Stefanie L. Davidson, MD


May 23, 2014

Editorial Collaboration

Medscape &

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Managing Patient Expectations

Hello. I am Dr. Stefanie Davidson from the Children's Hospital of Philadelphia. I recently returned from the 2014 American Association of Pediatric Ophthalmology and Strabismus (AAPOS) meeting in beautiful Palm Springs, California. I would like to share with you today some of the most interesting papers presented at the meeting.

The 2014 Frank D. Costenbader Lecture was given by Dr. John O'Neill.[1] By retelling his own experience, he provided an insightful and entertaining history of the founding of the AAPOS society. Specifically he described the early formative years of Drs. Frank Costenbader and Marshall Parks, the 2 most influential ophthalmologists in the development of pediatric ophthalmology as a unique and vital specialty.

Dr. Gillian Adams delivered the 2014 Philip Knapp lecture,[2] a lectureship given in the field of ocular motility by a non-North American ophthalmologist. Dr. Adams humbly shared her experience in managing patients who are dissatisfied with their strabismus surgery outcomes. Specifically, she discussed patients whom she considered to have good motor outcomes yet were unhappy postoperatively. Dr. Adams emphasized the importance of talking with patients during the consenting process to ensure that their preoperative expectations are in keeping with postoperative potential. Maintaining an awareness that patients may have emotional or psychological issues contributing to their expectations is extremely important.

Studies on Strabismus Surgery

Dr. Holmes and colleagues from the Mayo Clinic also recognized the importance of patient experience in assessing surgical success. In their study, "The Role of Health-Related Quality of Life When Evaluating Outcomes of Strabismus Surgery,"[3] they examined patients who, despite being designated as failures by motor and diplopia criteria, still report subjective improvement by health-related quality of life (HRQOL) score criteria using the Adult Strabismus 20 questionnaire. They suggest that quantitative HRQOL criteria should be considered when evaluating outcomes after strabismus surgery.

Another strabismus-related study focused on the development of anterior segment ischemia, a rare but serious and vision-threatening complication of strabismus surgery. The effect of rectus muscle recession, resection, and plication on anterior segment circulation in humans studied the impact of strabismus surgery on anterior segment circulation.

In this prospective blinded study of adult patients undergoing strabismus surgery, Oltra and colleagues[4] obtained preoperative and postoperative iris angiograms to study the effect of different surgical procedures on iris perfusion. They found that muscle plication preserves anterior segment circulation compared with rectus muscle recession or resection. They concluded that rectal muscle plication is a safer strengthening procedure than resection in patients with risk factors for anterior segment ischemia. This is important, given that resection is currently the most common strengthening procedure. This study suggests that plication is more effective in avoiding vision-threatening complications in at-risk patients.

Eyes on the iPads

The iPad was the focus of 2 innovative studies, one for vision screening and one for amblyopia treatment.

In their study of the validation of iPad-based simplified visual acuity testing (SVAT) in children, Hee-Jung Park and colleagues[5] reported the results of vision testing with SVAT at 1-meter distance on the iPad. They compared the results with established visual acuity protocols, including the Amblyopia Treatment Study and the electronic EDTRS. The results of iPad simplified visual acuity testing were comparable with these established criteria. The software is easy to use and allows wide distribution for use both in vision screening and in home monitoring of vision by parents. This has the potential to change the way vision screening is performed, bringing access into the home.

The iPad was also a focus for use as an adjunctive amblyopia treatment. Dr. Eileen Birch and her group[6] demonstrated the early promise of binocular iPad treatment for amblyopia in preschool children. With an anaglyphic iPad game that presents reduced contrast to the preferred fixating eye, participants aged 3-6 years were assigned to play 4 hours per week for 4 weeks or to a sham iPad treatment. In addition, 2 hours per day of patching was prescribed to each group. Findings revealed that the binocular iPad game resulted in more visual acuity improvement than the sham iPad group. Patients in the binocular iPad group had a lower rate of amblyopia recurrence at a 3-month post-treatment time interval.

Fluorescein Angiography in ROP

Lastly, a study titled "Serial Fundus Photography and Fluorescein Angiography After Off-Label Intravitreal Bevacizumab Treatment for Retinopathy of Prematurity: Importance of Monitoring Regression by Angiography in Off-Label Bevacizumab Treated Eyes" was delivered by Dr. Luxme Hariharan[7] on behalf of a group from Bascom Palmer. They used beautiful fundus images to elegantly illustrate the importance of using fluorescein angiography to assess the need for further treatment after bevacizumab injection. Active peripheral vessels were not visible on fundus imaging but were clearly apparent with angiography. The revealing images presented convincing evidence that fluorescein angiograms are critical to clearly demonstrate regression or progression of retinopathy of prematurity after treatment of intravitreal bevacizumab.

I'm Dr. Stefanie Davidson from the Children's Hospital of Philadelphia, and I have enjoyed sharing with you some of the most interesting studies presented at the 2014 AAPOS in Palm Springs, California. Thank you.