not reach visual acuity of 20/40 in spite of occlusion therapy. One of the reasons is a lack of adherence to therapy, which, however, could not be quantified in the past. Experience with new devices (occlusion dose monitors, ODMs) for electronic recording of occlusion has recently been reported. The aim of the present study was to evaluate the potential of the ODMs developed in The Netherlands. Various features were tested, including the reliability of the ODM recordings compared to diaries, two ODMs used simultaneously on one patch, the influence of the ambient temperature, and the specificity of the recording pattern for measurements on the eye.The ODMs were taped to the outside of the standard occlusion patch and measured the temperature difference between their front and back surfaces. Members of the research group and the families of two patients kept occlusion diaries while using the ODMs. Recorded and written occlusion periods were compared. Measurements were carried out under various conditions: patch with one ODM tightly on the eye or detached (allowing peeping); ODMs taped to various parts of the body; two ODMs simultaneously on one patch; variation of room temperature.There was good correspondence between the occlusion times recorded by the ODMs and those from the diaries, as well as between the recordings of two ODMs used simultaneously on one patch. High ambient temperatures (33 degrees C to 37 degrees C) prevented reliable ODM measurements. Measurements on other parts of the body were misclassified with probabilities between P=0.099 and P=0.325 as measurements with the patch tightly on the eye.In spite of some technical limitations, the ODMs provide a chance for reliable assessment of compliance and therefore objective information on dose-response function for occlusion therapy. This will lead to a more evidence-based treatment for amblyopia.

To identify the variation within and consistency amongst orthoptists when prescribing occlusion therapy for amblyopia in an objective survey.A questionnaire was designed with five case examples of amblyopic children and distributed at annual meetings of orthoptists in The Netherlands and Germany. It was filled in simultaneously within 15 min in complete silence to avoid any exchange of opinions between orthoptists that would reduce variability. For each case the orthoptists were asked to give their prescription of hours or days of occlusion.The questionnaire was filled in by 177 Dutch orthoptists and 227 German orthoptists. Their prescriptions of occlusion therapy were classified into five main regimens: part-time; part-time not every day; full-time; also occluding the amblyopic eye; alternating; and no occlusion therapy. The variation was large: the standard deviation was half the average prescribed hours of occlusion for each regimen in each of the five cases. All orthoptists were assigned a rank number for each of the five cases depending on whether their prescription was above or below average. These five rank numbers were not consistently above or consistently below average value per case.The number of prescribed hours of occlusion varied widely per regimen per case. Orthoptists were not consistently strict or lenient in their prescription of occlusion therapy.

Suppression in strabismus is more likely to occur when the images for the left- and right-eye are similar. In this study the relationship between the depth of strabismic suppression and the amount of dissimilarity between the images was quantified. Six subjects with microstrabismus looked at two identical colorful, cartoon images via mirrors. In the middle of each screen was a circular aperture with an opal glass, which was illuminated from the back by a halogen lamp during 300 ms with a gradual on- and offset in intensity. In the circular aperture images that slightly differed in shape were presented to both eyes. The dominant eye was presented a circle, the squinting eye a circle that, in four steps, changed its shape into a square. Under each of these four conditions, the image for the dominant eye was attenuated progressively by neutral density filters. When the image for the squinting eye was perceived, the depth of the suppression was thereby measured. It was found that suppression decreased with dissimilarity of the images.

Contains fulltext : 168029.pdf (Publisher’s version ) (Open Access) BACKGROUND: Utility of visual impairment caused by amblyopia is important for the cost-effectiveness of screening for amblyopia (lazy eye, prevalence 3-3.5 %). We previously measured decrease of utility in 35-year-old persons with unilateral persistent amblyopia. The current observational case-control study aimed to measure loss of utility in patients with amblyopia with recent decrease of vision in their better eye. As these patients are rare, the sample was supplemented by patients with bilateral age-related macular degeneration with similar decrease of vision. METHODS: From our out-patient department, two groups of patients with recent deterioration to bilateral visual acuity less than Snellen 0.5 (bilateral visual impairment, BVI) were recruited, with either persistent amblyopia and age-related macular degeneration (AMB + AMD), or with bilateral age-related macular degeneration (BAMD). To measure utility, the time trade-off method and the standard gamble method were applied through interviews. Correlations were sought between utility values and visual acuity, age and Visual Function Questionnaire-25 scores. RESULTS: Seventeen AMB + AMD patients (mean age 72.9 years), and 63 BAMD patients (mean age 79.6 years) were included in the study. Among AMB + AMD, 80 % were willing to trade lifetime in exchange for cure. The overall mean time trade-off utility was 0.925. Among BAMD, 75 % were willing to trade, utility was 0.917. Among AMB + AMD, 38 % accepted risk of death in exchange for cure, overall mean standard gamble utility was 0.999. Among BAMD, 49 % accepted risk of death, utility was 0.998. Utility was not related to visual acuity but it was to age (p = 0.02). CONCLUSION: Elderly patients with BVI, caused by persistent amblyopia and age-related macular degeneration (AMD) or by bilateral AMD, had an approximately 8 % loss of TTO utility. Notably, the 8 % loss in elderly with BVI differs little from the 3.7 % loss we found previously in 35-year-old persons with unilateral amblyopia with good vision in the other eye. The moderate impact of BVI in senescence could be explained by adaptation, comorbidity, avoidance of risk and a changed percept of cure.

· Background: Although there have been a number of studies on the size of the suppression scotoma in divergent strabismus, there have been no reports on the full extent (i.e. size as well as depth) of this scotoma. · Methods: Binocular static perimetry was used to measure suppression scotomas in five patients with primary divergent strabismus and ten patients with consecutive divergent strabismus. Four control subjects were also included in the study. With two modified Friedmann visual field analysers, we measured the visual field of both eyes under monocular and binocular viewing conditions. The objective angle of squint ranged from 3° to 25°. Best corrected visual acuity was at least 0.4, but mostly 1.0 in both eyes. · Results: All subjects had normal visual fields for each eye under monocular viewing conditions. In 12 of the 15 subjects, we found a large area of suppression encompassing the projection of the fixation point as well as that of the fovea in the non-fixating eye under binocular viewing conditions. In 2 of these 12 patients, one with primary and one with consecutive divergent strabismus, the area of suppression was located nasally to the postion of the fovea in the field of the non-fixating eye (nasal hemisuppression). In another two patients with divergent squint combined with vertical deviation, a small fixation-point suppression scotoma was found. The depth of suppression ranged from 3 dB to 16 dB. In one subject only, no suppression was found. · Conclusions: Our findings indicate that the shape of the suppression scotoma is not related to the origin of divergent strabismus or to the angle of squint. Our results also indicate that the critical age for the development of suppression in divergent squint might be up to 14 years.

Item does not contain fulltext OBJECTIVES: To study the incidence and risk factors for retinopathy of prematurity (ROP) in the Netherlands. STUDY DESIGN: Prospective, approximating population-based study that included infants with gestational age (GA) 28 days (OR 1.6, 95% CI 1.1-2.6, P = .03), and artificial ventilation >7 days (OR 1.6, 95% CI 1.1-2.5, P = .02). Prenatal glucocorticoids (OR 0.6, 95% CI 0.4-0.8, P < .001) and female sex (OR 0.7, 95% CI 0.5-0.99, P = .04) showed a lesser incidence of ROP. iNO remained significant after correction for all significant factors (OR 2.6, 95% CI 1.1-6.2, P = .03). CONCLUSION: In addition to established risk factors (GA, BW, stay at a neonatal intensive care unit >28 days, and artificial ventilation >7 days), treatment with iNO as risk factor for ROP is a novel finding.

The consequences of orbital floor fractures are different in children than in adults. Children have more elastic bones and increased chance of a trapdoor fracture, a fracture in which muscle tissue may be trapped.A 12-year-old girl presented to the general practitioner after she had been hit in her left eye by a swing. The patient had a painful eye and double vision. She was sent home with the advice to wake her every hour during the night. The next morning she went back to the general practitioner because she had been vomiting through the night and this time she was sent to the hospital. She was diagnosed with an orbital floor fracture with an entrapment of the inferior rectus muscle and underwent immediate surgery. Unfortunately, the release of the muscle had been too late and resulted in an uncorrectable diplopia.Warning signs of entrapment of the inferior rectus muscle are a painful eye with a mobility disorder in combination with nausea and vomiting. Immediate surgical intervention offers the best outcome in terms of recovery of the eye motility.

PURPOSE. The Dutch population-based child health monitoring program includes regular preverbal (age range, 1-24 months) and preschool (age range, 36-72 months) vision screening. This study is on the contribution of an organized vision screening program to the detection of amblyopia. METHODS. A 7-year birth cohort study of 4624 children was started in 1996/1997 in Rotterdam. Vision screening data were obtained from the child screening centers. Treating orthoptists working at the regional ophthalmology departments provided information about diagnosis and treatment. The diagnosis was reviewed by two experts. The parents provided additional information on their child's eye history through written questionnaires and telephone interviews. At age 7 years, the children underwent a final examination by the study orthoptists. RESULTS. Of the 3897 children still living in Rotterdam by 2004, 2964 (76.1%) underwent the final examination. Amblyopia was diagnosed in 100 (3.4%) of these (95% CI, 2.7-4.0). At age 7, 23% had visual acuity >0.3 logMAR. Amblyopia was caused by refractive error (n = 42), strabismus (n = 19), combined-mechanism (n = 30), deprivation (n = 7), or unknown (n = 2). Eighty-three amblyopia cases had been detected before age 7. Amblyopia detection followed positive results in vision screening in 56 children, either preverbal (n = 15) or preschool (n = 41). Twenty-six other amblyopes were self-referred (n = 12, before a first positive screening test), especially strabismic or combined-mechanism amblyopia; data were uncertain for one other positively screened amblyopic child. Amblyopia remained undetected until age 7 due to unsuccessful referral (n = 4, three with visual acuity >0.3 logMAR at age 7) or false-negative screening (n = 13). CONCLUSIONS. Most cases of amblyopia were detected by vision screening with visual acuity measurement. Preverbal screening contributed little to the detection of refractive amblyopia. (Invest Ophthalmol Vis Sci. 2010; 51:3476-3484) DOI:10.1167/iovs.08-3352

The human eye is suspended in the orbit. A miraculous interaction between pressure and tensile forces in the soft tissues keeps the eye in place, while a large range of rotational motion is enabled. This article discusses the factors (the geometrical shapes of the tissues, their material properties, their mechanical interactions, and the mechanical loads) that play a role in understanding soft tissue biomechanics and the suspension of the eye in the orbit.

Background: The Amblyopia and Strabismus Questionnaire (A&SQ) was previously developed to assess quality of life (QoL) in amblyopia and/or strabismus patients. Here, factor analysis with Varimax rotation was employed to confirm that the questions of the A&SQ correlated to dimensions of quality of life (QoL) in such patients. Methods: Responses on the A&SQ from three groups were analyzed: healthy adults (controls) (n = 53), amblyopia and/or strabismus patients (n = 72), and a historic cohort of amblyopes born between 1962-1972 and occluded between 1968-1974 (n = 173). The correlations among the responses to the 26 A&SQ items were factor-analysed by Principal Component Analysis (PCA). As the development of the A&SQ was intuitive-deductive, it was expected that the pattern of correlation could be explained by the five a priori hypothesized dimensions: fear of losing the better eye, distance estimation, visual disorientation, diplopia, and social contact and cosmetic problems. Distribution of questions along the factors derived by PCA was examined by orthogonal Varimax rotation. Results: Data from 296 respondents were analyzed. PCA provided that six factors (cutoff point eigenvalue >1.0) accumulatively explained 70.5% of the variance. All A&SQ dimensions but one matched with four factors found by Varimax rotation (factor loadings >0.50), while two factors pertained to the fifth dimension. The six factors explained 33.7% (social contact and cosmetic problems); 10.3% (near distance estimation); 8.7% (diplopia); 7.2% (visual disorientation); 6.3% (fear of losing the better eye); and 4.3% (far distance estimation), together 70.48% of the item variance. Conclusion: The highly explained variance in the A&SQ scores by the factors found by the PCA confirmed the a priori hypothesized dimensions of this QoL instrument. © The Author(s) 2009.

Orbital fat, or the fat behind the eye, plays an important role in eye movements. In order to gain a better understanding of orbital fat mobility during eye motion, MRI datasets of the eyes of two healthy subjects were acquired respectively in seven and fourteen different directions of gaze. After semi-automatic rigid registration, the Demons deformable registration algorithm was used to derive time-dependent three-dimensional deformation vector fields from these datasets. Visualisation techniques were applied to these datasets in order to investigate fat mobility in specific regions of interest in the first subject. A qualitative analysis of the first subject showed that in two of the three regions of interest, fat moved half as much as the embedded structures. In other words, when the muscles and the optic nerve that are embedded in the fat move, the fat partly moves along with these structures and partly flows around them. In the second subject, a quantitative analysis was performed which showed a relation between the distance behind the sciera and the extent to which fat moves along with the optic nerve.

To establish the English-language version of the Amblyopia and Strabismus Questionnaire (ASQE).Prospective cohort study.A structured translation process was followed to generate the ASQE, a 26-item instrument (originally in Dutch) containing five subscales for fear of losing the better eye, distance estimation, visual disorientation, double vision, and social contact and appearance. The ASQE was administered to 150 adults in a private practice setting. All had strabismus with or without amblyopia and visual acuity of 20/50 or better in at least one eye. Subjects also completed a brief disability questionnaire, and they were further characterized by levels of unilateral vision loss, diplopia, and asthenopia.ASQE scores were highly correlated with the disability questionnaire outcomes (r = -.76, P.0001). Internal consistency reliability (Cronbach alpha) of the subscales ranged from 0.80 to 0.92. Strong correlations were found between clinical characteristics and the ASQE (total score and subscale scores).The ASQE showed good psychometric properties that are in line with those of the original instrument. This, combined with strong correlations between ASQE scores and clinical characterization of the participants, establishes the ASQE as a useful tool for use in populations with strabismus and/or amblyopia.