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Online Advanced Release
Articles appearing in this "Online Advanced Release" section have been peer-reviewed and accepted for publication in the Journal of Pediatric Ophthalmology & Strabismus and posted online before print publication. Articles appear on this site after copyediting and author corrections, but before final proofing. The content of the article will usually remain unchanged, and possible further corrections are fairly minor. The final published article will specify the issue and page numbers. Once the final version is available in print, the version posted here will be removed from this site.
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Table of Contents
Outcome Study of Graded Unilateral Medial Rectus Recession for Small to Moderate Angle Esotropia
Lihua Wang, MD; Leonard B. Nelson, MD, MBASubmitted 2/29/09; Accepted 9/8/09; Posted 8/23/10
Purpose: To report an outcome study of 123 consecutive patients treated by graded unilateral medial rectus recession for small to moderate angle esotropia over an 8-year period with a minimum follow-up of 6 months.
Methods: The records of patients who underwent unilateral medial rectus recession for constant esotropia measuring 15 to 35 prism diopters (PD) were reviewed. Unilateral medial rectus recession of 5.0, 5.5, 6.0, 6.5, and 7.0 mm was performed for 15 to 18, 19 to 20, 21 to 25, 26 to 30, and 31 to 35 PD of esodeviation, respectively. Postoperative follow-up was at least 6 months. Successful alignment was defined as ±5 PD of orthophoria in primary and lateral gaze while viewing distant and near accommodative targets.
Results: The eyes of 96.8% of the patients were successfully aligned and the average deviation corrected was 17.33 ± 1.16 PD for 5 mm, 18.57 ± 2.51 PD for 5.5 mm, 23.67 ± 4.91 PD for 6 mm, 26.68 ± 3.87 PD for 6.5 mm, and 31.93 ± 3.26 PD for 7 mm unilateral medial rectus recession at 6-month follow-up. Seventy-four patients (83.2%) with more than 6 months of follow-up achieved successful alignment, 14 (15.7%) were undercorrected, and 1 (1.1%) was overcorrected.
Conclusion: Successful alignment was achieved in most esotropic patients treated by the graded unilateral medial rectus recessions. The surgical guidelines provide a reference for the treatment of small to moderate angle esotropia.
doi: 10.3928/01913913-20100818-05 [get full text]
Manifestations of Ocular Fundus in Children With Febrile Seizures
Hui Guo, MD; Yuqing Lan, MD; Mei Wang, MD; Jianhui Xiao, MD; Yuxin Hu, MD; Zhaoxia Xia, MDSubmitted 8/22/09; Accepted 6/14/10; Posted 8/23/10
Purpose: To study the potential incidence of retinopathy in children with febrile seizures.
Methods: Thirty-four children with febrile seizures, aged 3 months to 9 years and admitted from January 2000 to June 2008, were retrospectively analyzed. All cases received fundus examination within 24 hours after admission and the incidence of retinopathy was calculated.
Results: None of the subjects was found to have retinal hemorrhages. Therefore, using Hanley’s Rule of Three, the upper limit of 95% confidence interval of retinal hemorrhages following febrile seizures in children is less than 10%.
Conclusion: The incidence of retinal hemorrhages in children with febrile seizures is lower than 10%. If retinal hemorrhages are found in children with febrile seizures, other causes need to be considered.
doi: 10.3928/01913913-20100818-03 [get full text]
Frequent Prosthesis Refitting to Prevent Implant Exposure in Patients With Retinoblastoma
Basil K. Williams, Jr., BA; Amy C. Schefler, MD; Scott N. Garonzik; Daniel Gologorsky, BA; Wei Shi, MS; Ludimila L. Cavalcante; Milena L. Cavalcante; William J. Feuer, MS; Timothy G. Murray, MD, MBASubmitted 3/25/10; Accepted 6/15/10; Posted 8/23/10
Purpose: To examine the effects of prosthesis refitting on porous orbital implant exposure in 100 patients who underwent enucleation for retinoblastoma.
Methods: Parameters analyzed included patient’s age at enucleation, gender, implant type, frequency of prosthesis adjustment, and use of chemotherapy or radiation. The main outcome measures consisted of the condition of the fornices, condition of the implant (including conjunctival thinning), and condition and functioning ability of the prosthesis.
Results: Increased frequency of visits with the ocularist and number of prosthesis adjustments and refits significantly improved the condition of the implant, fornices, and prosthesis. The patient’s age at enucleation, gender, and use of chemotherapy or radiation did not have a significant effect on any of the outcome variables. The condition of the implant was significantly better for porous polyethylene than hydroxyapatite implants (P = .024). No implant exposures were observed.
Conclusion: Frequent adjustments and refits by the ocularist are significantly associated with a reduced rate of conjunctival thinning and complete avoidance of implant exposure in patients undergoing enucleation for retinoblastoma. These findings are particularly significant for this population, which historically has demonstrated a high rate of implant exposure.
doi: 10.3928/01913913-20100818-06 [get full text]
Scleral Fixation of Intraocular Lens in Eyes With History of Open Globe Injury
Touka Banaee, MD; Setareh Sagheb, MD
Submitted 4/25/10; Accepted 6/15/10; Posted 8/23/10
Purpose: To report the results and complications of scleral fixation of intraocular lens (SF-IOL) in traumatized eyes of children with iris defects and inadequate capsular support with technique customized to the condition of the eye.
Methods: Retrospective review of pediatric eyes with a history of open globe injury and SF-IOLs. All eyes had undergone pars plana vitrectomy and lensectomy after primary repair of the laceration. Site of scleral fixation and limbal incision were selected according to the site of traumatic scar, remaining capsular support, and keratometry.
Results: Ten patients with a mean age of 6.1 years were included. Mean duration of aphakia was 18.7 months. Five eyes had adequate capsular support for one haptic of the IOL. The only intraoperative complication was mild ciliary body hemorrhage. Mean follow-up was 11.8 months. Uncorrected visual acuity did not improve postoperatively in only one eye due to severe corneal astigmatism. Best-corrected visual acuity improved in 6 eyes. Mean postoperative sphere and cylinder were 1.8 and -3.05 diopters, respectively. The only postoperative complication was decentration of a sulcus-fixed haptic needing reoperation in one eye.
Conclusion: SF-IOL is a viable option for correcting traumatic aphakia and can have good results if customized to the condition of the eye.
doi: 10.3928/01913913-20100818-01 [get full text]
Conjunctival Cysts as a Complication After Strabismus Surgery
Ana Maria Guadilla, MD; Pilar Gómez de Liaño, MD; Pilar Merino, MD, PhD; Gema Franco, MDSubmitted 2/25/10; Accepted 7/9/10; Posted 8/23/10
Purpose: To identify possible factors associated with the development of a conjunctival cyst after surgery for strabismus.
Methods: A descriptive, longitudinal, and retrospective study was done including 12 cases from the past 20 years presenting a conjunctival cyst as a complication of strabismus surgery. Variables included age, sex, eye and muscle operated on, surgical technique used, surgeon, type of suture, and type of conjunctival incision. Fisher’s exact test and Pearson chi-square test were used for statistical analysis.
Results: The incidence of conjunctival cysts was 0.25%. Although ultimately statistically significant differences in the variables studied could not be demonstrated (P > .05), a greater incidence in the development of this complication in young patients who underwent recession (58.3%) as the surgical technique was observed.
Conclusion: Recession may be a risk factor in the development of a conjunctival cyst caused by the high frequency of dragging Tenon capsule during this surgical technique.
doi: 10.3928/01913913-20100818-02
[get full text]
Surgical Management of Adult Onset Age-Related Distance Esotropia
David Mittelman, MDSubmitted 5/24/10; Accepted 7/9/10; Posted 8/23/10
Objective: To study the effects of bilateral medial rectus recession for the management of adult onset age-related distance esotropia.
Methods: Ten patients with adult onset age-related distance esotropia measuring 14 prism diopters or greater underwent bilateral medial rectus recession to eliminate the need for prism glasses.
Results: In all but one case, the diplopia completely resolved postoperatively, with a median residual deviation of 1 prism diopter esophoria for distance and 2 prism diopters exophoria at near.
Conclusion: Bilateral medial rectus recession is a useful technique for the management of adult onset age-related distance esotropia.
doi: 10.3928/01913913-20100818-04 [get full text]
Christopher Hwang, BA; Vidya Phoenix, MD; Amy K. Hutchinson, MDSubmitted 11/23/09; Accepted 5/12/10; Posted 7/22/10
Purpose: To evaluate the preferences of pediatric ophthalmologists and vitreoretinal surgeons with regard to the initial management of scleral perforation during strabismus surgery and to determine whether they perceived one mode of treatment conferred a significant advantage over another in terms of the complication rate.
Methods: Six hundred sixty-five pediatric ophthalmologists and 494 vitreoretinal surgeons registered with their respective national organizations were invited by an e-mail to respond to an anonymous, web-based survey. The responses to the survey were compared between groups.
Results: A total of 169 ophthalmologists participated, 133 of whom were pediatric ophthalmologists and 36 vitreoretinal surgeons. Significantly more pediatric ophthalmologists than vitreoretinal surgeons recommend initially managing scleral perforation by observation (P = .001). Among pediatric ophthalmologists, method of treatment was not perceived to affect outcome (P = .75). However, laser photocoagulation was perceived to result in the best outcome among vitreoretinal surgeons (P = .03).
Conclusion: Significant differences exist among pediatric ophthalmologist and vitreoretinal surgeon management preferences and perceived treatment outcomes for scleral perforation
doi: 10.3928/01913913-20100719-03 [get full text]
Posterior Chamber Lens Implantation With Scleral Fixation in Children With Traumatic Cataract
Ihsan Caca, MD; Alparslan Sahin, MD; Seyhmus Ari, MD; Fuat Alakus, MDSubmitted 2/16/10; Accepted 5/6/10; Posted 7/22/10
Purpose: To evaluate the outcomes of posterior chamber lens implantation with scleral fixation (SF-PCIOL) in children with traumatic cataract.
Methods: Twenty-four eyes of 24 cases were included. All patients had corneal or corneoscleral lacerations that were primarily repaired. Traumatic cataract subsequently developed and SF-PCIOL was performed due to insufficient posterior capsule support.
Results: The average age of the patients was 5.8 years (range: 4 to 10 years). All cases had SF-PCIOL implanted via internal route using triangular double scleral flaps made of 9-0 polypropylene after a complete anterior vitrectomy. Average follow-up was 14.6 ± 4.3 months (range: 11 to 18 months). Visual acuity was increased at the last visit in 23 (96%) patients. Common postoperative complications were fibrinous reaction in 6 (25%) patients, transient intraocular pressure increase in 4 (17%) patients, membrane formation requiring removal in 1 (4%) patient, transient intraocular hemorrhage as vitreous hemorrhage in 1 (4%) patient, and retinal detachment in 1 (4%) patient after the postoperative second month.
Conclusion: SF-PCIOL is an effective and reliable method in patients with pediatric traumatic cataract who had insufficient posterior capsule support.
doi: 10.3928/01913913-20100719-01 [get full text]
Clinical Review of Periorbital Capillary Hemangioma of Infancy
Assad Jalil, MRCOphth; Anna Maino, FRCOphth; Rajan Bhojwani, FRCOphth; Mark Vose, FRCOphth; Jane Ashworth, PhD, FRCOphthSubmitted 3/14/10; Accepted 5/3/10; Posted 7/22/10
Purpose: To explore the role of intralesional steroid injections (ILSI) and oral steroids in the management of periocular hemangioma of infancy (HOI).
Methods: In this retrospective study, treatment options studied were observation, ILSI, and oral steroids. All children received adjunctive amblyopia treatment if required. The main indications for treatment were cosmetic, worsening astigmatism, and visual axis obscuration. Success was defined as complete HOI regression before the age of 5 years (cosmetic group), reduction of astigmatism of at least 1 diopter cylinder (DC) (astigmatism group), or no evidence of amblyopia at the last follow-up (visual axis obscuration group).
Results: Twenty-four of 41 children (58.5%) had amblyopia at presentation. Eighteen children formed the observation group, 17 children received ILSI, and 6 children received oral steroids. Successful outcome was achieved in all except 2 patients in the cosmetic group and 6 of 7 in the visual axis obscuration group. Mean astigmatic correction of all cases was 1.65 ± 1.34 DC before treatment and 0.91 ± 1.17 DC after treatment, the change being statistically significant (P < .001).
Conclusion: Observation appears to be a highly effective strategy if coupled with amblyopia therapy, especially for mild cases. Intralesional and oral steroids appear to be equally effective for lesions requiring treatment, but their exact role cannot be clearly determined in the presence of a spontaneously resolving lesion.
doi: 10.3928/01913913-20100719-04 [get full text]
Ocular Parasitic Diseases: A Review on Toxocariasis and Diffuse Unilateral Subacute Neuroretinitis
Rafael T. Cortez, MD; Gema Ramirez, MD; Lucienne Collet, MD; Gian Paolo Giuliari, MDSubmitted 1/04/10; Accepted 5/3/10; Posted 7/22/10
Parasitic infections may damage various ocular tissues, thereby causing visual dysfunction. In 1950, Wilder described the first case in which larval forms of nematodal intestinal roundworms (Ascaridoidea: Ascaris, Toxocara, Ancylostoma, Necator, and Strongyloides) were implicated as a cause of intraocular disease. This review focuses on two disorders associated with parasitic infections: ocular toxocariasis and diffuse unilateral subacute neuroretinitis.
doi: 10.3928/01913913-20100719-02 [get full text]
Longitudinal Study of Optic Cup Progression in Children
Hee-Jung Park, MD, MPH; Christian Hampp, PhD; Joseph L. Demer, MD, PhDSubmitted 1/2/10; Acceted 4/5/10; Posted 7/22/10
Purpose: To determine the normative rate of cup-to-disc-ratio (C:D) progression in children and the effect of prematurity and low birth weight on this rate.
Method: In a single pediatric ophthalmology practice, a single examiner evaluated optic cup size by serial ophthalmoscopy over a minimum of 5 years in 92 patients (184 eyes) without intraocular surgery or optic nerve disease. A cross-sectional analysis of C:D was performed per year of age from 0 to 10 years and linear regression was used to compare C:D progression between preterm and term children and between low versus normal birth weight children.
Results: Children exhibited progressive optic cupping. In term children, mean C:D increased by 0.0075 per year. Rate of mean C:D progression was double in children born preterm: 0.0160 (P = .049, comparison to term) per age-year. A similar, nonsignificant trend is observed when comparing low birth weight to normal children (P = .131).
Conclusion: Prematurity and low birth weight are associated with increased rate of cupping in children. Clinicians should recognize that C:D progression is not a specific sign of glaucoma in children.
doi: 10.3928/01913913-20100719-06 [get full text]
Optical Coherence Tomography as an Adjunctive Tool for Diagnosing Papilledema in Young Patients
Michael R. Martinez, MD; Avinoam Ophir, MDSubmitted 11/30/09; Accepted 3/30/10; Posted 7/22/10
Purpose: The authors examined the peripapillary (3.4-mm diameter) retinal nerve fiber layer thickness (RNFL thickness) as depicted by optical coherence tomography (OCT) in young patients with pseudopapilledema or papilledema.
Methods: In 17 consecutive patients (6 to 20 years old) with bilateral newly diagnosed papilledema or pseudopapilledema, the eye with the thicker mean global RNFL per patient was analyzed. Excluded were patients in whom cerebrospinal fluid opening pressure was between 190 and 250 mm H2O ("gray zone"). RNFL thickness was compared in eyes with papilledema and pseudopapilledema using the Mann-Whitney U test.
Results: Papilledema was clinically diagnosed in 9 patients and pseudopapilledema in 6 patients; 2 patients were excluded. Median RNFL thickness in the eyes with papilledema was greater than that of both eyes with pseudopapilledema and controls at all 12 clock hours. In all 9 patients with papilledema, RNFL was thickened contiguously for 8 to 12 clock hours above the upper 95% confidence interval limit of normal.
Conclusion: The peripapillary RNFL thickness as depicted by OCT was found to be a reliable adjunctive tool in the differentiation of newly diagnosed papilledema and pseudopapilledema in young patients. Larger cohorts are required to confirm these observations and conclusion.
doi: 10.3928/01913913-20100719-05 [get full text]
Are Most Sixth Nerve Palsies Really Paralytic?
Ayse Gul Altintas, MD; Hasan Basri Arifoglu, MD; Derya Dal, MD; Saban Simsek, MDSubmitted 11/3/09; Accepted 2/2/10; Posted 6/23/10
Background: Etiology and date of palsy are two important parameters that affect the treatment protocol of sixth nerve palsies. This study evaluated the treatment protocols and outcomes of treatment in sixth nerve palsies.
Methods: Thirty-four patients who had sixth nerve palsy were included. Botulinum toxin A (BTX) injection was performed on patients with acute sixth nerve palsy and paresis (BTX group), whereas chronic cases received only horizontal surgery (surgery group). All patients in the BTX group received a BTX injection into the ipsilateral medial rectus muscle. Patients in the surgery group underwent either ipsilateral medial rectus recession or recession combined with lateral rectus resection without the transposition procedure.
Results: Fifteen patients were treated with a BTX injection to the medial rectus muscle. One patient underwent ipsilateral medial rectus muscle recession and 6 patients received both medial rectus recession and lateral rectus resection in the same session. Measurement of esotropia was 24.9 prism diopters (PD) (range: 18 to 35 PD) before treatment in the BTX group. The recovery rate was 86.6% (13 of 15) without any residual deviation. In the surgery group, the mean preoperative deviation was 35.1 PD (range: 14 to 75 PD), which decreased to mean 2.57 PD (range: 0 to 10 PD) postoperatively. The achievement of orthotropia rate was 85.7%.
Conclusion: BTX injection was found to be an effective treatment because it prevented medial rectus contraction in acute sixth nerve palsies. Correction of deviation with the recession of contracted medial rectus muscles and resection of lateral rectus muscles without the need of transposition in chronic sixth nerve palsy testified that most sixth nerve palsies involve partial paralysis rather than complete paralysis.
doi: 10.3928/01913913-20100618-01 [get full text]
Measurement of Intraocular Pressure With Pressure Phosphene Tonometry in Children
Dorothy S. P. Fan, MSc, FRCS; Thomas Y. H. Chiu, MRCS; Nathan Congdon, MD, MPH; Jeffrey C. W. Chan, MBChB; Eva Y. Y. Cheung, MMedSc; Dennis S. C. Lam, MD, FRCS, FRCOphthSubmitted 9/11/09; Accepted 2/5/10; Posted 6/23/10
Purpose: To study the accuracy and acceptability of intraocular pressure (IOP) measurement by the pressure phosphene tonometer, non-contact tonometer, and Goldmann tonometer in children.
Methods: Fifty children (5 to 14 years old) participated in this prospective comparative study. IOP was measured with the pressure phosphene tonometer, non-contact tonometer, and Goldmann tonometer by three different examiners who were masked to the results. The children were also asked to grade the degree of discomfort from 0 to 5 (0 = no discomfort; 5 = most discomfort).
Results: The mean IOPs measured by the Goldmann tonometer, pressure phosphene tonometer, and non-contact tonometer were 15.9 mm Hg (standard deviation [SD]: = 5.5 mm Hg; range: 10 to 36 mm Hg), 16.0 mm Hg (SD: 2.9 mm Hg; range: 12 to 25 mm Hg), and 15.7 mm Hg (SD = 5.1 mm Hg; range: 8 to 32 mm Hg), respectively (P = .722). The mean difference between pressure phosphene tonometer and Goldmann tonometer readings was 2.9 mm Hg and that between non-contact tonometer and Goldmann tonometer readings was 2.1 mm Hg. The 95% confidence interval of the mean difference between pressure phosphene tonometer and Goldmann tonometer readings was –1.07 and 1.19, and that between non-contact tonometer and Goldmann tonometer readings was –1.07 and 0.53. The mean discomfort ratings for the pressure phosphene tonometer, non-contact tonometer, and Goldmann tonometer were 0.6, 2.0, and 2.3, respectively (P < .001).
Conclusion: Although the pressure phosphene tonometer was less accurate than the non-contact tonometer compared with Goldmann tonometer, it gave a reasonably close estimate and had a high specificity of raised IOP. In addition, measurement by the pressure phosphene tonometer is most acceptable to children. The pressure phosphene tonometer can be considered as an alternative method of IOP measurement in children.
doi: 10.3928/01913913-20100618-02 [get full text]
Strabismus in Pediatric Lens Disorders
Nomiki Spanou, MD; Lampros Alexopoulos, MD; Georgia Manta, MD; Despina Tsamadou, MD; Hristos Drakos, MD; Petros Paikos, MD, PhDSubmitted 11/25/08; Accepted 2/5/10; Posted 6/23/10
Purpose: To evaluate the prevalence and types of strabismus in children with cataract and ectopia lentis.
Methods: The authors retrospectively evaluated 860 children treated in the ophthalmological department of Children's Hospital "Agia Sophia" during the past decade. Their medical files with reference to strabismus prevalence, correlation between the time of strabismus occurrence and lens extraction surgery, and type of strabismus were studied.
Results: Of the 822 children with cataract, 337 had congenital cataract and 485 had acquired cataract. Strabismus occurred in 199 (24.2%) patients; 113 (56.8%) patients had esotropia and 86 (43.2%) patients had exotropia. Of the 38 children with ectopia lentis, strabismus occurred in 5 (13.2%); 1 patient had esotropia and 4 patients had exotropia. There is no significant difference in the time of appearance of strabismus in relation to the cataract operation, whereas there is a significant difference in ectopia lentis, although this may be a result of the small sample size. The incidence of strabismus is higher in patients with unilateral cataracts (27.4%) than in those with bilateral cataracts (19.6%). Strabismus occurred more frequently in patients with congenital cataracts (30.3%) than in acquired cases (20%), with esotropia being more common in congenital cataracts (76.5%) and exotropia more common in acquired cataracts (63.9%).
Conclusion: The authors believe it is imperative that great attention should be given to ocular alignment in addition to management of refractive error and intense amblyopia therapy during long-term follow-up.
doi: 10.3928/01913913-20100618-05 [get full text]
Outcomes of Surgery in Long-Standing Infantile Esotropia With Cross Fixation
Kadircan H. Keskinbora, MD, PhD; Tansu Gonen, MD; Fatih Horozoglu, MDSubmitted 9/17/09; Accepted 2/5/10; Posted 6/23/10
Background: This is a retrospective study to determine the outcomes of the surgical correction in long-standing infantile esotropia with cross fixation.
Methods: Medical charts of a group of patients with esotropia who had cross fixation and underwent surgery for strabismus between January 1991 and December 2004 were reviewed. The mean follow-up time was 4.7 years. Binocularity was measured by the Worth 4-dot test and Titmus stereo test. Twenty-six patients underwent surgery for strabismus. Twenty-one patients aged 8 to 26 years with a minimum 3-year postoperative follow-up were included. Five patients were excluded because they were lost to follow-up after surgery.
Results: Bimedial recession and resection of one lateral rectus muscle were performed in all patients. Recession of the inferior oblique muscle with anteriorization was performed in patients who had inferior oblique overaction. Orthotropia was attained in 14 patients, whereas residual esotropia was diagnosed in 5 patients. Two patients were diagnosed as having exotropia. Two patients required a second surgery for dissociated vertical deviation. Overall, 9 of the 21 patients had indications of binocular function and 12 remained the same in their stereoacuity.
Conclusion: Surgical correction of long-standing infantile esotropia with cross fixation in young adults may improve binocular function and allow long-term alignment stability.
doi: 10.3928/01913913-20100618-03 [get full text]
Glaucoma Following Infantile Cataract Surgery
Robert M. Saltzmann, MD; David R. Weakley, MD; Nalini K. Aggarwal, MD; Jess T. Whitson, MDSubmitted 12/8/08; Accepted 2/24/10; Posted 6/23/10
Purpose: To examine incidence, risk factors, and outcomes of glaucoma following infantile cataract extraction.
Methods: A retrospective chart review of all patients who underwent cataract extraction between January 1, 1993, and December 31, 2006 at the Children's Medical Center in Dallas.
Results: Sixty-four eyes met inclusion criteria, of which 11 eyes (17.2%) developed glaucoma during a mean follow-up of 65.1 ± 4.3 months. Age younger than 3 months at cataract diagnosis (odds ratio 4.89, P = .05) or cataract extraction (odds ratio 4.4, P = .047) and the presence of anterior chamber anomalies (odds ratio 8.0, P = .01) were the only risk factors found to have statistical significance for the development of glaucoma. Eight of 11 eyes with glaucoma (72.2%) required at least one surgical intervention. Three of 10 eyes (30%) had a final best-corrected visual acuity below 20/400 and another 4 eyes (40%) demonstrated some degree of amblyopia.
Conclusion: Despite modern microsurgical techniques, infantile cataract surgery continues to pose a risk of secondary glaucoma. This was particularly true when cataract was diagnosed and/or extracted in patients younger than 3 months of age. Most eyes that developed glaucoma required surgical management and visual outcomes continue to be poor in this group
doi: 10.3928/01913913-20100618-04 [get full text]
Juan P. Lopez, MD; Sharon F. Freedman, MD; Kelly Muir, MD; Lois Duncan, CO, COMT; Derek Stephens, PhD; Eshetu Atenafu, MSc; Alex V. Levin, MDSubmitted: 5/19/09; Accepted: 2/24/10; Posted: 5/21/10
Background: To investigate central corneal thickness (CCT) in children with glaucoma and at risk for glaucoma.
Methods: The study included 139 children with glaucoma: 66 at risk for glaucoma (ie, aphakia, aniridia, or uveitis) and 66 normal children. CCT was measured by ultrasound pachymetry and intraocular pressure (IOP) by applanation. Analysis of variance was used to compare CCT between groups. Correlation analysis assessed associations between CCT and ocular factors including spherical equivalent, cup-to-disc ratio, glaucoma medications, and number of intraocular surgeries.
Results: CCT was significantly higher for 141 eyes with glaucoma (mean: 0.598 mm, P < .001) and 76 eyes at risk for glaucoma (mean: 0.604 mm, P = .001) than for 66 normal eyes (mean: 0.558 mm). No significant difference was observed between at-risk (P = .989) and glaucoma eyes. Eyes with aphakia (0.653 mm) and aniridia (0.639 mm) had the thickest CCT values. Thinnest CCT was found in anterior segment dysgenesis and uveitis (mean: 0.541 mm). A significant positive correlation between CCT and spherical equivalent was found for glaucoma (r = 0.413; P < .001) and at-risk (r = 0.412; P < .0003) eyes, and between CCT and intraocular surgery for at-risk eyes (P = .0066). A significant negative correlation was found between CCT and cup-to-disc ratio for glaucoma eyes (r = -0.223; P = .01).
Conclusion: This is the largest series of CCT in pediatric glaucoma and related disorders. The data suggest caution in application of standard formulas for IOP-to-CCT correction when evaluating children with glaucoma because their mean CCT values extend far beyond values reported for normal eyes.
doi: 10.3928/01913913-20100518-03 [get full text]
Horizontal Misalignment in Patients With Unilateral Superior Oblique Palsy
David G. Telander, MD, PhD; Brent M. Egeland, MD; Stephen P. Christiansen, MDSubmitted: 8/25/09; Accepted: 2/24/10; Posted: 5/21/10
Purpose: To determine the frequency and distribution of horizontal misalignment in patients with unilateral superior oblique palsy (SOP) and to determine the indications for combining horizontal with vertical strabismus surgery.
Methods: Patients included in the study had a vertical heterophoria or tropia that fit Parks three-step test for SOP and had no previous strabismus surgery or other ocular motility disturbance. Ocular motility and alignment were recorded. Outcomes between patients who had vertical surgery alone and those who had combined vertical and horizontal surgery were compared using the Student’s t test.
Results: Of 205 patients, 121 (59.0%) had a horizontal misalignment in addition to vertical strabismus. Ninety-six patients (46.8%) required strabismus surgery. Of these, 29 had 8 prism diopters (PD) or more horizontal deviation. Twenty-two had vertical combined with horizontal surgery (V+H group). Although their initial deviation was greater, these patients had better surgical outcomes than patients who had vertical surgery alone (V group). The V+H group had a final mean horizontal deviation of 2.18 PD compared with 6.85 PD in the V group (P < .01). Postoperative vertical alignment in the V+H group was also superior with a final mean vertical deviation of 3.7 versus 6.8 PD for the V group (P = .12).
Conclusion: These results indicate that horizontal misalignment is common in patients with SOP. Patients with 8 PD or more horizontal deviation benefited from surgical correction of the horizontal deviation in addition to the vertical surgery.
doi: 10.3928/01913913-20100518-05 [get full text]
Infantile Aphakic Glaucoma: A Proposed Etiologic Role of IL-4 and VEGF
Inbal Michael, PhD; David S. Walton, MD; Shulamit Levenberg, PhDSubmitted: 9/09/09; Accepted: 2/24/10; Posted: 5/21/10
Purpose: To identify the factors secreted by lens epithelial cells (LECs) responsible for the altered trabecular meshwork (TM) cells and to compare their effect on monocultured TM cells with that of TM cells co-cultured with LECs.
Methods: Such factors were isolated using cytokine antibody array membranes, and their effect on TM cells was assessed by analyzing changes in morphology and gene expression. In addition, inhibition of the isolated factors was performed in the co-culture model by adding specific antibodies to the cell culture media.
Results: Transforming growth factor beta-2, interleukin-4 (IL-4), and vascular endothelial growth factor (VEGF) are presented as candidate cytokines responsible for the observed changes in LEC-TM co-cultures. Culturing TM cells in the presence of VEGF and IL-4 triggered alterations closely reflecting those observed in the LEC-TM co-culture model, where their inhibition significantly hindered the alteration of the TM cells.
Conclusion: These findings suggest a possible explanation for the development of infantile aphakic glaucoma, based on residual LECs secreting IL-4 and VEGF after removal of congenital cataract, which then alter trabecular meshwork cell morphology and gene expression.
doi: 10.3928/01913913-20100518-04 [get full text]
Jeong Ho Yi, MD; Seung Ah Chung, MD; Yoon Hee Chang, MD; Jong Bok Lee, MDSubmitted: 9/17/09; Accepted: 1/12/10; Posted: 5/21/10
Purpose: To analyze the practical aspects and advantages of one-stage adjustable surgery under topical anesthesia in concomitant horizontal strabismus.
Methods: A retrospective review of 363 patients was completed to assess (1) the frequency of need to perform adjustment, (2) the amount and pattern of adjustment, and (3) the final alignment at least 6 months after surgery. Intraoperative adjustment was performed strictly toward the aim of orthophoria or slight overcorrection (heterophoria < 6 prism diopters [PD]) while avoiding diplopia.
Results: Of the 363 patients, 261 (72%) required intraoperative adjustment. Of these, 85% of exotropes underwent a decreased amount of surgery compared with the standard amount, whereas 58% of esotropes underwent an increased amount of surgery. Forty-two patients underwent a one-muscle surgery instead of the scheduled two-muscle surgery, and all had less than 35 PD preoperative angle of deviation. Success rates were 83% in all patients with one-stage adjustable sutures and 87% in patients who underwent adjustment. In 42 patients with one-muscle surgery instead of two-muscle surgery, 32 (76%) obtained successful results.
Conclusion: Intraoperative adjustment was effective in concomitant horizontal strabismus surgery and can provide the opportunity to avoid a large overcorrection, especially in cases with moderate angle horizontal muscle surgery.
doi: 10.3928/01913913-20100518-06 [get full text]
Pediatric Uveitis Secondary to Probable, Presumed, and Biopsy-Proven Sarcoidosis
Daniel E. Choi, BA; Andrea D. Birnbaum, MD, PhD; Frederick Oh, MD; Howard H. Tessler, MD; Debra A. Goldstein, MD, FRCSSubmitted: 9/10/09; Accepted: 1/12/10; Posted: 5/21/10
Purpose: To describe pediatric patients with uveitis diagnosed as having sarcoidosis.
Methods: Medical records of pediatric patients evaluated between 1987 and 2008 were reviewed to identify those with ocular inflammation in whom a diagnosis of sarcoidosis was considered. A classification system including ocular findings and results of laboratory testing was devised and used to classify likelihood of sarcoidosis.
Results: Four hundred sixty children younger than 17 years were evaluated. Based on the classification system designed, 13 patients (2.8%) had probable, presumed, or definite sarcoidosis. The mean age was 11.6 years (range: 5 to 16 years). Elevated angiotensin-converting enzyme was measured in 6 patients and lysozyme in 5 patients. Five of 12 patients in whom chest imaging was performed had signs of sarcoidosis. Anterior segment involvement was non-granulomatous more often than granulomatous. Seven patients had multifocal choroiditis and 4 patients had retinal periphlebitis.
Conclusion: Ocular sarcoidosis is uncommon in children, even at a tertiary referral center. Pulmonary involvement was detected in slightly less than half of the patients who had imaging, in contrast to previous reports of almost universal lung involvement in children 8 to 15 years old. The classification system of presumed, probable, and definite sarcoidosis presented may be useful in clinical practice.
doi: 10.3928/01913913-20100518-01 [get full text]
Functional Results of the Surgical Repair of a Lacerated Canaliculus in Children
Alla Kwitny, MD; John D. Baker, MDSubmitted: 6/2/09; Accepted: 1/12/10; Posted: 5/21/10
Purpose: This study examined the functional success of surgical repair of lacerated canaliculi in a pediatric population.
Methods: A retrospective chart review was performed on 46 patients who had surgical repair of a lacerated canaliculus. Functional success was defined as no tearing or discharge present at the end of treatment.
Results: Forty-four of the 46 patients had repair with a Crawford tube. Of these, 39 presented for postoperative follow-up. Two patients had some tearing present at the time of tube removal. Eight patients whose tube fell out or was pulled out by the patient had no symptoms at their last visit. Fourteen patients were able to be contacted by phone for follow-up more than a year after treatment and 13 were symptom free. The child with reported discharge was more than 2 years post treatment and had not scheduled any return appointments to seek treatment.
Conclusion: Surgical repair of a lacerated canaliculus using a Crawford silicone tube in the pediatric population has an excellent chance of having a good functional outcome with no tearing or discharge present.
doi: 10.3928/01913913-20100518-02 [get full text]
Dilation and Probing of Schlemm’s Canal and Viscocanalostomy in Pediatric Glaucoma
Jeffrey S. Kay, MD; Robert Mitchell, OD; Joseph Miller, MDSubmitted: 3/4/09; Accepted: 1/12/10; Posted: 4/22/10
Purpose: To describe the authors’ experience using a novel surgical technique for treatment of childhood glaucoma.
Methods: Medical records of 24 consecutive patients and 39 eyes that underwent dilation and probing of Schlemm’s canal and viscocanalostomy between September 2002 and June 2008 were reviewed. Surgical success was defined as an intraocular pressure (IOP) of less than 23 mm Hg with or without glaucoma medication and without further surgical intervention.
Results: Mean age at surgery was 66 ± 66 months, with a mean preoperative IOP of 40.4 ± 10.2 mm Hg. Surgical success was achieved in 27 of 39 eyes (69%) with an average follow-up of 22 months. In patients without history of previous surgery and the diagnosis of primary congenital or juvenile glaucoma, surgical success was achieved in 17 of 19 eyes (89%) with an average follow-up of 20 months. There were no serious surgical complications associated with this procedure.
Conclusion: Goniosurgery with dilation and probing of Schlemm’s canal in combination with viscocanalostomy appears to be a safe and effective surgical modality to lower IOP. The procedure appears to be most effective in surgically naïve primary congenital and juvenile glaucoma.
doi: 10.3928/01913913-20100420-05 [get full text]
Decreased Contrast Sensitivity in Children and Adolescents With Type 1 Diabetes Mellitus
Constantine D. Georgakopoulos, MD; Maria I. Eliopoulou, MD; Artemis M. Exarchou, MD; Vasileios Tzimis, MD; Nikolaos M. Pharmakakis, MD; Bessie E. Spiliotis, MDSubmitted: 7/18/09; Accepted: 12/15/09; Posted: 4/22/10
Purpose: To evaluate contrast sensitivity in children and adolescents with diabetes mellitus without evidence of diabetic retinopathy.
Methods: Sixty patients with insulin-dependent diabetes mellitus (age range: 8 to 18 years) were studied. Their contrast sensitivity scores were obtained using the CSV-1000 device (Vector Vision, Dayton, OH) for four spatial frequencies and were compared with v scores of 45 age-matched and gender-matched “healthy” patients. Contrast sensitivity values were also correlated to patient’s age, duration of disease, and metabolic control of diabetes mellitus.
Results: The patients with insulin-dependent diabetes mellitus had a significant contrast sensitivity score reduction at all spatial frequencies tested. Glycosylated hemoglobin levels were inversely related to the contrast sensitivity thresholds. No significant correlation was found between the contrast sensitivity scores and the patient’s age or duration of disease.
Conclusion: Contrast sensitivity defects are detected in patients with insulin-dependent diabetes mellitus. These defects may represent an early dysfunction of the retina, visual pathway, or both in patients with insulin-dependent diabetes mellitus who do not show any signs of diabetic retinopathy.
doi: 10.3928/01913913-20100420-02 [get full text]
Physical Characteristics of Ocular Structures in Chinese Children With Emmetropia
Zhen-Yong Zhang, MD; Ren-Yuan Chu, MD; Xing-Ru Zhang, MS; Xing-Tao Zhou, MD; Matthew R. Hoffman, BS; Jin-Hui Dai, MDSubmitted: 6/13/09; Accepted: 11/19/09; Posted: 4/22/10
Purpose: To evaluate whether accommodation has effects on eye elongation.
Methods: Two hundred seventy-three eyes with a refractive error between +1.0 and -0.5 diopters were divided into three groups: pre-school children, grade-school children, and middle-school children. Ocular structures were measured using autorefraction and A-scan ultrasonography.
Results: There was a negative correlation between age and corneal power (r = -0.227, P = .0001), lens thickness (r = -0.263, P = .00001), and Gullstrand lens power (r = -0.452, P << .0001). There was a positive correlation between age and axial length (r = -0.432, P << .0001) and vitreous chamber depth (r = 0.505, P << .0001). Mean corneal power (P < .001) and lens power (P < .001) were significantly greater in pre-school children than in grade-school children, whereas axial length (P < .001) and vitreous chamber depth (P < .001) were greater in grade-school children. Mean lens thickness (P = .01) and lens power (P = .07) were higher in grade-school children than in middle-school children, whereas axial length (P = .024) and vitreous chamber depth (P < .001) were higher in middle-school children.
Conclusion: Ocular structures may play different roles in maintaining emmetropia. Accommodation during near work and its potential attendant hyperopic defocus could potentially drive eye elongation.
doi: 10.3928/01913913-20100420-06 [get full text]
Epiblepharon Related to High Body Mass Index in Korean Children
Hee Bae Ahn, MD; Jang Won Seo, MD; Jae Ho Yoo, MD; Woo Jin Jeong, MD; Woo Chan Park, MD; Sae Heun Rho, MDSubmitted: 5/6/09; Accepted: 11/12/09; Posted: 4/22/10
Purpose: To evaluate the clinical manifestations of epiblepharon in Korean children and the relationship between this condition and body mass index.
Methods: In a retrospective case–control study, 223 children 6 to 15 years of age treated surgically for epiblepharon were studied and compared with an age-matched control group of 264 children. Data on age, sex, weight, height, and recurrence were recorded.
Results: Mean age of the patients was 8.63 ± 4.43 years. Lower eyelids were commonly involved bilaterally. Chief complaints included ocular discomfort, eye rubbing, visual disturbances, photophobia, and epiphora. Minimal resection of orbicularis oculi with full-thickness eyelid rotatory suture for epiblepharon was performed on 223 patients. The body mass index in girls 12 to 15 years old with epiblepharon was significantly higher than that in children without epiblepharon (P < .05). There was a statistically significant correlation between the incidence of epiblepharon and obesity with aging in girls (P < .05). Reoperation was performed on 12 patients (4.4%) because of recurrence of corneal irritation with inverted eyelashes. Clinical factors such as sex, age, and body mass index did not affect the rate of recurrence.
Conclusion: Epiblepharon is one of the most common eyelid abnormalities among Asian children. Obese Korean girls aged 12 to 15 years demonstrated symptomatic epiblepharon at a statistically significant level.
doi: 10.3928/01913913-20100420-01 [get full text]
Ely Almeida Santos, MD; Rodrigo Pessoa Cavalcanti Lira, MD; Harley Edison Almaral Bicas, MD; Maria Isabelle Lynch Gaete, MDSubmitted: 4/13/09; Accepted: 11/12/09; Posted: 4/22/10
Purpose: To study the action of botulinum toxin A on isometric contraction of the medial and lateral rectus muscles in esotropic or exotropic patients.
Methods: Isometric contraction in patients with strabismus (exotropic and esotropic) and in volunteers without strabismus was compared 30 days after the use of botulinum toxin A.
Results: Findings show that this drug has changed the strength ratio between direct agonist and antagonist muscles. This has promoted the displacement of the point of equilibrium between muscle strengths toward the nasal direction in esotropic cases, toward the temporal direction in exotropic cases, and subsequent deviation of the eye toward its primary position. The average achieved correction was approximately 10 prism diopters in both groups of patients.
Conclusion: In both exotropia and esotropia, the average variations in the induced points of equilibrium related to injection of botulinum toxin A were similar. This means that the greatest percentage of corrections happened in cases of small deviations.
doi: 10.3928/01913913-20100420-07 [get full text]
Effect of Intracameral Cefuroxime on Fibrinous Uveitis After Pediatric Cataract Surgery
Dan Gradin, MD; Daniel Mundia, MBChB, MMedSubmitted: 5/14/09; Accepted: 10/8/09; Posted: 4/22/10
Purpose: To determine whether intracameral cefuroxime reduces postoperative fibrin formation after pediatric cataract surgery.
Methods: Children aged 3 months to 10 years with bilateral congenital or developmental cataracts who underwent surgery between February and July 2008 were eligible for inclusion in this prospective double-masked study. The same surgical technique was used in each eye. The intraocular lens was placed in either the bag or sulcus in both eyes. The same intraocular lens type was used in both eyes (polymethylmethacrylate). One eye was randomized to receive intracameral cefuroxime at the end of surgery and the fellow eye received saline. The surgeon was masked to the treatment assignment. The amount of fibrin formation in the anterior chamber of each eye was assessed by a masked grader on the fourth postoperative day.
Results: Seventy eyes of 35 children were included in the study. Fibrin formation was noted on the fourth postoperative day in 14 of 70 eyes (20%), 7 in the cefuroxime group and 7 in the saline group. The mean fibrin score was 0.57 ± 1.31 in the cefuroxime group and 0.49 ± 1.07 in the saline group. There was no statistically significant difference in the amount of fibrin formation between groups (P = .857, Wilcoxon ranked signs test).
Conclusion: Intracameral cefuroxime did not significantly reduce postoperative fibrin formation in this study. Fibrin formation does not appear to be due to bacterial contamination in most cases of pediatric cataract surgery.
doi: 10.3928/01913913-20100420-03 [get full text]
Binocular Function in Pseudophakic Children
Malcolm R. Ing, MDSubmitted: 5/26/09; Accepted: 9/22/09; Posted: 4/22/10
Purpose: The author reports the results of visual and binocular tests performed on patients who had primary insertion of intraocular lenses following the removal of cataracts in their childhood.
Methods: Monocular and binocular tests were performed on 21 patients using the same equipment for sensory testing for binocularity on all patients before the history was abstracted from the clinical records. These patients were selected from a consecutive series and observed for a minimum of 5 years by their surgeons.
Results: The mean age at surgery performed on the first eye was 6.3 years. The mean age at the date of the author’s examination was 16.5 years and the mean length of follow-up was 10.3 years. All but 2 patients had motor alignment within 8 prism diopters of orthotropia at near. Fusion and some stereopsis was found in 15 patients, but only 4 of these demonstrated fine (60 seconds of arc or better) stereoacuity. Patients with fine versus gross stereoacuity were compared and found to be similar in type of cataract, age at first surgery, interval between surgeries, length of follow-up, and refraction, but different in the quality of best-corrected visual acuity.
Conclusion: Although satisfactory motor alignment, fusion, and some stereopsis is present in the majority of patients, fine stereoacuity is uncommon in pseudophakic children.
doi: 10.3928/01913913-20100420-04 [get full text]
The Effect of Inferior Oblique Muscle Z Myotomy in Patients With Inferior Oblique Overaction
Se Yup Lee, MD; Hyun Kyung Cho, MD; Hyun Kyung Kim, MD; Young Chun Lee, MDSubmitted: 2/3/09; Accepted: 9/2/09; Posted: 3/23/10
Purpose: To investigate the surgical outcomes of inferior oblique muscle Z myotomy in patients with inferior oblique overaction (IOOA).
Methods: A prospective study was performed in 21 patients (primary IOOA in 13 patients, secondary IOOA in 8 patients) who underwent inferior oblique muscle Z myotomy. Patients with IOOA under the degree of +2 were included. Seventy percent of Z myotomies were performed at 6 mm along the physiological path after identifying the inferior oblique muscle through an inferotemporal fornix incision. A comparison was made before the operation and 3 months postoperatively on the degree of IOOA, vertical deviation, and cyclotorsion.
Results: Simultaneous horizontal rectus surgery was performed with inferior oblique muscle Z myotomy because all patients had combined horizontal deviation. The mean degrees of preoperative and postoperative IOOA were +1.9 ± 0.32 and +0.7 ± 0.67 in the primary IOOA group and +1.83 ± 0.41 and +0.17 ± 0.41 in the secondary IOOA group. Six of 7 patients in the primary IOOA group showed V-pattern strabismus, which was improved in all cases after the operation. In the secondary IOOA group, changes of preoperative and postoperative hypertropia and cyclodeviation were from 7.75 ± 6.64 prism diopters and 8.6 ± 2.31° to 1.2 ± 3.35 prism diopters and 4.7 ± 2.02·, respectively. Inadvertent complete myotomy occurred in 1 patient due to excessive traction by an assistant during the procedure.
Conclusion: Inferior oblique muscle Z myotomy was an effective surgical procedure in patients with primary and secondary IOOA under the degree of +2.
doi: 10.3928/01913913-20100318-03 [get full text]
Visual Outcome of Three Generations in a Turkish Family With Marfan Syndrome
Silay Canturk Ugurbas, MDSubmitted: 2/2/09; Accepted: 9/2/09; Posted: 3/23/10
Purpose: The long-term outcome and postoperative visual acuity in a single family with ectopia lentis secondary to Marfan syndrome is presented.
Methods: Thirteen family members, ages ranging from 3 to 47 years, were evaluated from 2006 to 2008. Ten members were found to have primary or secondary visual problems secondary to ectopia lentis.
Results: Evaluation of 10 members with subluxated lenses in three generations showed that the leading cause of loss of vision (< 20/200) was amblyopia (n = 5), followed by surgical complications (n = 2) and retinal detachment (n = 1). Moderate amblyopia was observed in 8 additional eyes. Of those with long axial length (> 25 mm, n = 10), visual acuity ranged from 20/400 to 20/70 and no eyes tested better than 20/40. In eight eyes with an axial length of less than 25 mm, visual acuity ranged between counting fingers and 20/30. In this group, 50% had a visual outcome of 20/40 or better. Two eyes had no light perception and phthisis secondary to surgical complications. Of the 18 eyes in which axial length data were available, more eyes in the axial myopia group had unfavorable visual outcome (P = .04, Wilcoxon signed rank test).
Conclusion: Amblyopia due to delayed surgical intervention was the leading cause of visual loss in three generations of this family. Axial high myopia was more frequent in deeply amblyopic family members.
doi: 10.3928/01913913-20100318-06 [get full text]
Corneal Curvature and Thickness Development in Premature Infants
Silvana De Silva, MD; Fulvio Parentin, MD; Paola Michieletto, MD; Stefano Pensiero, MDSubmitted: 1/30/09; Accepted: 9/2/09; Posted: 3/23/10
Purpose: Analysis of postnatal changes in central corneal thickness (CCT) and corneal curvature (CC) in premature infants, their relation, and their possible influence on eye growth and intraocular pressure (IOP) evaluation.
Methods: CCT and CC were assessed in both eyes of 56 premature infants, born at 24 to 32 weeks of gestational age (GA), and then two or three times at post-conceptional ages (PCAs) of 28 to 42 weeks.
Results: CC changed from 65.83 diopters at 28 weeks of PCA to 49.38 diopters at 42 weeks of PCA. CCT decreased from 794 to 559 µm at the same ages. The reductions of these two corneal parameters seem to be related to each other and begin immediately after birth.
Conclusion: In light of the few data available in the literature, these data provide more certainty about the CCT values of premature infants. The importance of CCT and CC fast variations after premature birth concerns both the knowledge of anterior segment development and the correct evaluation of IOP in immature eyes; the influence of these two parameters on the methods of IOP evaluation could be more remarkable at the lowest PCAs .
doi: 10.3928/01913913-20100318-02 [get full text]
Mehmet Saldir, MD; Serdar Umit Sarici, MD; Fatih Mehmet Mutlu, MD; Cem Mocan, MD; Halil Ibrahim Altinsoy, MD; Okan Ozcan, MDOriginally submitted: 11/3/08; Accepted: 7/27/09; Posted online: 2/23/10
Background: To determine the frequency of ophthalmologic problems and the risk factors that affect the occurrence of these problems in premature newborns with a gestational age of 32 weeks or less.
Methods: Premature newborns observed at a neonatal intensive care unit between January 2002 and March 2006 were included. A control visit including an ophthalmologic examination was performed at 10 months of age or later. Primary ocular morbidities were studied, and the association between these parameters and prenatal, perinatal, and neonatal characteristics were evaluated.
Results: A total of 169 premature newborns were included in the study, and they were examined at a mean age of 25.85 ± 11.79 months (range: 10 to 42 months). There was complete vision loss (blindness) in 1 (0.6%) case, strabismus in 15 (8.9%) cases, and refractive errors in 10 (5.9%) cases. Twenty (77%) cases with any abnormality and 50 (35%) cases with a normal examination at follow-up had a history of ROP at any stage during the neonatal period (P = .001). Short gestational age (P = .018), low birth weight (P = .002), and the presence of ROP requiring retinal surgery during the neonatal period (P = .007) were determined to be significant risk factors for the development of vision loss, strabismus, and refractive errors.
Conclusion: Neonates with a gestational age of 32 weeks or less, especially those younger than 30 weeks, should not only be screened for ROP in the neonatal period, but should also have regular follow-up examinations to check for the development of other ophthalmologic problems during infancy and early childhood.
doi: 10.3928/01913913-20100218-08 [get full text]
Termination of Amblyopia Treatment: When to Stop Follow-up Visits and Risk Factors for Recurrence
Christine De Weger, MSc; Henry J. B. Van Den Brom, MD; Robert Lindeboom, PhDOriginally submitted: 5/6/09; Accepted: 8/4/09; Posted online: 2/23/10
Background: This study estimated when it is safe to stop follow-up visits after cessation of amblyopia treatment and to identify factors associated with deterioration of visual acuity.
Methods: Study patients included 282 patients aged 7 to 13 years who were monitored for deterioration after cessation of amblyopia treatment (median follow-up: 3.9 years).
Results: Six (2.1%) patients lost 2 or more logarithm of the minimum angle of resolution levels of visual acuity and 77 (27.3%) patients lost 1 or more Snellen lines of visual acuity. Good compliance with re-treatment stopped further deterioration and lost visual acuity was regained (average follow-up after re-treatment: 3.3 years). Life-table-analysis indicated that 95% of the cases that deteriorated occurred within 24 months after cessation of treatment. Multivariable analysis corrected for duration of treatment uncovered factors independently associated with deterioration.
Conclusion: A clinically important risk of deterioration of visual acuity was found during the first 2 years after cessation of amblyopia treatment. Follow-up time longer than 2 years is recommended in the presence of a developing risk factor such as increasing anisometropia. With prompt re-treatment and good compliance, deterioration can be stopped and visual acuity can be restored.
doi: 10.3928/01913913-20100218-03 [get full text]
Nalini K. Aggarwal, MD; Sai B. Gandham, MD; Rebecca Weinstein, MD; Robert Saltzmann, MD; David S. Walton, MDOriginally submitted: 2/23/09; Accepted: 8/4/09; Posted online: 2/23/10
Purpose: To examine the clinical and gonioscopic findings in patients with glaucoma associated with Sturge–Weber syndrome.
Methods: Retrospective review of clinical findings of all patients with Sturge–Weber syndrome who presented between January 1978 and December 2003. Koeppe gonioscopy was performed under general anesthesia and findings were photographed when feasible. Iris color was documented by color sketch or photograph at initial presentation. Fisher exact test was used to determine whether the presence of heterochromia was statistically higher in the glaucomatous group.
Results: Fifty-five patients who met inclusion criteria were identified, of whom 44 (80%) had glaucoma. Unilateral glaucoma was diagnosed in 30 eyes and bilateral glaucoma in 14 eyes, yielding 58 eyes with glaucoma and 52 eyes without. Gonioscopic examination revealed distinct anatomic abnormalities in the anterior chamber angle in 32 (55%) of the glaucomatous eyes in contrast to the normal fellow eyes in patients with unilateral glaucoma and to the patients without glaucoma. Heterochromia iridis with darker iris on the glaucomatous side was present in 11 of the 30 patients with unilateral glaucoma (37%, P < .001) but in none of the patients without glaucoma.
Conclusion: The characteristics observed in the anterior chamber angle in this large, uniquely examined series are the first reported to the authors’ knowledge and may support a role for neural crest derived anomalies in the pathogenesis of glaucoma in these infant eyes. Careful examination for heterochromia iridis may be judicious in these patients.
doi: 10.3928/01913913-20100218-01 [get full text]
Augmentin Duo in the Treatment of Childhood Blepharokeratoconjunctivitis
Jasmina Cehajic-Kapetanovic, MA Phy Sci, BM BCh Oxon, MRCOphth; Jeff Kwartz, FRCOphthOriginally submitted: 10/10/08; Accepted: 8/4/09; Posted online: 1/22/10
Purpose: To report the use of Augmentin Duo 400/57 (GlaxoSmithKline, Middlesex, UK) in the treatment of childhood blepharokeratoconjunctivitis (BKC).
Methods: This is a retrospective interventional case series. The case notes of 7 consecutive patients treated with Augmentin Duo 400/57 for BKC during 18 months were reviewed. Diagnostic criteria for BKC were blepharitis including recurrent chalazia and meibomian gland dysfunction, eyelid margin telangiectasia and facial rosacea, recurrent episodes of chronic red eye, photophobia, watering, punctate superficial keratopathy, corneal neovascularization, and corneal ulcers.
Results: Seven children (age range: 6 to 14 years) were diagnosed as having BKC. All children received systemic Augmentin Duo 400/57 and showed considerable improvement within the first month of therapy. Six children had no recurrences during a mean follow-up of 6 months. No patients experienced any side effects from this treatment.
Conclusions: Augmentin Duo 400/57 has not previously been reported in the treatment of BKC in children. In this case series, Augmentin Duo 400/57 proved to be at least as effective as current treatments with systemic erythromycin or doxycycline with the advantage of a twice-daily dosage and a superior side-effect profile.
doi: 10.3928/01913913-20100118-01 [get full text]
Tess Garretty, DBOOriginally submitted: 10/6/08; Accepted: 6/17/09; Posted online: 1/22/10
Background: Convergence excess esotropia defines an esotropia on accommodation at near fixation with binocular single vision and motor fusion at distance fixation associated with a high accommodative convergence: accommodation (Ac/A) ratio. The effect of occlusion on exotropia has been well described and is known to alter the Ac/A ratio. This study examines the effect of monocular occlusion on convergence excess esotropia.
Methods: The Ac/A ratio was measured using the gradient method at 1/3 and 6 m in 10 patients with convergence excess esotropia immediately prior to and following a 30-minute period of monocular occlusion.
Results: Clinically and statistically significant differences to the angle of deviation and the Ac/A ratio were found in some patients following occlusion.
Conclusion: Ac/A ratio measurement in convergence excess esotropia is influenced by fusional tenacity. Disrupting this fusion with a period of monocular occlusion results in changes to the angle of deviation in some patients, suggesting subcategorization of this condition into true and simulated convergence excess esotropia. Measurements of the Ac/A ratio are influenced by fixation distance.
doi: 10.3928/01913913-20100118-03 [get full text]
Rhegmatogenous Retinal Detachment Following Treatment for Retinoblastoma
Swakshyar Saumya Pal, MD; Lingam Gopal, MD, FRCSEd; Vikas Khetan, MD; Amit Nagpal, MD; Tarun Sharma, MD, FRCSEd, MBAOriginally submitted: 2/17/09; Accepted: 6/17/09; Posted online: 12/23/09
Purpose: To elucidate characteristics of rhegmatogenous retinal detachment that developed in children who underwent treatment for retinoblastoma and to analyze the outcome following vitreoretinal surgery in such clinical settings.
Methods: This was a retrospective case series of 9 eyes of 9 patients who underwent vitreoretinal surgery for tumor control and retinal reattachment.
Results: At the time of diagnosis of rhegmatogenous retinal detachment, retinoblastoma was regressed in 6 eyes (67%). The retinal detachment involved less than two quadrants in 7 eyes (78%) and was caused by an atrophic break in 7 eyes. Seven eyes underwent a non-drainage scleral buckling procedure. Three eyes underwent vitreous surgery; in 2 of these eyes, tumor excision along with retinectomy using melphalan infusion was performed and eventually silicone oil tamponade was used. Retinal reattachment was achieved in all eyes with eventual tumor control in 7 eyes. The median follow-up after retinal reattachment surgery was 24 months.
Conclusion: Rhegmatogenous retinal detachment in treated eyes with retinoblastoma is usually caused by an atrophic retinal break. Retinal detachment can be repaired successfully in most eyes.
doi: 10.3928/01913913-20091218-03 [get full text]
Atropine Treatment of Amblyopia: Is a Swap in Fixation Necessary?
Josephine Leone, BOrth&OphthSc(Hons); Zoran Georgievski, BAppSc(Orth)(Hons); Konstandina Koklanis, PhDSubmitted: 4/25/09; Accepted: 6/17/09; Posted: 11/23/09
Purpose: To investigate the impact of fixation on vision outcomes in patients with amblyopia undergoing atropine treatment and the validity of the “cyclo-swap test” (CST) as a method of predicting atropine efficacy.
Method: Sixteen children with amblyopia were included. The initial examination included a vision assessment and CST, in which fixation was assessed at 1/3 m, 6 m, and at distances less than 1/3 m. Children were treated for 10 weeks and reviewed at 5-week intervals with cessation of atropine 4 days prior. Vision and fixation were assessed at the follow-up visits. Children demonstrating no fixation swap initially were additionally observed after 1 week of atropine treatment under maximum cycloplegia.
Results: Eight children demonstrated a fixation swap (FS group) to the amblyopic eye during the CST at either 1/3 or 6 m, and 8 demonstrated no fixation swap (NFS group). By the end of the 10-week treatment period, both groups demonstrated a mean visual acuity improvement of between 2 and 3 lines (FS = 0.22 log units; NFS = 0.27 log units). Six of the 8 children in the NFS group demonstrated improvement in vision, all of whom also demonstrated a fixation swap at some stage.
Conclusion: Vision improvement in patients using atropine is likely to be attributable to a fixation swap that occurs during the treatment phase. The CST performed at 1/3 and 6 m has little value in predicting improvements in vision; however, when performed at distances of less than 1/3 m, it may provide valuable clinical information about atropine efficacy.
doi: 10.3928/01913913-20091118-05 [get full text]
Ufuk Elgin, MD; Bülent Cankaya, MD; Tulay Simsek, MD; Aygen Batman, MDSubmitted: 12/3/08; Accepted: 6/17/09; Posted: 11/23/09
Purpose: To compare the optic disc topography parameters of children with juvenile diabetes mellitus and normal children using the Heidelberg Retinal Tomograph (HRT III) (Heidelberg Engineering, Heidelberg, Germany).
Methods: The topographic optic disc parameters (cup volume, cup area, rim volume, rim area, disc area, mean cup-to-disc ratio, and mean cup depth) of 28 non-glaucomatous eyes of 28 children with type 1 diabetes mellitus and 28 eyes of 28 age-matched healthy children were compared using the nonparametric Mann–Whitney U test.
Results: No statistically significant differences were found between cup volume (P = .782), cup area (P = .878), rim volume (P = .853), disc area (P = .452), mean cup-to-disc ratio (P = .852), and mean cup depth (P = .711) of eyes of cases with diabetes mellitus and normal subjects.
Conclusion: This result suggests that non-glaucomatous eyes of children with type 1 diabetes mellitus and healthy subjects have similar topographic optic disc characteristics.
doi: 10.3928/01913913-20091118-03 [get full text]
Kadircan H. Keskinbora, MD, PhDSubmitted: 5/4/09; Accepted: 6/9/09; Posted: 11/23/09
Purpose: To determine whether unilateral inferior oblique anterior transposition alone could be an effective procedure for treating superior oblique palsy with inferior oblique overaction.
Methods: The records of 38 patients who underwent unilateral inferior oblique anterior transposition for unilateral superior oblique palsy with inferior oblique overaction were evaluated. A comprehensive ocular examination including best-corrected visual acuity measurements, ductions, versions, and deviations at near and distance, head tilt test, abnormal head position, dilated fundus examination, and Titmus test was performed prior to and after surgery.
Results: The mean patient age was 29 years, the mean follow-up was 32 months, the mean preoperative hypertropia in primary position was 14.29 ± 7.7 prism diopters (PD), and the mean inferior oblique overaction was 3.63 ± 0.67. Anterior transposition of the inferior oblique muscle was effective across a wide range of preoperative primary position hypertropia (4 to 35 PD) with a mean reduction in postoperative hypertropia of 12 PD. Inferior oblique overaction was reduced in all patients. No patient demonstrated postoperative primary position hypotropia. Surgery improved stereoacuity nearly two units using the Titmus stereoacuity scale.
Conclusion: Anterior transposition of the inferior oblique muscle is effective in correcting inferior oblique overaction and primary position hypertropia in the treatment of unilateral superior oblique palsy.
doi: 10.3928/01913913-20091118-04 [get full text]
Incidence of Retinopathy of Prematurity in a Neonatal Intensive Care Unit in Nepal
Jyoti Baba Shrestha, MD; Sanyam Bajimaya, MD; Anand Sharma, MD; Jeevan Shresthal, FRCS, FRCOphth; Purna Karmacharya, MDSubmitted: 8/17/08; Accepted: 6/9/09; Posted: 11/23/09
Purpose: To determine the incidence of retinopathy of prematurity (ROP) in low birth weight premature infants admitted to the neonatal intensive care unit of a children’s hospital in Kathmandu.
Methods: A hospital-based prospective study was performed in neonates with a gestational age of less than 36 weeks or birth weight of less than 2,000 g during 1 year. Ophthalmologic examination was performed 2 to 4 weeks after birth and patients were observed until the retinal vascularization was complete. ROP was classified using the revised International Classification of Retinopathy of Prematurity.
Results: A total of 78 infants fulfilled the screening criteria. ROP was detected in 29.5% (n = 23) of neonates. Thirteen infants (16.7%) had stage 1 disease and 5 each (6.4%) were found to have stage 2 and stage 3 ROP. Threshold disease was present in 3.8% (n = 3) of infants with a gestational age of less than 32 weeks and birth weight less than 1,500 g who required laser treatment per Early Treatment of ROP criteria. Low birth weight (P < .01) and low gestational age (P < .01) were significantly associated with the incidence of ROP.
Conclusion: Prematurity and low birth weight were found to be major risk factors for ROP. ROP screening should be performed in such infants for early detection because its incidence is likely to increase as more premature infants survive with improved neonatal care.
doi: 10.3928/01913913-20091118-08 [get full text]
Comparative Study of Unilateral and Bilateral Surgery in Moderate Exotropia
Vimla Menon, MS; M. Ashok Singla, MD; Rohit Saxena, MD; Swati Phulijele, MDSubmitted: 2/23/09; Accepted: 5/15/09; Posted: 11/23/09
Purpose: To evaluate the surgical outcome of unilateral versus bilateral rectus recession for the correction of moderate exotropia.
Methods: This was a prospective study of 20 consecutive cases of intermittent exotropia ranging from 15 to 25 prism diopters (PD) randomized into two groups and operated on by a single surgeon. In the unilateral group, a recession of 7.0 to 7.5 and 8.0 to 8.5 was done for 15 to 20 PD and 21 to 25 PD of exotropia, respectively. In the bilateral group, a recession of 5.0 to 5.5 and 6.0 to 6.5 mm was done for 15 to 20 PD and 21 to 25 PD of exotropia, respectively. Surgical results of both groups were compared 3 months postoperatively.
Results: The mean age of patients was 8.5 years in the unilateral group and 11 years in the bilateral group. The mean preoperative exotropia was 21.0 ± 3.77 PD in the unilateral group and 22.9 ± 3.03 PD in the bilateral group. The mean postoperative deviation at 3 months was 5.5 ± 4.03 PD in the unilateral group and 2.8 ± 3.91 PD in the bilateral group. Consecutive persistent small-angle esotropia was seen in one patient in the bilateral group. There was no significant incomitance at 3 months in either group.
Conclusion: Unilateral and bilateral rectus recession are equally effective in mild to moderate exotropia.
doi: 10.3928/01913913-20091118-07 [get full text]
A New Transconjunctival Muscle Reinsertion Technique for Minimally Invasive Strabismus Surgery
Daniel S. Mojon, MD, FEBO, ExecMHSASubmitted: 11/2/08; Accepted: 5/15/09; Posted: 10/22/09
Purpose: To describe a novel, minimally invasive strabismus surgery (MISS) technique for horizontal rectus muscle recessions, plications, and advancements.
Methods: Subjects for this prospective study were the first 20 consecutive patients who underwent unilateral horizontal rectus muscle surgery with a transconjunctival suturing (TRASU) technique for primary muscle displacements of 4.5 mm or greater or for repeat muscle displacements of 3.0 mm or greater.
Results: The TRASU technique was associated with no increase in complication rate and was accomplished through a conjunctival approach with an incision that was smaller by 31% ± 11% compared to incisions for previously described MISS approaches. Of the 19 patients (20 eyes) returning for follow-up, 11 (55%) had minimal redness as the only grossly visible sign of surgery on the first postoperative day. By 6 months postoperatively, visual acuity and refractive error were not significantly different from preoperative values (P > .10 for each).
Conclusion: The TRASU technique is safe and can be accomplished through a conjunctival incision that averages two-thirds the size of incisions for previously reported MISS techniques.
doi: 10.3928/01913913-20091019-07 [get full text]
Is Buckle Surgery Still the State of the Art for Retinal Detachments Due to Retinal Dialysis?
Bernhard M. Stoffelns, MD, PhD; Gisbert Richard, MD, PhDSubmitted: 1/15/09; Accepted: 3/19/09; Posted: 10/22/09
Purpose: Retinal dialysis is a frequent cause of retinal detachment in infants and young adults. The authors report long-term results obtained with conventional detachment surgery in a large consecutive series.
Methods: Fifty-two eyes of 50 patients with retinal detachment due to dialysis underwent a segmental buckling procedure between January 1990 and December 1998. Patient characteristics and surgical results at 1 year of follow-up were evaluated. In 2007, 40 eyes from these groups were reexamined for long-term results (follow-up: 9 to 17 years; median: 13.4 years).
Results: The mean age of the patients was 12.8 years (range = 6 to 28 years). Preferred locations of the dialyses were inferotemporal (72%) and superonasal (16%). The macula was detached in 82%. At 1 year of follow-up, the retina was completely reattached after one surgical procedure in 87% and after two procedures in 97%. Long-term follow-up of 40 of 52 eyes revealed no retinal redetachment, but additional surgeries had been performed. Visual acuity improved in 70% of the eyes, but only 40% reattained reading vision due to the high rate of macula-off retinal detachment preoperatively.
Conclusions: Scleral buckling for retinal detachment due to dialysis yields good results, even in the long term, and remains the treatment of choice for these usually young patients despite the increasing popularity of primary vitrectomy.
doi: 10.3928/01913913-20091019-10 [get full text]
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