Department of Ophthalmology, Stanford University School of Medicine, Stanford, California.
Department of Pediatrics and Child Neurology, Loma Linda University Children's Hospital, Loma Linda, California.
JAMA Netw Open. 2019 Aug 2;2(8):e198273. doi: 10.1001/jamanetworkopen.2019.8273.
Visual impairment in children with brain tumors has received limited attention, as most pediatric neuro-oncology clinical trials neither require ophthalmologic evaluation on enrollment nor monitor effects of treatment on visual function during and after treatment.
To investigate ophthalmology referral patterns for children with primary brain tumors, the prevalence of visual sequelae, and the association between tumor characteristics and vision-related diagnoses.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included 141 children with primary brain tumors treated at Loma Linda University Children's Hospital and Eye Institute, a university-based tertiary referral center, between January 2013 and September 2017. Data analysis was completed in March 2019.
Comprehensive ophthalmologic evaluation for children with primary brain tumors.
Percentage of patients with ophthalmology evaluation, prevalence of abnormal ophthalmic findings, and their association with tumor characteristics.
A total of 141 children (73 [52%] male; median [range] age, 7 [0-18] years) with primary brain tumors were enrolled in this study. Seventy-three patients (41 [52%] male; median [range] age, 8 [0-17] years) never had formal ophthalmologic evaluation. Sixty-eight patients (32 [48%] male; median [range] age, 7 [0-18] years) were evaluated by 1 of 4 board-certified, fellowship-trained pediatric and/or neuro-ophthalmologists for any visual impairment over a total of 222 visits. Five-year overall survival for patients who had eye examination was not significantly different from those who did not (mean [SD] survival, 78.3% [6.2%] vs 84.9% [4.7%]). Median (range) time from tumor diagnosis to initial ophthalmologic evaluation was 9 (0-94) months. Only 10 of 68 children (15%) presented with visual symptoms at tumor diagnosis, while 61 of 68 (90%) had abnormal findings on examination, including strabismus (41 [60%]), visual acuity impairment (37 [54%]), amblyopia (26 [38%]), papilledema (24 [35%]), visual field defects (13 [19%]), optic atrophy (12 [18%]), and keratopathy (10 [15%]). Strabismus occurred more frequently in patients with posterior fossa tumors (26 of 68 in posterior fossa vs 15 of 68 in other locations; P = .02). The presence of visual field defects in patients with no visual symptoms was 15% (9 of 58). Radiation was significantly associated with amblyopia (odds ratio, 4.5; 95% CI, 1.2-15.7; P = .02).
In this study, more than 50% of children with primary brain tumors were not referred for ophthalmologic evaluation. Although visual symptoms were uncommon, visual impairments occurred more frequently than previously reported. Ophthalmologic evaluation is recommended to identify and manage visual impairment and prevent permanent vision loss in children with brain tumors.
儿童脑瘤患者的视力障碍受到的关注有限，因为大多数儿科神经肿瘤学临床试验在入组时既不需要眼科评估，也不监测治疗期间和治疗后的视力功能变化。
调查原发性脑肿瘤儿童的眼科转诊模式、视觉后遗症的发生率，以及肿瘤特征与与视力相关诊断之间的关系。
设计、地点和参与者：这是一项回顾性队列研究，纳入了 2013 年 1 月至 2017 年 9 月期间在洛马林达大学儿童医院和眼科研究所（一所大学附属的三级转诊中心）接受治疗的 141 名原发性脑肿瘤儿童。数据分析于 2019 年 3 月完成。
对原发性脑肿瘤儿童进行全面的眼科评估。
眼科评估患者的百分比、异常眼科发现的发生率，以及它们与肿瘤特征的关系。
共有 141 名（73 名[52%]为男性；中位[范围]年龄，7 [0-18] 岁）患有原发性脑肿瘤的儿童入组了本研究。73 名（41 名[52%]为男性；中位[范围]年龄，8 [0-17] 岁）从未进行过正式的眼科评估。68 名（32 名[48%]为男性；中位[范围]年龄，7 [0-18] 岁）由 4 名具有小儿和/或神经眼科专业认证的主治医生中的 1 名进行了评估，共进行了 222 次检查，以评估任何视力障碍。接受眼部检查的患者与未接受眼部检查的患者的 5 年总生存率无显著差异（平均[SD]生存率，78.3%[6.2%]比 84.9%[4.7%]）。从肿瘤诊断到首次眼科评估的中位（范围）时间为 9（0-94）个月。仅 10 名 68 名儿童（15%）在肿瘤诊断时出现视觉症状，而 68 名儿童中有 61 名（90%）在检查中发现异常，包括斜视（41 名[60%]）、视力障碍（37 名[54%]）、弱视（26 名[38%]）、视乳头水肿（24 名[35%]）、视野缺损（13 名[19%]）、视神经萎缩（12 名[18%]）和角膜病变（10 名[15%]）。后颅窝肿瘤患者斜视更常见（后颅窝 68 名中有 26 名，其他部位 68 名中有 15 名；P = .02）。无视觉症状患者中存在视野缺损的比例为 15%（58 名中的 9 名）。放射线治疗与弱视显著相关（优势比，4.5；95%CI，1.2-15.7；P = .02）。
在这项研究中，超过 50%的原发性脑肿瘤儿童未被转诊进行眼科评估。尽管视觉症状不常见，但视力障碍的发生率高于先前的报告。建议进行眼科评估，以发现和管理视力障碍，并预防脑肿瘤儿童的永久性视力丧失。
