The AS-20 benefits from reduction to 4 subscales (self-perception, interaction, reading function, and general function) and reducing the response options in the general function subscale from 5 to 4 options. The refined AS-20 may prove to be even more responsive to HRQOL changes in adult strabismus following treatment or changes over time.

Purpose To report changes in health-related quality of life (HRQOL) 1 year following strabismus surgery. Design Retrospective cohort study Methods 73 adults undergoing strabismus surgery in a single clinical practice completed the Adult Strabismus-20 (AS-20) HRQOL questionnaire pre-operatively and at 6 weeks and 1 year post-operatively. All included adults were successfully aligned at 6 weeks post-operatively. Success was defined based on clinical criteria. Change in AS-20 psychosocial and function scores was evaluated as: 1) difference in scores between 6 weeks and 1 year post-operatively and 2) proportions exceeding previously published limits of agreement at 6 weeks and 1 year. Results For patients successfully aligned at both 6 weeks and 1 year (n=51), further improvement in median scores was seen from 6 weeks to 1 year for both the psychosocial scale (83.8 vs 93.8; P<0.0001) and the function scale (72.5 vs 77.5; P=0.007). Also, a greater proportion exceeded limits of agreement at 1 year than at 6 weeks (psychosocial: 48% vs 30%; P=0.007, function: 67% vs 51%; P=0.01). For patients who became partial success (n=18) or failure (n=4) at 1 year there was a numerical decrease in scores at 1 year. Conclusions Adult strabismus patients who remain successfully aligned, show continued improvement in both psychosocial and function scores from 6 weeks to 1 year post-operatively, indicating that improvement in HRQOL is long-lasting. Evaluation of HRQOL should be considered when reporting strabismus surgery outcomes in clinical trials, and may prove helpful in assessing outcomes in clinical practice.

Purpose To report a diplopia questionnaire (DQ) with a data-driven scoring algorithm. Design Cross-sectional study. Participants To optimize questionnaire scoring: 147 adults with diplopic strabismus completed both the DQ and the Adult Strabismus-20 (AS-20) health-related quality of life (HRQOL) questionnaire. To assess test-retest reliability: 117 adults with diplopic strabismus. To assess responsiveness to surgery: 42 adults (46 surgeries). Methods The 10-item AS-20 function subscale score (scored 0 to 100) was defined as the gold standard for severity. A range of weights was assigned to the responses and to the gaze positions (from equal weighting to greater weighting of primary and reading). Combining all response option weights with all gaze position weights yielded 382,848 scoring algorithms. We then calculated 382,848 Spearman rank correlation coefficients comparing each algorithm with the AS-20 function subscale score. Main outcome measures To optimize scoring, Spearman rank correlation coefficients (measuring agreement) between DQ scores and AS-20 function subscale scores. For test-retest reliability, 95% limits of agreement, and intraclass correlation coefficient (ICC). For responsiveness, change in DQ score. Results For the 382,848 possible scoring algorithms, correlations with AS-20 function subscale score ranged from −0.64 (best correlated) to −0.55. The best-correlated algorithm had response option weights of 5 for rarely, 50 for sometimes, and 75 for often, and gaze position weights of 40 for straight ahead in the distance, 40 for reading, 1 for up, 8 for down, 4 for right, 4 for left, and 3 for other, totaling 100. There was excellent test-retest reliability with an ICC of 0.89 (95% confidence interval 0.84 to 0.92) and 95% limits of agreement were 30.9 points. The DQ score was responsive to surgery with a mean change of 51 ± 34 (p<0.001). Conclusions We have developed a data-driven scoring algorithm for the diplopia questionnaire, rating diplopia symptoms from 0 to 100. Based on correlations with HRQOL, straight ahead and reading positions should be highly weighted. The DQ has excellent test-retest reliability and responsiveness, and may be useful in both clinical and research settings.

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: 444 children (0 to <18 years old), across 10 diagnostic categories, were enrolled at two 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 0-4, 5-11 and 12-17 year olds and for each factor). Results: The Child 5-11 year-old PedEyeQ consisted of four unidimensional domains/ questionnaires: functional vision, bothered by eyes/vision, social, frustration/worry (10 items each). The Child 12-17 year-old PedEyeQ consisted of the same four domains (total 39 items). The Proxy 0-4 year PedEyeQ consisted of three questionnaires/domains: functional vision, bothered by eyes/vision, social (total 29 items). The Proxy 5-11 year-old consisted of five questionnaires/domains: functional vision, bothered by eyes/vision, social, frustration/worry, eyecare (total 39 items) as did the Proxy 12-17 year-old PedEyeQ (total 42 items). The Parent PedEyeQ, consisted of four questionnaires/domains: impact on parent/family, worry re child's eye condition, worry re child's self-perception and interactions, worry re child's visual function (total 35 items). Rasch look-up tables were created for scoring. Conclusions and Relevance: 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.

Background A change in the angle of deviation is often used to monitor change in severity of intermittent exotropia over time; nevertheless, thresholds for a clinically significant change in angle have not been determined. We analyzed variability due to test–retest differences and short-term variability in the condition to provide thresholds as a guide for assessing clinically significant, long-term change in angle of intermittent exotropia. Methods Twenty-six children with intermittent exotropia (median age, 7; range, 1–13 years) underwent repeat prism and alternate cover test measures during 3 or 4 examinations (2 hours apart) over the course of a day; 95% repeatability coefficients were derived to determine test–retest differences at distance and near fixation. Results Derived 95% repeatability coefficients at distance were 3.4Δ (95% CI, 0.7Δ–6.2Δ) for angles ≤20Δ and 7.2Δ (95% CI, 4.4Δ–9.9Δ) for angles >20Δ; at near, 6.6Δ (95% CI, 3.7Δ–9.6Δ) for angles ≤20Δ and 12.8Δ (95% CI, 5.3Δ–20.3Δ) for angles >20Δ. Conclusions Test–retest reliability data in this study provide thresholds to help determine clinically significant change in angle of strabismus in children with intermittent exotropia. These data should facilitate evidence-based assessment of long-term change in intermittent exotropia over time.