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MEPEDS & BPEDS Risk Factors Papers

MEPEDS & BPEDS Risk Factors Papers. 1. Specific Aims: . To estimate and compare the prevalence of strabismus, amblyopia, and refractive error in a population-based sample of African-American, Asian-American, Latinos, and Non-Hispanic White children 6 months through 72 months (6 years) of age.

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MEPEDS & BPEDS Risk Factors Papers

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  1. MEPEDS &BPEDSRisk Factors Papers 1

  2. Specific Aims: • To estimate and compare the prevalence of strabismus, amblyopia, and refractive error in a population-based sample of African-American, Asian-American, Latinos, and Non-Hispanic White children 6 months through 72 months (6 years) of age. 2

  3. Specific Aims: • To evaluate the association of selected demographic, behavioral, and biological risk factors with these ocular disorders. Risk factors of particular interest include demographic factors (e.g., age, sex, race/ethnicity, socioeconomic status), behavioral factors (e.g., maternal and paternal alcohol and tobacco use, acculturation, eye care service use and prenatal health services utilization), and biologic factors (e.g., birth-weight, gestational age, family history of strabismus). 3

  4. Specific Aims: • To evaluate the association of strabismus, amblyopia, refractive errorand visual impairment in children 36 to 72 months with limitations in age-appropriate health-related functional status. 4

  5. BACKGROUND MEPEDS AND BPEDS • Two population-based studies of pediatric eye conditions • Identical protocols for key clinical and questionnaire data. • Participants • African-American, Hispanic, Non-Hispanic White • Children 6 months to 72 months at enrollment • Residing in 74 census tracts in Inglewood, Riverside, Glendale, CA • 54 census tracts in Baltimore, MD 5

  6. GLENDALE SAN GABRIEL VALLEY RIVERSIDE INGLEWOOD BALTIMORE MEPEDS AND BPEDS Area Map UNITED STATES OF AMERICA 6

  7. MEPEDS AND BPEDS Recruitment and Data Collection • Eligible participants identified through a census of all residential household in selected census tracts in CA and MD • Recruitment from • 2003 – 2007 BPEDS • 2003 - 2010 MEPEDS • Detailed in-person interview with child’s parent at the clinic and comprehensive clinical eye examination 7

  8. MEPEDS AND BPEDS Data Collection -Questionnaire • Parental interview completed at MEPEDS or BPEDS clinic by trained interviewer: • Demographic • Age, race/ethnicity (self-reported), gender, household income, parent education, insurance (health, vision), regular primary care, self-reported difficulty accessing care, study site • Behavioral • Maternal alcohol during pregnancy (yes/no), maternal smoking during pregnancy (yes/no), history of breast feeding, birth weight, maternal age at child’s birth • Clinical, Ocular or Medical history • Spherical equivalent of RE, family history of strabismus or amblyopia, gestational age<36 weeks, cerebral palsy of child, Down Syndrome of child 8

  9. MEPEDS AND BPEDS Order of Examination 11

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  12. MEPEDS AND BPEDS RESULTS 14

  13. PURPOSE • The purpose of these papers is to identify demographic, behavioral, clinical, and ocular risk factors associated with • (1) myopia and hyperopia, (2)astigmatism, (3)inter-ocular visual acuity differences and bilaterally decreased visual acuity, and (4)strabismus • in Hispanic, non-Hispanic white, and African-American preschooler children • from the population-based Multi-Ethnic Pediatric Eye Disease Study (MEPEDS) in California and Baltimore Pediatric Eye Disease Study (BPEDS) in Maryland. 21

  14. Risk factors for Hyperopia and Myopia in Preschool Children: The Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Pediatric Eye Disease Study The Joint Writing Committee for theMulti-Ethnic Pediatric Eye Disease Study and Baltimore Pediatric Eye Disease Study Groups Ophthalmology 2011: Accepted for Publication on June 3, 2011 22

  15. Risk factors for Hyperopia and Myopia in Preschool Children • Definition • Myopia was defined as SE refractive error -1.00 diopter • Hyperopia as SE refractive error +2.00 diopters 23

  16. Risk factors for Hyperopia and Myopia in Preschool Children Figure 1 MEPEDS Eligible Participants (n=10,212) BPEDS Eligible Participants (n=4132) Participants who completed the clinical examination(n=8123) Participants who completed the clinical examination(n=2546) Combined African-American, Hispanic, and Non-Hispanic White MEPEDS/BPEDS participants who completed the clinical examination and eligible for risk factor analyses n=9970 Hyperopia Multivariate Analysis Myopia Multivariate Analysis * Unable to diagnose refractive error (n=77); MEPEDS: Multi-ethnic Pediatric Eye Disease Study; BPEDS: Baltimore Pediatric Eye Disease Study ** Unable to diagnose refractive error (n=77); Missing Maternal smoking data (n=1344); Missing Health insurance data (n=541) Participants with complete interview and examination data (n=9893) Participants excluded from the analyses due to incomplete data** (n=1401) Participants excluded from the analyses due to incomplete data* (n=77) Participants with complete interview and examination data (n=8569) 24

  17. Risk factors for Myopia in Preschool Children Table 2. Multivariable Logistic Regression Analysis of Risk Factors for Myopia (≤-1D) in the Multi-ethnic Pediatric Eye Disease Study and the Baltimore Pediatric Eye Disease Study D: diopters, OR: odds ratio, CI: confidence interval 25

  18. Risk factors for Hyperopia in Preschool Children Table 3. Multivariable Logistic Regression Analysis of Risk Factors for Hyperopia (≥+2D) in the Multi-ethnic Pediatric Eye Disease Study and the Baltimore Pediatric Eye Disease Study D: Diopters, OR: odds ratio, CI: confidence interval 26

  19. Risk factors for Hyperopia in Preschool Children Figure 2 Locally weighted regression line illustrating the independent association of the amount of maternal smoking during pregnancy and the estimated prevalence of hyperopia in both the Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Pediatric Eye Disease Study. The estimated prevalence of hyperopia was obtained using a stepwise logistic regression procedure that adjusts for other potential risk factors. 27

  20. Risk factors for Hyperopia and Myopia in Preschool Children • In Conclusion: • Both hyperopia and myopia are associated with astigmatism. • Independent associations with myopia are young age and African-American ethnicity, while • Hyperopia is associated with non-hispanic whites and exposure to maternal smoking during pregnancy. • Given that both myopia and hyperopia are risk factors for the development of amblyopia and strabismus, these risk factors should be considered when developing guidelines for screening and intervention in preschool children. 28

  21. Risk Factors for Astigmatism in Preschool Children: The Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Pediatric Eye Disease Study. The Joint Writing Committee for theMulti-Ethnic Pediatric Eye Disease Study and Baltimore Pediatric Eye Disease Study Groups Ophthalmology 2011: Accepted for Publication on June 3, 2011 29

  22. Risk Factors for Astigmatism in Preschool Children • Definitions • Astigmatism was defined using a threshold level of cylindrical refractive error in the right or left eye of ≥1.50 D expressed in positive correcting cylinder form. • Astigmatism type was defined by orientation as with-the-rule (WTR) (plus cylinder axis 90° ± 15°) and against-the-rule (ATR) (plus cylinder axis 180° ± 15°); all other orientations were considered oblique. • The eye with the greater absolute amount of cylindrical refractive error was considered to be the worse eye. 30

  23. Risk Factors for Astigmatism in Preschool Children Table 2. Independent Risk Factors for Astigmatism based on Multivariate Stepwise Regression in Participants from MEPEDS and BPEDS (N=8,579).Table 1 cont’d. Frequency Distribution of Demographic, Behavioral, Clinical, and Ocular Risk Factors in Children With and Without Astigmatism in the MEPEDS and the BPEDS (N=8,579). MEPEDS: Multi-Ethnic Pediatric Eye Disease Study. BPEDS: Baltimore Pediatric Eye Disease Study. *Stepwise multivariate model: All risk factors with P-value < 0.1 at the univariate level were entered into the multivariate model. Risk factors with P-value < 0.05 were kept in the multivariate model. SE: Spherical equivalent OR = Odds Ratio; 95% CI = 95 percent Confidence Interval **children with SE of -1.0Diopter or more extreme were considered myopes; children with SE of +2.0Diopter or more extreme were considered hyperopes. 31

  24. Risk Factors for Astigmatism in Preschool Children Table 3. Association Between Smoking and Astigmatism Stratified by Demographic Characteristics in Participants of the MEPEDS and BPEDS (N=8,579). *adjusted for age, race/ethnicity, gender, SE refractive error; MEPEDS: Multi-Ethnic Pediatric Eye Disease Study. BPEDS: Baltimore Pediatric Eye Disease Study.OR = Odds Ratio; 95% CI = 95 percent Confidence Interval 32

  25. Risk Factors for Astigmatism in Preschool Children Figure 2 33

  26. Risk Factors for Astigmatism in Preschool Children Figure 3 34

  27. Risk Factors for Astigmatism in Preschool Children • In Conclusion: • We found that astigmatism is common in infants, but normalizes for many infants by 12 months of age. • Hispanic and African American children are most likely to have astigmatism than NH White children. • Myopia and hyperopia are associated with higher risk of astigmatism. • Prenatal, maternal smoking was the single modifiable behavioral risk factor identified for astigmatism • while the prevalence of smoking during pregnancy is typically low, this association may suggest etiologic or genetic pathways for future investigation. 35

  28. Risk Factors Associated with Childhood Strabismus: The Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Pediatric Eye Disease Study The Joint Writing Committee for theMulti-Ethnic Pediatric Eye Disease Study and Baltimore Pediatric Eye Disease Study Groups Ophthalmology 2011: Accepted for Publication on June 3, 2011 36

  29. Risk Factors Associated with Childhood Strabismus • Definition: • Strabismus was defined as constant or intermittent heterotropia of any magnitude at distance and/or near fixation. 37

  30. Risk Factors Associated with Childhood Strabismus Table 3. Independent Risk Factors† for Childhood Esotropia in 6- to 72-month Old Children in the MEPEDS and BPEDS MEPEDS: Multi-Ethnic Pediatric Eye Disease Study; BPEDS: Baltimore Pediatric Eye Disease Study; OR = Odds ratio; CI = 95% confidence interval; SE = spherical equivalent; D = diopters †Based on multivariate stepwise logistic regression model *Adjusted for all factors listed in the table OR’s in bold are statistically significant 38

  31. Risk Factors Associated with Childhood Strabismus Figure 2 40

  32. Risk Factors Associated with Childhood Strabismus Table 4. Independent Risk Factors† for Childhood Exotropia in 6- to 72-Month-Old Children in the MEPEDS and BPEDS MEPEDS: Multi-Ethnic Pediatric Eye Disease Study, BPEDS: Baltimore Pediatric Eye Disease Study, OR = Odds ratio; CI = 95% confidence interval; SE = spherical equivalent; D = diopters †Based on multivariate stepwise logistic regression model *Adjusted for all factors listed in the table OR’s in bold are statistically significant **Level defined by the eye with the lower magnitude of astigmatism 39

  33. Risk Factors Associated with Childhood Strabismus Figure 5 42

  34. Risk Factors Associated with Childhood Strabismus Figure 4 41

  35. Risk Factors Associated with Childhood Strabismus • In Conclusion: • This study established a strong dose-dependent link between refractive errors and strabismus and • confirmed the role of other risk factors, such as premature birth and gestational exposure to maternal smoking. • Because refractive errors may be targeted for early intervention, our data provide valuable information to help guide providers and patient families in making informed decisions regarding management of early refractive error. • However, longitudinal study is needed both to confirm the predictive value of uncorrected refractive error, and to evaluate the potential impact of early treatment. 43

  36. Risk Factors for Decreased Visual Acuity in Preschool Children: the Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Pediatric Eye Disease Study The Joint Writing Committee for theMulti-Ethnic Pediatric Eye Disease Study and Baltimore Pediatric Eye Disease Study Groups Ophthalmology 2011: Accepted for Publication on June 3, 2011 44

  37. Risk Factors for Decreased Visual Acuity in Preschool Children • Definition: • Unilaterally decreased VA was defined as a 2-line IOD in best- measured logMAR VA with VA 20/32 or worse in the worse eye. • Bilateral decreased VA was defined as best VA worse than 20/50 in both eyes for children <48 months of age, or worse than 20/40 in both eyes for children ≥48 months of age. 45

  38. Risk Factors for Decreased Visual Acuity in Preschool Children Figure 1 46

  39. Risk Factors for Decreased Visual Acuity in Preschool Children Table 4. Independent risk factors* for inter-ocular visual acuity difference of two or more lines in preschool children in the Multi-Ethnic Pediatric Eye Disease Study and Baltimore Pediatric Eye Disease Study. 47

  40. Risk Factors for Decreased Visual Acuity in Preschool Children Table 5. Independent risk factors* for bilateral decreased visual acuity in preschool children in the Multi-Ethnic Pediatric Eye Disease Study and Baltimore Pediatric Eye Disease Study. SE: spherical equivalent. D: diopters. OR: Odds ratio. 95% CI: 95% confidence interval. *Based on a step-wise multiple regression model †Level of SE refractive error defined by less hyperopic eye and level of astigmatism defined by less astigmatic eye, or by eye with refractive error data if data missing for one eye. ** H.S.: high school. 48

  41. Risk Factors for Decreased Visual Acuity in Preschool Children Figure 2 49

  42. Risk Factors for Decreased Visual Acuity in Preschool Children Figure 3a 50

  43. Risk Factors for Decreased Visual Acuity in Preschool Children Figure 4a 51

  44. Risk Factors for Decreased Visual Acuity in Preschool Children Figure 4b 52

  45. Risk Factors for Decreased Visual Acuity in Preschool Children • In Conclusion: • Our data support the strong association of anisometropic and bilateral refractive errors with unilateral and bilateral decreased best-corrected VA, respectively. • We suggest an expanded range of refractive errors that should be considered as potentially contributing to amblyopia. • We have confirmed the high risk of unilateral VA deficits associated with esotropia and the low risk associated with exotropia. 53

  46. Risk Factors for Decreased Visual Acuity in Preschool Children In Conclusion (cont’d): • Prospective, longitudinal observation is required to establish the prognostic significance of risk factors that are present at an early age • Clinical trials are still needed to establish whether early treatment of refractive error or strabismus might improve long-term visual acuity outcomes. • Our data may help practitioners and parents make more informed decisions regarding the management of these conditions in preschool children. 54

  47. In Summary • Overall : • The study results provide initial cross sectional data that may help develop guidelines for pediatric vision screening • The size and population-based design of this study are its major strengths. • We believe our results may be generalized to other similar populations and are less likely to be impacted by referral or selection biases than findings from clinic-based studies. • The use of identical protocols in two sites with cross standardization of methods has allowed us to pool MEPEDS and BPEDS data with resulting gains in power and precision of our estimates of the strength of reported associations. 54

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