Bibliographic Source(s)

• American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Esotropia and exotropia. San Francisco (CA): American Academy of Ophthalmology; 2007. 34 p. [166 references]

Guideline Status

This is the current release of the guideline.

It updates a previous version: American Academy of Ophthalmology Pediatric Ophthalmology Panel. Esotropia and exotropia. San Francisco (CA): American Academy of Ophthalmology; 2002 Oct. 30 p. [118 references]

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all Preferred Practice Patterns are current each is valid for 5 years from the "approved by" date unless superseded by a revision.

Guideline Category

Diagnosis
Evaluation
Management
Prevention
Treatment

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Health Plans
Nurses
Physician Assistants
Physicians

Guideline Objective(s)

Esotropia

To restore normal ocular alignment thereby promoting development and preservation of binocular vision while addressing the following goals:

• Identify patients at risk for esotropia
• Detect esotropia
• Detect and treat amblyopia that may cause or be caused by esotropia
• Educate the patient and family/caregiver of the diagnosis treatment options and care plan
• Inform the patient's other health providers of the diagnosis and treatment plan
• Treat the esotropia (align the visual axes) in order to promote and maintain binocular vision (fusion stereopsis) prevent or facilitate treatment of amblyopia and restore normal appearance
• Limit the effects of amblyopia treatment on quality of life
• Lessen the effect of strabismus and amblyopia on employment and career choices
• Monitor vision and ocular alignment and modify therapy as appropriate

Exotropia

To restore normal ocular alignment while addressing the following goals:

• Identify children at risk for exotropia
• Detect exotropia
• Detect and treat amblyopia that may cause or be caused by exotropia
• Educate the patient and family/caregiver of the diagnosis treatment options and care plan
• Inform the patient's other health providers of the diagnosis and treatment plan
• Treat the exotropia (align the visual axes) in order to promote and maintain binocular vision (fusion stereopsis) prevent or facilitate treatment of amblyopia and restore normal appearance
• Limit the effects of amblyopia treatment on quality of life
• Lessen the effect of strabismus and amblyopia on employment and career choices
• Monitor vision and ocular alignment and modify therapy as appropriate

Target Population

• Individuals with childhood-onset esotropia
• Individuals with childhood-onset exotropia

Interventions and Practices Considered

Esotropia

Diagnosis

1. History
2. Examination including assessment of fixation pattern and visual acuity in each eye ocular alignment and motility extraocular muscle function detection of nystagmus sensory testing cycloplegic retinoscopy/refraction and fundoscopic examination

Treatment/Management

1. Correction of refractive errors
2. Bifocals
3. Prism therapy
4. Amblyopia treatment
5. Extraocular muscle surgery
6. Follow-up evaluation
7. Counseling/referral

Exotropia

Diagnosis

1. History
2. Examination including assessment of fixation pattern and visual acuity in each eye ocular alignment and motility extraocular muscle function detection of nystagmus sensory testing cycloplegic retinoscopy/refraction and fundoscopic examination

Treatment/Management

1. Correction of refractive status
2. Overcorrecting minus lens
3. Patching
4. Amblyopia treatment
5. Prism therapy
6. Convergence exercises for convergence insufficiency
7. Extraocular muscle surgery
8. Follow-up evaluation
9. Counseling/referral

Major Outcomes Considered

• Re-establishment of ocular alignment
• Promotion of binocular vision
• Promotion of stereopsis
• Restoration of normal oculofacial relationships

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

In the process of revising this document a detailed literature search in Medline and the Cochrane Library for articles in the English language was conducted on the subject of esotropia and exotropia for the years 2001 to 2006.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Strength of Evidence Ratings

Level I: Includes evidence obtained from at least one properly conducted well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.

Level II: Includes evidence obtained from the following:

• Well-designed controlled trials without randomization
• Well-designed cohort or case-control analytic studies preferably from more than one center
• Multiple-time series with or without the intervention

Level III: Includes evidence obtained from one of the following:

• Descriptive studies
• Case reports
• Reports of expert committees/organization (e.g. Preferred Practice Patterns [PPP] panel consensus with external peer review)

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The results of a literature search on the subject of esotropia and exotropia were reviewed by the Pediatric Ophthalmology/Strabismus Panel and used to prepare the recommendations which they rated in two ways. The panel first rated each recommendation according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient´s care in a meaningful way. The panel also rated each recommendation on the strength of the evidence in the available literature to support the recommendation made.

Rating Scheme for the Strength of the Recommendations

Ratings of Importance to Care Process

Level A defined as most important

Level B defined as moderately important

Level C defined as relevant but not critical

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

These guidelines were reviewed by Council and approved by the Board of Trustees of the American Academy of Ophthalmology (September 8 2007).

Major Recommendations

Ratings of importance to the care process (A-C) and ratings of strength of evidence (I-III) are defined at the end of the "Major Recommendations" field.

Esotropia

Diagnosis

The purpose of the comprehensive strabismus evaluation is to make the diagnosis establish baseline status and determine appropriate initial therapy. The possibility of restrictive paralytic or other neurologic causes (especially head trauma or increased intracranial pressure) for the strabismus should be considered. Because binocular vision can degrade rapidly in young children resulting in suppression and anomalous retinal correspondence early diagnosis and treatment are essential (Dickey & Scott 1988; Fawcett Leffler & Birch 2000; Wilson Bluestein & Parks 1993).

The examination of a patient who has childhood-onset strabismus includes all components of the comprehensive pediatric or adult ophthalmic evaluation in addition to the sensory motor refractive and accommodative functions (American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel 2007; American Academy of Ophthalmology Preferred Practice Patterns Committee 2005).

History

Although a thorough history generally includes the following items the exact composition varies with the patient's particular problems and needs:

• Demographic data [A:III] including identification of parent/caregiver and patient's gender and date of birth
• Documentation of identity and relationship of historian [B:III]
• The identity of other pertinent health care providers [A:III]
• The chief complaint and reason for the eye evaluation [A:III] including date of onset and frequency of the ocular misalignment; which eye is deviated and in what direction; the presence or absence of diplopia squinting or other visual symptoms. Review of photographs of the patient may be helpful.
• Ocular history [A:III] including other eye problems injuries diseases surgery and treatments (including eyeglasses and/or amblyopia therapy)
• Systemic history; birth weight; prenatal and perinatal history that may be pertinent (e.g. alcohol drug and tobacco use during pregnancy); past hospitalizations and operations; general health and development [A:III]
• Pertinent review of systems [B:III] including history of head trauma and relevant systemic diseases
• Family and social history [A:III] including eye conditions (strabismus amblyopia type of glasses and history of wear extraocular muscle surgery or other eye surgery and genetic diseases)
• Current medications and allergies [A:III]

Examination

The comprehensive strabismus examination should include the following elements:

• Assessment of fixation pattern and visual acuity in each eye [A:III]
• Ocular alignment and motility at distance and near [A:III]
• Extraocular muscle function (ductions and versions including incomitance such as A and V patterns) [A:III]
• Detection of nystagmus [A:III]
• Sensory testing [A:III]
• Cycloplegic retinoscopy/refraction [A:III]
• Fundoscopic examination [A:III]

Documentation of the child's level of cooperation with the examination can be useful in interpreting the results and in making comparisons between examinations.

Management

All forms of esotropia should be considered for treatment. [A:III] Ocular alignment should be established as soon as possible especially in young children to maximize binocularity (Bateman Parks & Wheeler "Discriminant analysis of congenital esotropia surgery" 1983; Birch et al. 2004) prevent or facilitate treatment of amblyopia (Dickey et al. 1991; Sperduto et al. 1983) and normalize appearance. [A:III] In almost all cases clinically important refractive errors should be corrected. [A:III] Amblyopia treatment is usually started before surgery because this may reduce the angle of strabismus (Koc et al.2006) or increase the likelihood of good postoperative binocularity (Birch et al. 2004; Weakley & Holland 1997) [A:III]

Choice of Therapy

The following treatment modalities are used alone or in combination as required to achieve the therapeutic goal:

• Correction of refractive errors (Pediatric Eye Disease Investigator Group 2002) [A:I]
• Bifocals (Ludwig Parks & Getson 1989) [A:II]
• Prism therapy (Repka Connett & Scott 1996; "Efficacy of prism adaptation" 1990) [A:II]
• Amblyopia treatment (Weakley & Holland 1997) [A:III]
• Extraocular muscle surgery (Bateman Parks & Wheeler "Discriminant analysis of acquired esotropia surgery" 1983) [A:III]

Treatment plans are formulated in consultation with the patient and parent/caregiver. The plans should be responsive to their expectations and preferences [A:III] including the family's/caregiver's perception of the existing alignment which may differ from the ophthalmologist's and what they hope to achieve with treatment. It is important that the family/caregiver and ophthalmologist agree on the goals of treatment before surgery is performed.

Follow-up Evaluation

Even when initial treatment results in good ocular alignment follow-up is essential since the child remains at high risk for developing amblyopia losing binocular vision and having a recurrence of strabismus. Until visual maturity is reached periodic evaluations are necessary (Bhola et al. 2006). [A:II] During the teenage years and if the examination has been stable follow-up evaluations are appropriate every 1 to 2 years thereafter (Scheiman et al. 2005). [A:I] New or changing findings may indicate the need for more frequent follow-up examinations.

Counseling and Referral

Childhood esotropia is a long-term problem that requires commitment from the parent/caregiver and ophthalmologist to achieve the best possible outcome.

The ophthalmologist should discuss the findings of the evaluation with the patient when appropriate as well as with the parent/caregiver. The ophthalmologist should explain the disorder and recruit the family in a collaborative approach to therapy. [A:III] Parents/caregivers of pediatric patients who understand the diagnosis and rationale for treatment are more likely to adhere to treatment recommendations (Newsham 2002; Norman et al. 2003).

Exotropia

Diagnosis

The purpose of the comprehensive strabismus evaluation is to make the diagnosis establish baseline status inform the family/caregiver and determine appropriate therapy. The possibility of restrictive paralytic or other neurologic causes (especially head trauma or increased intracranial pressure) for the strabismus should be considered.

The examination of a patient who has childhood-onset strabismus includes all components of the comprehensive pediatric or adult ophthalmic evaluation in addition to the sensory motor refractive and accommodative functions (American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel 2007; American Academy of Ophthalmology Preferred Practice Patterns Committee 2005)

History

Although a thorough history generally includes the following items the exact composition varies with the patient's particular problems and needs.

• Demographic data [A:III] including identification of parent/caregiver and patient's gender and date of birth
• Documentation of identity and relationship of historian [B:III]
• The identity of other pertinent health care providers [A:III]
• The chief complaint and reason for the eye evaluation [A:III] including date of onset and frequency of the ocular misalignment; which eye is deviated and in what direction; the presence or absence of diplopia squinting or other visual symptoms. Review of photographs of the patient may be helpful.
• Ocular history [A:III] including other eye problems injuries diseases surgery and treatments (including eyeglasses and/or amblyopia therapy)
• Systemic history; birth weight; prenatal and perinatal history that may be pertinent (e.g. alcohol drug and tobacco use during pregnancy); past hospitalizations and operations; general health and development [A:III]
• Pertinent review of systems [B:III] including history of head trauma and relevant systemic diseases
• Family and social history [A:III] including eye conditions (strabismus amblyopia type of glasses and history of wear extraocular muscle surgery or other eye surgery and genetic diseases)
• Current medications and allergies [A:III]

Examination

The comprehensive strabismus examination should include the following elements:

• Assessment of fixation pattern and visual acuity in each eye [A:III]
• Ocular alignment and motility at distance and near [A:III]
• Extraocular muscle function (ductions and versions including incomitance such as A and V patterns) [A:III]
• Detection of nystagmus [A:III]
• Sensory testing [A:III]
• Cycloplegic retinoscopy/refraction [A:III]
• Funduscopic examination [A:III]

Documentation of the child's level of cooperation with the examination can be useful in interpreting the results and in making comparisons between examinations.

Management

All forms of exotropia should be considered for treatment. [A:III] In most cases ocular alignment should be re-established as soon as possible especially in young children if the deviation is manifest a large percentage of the time. [A:III] However the optimal modes of therapy for exotropia the long-term benefit of early surgical correction and the superiority of bilateral versus unilateral surgery are not well established (Hatt & Gnanaraj 2006). Amblyopia is uncommon in patients with intermittent exotropia but it should be treated if present. [A:III]

Choice of Therapy

The following treatment modalities may be used alone or in combination as required to achieve the therapeutic goal:

• Correcting refractive errors [A:III]
• Overcorrecting minus lenses [A:III]
• Patching (antisuppression therapy) [A:III]
• Amblyopia treatment [A:III]
• Prism therapy [A:III]
• Convergence exercises for convergence insufficiency [A:III]
• Extraocular muscle surgery [A:III]

Follow-up Evaluation

Children with exotropia require follow-up evaluations to monitor the magnitude and frequency of the deviation visual acuity and binocularity. The frequency of the follow-up evaluations is based on the age of the child the ability to obtain an accurate visual acuity and the control of the deviation. Yearly examinations are appropriate until visual maturity is reached but they may be reduced in frequency thereafter if the strabismus has been stable. [A:III]

Follow-up evaluation includes interval history tolerance to treatment (if any) and routine examination and testing of ocular motility.

Counseling and Referral

The ophthalmologist should discuss the findings of the evaluation with the patient if appropriate as well as the parent/caregiver. The ophthalmologist should explain the disorder and recruit the family in a collaborative approach to therapy. [A:III] Parents/caregivers of pediatric patients who understand the diagnosis and rationale for treatment are more likely to adhere to treatment recommendations (Newsham 2002; Norman et al. 2003).

Table. Follow-up Eye Examination Guidelines for Children with Esotropia and Exotropia [A:III]

Note: More frequent visits may be necessary if amblyopia is present (see the National Guideline Clearinghouse (NGC) summary of the American Academy of Ophthalmology guideline Amblyopia) if patching therapy is being administered or if there is a recent deterioration of alignment.

Definitions:

Ratings of Importance to the Care Process

Level A defined as most important

Level B defined as moderately important

Level C defined as relevant but not critical

Ratings of Strength of Evidence

Level I: Includes evidence obtained from at least one properly conducted well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.

Level II: Includes evidence obtained from the following:

• Well-designed controlled trials without randomization
• Well-designed cohort or case-control analytic studies preferably from more than one center
• Multiple-time series with or without the intervention

Level III: Includes evidence obtained from one of the following:

• Descriptive studies
• Case reports
• Reports of expert committees/organization (e.g. Preferred Practice Patterns [PPP] Panel consensus with external peer review)

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred practice pattern guidelines. Pediatric eye evaluations. San Francisco (CA): American Academy of Ophthalmology; 2007.



• Bateman JB Parks MM Wheeler N. Discriminant analysis of acquired esotropia surgery. Predictor variables for short- and long-term outcomes. Ophthalmology 1983 Oct;90(10):1154-9. PubMed



• Bateman JB Parks MM Wheeler N. Discriminant analysis of congenital esotropia surgery. Predictor variables for short- and long-term outcomes. Ophthalmology 1983 Oct;90(10):1146-53. PubMed



• Bhola R Keech RV Kutschke P Pfeifer W Scott WE. Recurrence of amblyopia after occlusion therapy. Ophthalmology 2006 Nov;113(11):2097-100. PubMed



• Birch EE Stager DR Sr Berry P Leffler J. Stereopsis and long-term stability of alignment in esotropia. J AAPOS 2004 Apr;8(2):146-50. PubMed



• Dickey CF Metz HS Stewart SA Scott WE. The diagnosis of amblyopia in cross-fixation. J Pediatr Ophthalmol Strabismus 1991 May-Jun;28(3):171-5. PubMed



• Dickey CF Scott WE. The deterioration of accommodative esotropia: frequency characteristics and predictive factors. J Pediatr Ophthalmol Strabismus 1988 Jul-Aug;25(4):172-5. PubMed



• Efficacy of prism adaptation in the surgical management of acquired esotropia. Prism Adaptation Study Research Group. Arch Ophthalmol 1990 Sep;108(9):1248-56. PubMed



• Fawcett S Leffler J Birch EE. Factors influencing stereoacuity in accommodative esotropia. J AAPOS 2000 Feb;4(1):15-20. PubMed



• Hatt S Gnanaraj L. Interventions for intermittent exotropia. Cochrane Database Syst Rev 2006;3:CD003737. [33 references] PubMed



• Koc F Ozal H Yasar H Firat E. Resolution in partially accomodative esotropia during occlusion treatment for amblyopia. Eye 2006 Mar;20(3):325-8. PubMed



• Ludwig IH Parks MM Getson PR. Long-term results of bifocal therapy for accommodative esotropia. J Pediatr Ophthalmol Strabismus 1989 Nov-Dec;26(6):264-70. PubMed



• Newsham D. A randomised controlled trial of written information: the effect on parental non-concordance with occlusion therapy. Br J Ophthalmol 2002 Jul;86(7):787-91. PubMed



• Norman P Searle A Harrad R Vedhara K. Predicting adherence to eye patching in children with amblyopia: an application of protection motivation theory. Br J Health Psychol 2003 Feb;8(Pt 1):67-82. PubMed



• Pediatric Eye Disease Investigator Group. Spontaneous resolution of early-onset esotropia: experience of the Congenital Esotropia Observational Study. Am J Ophthalmol 2002 Jan;133(1):109-18. PubMed



• Preferred Practice Patterns Committee. Comprehensive adult medical eye evaluation. San Francisco (CA): American Academy of Ophthalmology (AAO); 2005. 15 p.  (Preferred practice pattern). [76 references]



• Repka MX Connett JE Scott WE. The one-year surgical outcome after prism adaptation for the management of acquired esotropia. Ophthalmology 1996 Jun;103(6):922-8. PubMed



• Scheiman MM Hertle RW Beck RW Edwards AR Birch E Cotter SA Crouch ER Jr Cruz OA Davitt BV Donahue S Holmes JM Lyon DW Repka MX Sala NA Silbert DI Suh DW Tamkins SM Pediatric Eye Disease Investigator Group. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005 Apr;123(4):437-47. PubMed



• Sperduto RD Seigel D Roberts J Rowland M. Prevalence of myopia in the United States. Arch Ophthalmol 1983 Mar;101(3):405-7. PubMed



• Weakley DR Jr Holland DR. Effect of ongoing treatment of amblyopia on surgical outcome in esotropia. J Pediatr Ophthalmol Strabismus 1997 Sep-Oct;34(5):275-8. PubMed



• Wilson ME Bluestein EC Parks MM. Binocularity in accommodative esotropia. J Pediatr Ophthalmol Strabismus 1993 Jul-Aug;30(4):233-6. PubMed

Type of Evidence supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations").

Potential Benefits

Esotropia

The potential benefits of treatment for esotropia include promoting binocular vision and normal visual acuity in each eye. If binocularity is achieved the number of surgical procedures over a lifetime and overall cost to society may be reduced. Fusion and stereopsis are necessary for some careers and may be useful in others as well as in athletic activities and activities of daily life. In addition ocular alignment at any age enhances social interactions by normalizing appearance as well as eye contact. Normal ocular alignment is important for the development of a positive self-image and social eye contact.

Exotropia

The potential benefits of treatment for exotropia include promoting binocular vision and normal visual function in each eye. The importance of normal ocular alignment on the development of a positive self-image should not be underestimated; the appearance of misaligned eyes impairs self-image and social interactions and may reduce employment opportunities.

Potential Harms

Esotropia

• Disadvantages of bifocals include expense appearance and potential rejection by the child.
• Press-on prisms cause visual symptoms that some children find objectionable are costly require re-evaluation (additional office visits) and may be unacceptable in children not otherwise wearing eyeglasses.

Exotropia

• Overcorrecting minus lens therapy may not be well tolerated visually by some young patients.
• Prolonged use of prisms may cause an undesirable reduction in fusional convergence amplitudes.

Qualifying Statements

• Preferred Practice Patterns provide guidance for the pattern of practice not for the care of a particular individual. While they should generally meet the needs of most patients they cannot possibly best meet the needs of all patients. Adherence to these Preferred Practice Patterns will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients´ needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice.
• Preferred Practice Patterns are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind from negligence or otherwise for any and all claims that may arise out of the use of any recommendations or other information contained herein.
• References to certain drugs instruments and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard that reflect indications not included in approved Food and Drug Administration (FDA) labeling or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use and to use them with appropriate patient consent in compliance with applicable law.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Personal Digital Assistant (PDA) Downloads
Quick Reference Guides/Physician Guides

For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

• American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Esotropia and exotropia. San Francisco (CA): American Academy of Ophthalmology; 2007. 34 p. [166 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American Academy of Ophthalmology without commercial support

Guideline Committee

Pediatric Ophthalmology/Strabismus Panel; Preferred Practice Patterns Committee

Composition of Group that Authored the Guideline

Members of the Pediatric Ophthalmology/Strabismus Panel: Linda M. Christmann MD Chair; Patrick J. Droste MD; Sheryl M. Handler MD American Association for Pediatric Ophthalmology and Strabismus Representative; Richard A. Saunders MD; R. Grey Weaver Jr. MD; Susannah G. Rowe MD MPH Methodologist; Norman Harbaugh MD FAAP American Academy of Pediatrics Representative; Donya A. Powers MD American Academy of Family Physicians Representative

Members of the Preferred Practice Patterns Committee: Sid Mandelbaum MD Chair; Emily Y. Chew MD; Linda M. Christmann MD; Douglas E. Gaasterland MD; Samuel Masket MD; Stephen D. McLeod MD; Christopher J. Rapuano MD; Donald S. Fong MD MPH Methodologist

Financial Disclosures/Conflicts of Interest

This author has disclosed the following financial relationships from January 2006 to August 2007:

Norman Harbaugh MD FAAP: Kids First – Grant support. Kids Time – Equity owner. Medimmune – Lecture fees. Centers for Disease Control Merck United Healthcare – Consultant/Advisor.

Guideline Status

This is the current release of the guideline.

It updates a previous version: American Academy of Ophthalmology Pediatric Ophthalmology Panel. Esotropia and exotropia. San Francisco (CA): American Academy of Ophthalmology; 2002 Oct. 30 p. [118 references]

All Preferred Practice Patterns are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all Preferred Practice Patterns are current each is valid for 5 years from the "approved by" date unless superseded by a revision.

Guideline Availability

Electronic copies: Available from the American Academy of Ophthalmology (AAO) Web site.

Print copies: Available from American Academy of Ophthalmology P.O. Box 7424 San Francisco CA 94120-7424; telephone (415) 561-8540.

Availability of Companion Documents

The following is available:

• Summary benchmarks for preferred practice patterns. San Francisco (CA): American Academy of Ophthalmology; 2007 Nov. 22 p.

Available in Portable Document Format (PDF) and as a Personal Digital Assistant (PDA) download from the American Academy of Ophthalmology (AAO) Web site.

Print copies: Available from American Academy of Ophthalmology P.O. Box 7424 San Francisco CA 94120-7424; telephone (415) 561-8540.

Patient Resources

None available

NGC STATUS

This summary was completed by ECRI on December 1 1998. The information was verified by the guideline developer on January 11 1999. This summary was updated on March 12 2003. The updated information was verified by the guideline developer on April 2 2003. This NGC summary was updated by ECRI Institute on February 5 2008. The updated information was verified by the guideline developer on February 27 2008.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. Information about the content ordering and copyright permissions can be obtained by calling the American Academy of Ophthalmology at (415) 561-8500.

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