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      Association between Childhood Strabismus and Refractive Error in Chinese Preschool Children

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          Abstract

          Purpose

          To investigate the association between concomitant esotropia or concomitant exotropia and refractive error in preschool children

          Methods

          A population-based sample of 5831 children aged 3 to 6 years was selected from all kindergartens in a representative county (Yuhuatai District, Nanjing, Jiangsu Province) of Nanjing, China. Clinical examinations including ocular alignment, ocular motility, visual acuity, optometry, stereopsis screening, slit lamp examination and fundus examination were performed by trained ophthalmologists and optometrists. Odd ratios (OR) and 95% confidence intervals (95% CI) were calculated to evaluate the association of refractive error with concomitant esotropia and concomitant exotropia.

          Results

          In multivariate logistic regression analysis, concomitant esotropia was associated independently with spherical equivalent anisometropia (OR, 3.15 for 0.50 to <1.00 diopter (D) of anisometropia, and 7.41 for > = 1.00 D of anisometropia) and hyperopia. There was a severity-dependent association of hyperopia with the development of concomitant esotropia, with ORs increasing from 9.3 for 2.00 to <3.00 D of hyperopia, to 180.82 for > = 5.00 D of hyperopia. Concomitant exotropia was associated with astigmatism (OR, 3.56 for 0.50 to 1.00 D of astigmatism, and 1.9 for <0.00 D of astigmatism), myopia (OR, 40.54 for -1.00 to <0.00 D of myopia, and 18.93 for <-1.00 D of myopia), and hyperopia (OR, 67.78 for 1.00 to <2.00 D of hyperopia, 23.13 for 2.00 to <3.00 D of hyperopia, 25.57 for 3.00 to <4.00 D of hyperopia, and 8.36 for 4.00 to <5.00 D of hyperopia).

          Conclusions

          This study highlights the close associations between refractive error and the prevalence of concomitant esotropia and concomitant exotropia, which should be considered when managing childhood refractive error.

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          Most cited references26

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          Psychosocial aspects of strabismus study.

          To assess the psychosocial implications of growing up with and living with socially noticeable strabismus. Self-report mailed questionnaire and the Hopkins Symptom Checklist. Patients with strabismus who were seen at the University of California, Davis, Medical Center, Department of Ophthalmology, from 1976 to 1989. Forty-three female and male subjects aged 15 years or older who had a history of childhood strabismus that was uncorrected or incompletely corrected past the age of 13 years. None. Participants' responses to our survey and to the Hopkins Symptom Checklist. Strabismus had a negative impact on many aspects of our subjects' lives. They report difficulty with self-image, securing employment, interpersonal relationships, school, work, and sports. Furthermore, difficulties encountered did not go away after childhood, rather, the problems encountered by our subjects intensified in the teenage and adult years. Subjects demonstrated generalized higher levels of distress on the Hopkins Symptom Checklist than age- and sex-matched controls (P < .01). Psychosocial difficulties relating to socially noticeable strabismus are not just a problem for school-children but also for teenagers and adults. Correction of strabismus in the older teenager or adult may offer them improvement in psychosocial functioning, a benefit not previously reported in the literature.
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            Factors associated with childhood strabismus: findings from a population-based study.

            To describe strabismus prevalence and associated factors in a representative sample of 6-year-old Australian children. Population-based cross-sectional study. One thousand seven hundred thirty-nine predominantly 6-year-old children resident in Sydney examined in 2003 and 2004. Cover testing was performed at near and distance fixation, and with spectacles if worn. Logarithm of the minimum angle of resolution visual acuity was measured in both eyes before and after pinhole correction, after correcting any cylindrical refraction >0.50 diopters and with spectacles, if worn. Cycloplegic autorefraction (cyclopentolate) and detailed dilated fundus examination were performed. Each child's medical and perinatal histories were sought in a detailed parental questionnaire. Strabismus was defined as any heterotropia at near or distance fixation, or both, on cover testing. Microstrabismus was defined as a deviation of fewer than 10 prism diopters. Strabismus was diagnosed in 48 children (2.8% of the population), 5 of whom had previously undergone surgical correction; 26 children (54%) had esotropia, 14 (29%) had exotropia, 7 (15%) had microstrabismus, and 1 child had VIth cranial nerve palsy. Prematurity was associated with a 5-fold increase in the risk of esotropia (odds ratio, 5.0; 95% confidence interval, 1.8-14.1). Visual impairment (with presenting correction) was significantly more common in children with (22.9%) than without (1.3%) strabismus (P<0.0001). The presence of strabismus was significantly associated with hyperopia, astigmatism, anisometropia, and amblyopia (P<0.0001). This report documents the prevalence of strabismus and its relation to other ocular signs and visual impairment in a representative sample of Australian school children. Presence of strabismus was significantly associated with prematurity.
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              Risk factors associated with childhood strabismus: the multi-ethnic pediatric eye disease and Baltimore pediatric eye disease studies.

              To investigate risk factors associated with esotropia or exotropia in infants and young children. Population-based cross-sectional prevalence study. Population-based samples of 9970 children 6 to 72 months of age from California and Maryland. Participants were preschool African-American, Hispanic, and non-Hispanic white children participating in the Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Eye Disease Study. Data were obtained by parental interview and ocular examination. Odd ratios and 95% confidence intervals were calculated to evaluate the association of demographic, behavioral, and clinical risk factors with esotropia and exotropia. Odds ratios (ORs) for various risk factors associated with esotropia or exotropia diagnosis based on cover testing. In multivariate logistic regression analysis, esotropia was associated independently with prematurity, maternal smoking during pregnancy, older preschool age (48-72 months), anisometropia, and hyperopia. There was a severity-dependent association of hyperopia with the prevalence of esotropia, with ORs increasing from 6.4 for 2.00 diopters (D) to less than 3.00 D of hyperopia, to 122.0 for 5.00 D or more of hyperopia. Exotropia was associated with prematurity, maternal smoking during pregnancy, family history of strabismus, female sex, astigmatism (OR, 2.5 for 1.50 to <2.50 D of astigmatism, and 5.9 for ≥2.5 D of astigmatism), and anisoastigmatism in the J0 component (OR, ≥2 for J0 anisoastigmatism of ≥0.25 D). Prematurity and maternal smoking during pregnancy are associated with a higher risk of having esotropia and exotropia. Refractive error is associated in a severity-dependent manner to the prevalence of esotropia and exotropia. Because refractive error is correctable, these risk associations should be considered when developing guidelines for the screening and management of refractive error in infants and young children. The author(s) have no proprietary or commercial interest in any materials discussed in this article. Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                20 March 2015
                2015
                : 10
                : 3
                : e0120720
                Affiliations
                [1 ]First Clinical Medical College of Nanjing Medical University, Jiangsu Province, China
                [2 ]Department of ophthalmology, Wuxi No.2 People's Hospital, Jiangsu Province, China
                [3 ]Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Jiangsu Province, China
                [4 ]Maternal and Child Healthcare Hospital of Yuhua District, Nanjing, China
                [5 ]Department of Ophthalmology, Jiangsu Province Hospital, the First Affiliated Hospital with Nanjing Medical University, Jiangsu Province, China
                Medical College of Soochow University, CHINA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: HL JJY HZ RBY JB HD JC. Performed the experiments: HL JJY HZ RBY JB HD JC. Analyzed the data: HL JJY HZ RBY. Contributed reagents/materials/analysis tools: HZ RBY. Wrote the paper: HZ HL.

                Article
                PONE-D-14-45528
                10.1371/journal.pone.0120720
                4368197
                25793499
                e76a9ae1-6fe6-4be7-9670-12dfde6390a7
                Copyright @ 2015

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

                History
                : 4 November 2014
                : 25 January 2015
                Page count
                Figures: 0, Tables: 4, Pages: 11
                Funding
                The authors received funding from the Science and Technology Bureau of Yuhuatai District. The grant numbers are 201001110 and the URL is http://www.njkj.gov.cn/. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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                Research Article
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