Leske, David A.

ABSTRACT Purpose To validate a custom smartphone application for at‐home visual acuity (VA) measurement in children. Methods A total of 452 children aged 3–17.5 years participated. Certified examiners measured in‐office test–retest VA (logMAR) using gold‐standard Amblyopia Treatment Study HOTV (3‐to‐6‐year‐olds, younger cohort) or electronic Early Treatment of Diabetic Retinopathy Study (7‐to‐17.5‐year‐olds, older cohort) protocols at 3–4.5 m and app‐based VA at 1.5 m. Caregivers measured at‐home app‐based VA at 1.5 m. Results Comparing at‐home app‐based with gold‐standard VA, in eyes 20/40 or better, 95% (143/151) and 93% (91/98) of the younger and older cohorts were within 2 lines, respectively (mean differences: younger = −0.03, older = −0.04; 95% limits‐of‐agreement half‐width (LOA): younger = ±0.26, older = ±0.22). In eyes 20/50 or worse, 66% (42/64) and 75% (76/101) of the younger and older cohorts were within 2 lines, respectively (mean differences: younger = 0.11, older = 0.13, LOA: younger = ±0.50, older = ±0.51). Comparing in‐office app‐based VA with gold‐standard VA, in eyes 20/40 or better, 98% (160/164) and 94% (99/105) of the younger and older cohorts were within 2 lines, respectively (mean differences: younger = −0.03, older = −0.03; LOA: younger = ±0.22; older = ±0.24). In eyes 20/50 or worse, 85% (60/71) and 91% (101/111) of the younger and older cohorts were within 2 lines, respectively (mean differences: younger = 0.04; older = 0.04; LOA: younger = ±0.39; older = ±0.24). For gold‐standard test–retest, in eyes 20/40 or better, 99% (163/164) and 99% (104/105) of the younger and older cohorts had retest within 2 lines, respectively (mean differences: younger = 0.00; older = 0.01; LOA: younger = ±0.17; older = ±0.11). For 20/50 or worse, 92% (66/72) and 100% (111/111) in the younger and older cohorts were within 2 lines, respectively (mean differences: younger = 0.01; older = 0.02; LOA: younger = ±0.35; older = ±0.15). Conclusions Our app demonstrated good concordance with the gold standard at home and in the office for eyes with VA of 20/40 or better. However, concordance decreased considerably for eyes with VA 20/50 or worse, particularly at home.

Importance The long-term outcomes of surgery for pediatric traumatic cataract are not well described; understanding these outcomes would inform parental expectations. Objective To report visual acuity (VA) outcomes and cumulative incidence of ocular complications by 5 years following lensectomy for pediatric traumatic cataract. Design, Setting, and Participants This prospective cohort study was conducted across 32 sites in the US and Canada among 75 children undergoing lensectomy from birth to less than 13 years of age for unilateral traumatic cataract. Of 75 children, 60 had primary intraocular lens (IOL) placement; 15 were left aphakic. Data were collected from August 2012 to February 2020. Data analysis was performed from October 2022 to May 2025. Exposure Lensectomy. Main Outcomes and Measures The primary outcomes were best-corrected VA 5 years after lensectomy; period prevalence of strabismus and glaucoma (including cases diagnosed before lensectomy); surgery for visual axis opacification (VAO); and cumulative incidence of ocular complications by 5 years. Annual data collection was from medical record reviews through 5 years following lensectomy. Results Among 75 participants, 28 (37%) were female, and median (range) age at lensectomy was 7.4 years (0.1-13 years). Median (IQR) best-corrected VA at 5 years (available for 37 participants [49%]) was 20/63 (20/35-20/159) in pseudophakic eyes (n = 29; mean [SD] age at surgery, 7.2 [3.0] years) and 20/258 (20/56-<20/800) in aphakic eyes (n = 8; mean [SD] age at surgery, 5.5 [4.3] years). Age-normal VA was achieved by 6 pseudophakic eyes (21%; 95% CI, 10%-38%) and 1 aphakic eye (13%; 95% CI, 2%-47%). The 5-year period prevalence of glaucoma was 9% in pseudophakic eyes (95% CI, 1%-16%) and 9% in aphakic eyes (95% CI, 0%-24%). The 5-year cumulative incidence of surgery for VAO was 47% in pseudophakic eyes (95% CI, 31%-60%) and 13% in aphakic eyes (95% CI, 0%-28%). The risk was greater in eyes that did not undergo an anterior vitrectomy (84%; 95% CI, 55%-94%) vs eyes that did (15%; 95% CI, 2%-26%) (age-adjusted hazard ratio, 11.4; 95% CI, 4.6-33.1; P < .001). Conclusions and Relevance In this cohort study, while only half of the study participants had a 5-year follow-up visit, achieving age-normal VA was uncommon among the cohort in whom a best-corrected VA was determined. The prevalence of glaucoma at 5 years was low among those with 5-year follow-up, while nearly half of the pseudophakic eyes needed surgery for VAO supporting the need to monitor these children.

SIGNIFICANCE This pilot randomized trial, the first to evaluate a specific base‐in relieving prism treatment strategy for childhood intermittent exotropia, did not support proceeding to a full‐scale clinical trial. Defining and measuring prism adaptation in children with intermittent exotropia are challenging and need further study. PURPOSE This study aimed to determine whether to proceed to a full‐scale trial of relieving base‐in prism spectacles versus refractive correction alone for children with intermittent exotropia. METHODS Children 3 years old to those younger than 13 years with distance intermittent exotropia control score of ≥2 points on the Intermittent Exotropia Office Control Scale (Strabismus 2006;14:147–150; 0 [phoria] to 5 [constant]), ≥1 episode of spontaneous exotropia, and 16 to 35∆ by prism‐and‐alternate‐cover test, who did not fully prism adapt on a 30‐minute in‐office prism‐adaptation test were randomized to base‐in relieving prism (40% of the larger of distance and near exodeviations) or nonprism spectacles for 8 weeks. A priori criteria to conduct a full‐scale trial were defined for the adjusted treatment group difference in mean distance control: “proceed” (≥0.75 points favoring prism), “uncertain” (>0 to <0.75 points favoring prism), or “do not proceed” (≥0 points favoring nonprism). RESULTS Fifty‐seven children (mean age, 6.6 ± 2.2 years; mean baseline distance control, 3.5 points) received prism (n = 28) or nonprism (n = 29) spectacles. At 8 weeks, mean control values were 3.6 and 3.3 points in prism (n = 25) and nonprism (n = 25) groups, respectively, with an adjusted difference of 0.3 points (95% confidence interval, −0.5 to 1.1 points) favoring nonprism (meeting our a priori “do not proceed” criterion). CONCLUSIONS Base‐in prism spectacles, equal to 40% of the larger of the exodeviations at distance or near, worn for 8 weeks by 3‐ to 12‐year‐old children with intermittent exotropia did not yield better distance control than refractive correction alone, with the confidence interval indicating that a favorable effect of 0.75 points or larger is unlikely. There was insufficient evidence to warrant a full‐scale randomized trial.

ImportanceGlaucoma can develop following cataract removal in children.ObjectiveTo assess the cumulative incidence of glaucoma-related adverse events (defined as glaucoma or glaucoma suspect) and factors associated with risk of these adverse events in the first 5 years after lensectomy prior to 13 years of age.Design, Setting, and ParticipantsThis cohort study used longitudinal registry data collected at enrollment and annually for 5 years from 45 institutional and 16 community sites. Participants were children aged 12 years or younger with at least 1 office visit after lensectomy from June 2012 to July 2015. Data were analyzed from February through December 2022.ExposuresUsual clinical care after lensectomy.Main Outcomes and MeasuresThe main outcomes were cumulative incidence of glaucoma-related adverse events and baseline factors associated with risk of these adverse events.ResultsThe study included 810 children (1049 eyes); 443 eyes of 321 children (55% female; mean [SD] age, 0.89 [1.97] years) were aphakic after lensectomy, and 606 eyes of 489 children (53% male; mean [SD] age, 5.65 [3.32] years) were pseudophakic. The 5-year cumulative incidence of glaucoma-related adverse events was 29% (95% CI, 25%-34%) in 443 eyes with aphakia and 7% (95% CI, 5%-9%) in 606 eyes with pseudophakia; 7% (95% CI, 5%-10%) of aphakic eyes and 3% (95% CI, 2%-5%) of pseudophakic eyes were diagnosed as glaucoma suspect. Among aphakic eyes, a higher risk for glaucoma-related adverse events was associated with 4 of 8 factors, including age less than 3 months (vs ≥3 months: adjusted hazard ratio [aHR], 2.88; 99% CI, 1.57-5.23), abnormal anterior segment (vs normal: aHR, 2.88; 99% CI, 1.56-5.30), intraoperative complications at time of lensectomy (vs none; aHR, 2.25; 99% CI, 1.04-4.87), and bilaterality (vs unilaterality: aHR, 1.88; 99% CI, 1.02-3.48). Neither of the 2 factors evaluated for pseudophakic eyes, laterality and anterior vitrectomy, were associated with risk of glaucoma-related adverse events.Conclusions and RelevanceIn this cohort study, glaucoma-related adverse events were common after cataract surgery in children; age less than 3 months at surgery was associated with elevated risk of the adverse events in aphakic eyes. Children with pseudophakia, who were older at surgery, less frequently developed a glaucoma-related adverse event within 5 years of lensectomy. The findings suggest that ongoing monitoring for the development of glaucoma is needed after lensectomy at any age.

SIGNIFICANCE When exploring relationships among clinical measures and patient‐reported outcome measures in adults with convergence insufficiency, worse symptoms (Convergence Insufficiency Symptom Survey [CISS] score) seemed to be correlated with worse reading function domain score (Adult Strabismus‐20 quality‐of‐life questionnaire). After treatment, improved symptoms were associated with improved reading function quality of life. PURPOSE This study aimed to explore relationships between clinical measures and patient‐reported outcome measures in adults undergoing treatment for symptomatic convergence insufficiency. METHODS In a prospective multicenter observational study, we evaluated adults with symptomatic convergence insufficiency (i.e., clinical measures of near exodeviation, receded near point of convergence, reduced near positive fusional vergence; CISS score ≥21). Fifty‐seven participants treated with vision therapy/exercises (n = 35) or base‐in prism (n = 22) were analyzed. Spearman correlation coefficients ( R ) were used to assess associations among the three clinical measures and patient‐reported outcome measures (CISS, Diplopia Questionnaire, four Adult Strabismus‐20 quality‐of‐life domains) before treatment (baseline) and after 10 weeks and 1 year. Associations were interpreted to be present when the lower limit of the 95% confidence interval (CI) was moderate to strong ( R ≥ 0.4). RESULTS Among multiple exploratory analyses, the only moderate to strong baseline correlation was between worse CISS and worse Adult Strabismus‐20 reading function scores ( R = 0.62; 95% CI, 0.43 to 0.76). Regarding change in measures with treatment, the only moderate to strong correlations were between improved CISS and improved Adult Strabismus‐20 reading function scores for prism at 10 weeks ( R = 0.78; 95% CI, 0.52 to 0.91) and 1 year ( R = 0.85; 95% CI, 0.65 to 0.94) and for vision therapy/exercises at 1 year ( R = 0.78; 95% CI, 0.57 to 0.89). CONCLUSIONS In exploratory analyses, we found positive correlations between CISS symptom scores and reading function quality‐of‐life scores. The absence of correlations between symptoms and individual clinical measures is consistent with clinical experience that, in convergence insufficiency, symptoms and clinical findings can be discordant.

ObjectivesTo investigate the relationship between choroidal nevus and melanoma thickness measured with or without the sclera included by B‐scan ultrasound and to present a simple conversion formula.MethodsMedical records were retrospectively reviewed for choroidal nevus or melanoma evaluated at the Mayo Clinic in Rochester, Minnesota, with B‐scan ultrasound between February 4, 2004, and April 23, 2020. Charts were retrospectively reviewed for high‐quality B‐scan images in which the ultrasound transducer was perpendicular to the lesion, measuring the tumor thickness without the sclera included. Measurements were repeated with the sclera included for each patient. Univariate and multiple linear regression analyses were performed to identify factors correlated with scleral thickness.ResultsThere were 201 tumors included in the study, with a mean patient age ± SD of 61 ± 14 years, largest tumor basal diameter of 11.8 ± 4.8 mm, tumor thickness without the sclera included of 3.72 ± 2.7 mm, and thickness with the sclera included of 4.54 ± SD 2.8 mm. On the univariate analysis, factors associated with perceived scleral thickness by B‐scan ultrasound included age (P < .001), tumor thickness (P < .001), and basal diameter (P = .06). On the multivariate analysis, factors associated with perceived scleral thickness included age and tumor thickness (P < .001) for all tumors and for the subset of 141 tumors with a thickness of 2 mm or greater (P < .001). For tumors of 2 mm or greater in thickness, perceived scleral thickness by ultrasound can be estimated by the formula 0.00495(patient age) + 0.02451(tumor thickness without the sclera) + 0.42549.ConclusionsWe present a simple formula for converting between B‐scan ultrasound measurements of choroidal nevus and melanoma measuring 2 mm or greater in thickness with and without the sclera included.