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The objectives of the present study were to evaluate whether investigator bias influenced the Convergence Insufficiency Symptom Survey (CISS) scores of children with normal binocular vision (NBV) in our original validation study, reevaluate the usefulness of the cutoff score of 16, and reexamine the validity of the CISS.Six clinical sites participating in the Convergence Insufficiency Treatment Trial (CITT) enrolled 46 children 9 to18 years with NBV. Examiners masked to the child's binocular vision status administered the CISS. The mean CISS score was compared with that from the children with NBV in the original, unmasked CISS study and also to that of the 221 symptomatic convergence insufficiency (CI) children enrolled in the CITT.The mean (+/-standard deviation) CISS score for 46 subjects with NBV was 10.4 (+/-8.1). This was comparable with our prior unmasked NBV study (mean = 8.1 (+/-6.2); p = 0.11) but was significantly different from that of the CITT CI group (mean = 29.8 +/- 9.0; p0.001). Eighty-three percent of these NBV subjects scored16 on the CISS, which is not statistically different from the 87.5% found in the original unmasked study (p = 0.49).Examiner bias did not affect the CISS scores for subjects with NBV in our prior study. The CISS continues to be a valid instrument for quantifying symptoms in 9 to18-year-old children. These results also confirm the validity of a cut-point ofor = 16 in distinguishing children with symptomatic CI from those with NBV.

Background Optical coherence tomography (OCT) is a noninvasive, noncontact transpupillary imaging technology that can image retinal structures in vivo with a resolution of up to 10 microns. Anatomic layers within the retina can be differentiated and retinal thickness measured. The objective is to demonstrate clinical viability and useful interpretation of macular images derived from a commercially available OCT instrument. Methods A Stratus OCT™ (Zeiss-Humphrey, Dublin, California) imaging system was used to evaluate several pathological presentations of the macula in selected patients. Conditions illustrated in this case series were macular holes, epiretinal membranes, macular edema, idiopathic central serous choroidopathy, detachments of pigment epithelium and sensory retina, choroidal neovascular membranes, and retinal vascular occlusions. Conclusions Acquired OCT images achieved structural information regarding anatomical characteristics of the conditions scanned. A cross-sectional resolution of 10 microns was accomplished, which is 10 times greater than current ultrasound. OCT provides important information that may be critical in the diagnosis and management of some ocular conditions. Its high-resolution scans may contribute to the better understanding of disease pathogenesis, as well as assistance in or confirmation of a diagnosis. This imaging technology provides important information beyond what can be seen on clinical examination, and offers a useful adjunct to other diagnostic imaging tools such as fundus photography, fluorescein angiography, and indocyanine green angiography.

Unilateral proptosis in a young child can often be the presenting sign of an orbital mass. Appropriate management of these lesions requires a thorough knowledge of the types of orbital tumors which may present in the pediatric age group, as well as knowing the most appropriate work-up necessary to obtain an accurate diagnosis. This paper will describe a case of a 13-year-old African-American female who presented with uniocular proptosis, blackouts of her vision, dull aching pains in certain positions of gaze, resistance to retropulsion, and mild disc edema. An orbital mass was confirmed following a work-up which included an ultrasound of the orbit and a CT scan. The differential diagnoses included an orbital hemangioma or schwannoma. A diagnosis of a schwannoma involving the orbit was made following surgical removal of the lesion. A review of common orbital tumors seen in children will be presented in addition to the appropriate work-up and management of these lesions.

Background: The incidence of HIV infection in the general population continues to grow as a cure is yet to be found. Fortunately, great strides have been made in treating this multifactorial disease so patients are living longer and more productive lives. As a result, there is a growing demand from all health care disciplines, including optometry, to provide care for patients with HIV infection. Methods: From June 1, 1994 through May 30, 1995, HIV seropositive patients presenting to the primary care optometry clinic at the Bascom Palmer Eye Institute were identified from the total clinic population. All patients presented to the clinic as part of a routine eye exam or were referred by a primary physician. All abnormal findings were recorded in a log in addition to the CD4+ T-cell count. Results: One hundred and fifty HIV seropositive patients were identified from the clinic population. Fifty percent were ocularly abnormal including 31 patients (20.7%) with HIV microangiopathy, and nine patients (6%) with CMV retinitis. One hundred and eighteen patients (78.7%) knew their CD4 count. There was a correlation between HIV-related ocular findings and low CD4 counts. Similarly 65.6% of the patients who did not know or did not share their CD4 counts had abnormalities in their eye exam with 52.4% being HIV related. Conclusion: Optometrists play an important part of the health care team since patients with HIV infection present to primary care optometrists for comprehensive eye care as demonstrated in this study. The optometrist must be aware of the status of their CD4 count as this helps determine the risk for having HIV-related problems. Many patients will be able to provide this information as shown. Caution must be displayed with patients who do not know their CD4 count as this may be a poor prognostic sign. Finally, optometrists must educate patients about the risk for developing ocular complications from HIV as part of their eye care as both HIV microangiography and CMV retinitis were the most common AIDS-related ocular findings.

Contrast sensitivity was determined for dyslexic and normal readers. When testing with temporally ramped (i.e. stimuli with gradual temporal onsets and offsets) gratings of 0.6, 4.0, and 12.0 cycles/deg, we found no difference in contrast sensitivity between dyslexic readers and controls. Using 12.0 cycles/deg gratings with transient (i.e. abrupt) onsets and offsets, we found that dyslexic individuals had, compared to controls, markedly inferior contrast sensitivity at the shortest stimulus durations (i.e. 17, 34, and 102 ms). This deficit may reflect more sluggish temporal summation. There was no difference in sensitivity to 0.6 cycles/deg gratings with transient onsets and offsets. Under these conditions, the two groups showed a consistent and equal increase in sensitivity relative to the ramped baseline condition at 0.6 cycles/deg at the longer stimulus durations. This demonstrates that dyslexic readers have no deficit in their ability to detect stimulus transients, a finding which appears to be inconsistent with a transient system deficit. That detection of the low-frequency stimuli was mediated by the transient system is further indicated by the fact that these stimuli were more susceptible to forward masking than were the high-frequency stimuli. The effects of masking of both high and low spatial-frequency stimuli were about equal for dyslexic readers and controls. This is not in agreement with the transient system deficit theory, according to which one would expect there to be less masking of high spatial-frequency stimuli in the case of dyslexic readers.

Background Vitreomacular traction (VMT) syndrome is characterized as a partial detachment of the posterior vitreous with persistent adherence to the macula. The dynamic process associated with macular traction may induce a variety of macular conditions including cystoid macular edema (CME), epiretinal membranes (ERM), and macular hole formation. Methods Dilated fundus evaluations as well as Stratus and Cirrus optical coherence tomography (OCT) (Zeiss-Humphrey, Dublin, California) imaging were used to evaluate patients with various maculopathies associated with VMT. Conclusion The use of the OCT has enhanced the evaluation of the vitreal-retinal interface, leading to a better understanding of VMT. Once thought to be a rare distinct clinical entity, VMT is now considered a spectrum of macular diseases. The understanding of VMT and its role in the pathophysiology of various macular conditions may facilitate diagnosis and management of these conditions.

Purpose To describe the clinical presentation and treatment of ocular rosacea in children, an often unrecognized entity. Methods Retrospective chart review of 20 patients (age, 22 months to 17 years) who presented during childhood with corneal pathology, lid margin disease, and skin changes consistent with ocular rosacea. All patients were evaluated by the Cornea/External Disease Division of a tertiary-care facility, Bascom Palmer Eye Institute, Miami, FL, between 1990 and 2003. Results Sixty percent of patients improved after treatment with systemic erythromycin or doxycycline and topical low-dose steroid preparations. Ten percent of patients experienced no change in symptoms with treatment, and 30% of patients had incomplete follow-up to determine success of treatment. The patients maintained remission for up to 4 years after a slow taper of systemic treatment. The mean length of follow-up was 19.6 months (range, 0-9 years). Conclusions Early recognition and treatment of ocular rosacea in children may improve patient outcome by limiting progression of corneal pathology, including scarring and vascularization.

Background Polypoidal choroidal vasculopathy (PCV) is a unique form of occult choroidal neovascular membrane. The clinical presentation and angiographic findings distinguish idio-pathic PCV from other known neovascular and choroidal degenerative disorders. The characteristic morphology of PCV includes the presence of a branching network of inner choroidal vessels with terminal aneurysmal dilations. Other key findings include subtle nodular protrusions, which may precede multiple serosanguineous retinal pigment epithelial detachments. If Bruch's membrane is compromised, there is an additional risk of exudative retinopathy or vitreal hemorrhage. Case Reports Three patients with polypoidal choroidal vasculopathy are described with visual impairment secondary to irregular choroidal vascular lesions producing recurrent subretinal hemorrhages and exudative retinopathy. Conclusions The characteristic presentation and clinical course of polypoidal choroidal vasculopathy distinguish it from the typical presentation of age-related macular degeneration and other causes of hemorrhagic and exudative retinopathy. Imaging techniques such as fluorescein angiography, indocyanine green angiography, and optical coherence tomography may assist in the accurate diagnosis of PCV, so that appropriate treatment and management can be provided. In patients who manifest exudative, hemorrhagic retinopathy, with no signs of active inflammation or an anatomic predisposition to choroidal neovascularization, PCV should be considered.

Background A new form of exudative age-related macular degeneration (ARMD), retinal angiomatous proliferation (RAP), has been described in which neovascularization begins in the deep retina, extends through the subretinal space, and eventually communicates with choroidal neovascularization. Methods Case series. Results Common clinical features of RAP include small multiple intra-retinal hemorrhages, intra-retinal edema, vascularized pigment epithelial detachments (PEDs), and retinal choroidal anastomosis (RCA). Fluorescein angiography (FA) reveals ill-defined, occult choroidal neovascularization. Indocyanine green (ICG) angiography is useful in early stages because ’hot spots’ can be detected before clinical or FA characteristics are present. Optical coherence tomography (OCT) is useful in illustrating some of the clinical and FA characteristics. The use of photodynamic therapy (PDT), combined with intravitreal triamcinolone injection, was successful in stabilizing the RAP lesion in one case discussed in this report. Conclusions Retinal angiomatous proliferation is a newly recognized entity of exudative age-related macular degeneration with its own set of clinical, FA, ICG angiography, and OCT features. Experimental treatments such as the use of PDT combined with intravitreal triamcinolone injection demonstrate potential success with this entity. The biggest hope appears to be anti-angiogenic factors currently in clinical trials for the treatment of exudative ARMD.

Background The different variants of the iridocorneal endothelial (ICE) syndrome were separately described in the early to mid-1900's and were eventually linked to a common etiology of an abnormal corneal endothelium. The ICE syndrome typically manifests in early to middle adulthood, usually occurs in women, and is almost always unilateral. Management of patients with any variant of the ICE syndrome challenges even the best clinicians. Case Report We present a 52-year-old patient with Chandler's syndrome. Our patient shared many of the classic characteristics of Chandler's syndrome, including peripheral anterior synechiae and corneal edema, with one unusual aspect—the patient was male. Details regarding the subsets of the ICE syndrome, differential diagnosis, and current understanding of the pathophysiology are also reviewed. Conclusion The ICE syndrome is a progressive anterior segment disease that is quite difficult to manage. Corneal edema, increased IOP, and glaucoma are all sequelae of these conditions and, even in the best hands, are extremely challenging to manage. Today, nearly 100 years after Harms described the first patient with an ICE syndrome, we still do not know the exact mechanism for the corneal endothelial changes. Many investigations have been made into the causative agent or stimulus for abnormal endothelial growth in the ICE syndrome. No definitive proof has been established, but a relationship may exist with the Herpes Simplex and Epstein–Barr viruses. Further investigation is needed to determine the most-appropriate treatment and management of the ICE syndrome.

The efficacy, ease of use, and favorable side effect profile has increased the popularity of the prostaglandin analogs for topical treatment of a variety of glaucoma types. We undertook a cost analysis study of all the prostaglandin analogs.Mean number of drops per bottle, mean drop volume, total bottle volume, percent overfill per bottle, mean national bottle cost, daily cost of therapy, and yearly cost of therapy were calculated for all four of the prostaglandin analogs.Yearly cost of monocular therapy was $230.68 for latanoprost, $219.37 for travoprost, $211.34 for bimatoprost, and $178.85 for unoprostone. Unoprostone was by far the least expensive of the prostaglandin analogs tested. Bimatoprost, latanoprost, and travoprost were essentially the same price, varying in yearly cost to the patient by less than twenty dollars. Bimatoprost had the most expensive bottle price, unoprostone the least expensive. Bimatoprost also had the largest percentage of overfill from labeled volume. Unoprostone had the most monocular treatment days per bottle.Cost, in addition to efficacy and side affect profile, should be considered when determining which prostaglandin analog to prescribe to glaucoma patients.