Publications by authors named "Sarah R Hatt"

85 Publications

Health-related quality of life in children with untreated intermittent exotropia and their parents.

J AAPOS 2021 Mar 8. Epub 2021 Mar 8.

Southern California College of Optometry at Marshall B. Ketchum University, Fullerton.

Purpose: To determine whether health-related quality of life (HRQOL) scores improved or worsened over 3 years of observation in childhood intermittent exotropia without treatment.

Methods: A total of 111 children aged 3-11 years with intermittent exotropia were assigned to observation in a previously reported randomized trial comparing patching with observation. The intermittent exotropia questionnaire (IXTQ) was administered at baseline, 6 months, and 36 months. Rasch-calibrated IXTQ domain scores (Child, Proxy, Parent-psychosocial, Parent-function, and Parent-surgery) were compared between time points. The Child IXTQ was administered only to children ≥5 years of age (n = 78).

Results: Overall, Child IXTQ and Proxy IXTQ scores showed no significant change over 36 months (mean improvement from baseline to 36 months of 3.2 points [95% CI, -1.9 to 8.2] and -2.4 points [95% CI: -7.9 to 3.1], resp.). By contrast, Parent-psychosocial, Parent-function, and Parent-surgery domain scores all improved over 36 months (mean improvements of 12.8 points [95% CI, 5.9-19.6] and 14.2 points [95% CI, 8.0-20.3] and 18.5 points [95% CI, 9.7-27.3], resp.).

Conclusions: HRQOL of children with intermittent exotropia remains stable with observation over 3 years (by both child and proxy report), whereas parental HRQOL improves.
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http://dx.doi.org/10.1016/j.jaapos.2020.10.011DOI Listing
March 2021

Quality of life and functional vision across pediatric eye conditions assessed using the PedEyeQ.

J AAPOS 2021 Feb 16. Epub 2021 Feb 16.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota; Department of Ophthalmology and Vision Science, University of Arizona-Tucson. Electronic address:

Purpose: To evaluate eye-related quality of life (ER-QOL) and functional vision across a wide range of pediatric eye conditions, using the Pediatric Eye Questionnaires (PedEyeQ).

Methods: A total of 1,037 children with an eye condition and 254 visually normal controls, across 0-4, 5-11, and 12-17 years age groups, completed the following questionnaires: Child PedEyeQ (Functional Vision, Bothered by Eyes/Vision, Social, Frustration/Worry domains), Proxy PedEyeQ (same domains plus Eye Care), and Parent PedEyeQ (Impact on Parent and Family, Worry about Child's Eye Condition, Worry about Child's Self-perception and Interactions, and Worry about Functional Vision domains). The primary eye condition was classified as amblyopia (n = 171), cataract (n = 99), cerebral visual impairment (CVI; n = 50), cornea (n = 20), eyelid (n = 35), glaucoma (n = 24), nystagmus (n = 57), orbital (n = 19), pupil/iris (n = 7), refractive error (n = 119), retina (n = 82), strabismus (n = 332), and uveitis (n = 22).

Results: PedEyeQ domain scores (scaled 0-100) were significantly worse across eye conditions, compared with controls. Child PedEyeQ greatest differences were on the Bothered by Eyes/Vision domain (nystagmus 5-11 years, -26 points [95% CI, -39 to -12]; nystagmus 12-17 years, -45 [95% CI, -61 to -28]). Proxy PedEyeQ differences were greatest on Functional Vision (CVI 0-4 years, -45 [95% CI, -56 to -34]; CVI 5-11 years, -58 [95% CI, -72 to -43]; nystagmus 12-17 years, -50 [95% CI, -69 to -31]). Parent PedEyeQ differences were greatest on Worry about Child's Functional Vision (CVI 0-4 years, -64; 95% CI -77 to -50).

Conclusions: The PedEyeQ detects reduced ER-QOL and functional vision across pediatric eye conditions, and across age groups, indicating its utility for clinical practice and clinical trials.
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http://dx.doi.org/10.1016/j.jaapos.2020.10.010DOI Listing
February 2021

Comparison of Methods for Measuring Cyclodeviation.

Am J Ophthalmol 2020 Nov 27;224:332-342. Epub 2020 Nov 27.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA; Department of Ophthalmology and Vision Science, University of Arizona-Tucson, Tucson, Arizona, USA. Electronic address:

Purpose: To compare the double-Maddox rod test with other methods of measuring cyclodeviation DESIGN: Retrospective cohort study.

Methods: We retrospectively identified 153 adults in a clinical practice with cyclodeviation assessed using double-Maddox rods, of whom 105 were also assessed using fusible synoptophore targets, 73 using nonfusible synoptophore targets, 118 using single-Maddox rod, and 43 using fundus photography. Relationships between double-Maddox rod and other tests were evaluated by calculating mean differences with 95% confidence intervals (CI), intraclass correlation coefficients (ICC), and Bland-Altman plots with linear regression.

Results: Synoptophore cross-in-circle targets and the largest (of right or left) single-Maddox rod values were similar to double-Maddox values (mean differences: -1.2° and 0.1°, respectively; ICC: 0.79 and 0.82, respectively). Synoptophore house targets measured less excyclodeviation (mean difference: -2.7°; ICC: 0.71). Mean summed single-Maddox rod values were somewhat similar to double-Maddox values (mean difference: 1.5°; ICC: 0.85), but differences increased with greater cyclodeviation (r = 0.2678; P < .001). Fundus photographs showed large, uncorrelated differences compared with double-Maddox rod test, when summing right and left eyes and when using the largest of right or left (mean differences: 12.2° and 6.2°; ICC: -0.02 and 0.21, respectively), and differences increased with greater cyclodeviation (r = 0.4094; P < .001 and r = .1143; P= .03, respectively).

Conclusions: There was good agreement between double-Maddox and the largest single- Maddox test values and synoptophore cross-in-circle targets but poorer agreement with other tests. Further study is needed to understand which measurements best reflect true cyclodeviation and relationships with symptoms.
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http://dx.doi.org/10.1016/j.ajo.2020.11.005DOI Listing
November 2020

Association of Visual Acuity with Eye-Related Quality of Life and Functional Vision Across Childhood Eye Conditions.

Am J Ophthalmol 2021 03 28;223:220-228. Epub 2020 Oct 28.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA; Department of Ophthalmology and Vision Science, University of Arizona-Tucson, Tucson, Arizona. Electronic address:

Purpose: We evaluated relationships between visual acuity (VA) and eye-related quality of life and functional vision in children, across a spectrum of pediatric eye conditions, using the Pediatric Eye Questionnaire (PedEyeQ).

Design: Cross-sectional study.

Methods: Three hundred ninety-seven children (5-11 years of age) with an eye condition and 104 visually normal control subjects completed the Child PedEyeQ (functional vision, bothered by eyes/vision, social, and frustration/worry domains). One parent for each child completed the Proxy PedEyeQ (same domains as child plus eye care) and parent PedEyeQ (impact on parent and family, worry about child's eye condition, worry about child's self-perception and interactions, and worry about functional vision domains). Each domain was Rasch-scored and Spearman rank correlations were calculated to evaluate relationships between better-seeing-eye and worse-seeing-eye VA and PedEyeQ domain score.

Results: There was a significant relationship between poorer better-seeing-eye VA and lower (worse) PedEyeQ score on 2 of 4 child domains (e.g., functional vision, r = -0.1474; P = .005), on 2 of 5 proxy PedEyeQ domains (e.g., functional vision, r = -0.2183; P < .001), and on 2 of 4 parent PedEyeQ domains (e.g., impact on parent and family, r = -0.1607; P = .001). Worse-seeing-eye VA was associated with lower PedEyeQ scores across all child, proxy and parent domains (P < .01 for each) with the exception of the child social domain (P = .15).

Conclusions: Both better-seeing-eye and worse-seeing-eye VA were associated with functional vision and eye-related quality of life in children, assessed using the PedEyeQ, although other factors may also influence relationships. These data further validate using the PedEyeQ across pediatric eye conditions.
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http://dx.doi.org/10.1016/j.ajo.2020.10.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7979455PMC
March 2021

Binocular Interference vs Diplopia in Patients With Epiretinal Membrane.

JAMA Ophthalmol 2020 Sep 10. Epub 2020 Sep 10.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.

Importance: Patients with epiretinal membrane (ERM) sometimes close 1 eye for improved vision, but associations have not been rigorously studied.

Objective: To evaluate associations with monocular eye closure in patients with ERM, and to report binocular interference (closing 1 eye to improve visual quality).

Design, Setting, And Participants: Retrospective medical record review of an adult strabismus clinic at a tertiary referral center. Patients with ERM referred from retina clinicians between June 2010 and October 2019 who completed the Adult Strabismus (AS)-20 questionnaire, including the question: "I cover or close one eye to see things better." Two groups were identified: (1) patients reporting eye closure sometimes or more, and (2) patients reporting no eye closure (as control patients).

Main Outcomes And Measures: Frequencies of (1) central-peripheral rivalry (CPR)-type diplopia (dragged fovea diplopia); (2) binocular interference (monocular eye closure but no diplopia or strabismus); and (3) other, associated with monocular eye closure. Visual acuity, metamorphopsia, aniseikonia, and AS-20 quality of life domain scores (self-perception, interactions, reading function, and general function) compared between binocular interference, CPR-type diplopia, and control patients.

Results: A total of 124 patients with ERM (58 of 124 were women [47%]; mean [SD] age, 70 [9] years) reported monocular eye closure. Associations were binocular interference in 36 (29%; 95% CI, 21%-38%), CPR-type diplopia in 34 (27%; 95% CI, 20%-36%), and other (primarily strabismus) in 54 (44%). Compared with control patients with ERM (n = 11), patients with ERM and binocular interference had worse quality of life on AS-20 reading function (95 vs 62; mean difference, 22 points; 95% CI, 7-27 points; P = .007) and general function (89 vs 68; mean difference, 23 points; 95% CI, 13-34 points; P = .01) domains. Compared with CPR-type diplopia, patients with binocular interference had poorer worst-eye visual acuity (median 0.50 vs 0.30 logMAR [20/63 vs 20/40]; mean difference, 0.13 logMAR; 95% CI, 0.00-0.25 logMAR [20/20 to 20/35]; P = .03), and a larger interocular difference (0.46 vs 0.19 logMAR [20/58 vs 20/30]; mean difference, 0.15 logMAR; 95% CI, 0.03-0.28 logMAR [20/21 to 20/38]; P = .004).

Conclusions And Relevance: Study findings suggest that binocular interference, manifesting as monocular eye closure (without diplopia or strabismus), is a distinct entity affecting quality of life in patients with epiretinal membrane.
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http://dx.doi.org/10.1001/jamaophthalmol.2020.3328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489379PMC
September 2020

Understanding the Impact of Residual Amblyopia on Functional Vision and Eye-related Quality of Life Using the PedEyeQ.

Am J Ophthalmol 2020 10 5;218:173-181. Epub 2020 Jun 5.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Purpose: To evaluate the effect of residual amblyopia on functional vision and eye-related quality of life (ER-QOL) in children and their families using the Pediatric Eye Questionnaire (PedEyeQ).

Design: Prospective cross-sectional study.

Methods: Seventeen children with residual amblyopia (no current treatment except glasses), 48 visually normal controls without glasses, and 19 controls wearing glasses (aged 8-11 years) completed the Child 5-11 year PedEyeQ. One parent for each child completed the Proxy 5-11 PedEyeQ, Parent PedEyeQ. Rasch-calibrated domain scores were calculated for each questionnaire domain and compared between amblyopic children and controls.

Results: PedEyeQ scores were significantly lower (worse) for children with residual amblyopia than for controls without glasses across all domains: Child PedEyeQ greatest mean difference 18 points worse on Functional vision domain (95% confidence interval [CI] -29 to -7; P < .001); Proxy PedEyeQ greatest mean difference 31 points worse on Functional vision domain (95% CI -39 to -24; P < .001); Parent PedEyeQ greatest mean difference 34 points worse on the Worry about child's eye condition domain (95% CI -46 to -22; P < .001). Compared with controls wearing glasses, PedEyeQ scores were lower for residual amblyopia on the Child Frustration/worry domain (P = .03), on 4 of 5 Proxy domains (P ≤ .05), and on 3 of 4 Parent domains (P ≤ .05).

Conclusions: Residual amblyopia affects functional vision and ER-QOL in children. Parents of amblyopic children also experience lower quality of life. These data help broaden our understanding of the everyday-life impact of childhood residual amblyopia.
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http://dx.doi.org/10.1016/j.ajo.2020.05.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731442PMC
October 2020

Association of Strabismus With Functional Vision and Eye-Related Quality of Life in Children.

JAMA Ophthalmol 2020 05;138(5):528-535

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.

Importance: Strabismus is common, affecting 2% to 4% of children, but how children and their families are affected in everyday life is poorly understood.

Objective: To evaluate the association of strabismus with functional vision and eye-related quality of life in children and their families using the Pediatric Eye Questionnaire (PedEyeQ).

Design, Setting, And Participants: This cross-sectional study was conducted between December 2017 and October 2019 and included 91 children with strabismus and 166 visually normal controls across 3 age groups (0-4, 5-11, and 12-17 years) who were enrolled at Mayo Clinic, Rochester, Minnesota, and Retina Foundation of the Southwest, Dallas, Texas.

Exposures: Children completed the child PedEyeQ (5 to 11- and 12 to 17-year versions: functional vision, bothered by eyes/vision, social, and frustration/worry domains); parents completed the proxy (0 to 4-, 5 to 11-, and 12 to 17-year versions: functional vision, bothered by eyes/vision, social, frustration/worry, and eye care domains) and the parent PedEyeQ (impact on parent and family, worry about child's eye condition, worry about child's self-perception and interactions, and worry about child's functional vision domains). Rasch-calibrated PedEyeQ scores were calculated for each domain and converted to 0 (worst) to 100.

Main Outcomes And Measures: PedEyeQ domain scores.

Results: Of 91 participants with strabismus, 41 (45.1%) were girls, 74 (81.3%) were white, 4 (4.4%) were Asian, 5 (5.5%) were more than 1 race, 5 (5.5%) were African American, and 2 (2.2%) were American Indian/Alaska Native. Child PedEyeQ domain scores were lower with strabismus vs visually normal controls among children ages 5 to 11 years and the greatest mean (SD) difference was in functional vision (12 [14] points; 95% CI, 6-18; P = .001), and among children ages 12 to 17 years, the greatest mean (SD) difference was in frustration/worry (27 [13] points; 95% CI, 18-36; P < .001). Proxy PedEyeQ domain scores were also lower with strabismus. The greatest difference among children ages 0 to 4 years was in functional vision (13 [9] points; 95% CI, 9-16; P < .001), among children ages 5 to 11 years was in functional vision (26 [10] points; 95% CI, 22-30; P < .001); and among children ages 12 to 17 years was in functional vision (21 [12] points; 95% CI, 12-30; P < .001), social (21 [13] points; 95% CI, 12-30; P < .001), and frustration/worry (21 [13] points; 95% CI, 12-30; P < .001). Parent PedEyeQ domain scores were lower with strabismus; the greatest difference was in worry about child's eye condition (38 [14] points; 95% CI, 34-42; P < .001).

Conclusions And Relevance: Strabismus is associated with reduced functional vision and eye-related quality of life in children. Parents of children with strabismus also experience a reduced quality of life. These findings advance our understanding of how strabismus affects children and their families and should be considered when defining patient management goals.
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http://dx.doi.org/10.1001/jamaophthalmol.2020.0539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7099455PMC
May 2020

Occlusion for stimulus deprivation amblyopia.

Cochrane Database Syst Rev 2020 03 23;3:CD005136. Epub 2020 Mar 23.

Royal Victoria Infirmary, Department of Ophthalmology, Claremont Wing, Queen Victoria Road, Newcastle upon Tyne, UK, NE1 4LP.

Background: Stimulus deprivation amblyopia (SDA) develops due to an obstruction to the passage of light secondary to a condition such as cataract. The obstruction prevents formation of a clear image on the retina. SDA can be resistant to treatment, leading to poor visual prognosis. SDA probably constitutes less than 3% of all amblyopia cases, although precise estimates of prevalence are unknown. In high-income countries, most people present under the age of one year; in low- to middle-income countries, people are likely to be older at the time of presentation. The mainstay of treatment is correction of the obstruction (e.g., removal of the cataract) and then occlusion of the better-seeing eye, but regimens vary, can be difficult to execute, and traditionally are believed to lead to disappointing results.

Objectives: To evaluate the effectiveness of occlusion therapy for SDA in an attempt to establish realistic treatment outcomes and to examine evidence of any dose-response effect and assess the effect of the duration, severity, and causative factor on the size and direction of the treatment effect.

Search Methods: We searched CENTRAL (2018, Issue 12), which contains the Cochrane Eyes and Vision Trials Register; Ovid MEDLINE; Embase.com; and five other databases. We used no date or language restrictions in the electronic searches. We last searched the databases on 12 December 2018.

Selection Criteria: We planned to include randomized controlled trials (RCTs) and controlled clinical trials of participants with unilateral SDA with visual acuity worse than 0.2 LogMAR or equivalent. We specified no restrictions for inclusion based upon age, gender, ethnicity, comorbidities, medication use, or the number of participants.

Data Collection And Analysis: We used standard Cochrane methodology.

Main Results: We identified no trials that met the inclusion criteria specified in the protocol for this review.

Authors' Conclusions: We found no evidence from RCTs or quasi-randomized trials on the effectiveness of any treatment for SDA. RCTs are needed in order to evaluate the safety and effectiveness of occlusion, duration of treatment, level of vision that can be realistically achieved, effects of age at onset and magnitude of visual defect, optimum occlusion regimen, and factors associated with satisfactory and unsatisfactory outcomes with the use of various interventions for SDA.
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http://dx.doi.org/10.1002/14651858.CD005136.pub4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7089638PMC
March 2020

Eye-related quality of life and functional vision in children wearing glasses.

J AAPOS 2020 04 28;24(2):91.e1-91.e6. Epub 2020 Feb 28.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Purpose: To evaluate eye-related quality of life (ER-QOL) and functional vision in children wearing glasses using the Pediatric Eye Questionnaire (PedEyeQ).

Methods: Children 5-17 years of age with normal visual acuity who wore glasses for correction of refractive error and with no other eye condition or treatment and control subjects who did not wear glasses, along with 1 parent for each child, were prospectively enrolled. Children completed the Child 5-11 or 12-17 PedEyeQ (four domains); parents completed the Proxy 5-11 or 12-17 questionnaires (perceived effect on child; five domains) and also the Parent questionnaire (effect on parent themselves; four domains). Each domain was Rasch-scored (converted to 0-100), and scores between groups were compared.

Results: A total of 40 subjects and 99 non-glasses-wearing controls, along with 1 parent for each child, were included. Children 5-11 and 12-17 years of age who wore glasses had lower PedEyeQ scores across all domains compared with controls (mean differences, -6 to -15; P ≤ 0.04 for each domain). Proxy scores were also lower for glasses wearers across age groups and domains (mean differences, -4 to -18; P ≤ 0.02), and Parent scores were lower for parents of children wearing glasses (mean differences, -6 to -18; P < 0.001 for each domain).

Conclusions: In this study, glasses wearers had reduced ER-QOL and functional vision compared with control subjects. Parents of children wearing glasses also experience reduced quality of life.
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http://dx.doi.org/10.1016/j.jaapos.2019.12.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7667888PMC
April 2020

Test-retest reliability of the revised diplopia questionnaire.

J AAPOS 2019 12 23;23(6):319.e1-319.e5. Epub 2019 Oct 23.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Purpose: To evaluate misclassification of diplopia "success" when using a standardized diplopia questionnaire (DQ), and to report test-retest reliability of the DQ.

Methods: We retrospectively identified a cohort of 100 patients with stable strabismus (<5 change in prism and alternate cover test measurements at distance and near), stable visual acuity, no change in treatment, and no clinical evidence of change, with completed DQ at two consecutive office visits (median, 71 days apart; range, 5-350 days). To evaluate the rate of misclassification of "success" and "not success," we compared the second to the first administration of the DQ using two established definitions of success: (1) "rarely" or "never" for straight ahead distance and (2) "rarely" or "never" for straight-ahead distance and reading. For DQ test-retest variability, 95% limits of agreement (LOA) and intraclass correlation coefficients (ICC) were calculated on DQ scores (0-100 scale).

Results: When defining success as rarely or never diplopic for distance, misclassification occurred in 12 (12%) of 100 (95% CI, 6%-20%). When defining success as rarely or never diplopic for distance and reading, misclassification occurred in 14 (14%) of 100 (95% CI, 8%-22%). The 95% LOA for the DQ score were 35.2 points, and ICC was 0.85 (95% CI, 0.79-0.90).

Conclusions: We have quantified misclassification and test-retest variability when using the DQ dichotomously or as a continuous measure, equipping the clinician to better interpret DQ outcome data in practice and research.
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http://dx.doi.org/10.1016/j.jaapos.2019.08.277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6925322PMC
December 2019

Diplopia after strabismus surgery for adults with nondiplopic childhood-onset strabismus.

J AAPOS 2019 12 3;23(6):313.e1-313.e5. Epub 2019 Oct 3.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Purpose: To describe frequency of postoperative diplopia after strabismus surgery in nondiplopic adults with childhood-onset strabismus and to report health-related quality-of-life (HRQOL) outcomes.

Methods: We prospectively enrolled 79 adults with no diplopia in any gaze who had childhood-onset strabismus and were scheduled for strabismus surgery. Diplopia was assessed preoperatively and at 6 weeks and 1 year postoperatively using a standardized diplopia questionnaire with 5 response options in 7 gaze positions. HRQOL was assessed using the Adult Strabismus-20 (AS-20) questionnaire, with self-perception, interactions, reading function, and general function domains.

Results: Constant diplopia in straight-ahead distance and reading gaze occurred in 1 patient (1% [95% CI, 0%-7%] at 6 weeks and 2% [95% CI, 0%-10%] at 1 year). Regarding the rate of any diplopia (including rarely) in any gaze, 15 of 78 patients (19%) reported diplopia at 6 weeks, of whom 13 had diplopia in straight-ahead distance gaze; 8 (10%), in reading gaze. At 1 year, 8 of 51 patients (16%) reported any diplopia (including rarely) in any gaze, of whom 7 had diplopia in straight-ahead distance gaze and 4 (8%) in reading gaze. Mean AS-20 scores improved at 1 year overall (by 32, 19, 14, and 15 points, resp., per domain) and for the 8 diplopic patients (by 21, 13, 16, and 11 points).

Conclusions: In adults with nondiplopic strabismus, constant postoperative diplopia is rare, although the rate of intermittent diplopia is higher. Even when postoperative diplopia occurs, HRQOL often improves.
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http://dx.doi.org/10.1016/j.jaapos.2019.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6925318PMC
December 2019

Validation of the Pediatric Eye Questionnaire in Children with Visual Impairment.

Am J Ophthalmol 2019 12 1;208:124-132. Epub 2019 Aug 1.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Purpose: To evaluate the recently developed Pediatric Eye Questionnaire (PedEyeQ) in visually impaired and visually normal children, as an initial validation of the PedEyeQ.

Design: Questionnaire validation study.

Methods: A total of 48 children with visual impairment (retinal, cortical, and corneal conditions) and 59 visually normal controls were enrolled at 2 centers. Five- to 17-year-old children completed the Child PedEyeQ (5-11- and 12-17-year-old versions), and parents completed the Proxy PedEyeQ (0-4-, 5-11-, and 12-17-year-old versions) and the Parent PedEyeQ. Rasch scores were calculated by age group for each distinct domain within each age-specific PedEyeQ (converted to 0-100 for interpretation). Domains for the Child PedEyeQ are functional vision, bothered by eyes/vision, social, and frustration/worry. Proxy PedEyeQ domains are functional vision, bothered by eyes/vision, social, frustration/worry, and eye care. Parent PedEyeQ domains are impact on parent and family, worry about child's eye condition, worry about child's self-perception/interactions, and worry about child's functional vision. For each domain, median PedEyeQ scores were compared between visually impaired and visually normal cohorts.

Results: Child 5-11 and 12-17 PedEyeQ scores were significantly lower (worse) for visually impaired children than for controls for each domain (P < .007), except for the social domain in 5-11-year-old children (P = .13). In addition, Proxy 0-4-, 5-11-, and 12-17-year-old PedEyeQ scores, and Parent PedEyeQ scores, were lower for visually impaired children across all domains (P < .001).

Conclusions: Visually impaired children and their parents had significantly lower (worse) PedEyeQ scores than visually normal controls, across functional vision and eye-related quality of life domains, demonstrating known-group validity of the PedEyeQ in children with visual impairment.
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http://dx.doi.org/10.1016/j.ajo.2019.07.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6888999PMC
December 2019

Treatment for Central-Peripheral Rivalry-Type Diplopia ("Dragged-Fovea Diplopia Syndrome").

Am J Ophthalmol 2019 12 16;208:41-46. Epub 2019 Jul 16.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Purpose: To report the effectiveness of treatments for central-peripheral rivalry (CPR)-type diplopia due to retinal misregistration.

Design: Retrospective, interventional case series.

Methods: Fifty adults with retinal misregistration and CPR-type diplopia (minimum frequency of "sometimes" at distance and/or for reading) caused by epiretinal membrane (n = 44) or other retinal disorders (n = 6) were enrolled in this study, conducted at adult strabismus clinics, Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, a tertiary medical center. Treatments included Bangerter filter, adhesive tape, Fresnel prism, clear prism (incorporated into glasses or loose prism in the office), iseikonic manipulation (using iseikonic lenses or contact lenses), a MIN lens, or epiretinal membrane (ERM) peeling (alone or in any combination). Not all patients underwent all of these treatments.

Results: Main outcome measurements were diplopia frequency, evaluated using the Diplopia Questionnaire. Success was defined as "never" or "rarely" diplopic for distance and reading, using the Diplopia Questionnaire, at an outcome examination as close as possible to 6 months. Overall, 17 of 50 patients (34%; 95% confidence interval [CI], 21%-49%) were classified as successful. Fresnel prism was successful in 4 of 7 patients (57%; 95% CI, 18%-90%); Bangerter filter in 4 of 28 patients (14%; 95% CI, 4%-33%); ERM peeling in 8 of 18 patients (44%; 95% CI, 22%-69%); and iseikonic manipulation in 1 of 23 patients (using a contact lens; 4%; 95% CI, 0%-22%).

Conclusions: CPR-type diplopia may be relieved in some patients using nonsurgical treatment options consisting of Fresnel prism or Bangerter filter. ERM peeling was surprisingly successful and should be considered.
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http://dx.doi.org/10.1016/j.ajo.2019.06.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6889009PMC
December 2019

Patient-derived questionnaire items for patient-reported outcome measures in adults with strabismus.

J AAPOS 2019 04 25;23(2):100-101.e3. Epub 2019 Jan 25.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

In a previous study we performed individual interviews of adults with strabismus and identified specific health-related quality of life concerns. In this present report we provide the entire list of specific questionnaire items that were created, one for each concern articulated in the interviews. Our aim in reporting this full list of 181 individual, patient-derived questionnaire items is to provide a resource to clinicians and researchers interested in developing patient-reported outcome measures for adults with strabismus.
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http://dx.doi.org/10.1016/j.jaapos.2018.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589376PMC
April 2019

Development of Pediatric Eye Questionnaires for Children With Eye Conditions.

Am J Ophthalmol 2019 04 14;200:201-217. Epub 2019 Jan 14.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Purpose: To develop patient-derived Pediatric Eye Questionnaires (PedEyeQ) to separately assess eye-related quality of life (ER-QOL) and functional vision in children with eye conditions.

Design: Questionnaire development study.

Methods: A total of 444 children (0 to <18 years old), across 10 diagnostic categories, were enrolled at 2 sites. All parents (n = 444) and 277 children (5 to <18 years old) completed master questionnaires, developed from patient-derived concerns. Factor analysis was performed to identify unidimensional domains (eigenvalue >1.0) and Rasch analyses (differential item functioning, targeting, fit) to reduce items (separate analyses for subjects aged 0-4, 5-11, and 12-17 years and for each factor).

Results: The Child 5- to 11-year-old PedEyeQ consisted of 4 unidimensional domains/questionnaires: functional vision, bothered by eyes/vision, social, frustration/worry (10 items each). The Child 12- to 17-year-old PedEyeQ consisted of the same 4 domains (total 39 items). The Proxy 0- to 4-year-old PedEyeQ consisted of 3 questionnaires/domains: functional vision, bothered by eyes/vision, social (total 29 items). The Proxy 5- to 11-year-old PedEyeQ consisted of 5 questionnaires/domains: functional vision, bothered by eyes/vision, social, frustration/worry, eye care (total 39 items), as did the Proxy 12- to 17-year-old PedEyeQ (total 42 items). The Parent PedEyeQ consisted of 4 questionnaires/domains: impact on parent/family, worry regarding child's eye condition, worry regarding child's self-perception and interactions, worry regarding child's visual function (total 35 items). Rasch look-up tables were created for scoring.

Conclusions: By following a rigorous approach, we have developed Pediatric Eye Questionnaires for separately assessing functional vision and ER-QOL domains in children of any age and with any eye condition.
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http://dx.doi.org/10.1016/j.ajo.2019.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6730562PMC
April 2019

New Onset vs Resolution of Central-Peripheral Rivalry-Type Diplopia in Patients Undergoing Epiretinal Membrane Peeling.

JAMA Ophthalmol 2019 03;137(3):293-297

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.

Importance: The peeling of an epiretinal membrane (ERM) is commonly performed for poor visual acuity and/or metamorphopsia, but to our knowledge, its influence on central-peripheral rivalry (CPR)-type diplopia has not been rigorously studied.

Objective: To evaluate the occurrence of either resolution or new-onset CPR-type diplopia in patients undergoing ERM peeling.

Design, Setting, And Participants: This prospective cohort study was conducted from July 2014 to April 2018 at a tertiary referral medical center and included 33 adults with ERM who were undergoing peeling surgery with planned preoperative to postoperative analysis.

Interventions: A standardized diplopia questionnaire completed before undergoing and 6 months following ERM peeling.

Main Outcomes And Measures: For patients with CPR-type diplopia before ERM peeling (rated "sometimes" or more for distance straight ahead or reading using the diplopia questionnaire), we calculated the proportion with resolution of diplopia postpeel ("never" for distance straight ahead and reading on the diplopia questionnaire) and compared clinical characteristics between those with resolution and those without. For patients with no diplopia prepeeling ("never" for distance straight ahead and reading on the diplopia questionnaire), we calculated the proportion with new-onset CPR-type diplopia postoperatively and compared clinical characteristics between those with new-onset diplopia and those who remained without diplopia.

Results: Of 33 patients (median age, 67 years [range, 51-87 years]; 18 men [55%]), 12 (36%) had CPR-type diplopia preoperatively and 21 (64%) did not have diplopia preoperatively. Six months postoperatively, 4 of 12 patients with diplopia (33%; 95% CI, 10%-65%) had resolution of diplopia, and 4 of 21 patients without diplopia (19%; 95% CI, 5%-42%) had new-onset diplopia. Better postoperative operated-eye visual acuity appeared somewhat associated with new-onset diplopia postoperatively (mean [SD] visual acuity, 0.08 [0.10] logMAR; approximately 20/25 vs 0.34 [0.33] logMAR; approximately 20/40; difference, -0.27; 95% CI, -0.62 to 0.09; P = .07), as did greater postoperative aniseikonia (14% [5%] vs 6% [4%]; difference, 8%; 95% CI, 2%-13%; P = .04).

Conclusions And Relevance: These data suggest that epiretinal membrane peeling may result in resolution of diplopia in some patients but new-onset diplopia in others. These findings may be valuable when counseling patients regarding the risks of new-onset diplopia.
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http://dx.doi.org/10.1001/jamaophthalmol.2018.6042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439706PMC
March 2019

Patient-derived questionnaire items for patient-reported outcome measures in pediatric eye conditions.

J AAPOS 2018 12 21;22(6):445-448.e22. Epub 2018 Sep 21.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Purpose: To identify specific health-related quality of life (HRQOL) and functional vision concerns of children with eye conditions, and create comprehensive lists of potential questionnaire items as a first step in developing patient-reported outcome measures.

Methods: Children experiencing a range of pediatric eye conditions, along with one of their parents, were interviewed to identify specific concerns. Transcribed interviews were reviewed, and specific HRQOL and functional vision concerns were coded independently by two reviewers. Coded concerns were reviewed to formulate questions to address specific child concerns (derived from child and parent interviews) and specific parent concerns. Questions were grouped into bins of like questions. Two comprehensive lists of questions were formulated, one addressing child-related concerns and one addressing parent-related concerns.

Results: This study included 180 children and 328 parents. A total of 614 individual child questions were grouped into 36 bins (eg, appearance, coordination, glasses, learning), and 589 parent questions were formulated and grouped into 61 bins (eg, having to assist the child, worry about deterioration, time off work, safety).

Conclusions: Using rigorous methods based on individual interviews, we identified a comprehensive list of patient- and parent-derived questionnaire items that address functional vision and HRQOL concerns of children with eye conditions and of their parents. We plan to use this large pool of potential questionnaire items to develop a formal set of pediatric outcome measures, and this pool of questions may also be a resource for future research.
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http://dx.doi.org/10.1016/j.jaapos.2018.05.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6347122PMC
December 2018

Dose Effect and Stability of Postoperative Cyclodeviation After Adjustable Harada-Ito Surgery.

Am J Ophthalmol 2018 12 3;196:91-95. Epub 2018 Sep 3.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Purpose: To report the dose-response relationship of adjustable Harada-Ito surgery, and postoperative stability of cyclodeviation.

Design: Retrospective cohort study.

Methods: Twenty patients underwent a unilateral adjustable Harada-Ito advancement of the anterior fibers of the superior oblique tendon, with or without resection. The surgical dose was calculated as resection plus advancement plus adjustment. Cyclodeviation was measured using double Maddox rods at preoperative and postoperative time points. We assessed dose effect by calculating change in cyclodeviation from preoperatively to postadjustment and evaluated the dose-response relationship by Spearman rank methods. Postoperative stability of cyclodeviation was assessed by comparing postadjustment measurements with 1-day and 6-week measurements, and also 1- and 5-year measurements, when available.

Results: Change in cyclodeviation from preoperatively to postadjustment ranged from 7 to 20 degrees of incyclo effect. There was a dose effect of 1.3 degrees per mm (r = 0.52, P = .019). Postoperative incyclodeviation unwound a mean of 3.6 degrees ± 2.5 degrees between postadjustment and day 1. Overall change between postadjustment and the 6-week window was 6.5 ± 2.9 degrees in an excyclo direction. Unwinding continued with a mean change of 0.2 ± 2.6 degrees between the 6-week and 1-year windows, and of 0.4 ± 2.1 degrees between 1-year and 5-years windows.

Conclusions: Adjustable Harada-Ito advancement of the anterior fibers of the superior oblique tendon has a dose response of 1.3 degrees per millimeter, but its effect regresses over time. Based on our data, an immediate postoperative target incyclodeviation of 7 degrees is reasonable.
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http://dx.doi.org/10.1016/j.ajo.2018.08.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309541PMC
December 2018

Role of a Standardized Prism Under Cover Test in the Assessment of Dissociated Vertical Deviation.

Strabismus 2018 03 2;26(1):1-5. Epub 2018 Feb 2.

a Department of Ophthalmology , Mayo Clinic , Rochester , MN , USA.

Background: Dissociated vertical deviation (DVD) is commonly measured using a prism and alternate cover test (PACT), but some providers use a prism under cover test (PUCT). The aim of this study was to compare a standardized PUCT measurement with a PACT measurement, for assessing the magnitude of DVD.

Methods: Thirty-six patients with a clinical diagnosis of DVD underwent measurement of the angle of deviation with the PACT, fixing with the habitually fixing eye, and with PUCT, fixing both right and left eyes. The PUCT was standardized, using a 10-second cover for each prism magnitude, until the deviation was neutralized. The magnitude of hyperdeviation by PACT and PUCT was compared for the non-fixing eye, using paired non-parametric tests. The frequency of discrepancies more than 4 prism diopters (PD) between PACT and PUCT was calculated.

Results: The magnitude of hyperdeviation was greater when measured with PUCT (range 8PD hypodeviation to 20PD hyperdeviation) vs. PACT (18PD hypodeviation to 25PD hyperdeviation) with a median difference of 4.5PD (range -5PD to 21PD); P < 0.0001. Eighteen (50%) of 36 measurements elicited >4PD hyperdeviation (or >4PD less hypodeviation) by PUCT than by PACT.

Conclusions: A standardized 10-second PUCT yields greater values than a prism and alternate cover test in the majority of patients with DVD, providing better quantification of the severity of DVD, which may be important for management decisions.
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http://dx.doi.org/10.1080/09273972.2017.1391850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330102PMC
March 2018

Test-retest variability of cyclodeviations measured using the double Maddox rod test.

J AAPOS 2018 04 6;22(2):146-148.e1. Epub 2018 Jan 6.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

The double Maddox rod test is often used to measure cyclodeviations and to monitor change over time. The purpose of this study was to estimate test-retest reliability and the amount of cyclodeviation that would be considered real change using 95% limits of agreement. We retrospectively studied 86 clinically stable patients with double Maddox rod measurements 5-175 days apart (median, 69 days). The range of cyclodeviation at the first measurement was 6° incyclodeviation to 15° excyclodeviation. We calculated the half width of the 95% limits of agreement to be 4.7°, which means that a change of ≥5° in cyclodeviation would be considered a real change. The threshold of 5° should be used when assessing change between two measurements made with double Maddox rods.
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http://dx.doi.org/10.1016/j.jaapos.2017.09.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916581PMC
April 2018

Factors Associated With Failure of Adult Strabismus-20 Questionnaire Scores to Improve Following Strabismus Surgery.

JAMA Ophthalmol 2018 01;136(1):46-52

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.

Importance: Health-related quality of life (HRQOL) typically improves following strabismus surgery. Nevertheless, for some patients, HRQOL does not improve, and reasons for this are unknown.

Objective: To identify factors associated with failure of adult strabismus-20 (AS-20) HRQOL scores to improve following strabismus surgery.

Design, Setting, And Participants: Prospective observational case series at the Mayo Clinic, Rochester, Minnesota, comprising 276 adults, between July 2012 and August 2016.

Main Outcomes And Measures: Participants completed the AS-20 HRQOL questionnaire, diplopia questionnaire, Center for Epidemiologic Studies Depression Scale-Revised (CESD-R) (depressive symptoms), and Type-D Scale 14 questionnaire (type-Distressed [type-D] personality) both preoperatively and 6 weeks postoperatively. To assess factors associated with failure of HRQOL to improve (no change or decrease in score), univariate and multiple logistic regression analyses were performed. Each of the 4 AS-20 domains (self-perception, interactions, reading function, and general function) were analyzed separately including only patients able to improve at least by the magnitude of previously defined 95% limits of agreement. Factors assessed were age (at onset and at surgery), sex, number of previous surgeries, presence of visually obtrusive facial anomaly, visual acuity, preoperative and postoperative diplopia questionnaire scores, alignment (as a vector), presence of esotropia, presence of a vertical deviation, CESD-R scores, and type-D personality. Stepwise multiple logistic regression analyses were performed to assess factors associated with failure of AS-20 scores to improve for each domain.

Results: Of the 276 participants, the median age was 57 years (range, 18-91 years), 153 were women (55%), and 266 were white (96%). Failure to improve was associated with worse diplopia postoperatively on the self-perception (adjusted risk ratio [RR], 1.01; 95% CI, 1.00-1.02), reading function (adjusted RR, 1.02; 95% CI, 1.01-1.03), and general function domains (adjusted RR, 1.02; 95% CI, 1.01-1.03). In addition, failure to improve on the self-perception domain was associated with type-D personality postoperatively (adjusted RR, 4.26; 95% CI, 1.90-9.57) and failure to improve on the interactions domain was associated with postoperative depressive symptoms (adjusted RR, 1.04; 95% CI, 1.02-1.06) and coexisting visually obtrusive anomaly (adjusted RR, 2.12; 95% CI, 1.04-4.32).

Conclusions And Relevance: Postoperative diplopia, depressive symptoms, type-D personality, and visually obtrusive facial anomalies were associated with failure of AS-20 scores to improve (remaining the same or worsening) following strabismus surgery. The association of nonstrabismus factors may have implications for patient treatment and is worthy of continued study.
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http://dx.doi.org/10.1001/jamaophthalmol.2017.5088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833608PMC
January 2018

Prevalence and Associations of Central-Peripheral Rivalry-Type Diplopia in Patients With Epiretinal Membrane.

JAMA Ophthalmol 2017 12;135(12):1303-1309

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota

Importance: The prevalence and clinical associations of patients with epiretinal membrane (ERM) who develop central-peripheral rivalry (CPR)–type diplopia are unknown.

Objectives: To determine the prevalence of CPR-type diplopia in retinal disease clinic patients with ERM and to determine clinical findings associated with CPR-type diplopia.

Design, Setting And Participants: A prospective cross-sectional study of 31 patients with ERM from retinal disease clinics to determine the prevalence of CPR-type diplopia. A retrospective case cohort of 25 additional patients with ERM, selected from adult strabismus clinics, was added (total = 56) to determine clinical associations with CPR-type diplopia. All data were collected between June 2014 and November 2016; prospective cohort data were collected from June 2016 to November 2016.

Main Outcomes And Measures: The presence of diplopia was determined by patient history and diplopia questionnaire responses. Visual acuity and ocular alignment were recorded. Metamorphopsia was documented qualitatively by evaluation of the door frame and Amsler grid and measured quantitatively using M-charts and D-charts. Aniseikonia was determined by subjective description and results of the Awaya new aniseikonia test. Retinal misregistration testing consisted of optotype-frame test and synoptophore; CPR-type diplopia was defined as diplopia associated with evidence of retinal misregistration when other causes did not fully explain diplopia. Outcomes were as follows: prevalence of CPR-type diplopia in patients with ERM seen in retinal disease clinics, and whether or not clinical findings differed between patients with ERM and CPR-type diplopia vs patients with ERM without CPR-type diplopia.

Results: Of the 31 patients with ERM seen in retinal disease clinics, 16 were women and 15 were men; the mean (SD) age was 69 (10) years. The prevalence of any diplopia was 23% (7 of 31; 95% CI, 10% to 41%), with CPR-type diplopia present in 16% (5 of 31; 95% CI, 5% to 34%). For analysis of associations, 12 of 56 patients (21%) had CPR-type diplopia and 37 (66%) had no diplopia. Seven of the 56 patients were excluded for other types of diplopia. Patients with CPR-type diplopia had better worse-eye visual acuity (mean difference, −0.23; 95% CI, −0.37 to −0.09 logMAR, P = .003), and more severe quantitative metamorphopsia (mean M-score difference 0.6; 95% CI, 0.05 to 1.1, P = .01) than patients without diplopia, but similar aniseikonia (Awaya new aniseikonia test; mean difference 0.6%; 95% CI, −2.9% to 4.0%, P = .33) and similar evidence of retinal misregistration (100% vs 73%; P = .09) by any test.

Conclusions And Relevance: Our findings suggest that CPR-type diplopia is not uncommon in patients with ERM. On average, patients with CPR-type diplopia have better visual acuity and more metamorphopsia than those without CPR-type diplopia, but there is considerable individual variability. Aniseikonia and retinal misregistration are similar between patients with ERM associated with CPR-type diplopia and those without CPR-type diplopia. Retinal misregistration with coexistent metamorphopsia appears necessary but is not sufficient for CPR-type diplopia.
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http://dx.doi.org/10.1001/jamaophthalmol.2017.4350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583528PMC
December 2017

Incidence and Etiology of Presumed Fourth Cranial Nerve Palsy: A Population-based Study.

Am J Ophthalmol 2018 Jan 2;185:110-114. Epub 2017 Nov 2.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Purpose: To determine the incidence of isolated, presumed fourth nerve palsy in a defined population, and to report the frequency of each cause.

Design: Retrospective, population-based case series.

Methods: A population-based database was used to identify all cases of isolated fourth nerve palsy in Olmsted County, Minnesota, USA diagnosed over a 15-year period (January 1, 1978 to December 31, 1992). The most likely etiology was determined by review of the entire medical record by 2 ophthalmologists. A priori definitions were applied for assigning cause. The incidence of fourth nerve palsy and the frequency of each etiology were calculated. Decade of life at presentation was recorded.

Results: Seventy-three patients (74 episodes, 70 [95%] unilateral) were identified. Mean age at presentation was 41.8 (range 3.3-81.6) years. The age- and sex-adjusted annual incidence rate was 5.73 per 100 000 per year (95% confidence interval [CI] 4.31-7.14). The most common etiology was presumed congenital (49%), followed by hypertension (18%) and trauma (18%). One patient (1%) had fourth nerve palsy owing to a known intracranial neoplasm. For 3 patients (4%) the cause of fourth nerve palsy was undetermined. The most common decade of presentation overall was the fourth decade, including for presumed congenital cases.

Conclusions: In this population-based study, the majority of isolated fourth nerve palsies were presumed congenital, even though they presented throughout adulthood. Other etiologies such as hypertension and trauma were less frequent, and in no case was an isolated fourth nerve palsy the presenting sign of an intracranial tumor.
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http://dx.doi.org/10.1016/j.ajo.2017.10.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5784757PMC
January 2018

Factors associated with atypical postoperative drift following surgery for consecutive exotropia.

J AAPOS 2017 Oct 1;21(5):360-364. Epub 2017 Sep 1.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Purpose: To evaluate the associations of clinical and surgical factors with atypical postoperative drift following surgery for consecutive exotropia.

Methods: A total of 66 patients with consecutive exotropia (≥10 at distance), after historical surgery for esotropia were retrospectively identified at a tertiary medical center. All patients underwent unilateral lateral rectus recession (on adjustable suture) with medial rectus advancement and/or resection. Immediate postoperative target angle was 4-10 of esotropia at distance, anticipating mild postoperative exodrift. Actual postoperative drift was calculated as change in distance deviation from immediately postadjustment to 6 weeks. Typical drift was defined as 0-9 of exodrift. Excessive exodrift was defined as ≥10. Esodrift was defined as 1 or more. Univariate and multiple logistic regression analyses were performed to evaluate for associations with a wide range of clinical and surgical factors.

Results: Overall there was a median exodrift (4, quartiles 0-10). Of the 66 patients, 18 (27%) showed excessive exodrift; 15 (23%), esodrift. In multiple logistic analyses, larger preoperative distance exodeviation was associated with excessive exodrift (P = 0.01), and non-normal medial rectus attachment status (abnormal [stretched scar, pseudo-tendon], attached to pulley, or behind pulley) was associated with esodrift (P = 0.02).

Conclusions: Approximately half of patients show atypical drift following unilateral surgery for consecutive exotropia, with larger preoperative distance exodeviation associated with exodrift and non-normal medial rectus muscle status with esodrift. Knowing these associations may help when counseling patients regarding surgical outcomes.
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http://dx.doi.org/10.1016/j.jaapos.2017.07.201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734656PMC
October 2017

One- Versus Two-Muscle Surgery for Presumed Unilateral Fourth Nerve Palsy Associated With Moderate Angle Hyperdeviations.

Am J Ophthalmol 2017 Oct 4;182:1-7. Epub 2017 Jul 4.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Purpose: To compare 1-muscle vs 2-muscle surgery for moderate-angle hyperdeviations owing to presumed unilateral fourth nerve palsy.

Design: Retrospective chart review.

Methods: Seventy-three patients (aged 5-86 years) underwent either 1- or 2-muscle surgery at our institution for moderate hyperdeviation owing to presumed unilateral fourth nerve palsy, measuring 14-25 prism diopters (PD) in straight-ahead gaze at distance fixation. Six-week and 1-year motor success was defined as zero vertical deviation or 1-4 PD undercorrection at distance, overcorrection as any reversal of hypertropia, and undercorrection as >4 PD. Diplopia success was defined as no diplopia, or only rarely for distance straight ahead and reading.

Results: Twenty-eight patients underwent 1-muscle surgery, and 45 patients underwent 2-muscle surgery. Motor success was similar (64% vs 67%, P > .99 at 6 weeks; 47% vs 55%, P = .8 at 1 year, n = 46), but there were more undercorrections at 6 weeks with 1-muscle surgery (36% vs 16%, P = .09) and more overcorrections at 6 weeks with 2-muscle surgery (0% vs 18%, P = .02). Diplopia success was also somewhat similar between 1- and 2-muscle surgery at 6 weeks (73% vs 60%, P = .5) and 1 year (45% vs 59%, P = .5).

Conclusion: For moderate-angle hyperdeviations owing to presumed unilateral fourth nerve palsy, there appears no clear advantage of 2-muscle surgery for motor outcomes. Diplopia success was similar between 1- and 2-muscle surgery, owing to a greater number of less symptomatic undercorrections with 1-muscle surgery and a smaller number of more symptomatic overcorrections with 2-muscle surgery.
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http://dx.doi.org/10.1016/j.ajo.2017.06.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5610632PMC
October 2017

Bilateral childhood visual impairment: child and parent concerns.

J AAPOS 2017 Jun 17;21(3):183.e1-183.e7. Epub 2017 May 17.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Purpose: To identify specific health-related quality of life and visual function concerns affecting children with bilateral visual impairment as expressed by children or one of their parents (proxy) and concerns affecting the parents themselves.

Methods: A total of 37 children <16 years of age with visual impairment (visual acuity worse than 20/70 in the better eye) and one parent for each child were prospectively enrolled. Semistructured individual interviews were performed with children 5-15 years of age (n = 16) and with one parent for each child (ages 0-15 years, N = 37). Interview transcripts were analyzed using NVivo software. Categories of concern were identified from both child and parent interviews, from which broad themes were identified. The frequencies of the themes and specific categories of concerns were calculated.

Results: Regarding the child's experience, categories of concern were grouped into 6 themes: visual function (expressed by 13 of 16 children [81%] and 33 of 37 parents [89%]), treatment (63% and 54%), emotions (50% and 68%), social (50% and 70%), physical discomfort (50% and 22%), and worry (38% and 8%). Concerns expressed regarding the parents' own experience were grouped into 5 themes: worry (100%), compensate-adjust for condition (89%), treatment (84%), emotions (81%), and affects family (46%).

Conclusions: Individual interviews identified a wide spectrum of concerns in children with visual impairment and their parents, affecting functional, emotional, social and physical domains. Specific concerns will be used to develop patient-derived questionnaires for quantifying the effects of visual impairment on children and parents in everyday life.
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http://dx.doi.org/10.1016/j.jaapos.2017.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5563162PMC
June 2017

Causes of Diplopia in Patients With Epiretinal Membranes.

Am J Ophthalmol 2017 Jul 27;179:39-45. Epub 2017 Apr 27.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Purpose: To describe the causes of diplopia in patients with an epiretinal membrane (ERM) and presenting diplopia.

Design: Retrospective observational case series.

Methods: We reviewed patients diagnosed with an ERM, who had been seen by both retinal and strabismus specialists in a tertiary medical center. Data recorded: orthoptic evaluation, retinal misregistration (optotype-frame test, and synoptophore central peripheral superimposition slides at 5 and 10 degrees), and cause of any diplopia (retinal misregistration vs strabismus vs optical/refractive error). We defined central-peripheral rivalry-type diplopia as presenting symptomatic diplopia with evidence of retinal misregistration, and where other causes did not fully explain diplopia. The frequency of each cause of diplopia in patients with ERM was determined.

Results: Of 50 patients with ERM, 25 had symptomatic diplopia and 25 had no diplopia. Eleven of 25 diplopic patients (44%) had retinal misregistration as the sole cause (central-peripheral rivalry-type diplopia), 7 (28%) strabismus (1 of 7 initally appeared to have central-peripheral rivalry-type diplopia), 1 (4%) optical/refractive error (monocular diplopia), 2 (8%) mixed retinal misregistration (central-peripheral rivalry-type diplopia) and strabismus, and for 4 (16%) diplopia cause was indeterminate. Unexpectedly, 15 of 25 patients without diplopia (60%) had evidence of retinal misregistration.

Conclusions: Patients with ERM and presenting diplopia may have 1 of several causes of diplopia, most commonly retinal misregistration (central-peripheral rivalry-type diplopia). Nevertheless, diplopic patients with retinal misregistration may also have treatable strabismus or optical/refractive error as the primary barrier to single vision and therefore many potential barriers to single vision should be considered.
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http://dx.doi.org/10.1016/j.ajo.2017.04.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5699521PMC
July 2017

Intraoperative Findings in Consecutive Exotropia with and without Adduction Deficit.

Ophthalmology 2017 06 24;124(6):828-834. Epub 2017 Feb 24.

Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:

Purpose: Consecutive exotropia may be associated with limited adduction, which has been reported to be caused by 1 or more anatomic abnormalities of rectus muscles or their insertions. We studied the relative frequency of grades of adduction deficit and the relative frequency of abnormal anatomic findings.

Design: Retrospective cohort study.

Participants: Patients undergoing surgery for consecutive exotropia.

Methods: Preoperative duction deficits were graded on a -5 (severe limitation) to 0 (normal) scale. Operative reports were reviewed to classify intraoperative factors: (1) medial rectus muscle attachment type (normal, abnormal [slipped or stretched scar], attached to pulley, behind pulley, or mixed [a tenuous normal attachment, but with muscle fibers also attached to the pulley or behind the pulley]), (2) medial rectus muscle distal fiber location (millimeters from original insertion), and (3) lateral rectus muscle tightness (normal, mild restriction, moderate restriction).

Main Outcome Measures: Relationship of grade of adduction deficit to each intraoperative factor.

Results: Of 143 eyes, 124 (87%) had an adduction deficit. Eyes with abnormal (n = 23), pulley (n = 9), behind pulley (n = 8), or mixed (n = 7) attachments had worse adduction deficits than normal attachments (n = 96; P < 0.02). There was a significant correlation between distal medial rectus muscle fiber location (0-19.5 mm recessed) and grade of adduction deficit (P < 0.0001). Eyes with mild or moderate lateral rectus muscle tightness on forced duction testing (n = 48/143 eyes) had worse adduction deficits than eyes without tightness (P < 0.001). Nevertheless, despite overall correlation, there was considerable individual variability. For example, for -1 and -2 adduction deficits, medial rectus muscle attachment could be at the pulley, behind the pulley, or include the pulley (19/87 eyes [22%]), and the lateral rectus muscle was tight in 36 of 87 eyes (41%).

Conclusions: Adduction deficits are common in patients with consecutive exotropia. Overall, more severe preoperative adduction deficits are associated with medial rectus muscle insertion abnormalities and abnormal forced ductions, but frequently there are exceptions. Severe medial rectus muscle insertion abnormalities, including lost muscles, may be found despite mild preoperative adduction deficits.
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http://dx.doi.org/10.1016/j.ophtha.2017.01.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5440204PMC
June 2017

Comparison of Rating Scales in the Development of Patient-Reported Outcome Measures for Children with Eye Disorders.

Strabismus 2017 03 6;25(1):33-38. Epub 2017 Feb 6.

a Department of Ophthalmology , Mayo Clinic, Rochester , MN , USA.

Background: A rating scale is a critical component of patient-reported outcome instrument design, but the optimal rating scale format for pediatric use has not been investigated. We compared rating scale performance when administering potential questionnaire items to children with eye disorders and their parents.

Methods: Three commonly used rating scales were evaluated: frequency (never, sometimes, often, always), severity (not at all, a little, some, a lot), and difficulty (not difficult, a little difficult, difficult, very difficult). Ten patient-derived items were formatted for each rating scale, and rating scale testing order was randomized. Both child and parent were asked to comment on any problems with, or a preference for, a particular scale. Any confusion about options or inability to answer was recorded.

Results: Twenty-one children, aged 5-17 years, with strabismus, amblyopia, or refractive error were recruited, each with one of their parents. Of the first 10 children, 4 (40%) had problems using the difficulty scale, compared with 1 (10%) using frequency, and none using severity. The difficulty scale was modified, replacing the word "difficult" with "hard." Eleven additional children (plus parents) then completed all 3 questionnaires. No children had problems using any scale. Four (36%) parents had problems using the difficulty ("hard") scale and 1 (9%) with frequency. Regarding preference, 6 (55%) of 11 children and 5 (50%) of 10 parents preferred using the frequency scale.

Conclusions: Children and parents found the frequency scale and question format to be the most easily understood. Children and parents also expressed preference for the frequency scale, compared with the difficulty and severity scales. We recommend frequency rating scales for patient-reported outcome measures in pediatric populations.
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http://dx.doi.org/10.1080/09273972.2016.1276941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617644PMC
March 2017

Symptoms in Children with Intermittent Exotropia and Their Impact on Health-Related Quality of Life.

Strabismus 2016 12 11;24(4):139-145. Epub 2016 Nov 11.

a Department of Ophthalmology , Mayo Clinic , Rochester , MN , USA.

Purpose: In childhood intermittent XT, the frequency and type of symptoms have not been rigorously studied. We aimed to identify specific symptoms in children with intermittent XT, their frequency, and effects on health-related quality of life (HRQOL).

Methods: 35 children (5-13 years) with intermittent XT without previous surgery were enrolled in a prospective cohort study. Specific symptoms were identified from a previous study involving child and parent interviews and formulated as a 22-item symptom questionnaire. A frequency Likert-type rating scale was used and a response of "sometimes" or more was considered consistent with having the symptom. All 35 children, along with one parent for each child, also completed the patient-derived intermittent XT HRQOL questionnaire (IXTQ) with Child, Proxy, and Parent components. The frequency of symptoms was calculated, and the relationship between individual symptom question scores and Child, Proxy, and Parent HRQOL scores, was evaluated in multivariate linear regression analyses.

Results: The mean number of specific symptoms was 7 (range 2 to 19). The most frequently reported were: rubbing the eye (29 [83%] of 35), problems with eyes in the sun, and the eyes feeling tired (each 22, 63%). Lower (worse) Child IXTQ HRQOL scores were associated with symptoms of difficulty focusing eyes (P=0.0007), double vision (P=0.007), eyes hurting (P=0.006), and problems with eyes in the sun (P=0.06). There were weak associations between Proxy IXTQ and Parent IXTQ scores and child symptoms. Overall, 7 symptom questions were associated with reduced HRQOL in multivariate models.

Conclusion: Children with intermittent XT frequently experience symptoms, some of which impact the child's HRQOL. Formal assessment of symptoms may aid understanding of the effects of intermittent XT on an individual child, and could use just the 7 symptom questions associated with reduced HRQOL.
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http://dx.doi.org/10.1080/09273972.2016.1242640DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338296PMC
December 2016