Improving the pediatric eye examination can be done with several small steps, according to Jeff Locke, MSc, OC (C), COMT, a past copresident of the Canadian Orthoptic Society.

Locke, an orthoptist/instructor and team lead in the visual electrophysiology lab at IWK Health in Halifax, Nova Scotia, Canada, discussed the issue of finessing the pediatric eye examination.

“We can streamline things and make the examination 1% better by being more competent in assessing visual acuity, checking for binocular single vision, and knowing what visual electrophysiology can do in this age group,” said Locke.

In order for vision to be normal, stimuli need to get through our optics to the retina, for the retina to relay to the optic nerve, and for the optic nerve to relay to the cortex.

“Acuity can be based on what aspects of the pathway are stimulated,” Locke explained.

To benchmark 20/20 vision in an infant, the testing types and acuity being measured need to be altered, said Locke.

“We need to shift to more detection-based acuity vs. recognition,” he said.

In pre-verbal children, forced-choice preferential looking (FPL) tests like Cardiff and Teller are not the most accurate in detecting and managing amblyopia, he pointed out.

Locke noted that it is easy to get complacent with FPL tests and stop documenting those earlier learned tests.

As a child reaches more visual milestones as they age from newborn to 1 year, the physician can perform more complex testing.



The challenges of examining visual fields in children

“It does not mean that those tests administered during earlier milestones [when a child was younger] are no longer useful,” he explained. “They can add great qualitative aspects to your vision examination.”

Indeed, vision testing in infants needs to have qualitative more than quantitative assessments, said Locke. 

A quantitative test like the FPL test serves as a benchmark for normal vision in infants and provides a value over time, he noted. That said, qualitative tests are quick to perform and can aid in detecting asymmetry in vision, Locke said.

In terms of vision assessment tests, Locke pointed to research that concluded optokinetic nystagmus induction methods have been found to be suboptimal in determining visual acuity thresholds. 

He noted that they can be a great qualitative indicator of the visual pathway as intact pursuit and saccadic centers are needed, as is normal cranial nerve innervation to the extraocular muscles.

Looking to the future of pediatric ophthalmology

 has suggested a strategy for a pediatric visual acuity examination, Locke pointed out.

“[The study authors] advised for best compliance to start with binocular visual acuity with Cardiff at 50 cm, followed by induced tropia,” Locke said. “Once these are successfully completed, you can then try monocular visual acuity at 50 cm with your FPL Cardiff [test]. Their view was assessing both FPL Cardiff at 50 cm and induced tropia allows for more accurate visual assessment and allows practitioners to obtain more information should they lose cooperation [from the pediatric patient].”

An educated assumption is being made based on observational data and detection-based acuity with pediatric exams, Locke pointed out.

“When trying to make a comparison between detection-type of acuities, like with forced-choice preferential looking, we are likely overestimating acuity, and it becomes challenging to detect mild to moderate levels of amblyopia,” he said. “Each detection type of acuity has shown validity in assessing the pediatric population, but the sensitivity in detecting amblyopia is variable among tests. None appear to be as robust as crowding-based testing.”



Managing a changing landscape of IRD pediatric cases

The goal needs to be to maximize the visual examination by combining multiple methods of detection-based testing, not only to increase the sensitivity, but also to gain more general, ocular health knowledge of the pediatric patient, Locke explained.

“Do as much as you can binocularly [assessment] while the child is getting comfortable with you, but at the same time, you are extracting data,” he said.

The FPL test outcome should not be the only end point in a pediatric vision assessment, Locke stressed.

“Make your exam 1% better by adding a qualitative measurement into the mix,” he said.

And for those who do not use the FPL test, Locke advised setting a grading standard across the clinic for fixation testing to help follow amblyopia over time, noting that children do not need to be old enough to respond verbally before binocularity is assessed.

There are, however, some objective methods being employed to get a sense of binocularity.



It takes a village to beat visual system diseases in children


“We can test motor fusion capability in infants, and newer investigations in the use of the FPL test in stereopsis are emerging,” he said.

Detecting stereopsis will help guide a care plan and add confidence to the visual acuity assessment, Locke noted.

The challenge with visual electrophysiology in pediatrics is that most of the tests require an infant or toddler who is being assessed to cooperate in order for accurate results to be obtained, making the tests not always practical, with the exception of the electroretinogram (ERG), which can be done under sedation, Locke said.

“The ERG is our bread and butter, but they cannot localize dysfunction specifically to the macula,” he said.

Visually evoked potentials (VEPs) offer an objective measurement at the cortex, but anomalies at any level of the optic pathway (optics, macula, optic nerve, optic pathway) can result in VEP pathology, Locke noted.

Another clinical pearl he offered is that assessors avoid having their backs turned from their pediatric patients.

Locke suggested placing the computer screen where information is being inputted in such a way as to maintain a line of sight to the child being assessed. 





This article is based on a presentation at the virtual 31st annual Jack Crawford Day pediatric ophthalmology update. Locke has no financial disclosures related to this content.


1. Kutschke PJ. Preverbal assessment for amblyopia. 

2. Nanda KD, Blaha B, Churchfield WT, Fulwylie CR, Medsinge A, Nischal KK. Induced tropia test and visual acuity testing in nonverbal children. 

. 2018;68(4):134-136. doi:10.1080/2576117X.2018.1525235

Articles

Focus on maximizing visual examination by combining methods of detection-based testing.

Physicians finessing the pediatric eye examination

Preliminary results of 2 ongoing phase 1/2 clinical trials evaluating the effects of subretinal gene therapies for achromatopsia (ACHM) indicate that both drugs, AGTC-401 and AGTC-402 (Applied Genetic Technologies Corporation), seem safe and well tolerated in patients with ACHM.

It is noteworthy that data from both studies are showing encouraging signs of biologic activity, according to Mark E. Pennesi, MD, PhD, an associate professor of ophthalmology, molecular and medical genetics; Kenneth C. Swan Endowed Professor; and division chief of ophthalmic genetics at Oregon Health and Science University’s Casey Eye Institute in Portland.

Investigators start pivotal subretinal gene therapy trial

ACHM is an autosomal recessive disease that causes a cone dysfunction syndrome, with the bulk of the mutations found in 2 genes, 

Two clinical trials of the affected genes are underway. One is a long-term follow-up gene therapy study for achromatopsia 

, at Moorfields Eye Hospital in London, England, and Kellogg Eye Center in Ann Arbor, Michigan. 

The other is a natural history study of achromatopsia 

Patients with ACHM have central vision in the range of 20/100 to 20/200, nystagmus, color vision defects, photophobia, and high myopia. 

Electroretinography (ERG) shows severely decreased cone function but normal rod function, Pennesi explained. Both trials are phase 1/2, open-label, dose-escalation studies.



The increasing potential of electroretinography in ophthalmic diagnostics

The enrolled patients were treated with 1 subretinal injection of either AGTC-401 (rAAV2tYF-PR1.7-hCNGB3; 26 patients) or AGTC-402 (rAAV2tYF-PR1.7-hCNGA3; 19 patients) into the macular region on 1 eye (study eye). All patients were 14 years or older.

Participants were sequentially assigned to 1 of 4 dosing groups in both studies. 

The primary end points were changes in the best-corrected visual acuity, light discomfort testing by ocular photosensitivity analyzer, ERG and multifocal ERG, retinal sensitivity by static perimetry and microperimetry, color vision testing using the Farnsworth D15 and color assessment and diagnosis tests, and patient-reported outcomes using the quality-of-life Visual Light Sensitivity Questionnaire-8.

Most ocular adverse events were mild to moderate in nature. Of those that occurred in more than 20% of eyes, the most common was conjunctival hemorrhage, which likely was related to the surgical procedure. 

Vitreous and anterior chamber cells were seen more frequently in the ACHM-

The first steps in gene therapy for achromatopsia

 group, 2 patients had a serious adverse event. One was a macular hole related to the study surgery, and the other was ocular hypertension related to the steroids prescribed. It was controlled with modification of the steroids.

 group had steroid-related increased intraocular pressure that was controlled with modification of the steroids.

The preliminary results also showed improvements in photosensitivity and 2-color dark light-adapted perimetry in 3 of the 16 patients in the 


This article is adapted from Pennesi’s presentation at the Association for Research in Vision and Ophthalmology’s 2021 virtual annual meeting. He is a consultant to Applied Genetic Therapies Corporation.

Clinical trials show subretinal agents are safe, well tolerated by patients.

Targeting gene therapy for achromatopsia

Reviewed by Friederike C. Kortuem, MD, MSc

Treatment with voretigene neparvovec-rzyl (Luxturna, Spark Therapeutics) resulted in a short-term change in the foveal morphology in a 15-year-old girl with visual impairment, according to Friederike C. Kortuem, MD, MSc, from the Eye Clinic Tübingen, Eberhard Karls University of Tübingen in Baden-Württemberg, Germany. 

The impairment included nyctalopia and decreased visual acuity (VA) in early childhood.

Visual deterioration generally occurs early in Leber congenital amaurosis type 2 (LCA2) and early-onset severe retinal dystrophy (EOSRD), from as soon as birth to 5 years of age. 



First patient dosed in optogenetic gene therapy trial



Characteristically, rapid degeneration of the rods and cones, visual field reduction, sluggish or near-absent pupillary responses, photophobia, nystagmus, and nyctalopia can occur. By the 4th decade of life, patients usually are legally blind.

Subretinal administration of voretigene neparvovec-rzyl in an adeno-associated viral vector was approved in the US by the FDA in 2017 and in Germany in 2019 to treat retinal dystrophies caused by bi-allelic RPE65 mutations; RPE65 is involved in the vitamin A restoration cycle in the eye.


The current patient had an RPE65 homozygous mutation. The VA in the right eye at examination was 20/63, and the anterior segment was unremarkable. 

The retinal examination in that eye showed central macular atrophy, narrowed vessels, and diffuse peripheral atrophy.

 Kortuem demonstrated the overall decreased retinal thickness in the right eye.

The clinical examinations included measurement of the best-corrected VA (BCVA), spectral-domain 

 (OCT), and adaptive optics retinal imaging.

At baseline, the patient was injected with the gene therapy vector, which was successfully positioned between the neural retina and the retinal pigment epithelium. 

She was evaluated at baseline and then at 2 and 5 weeks and 3 months following treatment.

At baseline, compared with healthy individuals of the same age, this patient’s retina was thinner. 

Kortuem showed that the central fovea had alterations in its layers and the retinal structures were not well demarcated, in contrast to the parafoveal layer with a preserved outer retina and photoreceptors.

As soon as 2 weeks after treatment, the foveal layer started to change. The external limiting membrane was visualized in the fovea.

“The overall disrupted appearance improved,” Kortuem commented.

After 5 weeks, the layering of the central fovea further improved out to 3 months.

Expansion study examines safety, efficacy of subretinal gene therapy for X-linked RP

The adaptive optics images obtained at baseline showed a mosaic of disrupted photoreceptor cells that, according to Kortuem, is characteristic of inherited retinal diseases. 

Following treatment, the superior nasal area appeared partly clear, and the cones were identifiable. 

In the first 5 weeks following treatment, the initially patchy areas seemed to be decreasing over time. 

These morphologic rescue parameters changed gradually over time and were correlated partly with the improvement in the foveal-mediated vision after the treatment.

Regarding the safety of the treatment, no signs of inflammation were observed.

Cone functionality improved slightly and the patient reported “brighter” vision, which she also reported 5 weeks after surgery. At 3 months after surgery, the objective changes persisted.

The VA remained stable from baseline to week 5 and then improved by 1 line to 20/50. The contrast sensitivity also remained stable over time.

Retinal therapeutic clinical trials address disease at cor

Chromatic pupil campimetry showed a dramatic increase in the central 10 degrees of the pupil from week 2 to week 5 and this improvement persisted to month 3.

“Rapid changes in the photoreceptor morphology seen on OCT and adaptive optics imaging after successful gene therapy in patients with LCA and EORD can be quantifiable at the individual level,” Kortuem concluded. 


e:friederike.kortuem@med.uni-tuebingen.de


This article is adapted from Kortuem’s presentation at the Association for Research in Vision and Ophthalmology 2021 virtual annual meeting. She has no financial interest in this subject matter.

As soon as 2 weeks after treatment, changes occur to foveal layer.

Gene therapy sparks foveal morphologic changes in LCA

 have a very high-tech, sophisticated optical system that works excellently when the cornea is in perfect condition. Therefore, they are contraindicated in patients who have corneal haze, scar, or oedema.

A patient who has a posterior corneal elevation is susceptible to higher-order aberrations (HOAs) or early keratoconus. 

Early clinical experience with next-generation lens

Consequently, many surgeons will refrain from using premium IOLs in such cases. As one of the first surgeons in Saudi Arabia to use a trifocal lens, I meticulously select my patients.



In Saudi Arabia, keratoconus is prevalent because of the dry atmosphere, seasonal allergies, and consanguinity. 

However, not all patients have the same severity of disease. Some live their entire lives without knowing they have keratoconus or without signs of the condition. Others present early with signs and symptoms.

Many patients who present to me with the desire to be spectacle-free have questionable corneal tomography images. 

The first patient with keratoconus I treated with a trifocal lens (AT LISA tri toric 939 M/MP; Carl Zeiss Meditec) was one of my colleagues, a 52-year-old physician with a mild but stable form of keratoconus.

Her central cornea seemed to be normal and the steepening was at the inferior part of the cornea, sparing the central 5-mm zone. The HOA at the 6-mm zone was 1.2 μm, outside the normally accepted range of up to 0.5 μm.



Curvature-changing IOL: New frontier in cataract and presbyopia surgeries

The patient was keen to try trifocal lenses, so after long discussion and counselling the procedure was undertaken. 

Postoperatively, she was incredibly happy, with uncorrected visual acuity 6/6 at near, distance, and intermediate. She had no visually disturbing aberrations.

I then performed the same procedure on her sister, who suffers from subclinical keratoconus and who also responded very well. 

That is when I began to consider premium 

 for certain cases of patients with keratoconus. I developed my own criteria for selection and, so far, patients have been very satisfied.

I have performed this procedure on 4 patients (8 eyes) with different categories of keratoconus but who all have 1 thing in common—the central 5-mm zone with an accepted range of HOA. It is not extremely high, but it is apparent that they do not have a normal posterior cornea.



Estimating the total cornea power in keratoconus patients


During diagnosis, all patients undergo a routine, complete ophthalmic examination, which includes dry and wet refraction. 

Patients also undergo a meticulous clinical assessment and detailed history taking, including family history, previous trauma, allergies, any spectacles changes and the frequency of these changes, and contact lens use.

Next, we perform corneal tomography, which is key for diagnosing keratoconus and precisely shows the anterior corneal curvature and the posterior corneal curvature.

Using 4-maps analysis, I perform the Belin/Ambrosio Enhanced Ectasia analysis and I study them carefully. Then I check the elevation maps, both in the forms of best-fit sphere and the best-fit toric ellipsoid.

I compare the maps and see whether the patient has good spectacle correction. If the patient does not have high central aberration, I then consider implanting a trifocal lens.

I speak with the patients about HOA photic phenomena and explain that they should anticipate some glare and halos over time. 

Presbyopia-correcting IOL with nondiffractive design offers gains

I show them a picture of what glare and halos will look like so they know what to expect in the coming weeks. I also discuss mental adaptation and how their vision might be adapted to some aberration.

The good thing about patients with keratoconus is that they are used to a minimum amount of light, glare, and halos. If their central vision is OK, it is not exaggerated by premium lenses. 

In all of my cases, glare and halos have turned out to be benign. However, I still like to set realistic expectations for patients.

I perform a routine phacoemulsification and painstakingly center the

. The plate-haptic design IOL centers itself easily and this is a strong point in favor of this design.

I like to place 1 suture to be sure that the lens does not move, especially if ectatic corneas have delayed healing or might have microleaks and fluctuation in eye pressure, which can change the lens position. 

If the patient is receiving a toric lens, I ensure that the anterior chamber maintains its stability.




The postoperative regimen is similar to that of a routine phaco procedure. I examine the patient and remove the suture within the first week and no later than 2 weeks from surgery. Then I reassess the patient’s vision at 2 weeks, 6 weeks, and 3 months. 

One step of utmost importance is assuring the patient that the lens is removable if he or she is not happy. 

I offer patients a lens removal within the first 6 weeks if the aberration is higher than anticipated, and this provides some reassurance for the patient.


A 56-year-old breast cancer survivor with subclinical keratoconus wanted to treat herself by getting her eyesight back. She had heard about premium lenses and presented to me with a specific interest in trying them.



Vision simulator provides preoperative glimpse at postoperative eyesight

Considering her condition, I conducted an examination and determined that she was fine to move forward with the procedure. She told me that she was reborn after 2 things: recovering from breast cancer and being spectacle-free for the first time in her life.

A 48-year-old man in a sensitive diplomatic position presented to me and shared that his use of spectacles was causing some embarrassment because there were times when he was unable to wear them but still required to read things and he felt that this was disabling him. 

He was considering leaving his job because of his inability to focus.

He had posterior corneal elevation. The procedure was successful, and he has returned to work without anyone knowing that he had undergone the procedure.


Sometimes, surgeons can be afraid of technology because we do not know what is hidden behind it, and we refrain from exploring new advancements because we do not want our patients to have an unsatisfactory experience.

Corneal crosslinking outcomes look good for pediatric keratoconus


Given my recent experience with implanting premium lenses in challenging cases, I have changed my perspective and now view these opportunities as another way to give my patients a chance and a better outcome.

With the confidence that I can exchange the lens with minimum complications as a backup plan and considering that there is no cost to the patient because I work in a government hospital, I have to ask myself why not.

In the end, the patients with keratoconus who have received premium lenses are the happiest patients I have. 

This is probably because they are used to some amount of HOA, so they adapt to their new

 faster and have higher tolerance than individuals with normal eyes.


Al Saati is chief of the Anterior Segment Division at Prince Sultan Military Medical City, Riyadh, Saudi Arabia. She has no financial disclosures to make regarding any of the lenses used in this case series.

Trifocal IOLs can, if implanted with caution, be suitable for patients with keratoconus.

Posterior corneal elevation: Is there a role for premium IOLs?

Pooled data from the phase 2 and 3 clinical trials of teprotumumab-trbw, (Tepezza; Horizon Therapeutics) showed that the drug significantly improved the clinical course of active thyroid eye disease (TED) over the long term in many patients and even in those with more severe baseline disease.

TED is characterized by inflammation and proptosis and diplopia refractory to treatment. 

Study: Therapy reduces proptosis, diplopia in TED



Teprotumumab, which seems to be an important therapeutic advancement for this patient population, is an insulinlike growth factor 1 receptor–inhibiting monoclonal antibody that received FDA approval in January 2020, based on 2 double-masked, placebo-controlled, multicenter, randomized trials carried out in the United States and Europe.

George J. Kahaly, MD, PhD, and colleagues took their investigation a step further in the current pooled analysis, focusing on proptosis and diplopia by evaluating the short- and long-term aggregate response to teprotumumab from the pair of phase 2 and phase 3 trials. 

He is a professor of medicine and endocrinology/metabolism, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany.

In those 24-week studies, the patients received either active treatment or placebo once every 3 weeks, for a total of 8 infusions. 

Patients were evaluated at 7, 24, and 51 weeks after the last infusion of teprotumumab. 

Advancement in TED treatment is a bright spot

The investigators calculated the composite outcome of the data from the 2 trials as the proportions of patients with improvement in 1 eye in at least 2 of these parameters: proptosis, diplopia, eyelid swelling, lid aperture, global motility, and the Clinical Activity Score (CAS) without decreases in at least 2 of these in either eye.

Eighty-four patients were randomly assigned to teprotumumab and 87 to placebo.

At the 24-week evaluation, the authors reported that more patients randomly assigned to teprotumumab achieved a minimal 2-mm decrease in proptosis compared with placebo—77% vs 15%, respectively, a difference that achieved significance (P < .0001). 

The number of diplopia responders was also significantly higher with teprotumumab than placebo at week 24—70% vs 18%, respectively, except among tobacco users and those with a low thyrotropin binding inhibiting immunoglobulin serum concentration.

 Large improvements in quality of life also were seen. The beneficial results also withstood the test of time. 

Thyroid eye disease: Not limited to visual impairment

Seven weeks after the last dose of teprotumumab, the following responses were seen: proptosis (87%), diplopia (66%), and the composite ophthalmic response (92%). 

There was no evidence of acute TED rebound 7 weeks after the last drug infusion. 

No new safety concerns were found during follow-up or in the pooled analysis compared with the safety evaluation in the 24-week studies. 


This study was funded by Horizon Therapeutics.

1. Kahaly GJ, Douglas RS, Holt RJ, Sile S, Smith TJ. Teprotumumab for patients with active thyroid eye disease: a pooled data analysis, subgroup analyses, and off-treatment follow-up results from two randomised, double-masked, placebo-controlled, multicentre trials. 

. 2021;9(6):360-372. doi:10.1016/S2213-8587(21)00056-5

Sustained findings over long term indicate no rebound of disease.

Phase 2/3 results show teprotumumab effective treatment option for TED

Reviewed by Raymond Buncic, MD, CM, FRCSC

It is vital for ophthalmologists to differentiate ocular nystagmus, saccadic disorders, and central nervous system nystagmus to reach the correct diagnosis and decide on the management, according to Raymond Buncic, MD, CM, FRCSC, a senior clinical neuro-ophthalmologist in the Department of Ophthalmology and Vision Sciences at the Hospital for Sick Children in Toronto, Canada.

Buncic recommended that ophthalmologists pay studied attention to the direction of eye movements, the speed of movement, and the presence or absence of patterns in the movement.

VA, visual function are going the way of ocular inflammation

“We need to first differentiate between the type of eye movement and categorize it as an ocular nystagmus or not,” he explained. “We need to know if it is truly nystagmus at all and differentiate it from a saccadic disorder like opsoclonus, which may require a more general medical assessment and management.”

One of the key characteristics of nystagmus is that it most often has a slow phase during its repetitive eye movement, Buncic said. 

In contrast, saccadic disorders feature no slow phase, are irregular and fixation dependent, have variable movement, and lack recognizable patterns and a repetitive nature, he said.

“It can be hard to tell if there is slow movement because the movements are so fast,” Buncic explained. “We also look for patterns of movement to see if it is the same nystagmus over and over. We look at eyes for symmetry of movement.”

Multicolor and autofluorescence imaging: What’s in a name?

Once an ophthalmologist has decided that the presentation is nystagmus, then it must be determined if it is an ocular type of nystagmus or a neurological type of nystagmus, according to Buncic.

To differentiate between ocular and neurological nystagmus, clinicians need to consider features that might provide clues as to the nature of the nystagmus, he explained. 

In ocular nystagmus, vision is often affected, intensity is variable, and movement is usually constantly monoplanar (ie, not changing direction from horizontal to vertical). 

In contrast, in neurological nystagmus, there is often oscillopsia, movement is multidirectional, and there is a repetitive pattern of movement (ie, downbeat nystagmus or see-saw nystagmus).

In cases of ocular nystagmus with movements in the horizontal plane, conversion to a vertical nystagmus in up or down gaze indicates more of a neurological problem, Buncic noted.

Some forms of nystagmus can be more easily detected than others because of the small amplitude of movements.

Do you 'need' or just 'want' that new diagnostic imaging device?

“Typically, the movements are either slow in both directions (pendular) or slow in one and quick or jerky in the other (jerk nystagmus) in primary gaze,” he said.

In cases of incomplete albinism, when iris transillumination may be difficult to see with the microscope in the moving eyes, multichannel visual evoked potentials (VEP) are useful to demonstrate the abnormal chiasmal visual fiber crossing that exists in albinism, explained Buncic.

Assessing for infantile nystagmus involves obtaining developmental and family history and performing a clinical assessment of vision. 

Buncic stressed that it is critical to consider the presence of any abnormality that may be impeding vision in the front or back of the eye.

, maculopathy, foveal hypoplasia, optic nerve hypoplasia, or atrophy, are usually obvious on examination, according to Buncic.

“Some of these will require a neurological investigation,” he noted. “The ocular exam is very important and involves documentation with photography and OCT [optical coherence tomography]. This gives us a chance to look back and contemplate when we have a few quiet moments for further analysis.”

Visualization with en face OCT offers value for ophthalmologists

When a less obvious retinal problem such as a retinal dystrophy is suspected or the fundus looks normal, an electroretinogram will usually prove helpful in establishing the diagnosis, Buncic pointed out.

If spasmus nutans, usually characterized by exceptionally large amplitude head bobbing and abnormal head posture, is suspected, imaging should be conducted to rule out the rare, reported cause of an optic nerve tumor (optic glioma), he said.

In a series of infants with nystagmus presenting with optic pathway gliomas at the Hospital for Sick Children, Buncic noted that the main diagnostic trait was later onset.

“The overriding diagnostic characteristic was slightly later onset, 3 months or later after birth,” he said. “The other main criterion was initial uniocularity.”

Buncic and co-investigators did not find any cases of spasmus nutans in their series of optic pathway gliomas, but spasmus nutans is reported in these gliomas in the literature.

Monocular nystagmus is a clue toward either amblyopia or an optic pathway glioma, Buncic explained.

“There should be supporting evidence for amblyopia if you are going to make that diagnosis,” he said.

As a rule, if a neurological nystagmus is suspected, a child should be referred for magnetic resonance imaging and for management by a neurologist, he said.

The 2 most important saccadic disorders to keep in mind are opsoclonus-myoclonus syndrome, which can be caused by a neuroblastoma in children or be parainfectious, and the intermittent, voluntary “nystagmus” in children, which is benign but can be very alarming and distressing to parents when children continue to engage in this activity, Buncic concluded. 


This article is based on a presentation at the virtual Jack Crawford Day Conference, a pediatric ophthalmology update. Buncic has no financial disclosures related to this content.

First step is ruling out ocular nystagmus, saccadic disorder.

A patient’s eye movements can unlock diagnosis

Findings of a retrospective, comparative cohort study demonstrate benefit for integration of spectral-domain 

 in a diabetic retinopathy (DR) telemedicine screening program.

Lloyd P. Aiello, MD, PhD, presented study data from 422 eyes of 211 patients with diabetes who were consecutively imaged between January 8 and March 16, 2020, using the commercially available platform Monaco (Optos), which allows SD-OCT and UWF imaging in a single sitting. 

Linking patient imaging data to AAO IRIS Registry


Participants were seen in a UWF image-based DR teleophthalmology program at Joslin Diabetes Center in Boston, Massachusetts.

The results showed that the dual imaging substantially increased detection and reduced false positive assessments of 

Dual imaging may reduce costs, unnecessary referrals, telehealth study results show.

Ophthalmology Times: July 1, 2021

Physicians finessing the pediatric eye examination

Targeting gene therapy for achromatopsia

Gene therapy sparks foveal morphologic changes in LCA

Posterior corneal elevation: Is there a role for premium IOLs?

Phase 2/3 results show teprotumumab effective treatment option for TED

A patient’s eye movements can unlock diagnosis

Improving macular pathology detection in telemedicine screening

Intravitreal injections and endophthalmitis: Does lidocaine gel change the risk of the infection?

Advancements with preloaded IOL injectors

MIGS helping to personalize glaucoma surgery options

Timing and earlier neurolept anesthesia for laser-assisted cataract surgery

Real-world outcomes validate intraocular drug delivery method

Advancement in TED treatment is a bright spot

IOL dilemma: Replacement or rescue