Visual results after early surgical treatment of unilateral congenital cataracts

The authors reviewed the records of 25 consecutive patients who had been operated on for unilateral congenital cataracts at 1 year of age or younger and who had been followed for a period of 5 years or longer. Excluded were patients who demonstrated retinal and optic nerve anomalies. Five eyes achieved 20/40 or better Snellen visual acuity, 5 eyes achieved 20/50 to 20/100 visual acuity, and 15 eyes had 20/200 or less visual acuity. All patients with visual acuity of 20/40 or better had cataract surgery performed before 17 weeks of age, the critical period, and surgery was scattered within this time frame. For surgery performed between 17 weeks and 1 year of age, the best achieved visual acuity in children with surgically significant unilateral congenital cataracts was between 20/50 and 20/100. There was no correlation between the age at the time of surgery and the attainment of these visual levels in this patient subset.

Management of posterior lenticonus

Posterior lenticonus is associated with progressive lens opacification. We report a series of 40 consecutive patients (41 eyes) with posterior lenticonus who were treated by three pediatric ophthalmologists between 1974 and 1988. Prior to cataract surgery, appropriate patients were treated with atropine dilatation, spectacle correction including bifocals for refractive errors, and amblyopia occlusion therapy. Indications for surgery were a measured decrease in visual acuity, the loss of a central fixation reflex, or the onset of strabismus. The age at which cataract surgery was performed ranged from 2 months to 12 years (mean 4 years, 6 months). Nineteen eyes (49%) achieved postoperative acuities in the 20/20 to 20/40 range, 7(18%) eyes achieved 20/50 to 20/100, 4 (10%) eyes achieved 20/200, and 4 (10%) eyes achieved less than 20/200. Two (5%) young patients had central, steady, and maintained visual fixation reflexes and 3 (8%) additional patients had central, steady, but not maintained reflexes. After cataract surgery and aphakic optical correction, amblyopia was present in 84% of patients and strabismus was present in 51% of patients. The patients in this study had sufficient optical distortion to produce amblyopia. Cataract removal and optical correction alone did not correct the vision; occlusion therapy for amblyopia was required. Earlier surgery may be indicated to prevent visual deprivation amblyopia in patients with posterior lenticonus.

The branchio-oculo-facial syndrome

We review 13 reported cases and add the evaluations of 2 new patients with the branchio-oculo-facial (BOF) syndrome, a recently delineated autosomal dominant disorder with highly variable expression. This condition has a distinctive phenotype with characteristic craniofacial abnormalities consisting of aplastic or hemangiomatous cervical skin lesions with or without branchial sinuses; malformed, rotated auricles; and ocular abnormalities, which include microphthalmia or anophthalmia, coloboma, and cataract. The term pseudocleft has been used to describe the upper lip and philtrum abnormality found in mild cases, but the expression may extend to that of a complete cleft lip and palate. This unique disorder may go undetected in patients followed in cleft palate or craniofacial clinics and may not be recognized in patients with mild expressions. Genetic counseling for affected individuals is imperative because of the 50 percent recurrence risk. We emphasize the multidisciplinary care required to correct their craniofacial anomalies.

Development of grating acuity in infants with regressed stage 3 retinopathy of prematurity

The acuity card procedure was used to measure grating acuity in 17 infants with regressed Stage 3 retinopathy of prematurity (ROP) who had no lasting anatomic changes in the retina or optic nerve. Results were compared with those of 28 healthy preterm infants and 28 infants matched by birth weight and gestational age who did not have Stage 3 ROP. Infants in the ROP group showed delayed grating acuity development until 2 years of age. This difference among groups was significant at the 3-5- and 10-12-month test ages but not at the 0-1-, 8-9-, and 16-18-month test ages. Post hoc analyses indicated that the delay in acuity development shown by the ROP group was due to the poor acuity scores of the infants in that group who had central nervous system abnormalities of periventricular leukomalacia or severe (Grade III or IV) intraventricular hemorrhage. When the data of these infants were removed from the analysis, the ROP group showed acuity development similar to that of both the healthy preterm group and the group of infants with matched birth weights and gestational ages who did not have Stage 3 ROP.

Acuity card assessment of visual function in the cryotherapy for retinopathy of prematurity trial

The primary outcome measure of the effectiveness of cryotherapy in the original design of the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) was the anatomic status of the retina, as documented by fundus photography 3 months and 12 months after infants had received treatment. The authors describe the addition of a measurement of visual function, the Acuity Card procedure, to the CRYO-ROP study. After training, four visual-acuity testers attempted to measure monocular grating acuity in all randomized infants and approximately one fourth of the natural-history infants in the study, tested at 1 year postcryotherapy or 1 year postterm. In 95% of infants on whom testing was attempted, monocular acuity values from each eye were obtained. Interobserver test-retest results on 25 eyes of 13 randomized infants agreed to within one octave or better in all but one of the eyes. The high testability rate and good interobserver agreement suggest that the Acuity Card procedure has been a successful method of assessing visual function in the CRYO-ROP study.

Retinopathy of prematurity: the relationship with intraventricular hemorrhage and bronchopulmonary dysplasia

We studied prospectively a cohort of 326 neonates weighing 500-1250 gm at birth. These babies were all born at Magee-Womens Hospital during 1986 and 1987. Sixty-five percent survived and were discharged from the hospital, and 197 of the survivors (93%) had at least one ophthalmological exam before their discharge. Of the patients who were examined, 34% had retinopathy of prematurity (ROP) and 12% had stage 3 or 4 ROP in at least one eye. There were six neonates with at least one blind eye, giving an estimated prevalence of blindness caused by ROP of 301 per million live births. By univariate analysis there was a strong association of ROP with birthweight, oxygen exposure, respirator treatment, and intraventricular hemorrhage (IVH). By multivariate analysis, only the respirator treatment was significantly associated with ROP. When birthweight, oxygen exposure, and IVH were controlled, a baby requiring more than 28 days of ventilator treatment was 4.07 times more likely to have stage 3 or 4 ROP than a baby with less ventilator exposure. These data confirm the strong association of ROP with bronchopulmonary dysplasia (BPD), low birth-weight, and IVH, and suggest that the key component among these interrelated variables may be time spent on a ventilator.

Persistent hyperplastic primary vitreous with vertical transmission

The authors report a 15-month-old white male and his 30-year-old mother who both have persistent hyperplastic primary vitreous (PHPV) unassociated with other congenital anomalies. Although there are two previous reports of PHPV in siblings suggesting autosomal recessive inheritance, this is the first report compatible with autosomal dominant inheritance.

Ophthalmologic complications of meningomyelocele: a longitudinal study

Patients with spina bifida have multiple ophthalmologic problems, many of which are preventable. Most of the problems are related to the hydrocephalus, which is caused by the coexisting Arnold-Chiari malformation. When patients are treated for hydrocephalus, and comprehensive eye care is available, 94% of the patients will have 6/12 visual acuity or better. Strabismus is common but it responds well to medical and surgical treatment. Children with spina bifida should have frequent examinations by an ophthalmologist who is familiar with the diagnosis and management of the defects recorded in this study.

Management of strabismus with botulinum A toxin

Three hundred eight patients with strabismus were treated with botulinum A toxin (Oculinum) chemodenervation; 153 were followed by the authors for at least 6 months. In this study group, 97 received botulinum A toxin injections as the primary method of treatment of their ocular deviation. Fifty-six received injections after traditional extraocular muscle surgery. Botulinum A toxin was useful for management of patients with recent surgical overcorrections and for management of some patients with sixth cranial nerve palsy. Chemodenervation of an extraocular muscle was not as successful as traditional strabismus surgery for treatment of infantile esotropia and other comitant deviations. Botulinum A toxin injection was ineffective in patients who had restrictive strabismus. This drug has limited application in the management of patients with strabismus.

Visual field development in infants with stage 3 retinopathy of prematurity

Binocular visual field development was measured in 11 infants who had stage 3 ROP in early infancy and in 11 infants without ROP, matched for birthweight and gestational age. Kinetic perimetry was used to measure visual fields along the 45 degree, 135 degree, 225 degree and 315 degree half-meridia. Infants were tested at 4, 9, and 18 months from due date. Analyses of variance were used to compare results of the two groups for each age tested. Results at the 4-month test age indicated that both groups had visual fields within the normal range for their age. However, at the 9-month test age the ROP group showed a significantly (P less than 0.05) smaller visual field than the control group. At 18 months, the ROP group still showed smaller visual fields than the control group, but the difference was not significant. The results suggest that dysfunction of the peripheral retina associated with ROP may produce a constriction of the visual field or a delay in visual field development.

Treatment of congenital unilateral upper eyelid retraction with a marginal myotomy procedure

Two children with congenital unilateral upper eyelid retraction were treated successfully with surgery at 2 years of age. Excellent results were obtained using a modification of Grove's marginal myotomy procedure for lengthening the levator palpebrae superiorus muscle. To our knowledge, early surgical treatment for this rare idiopathic disorder has not been reported previously.

Management of facial spasm with Clostridium botulinum toxin, type A (Oculinum)

One hundred five patients received 391 graded injections of Clostridium botulinum type A toxin (Oculinum) to treat uncontrollable facial muscle spasm. Patients had essential blepharospasm (n = 61), hemifacial spasm (n = 24), or aberrant regeneration of the seventh cranial nerve (n = 20). Muscle spasms were reduced within two days of the first injection of toxin and, in most cases, the drug effect lasted three to four months. Control of facial muscle spasm was achieved in all patients. Complications related to treatment included transient blepharoptosis (n = 7), diplopia (n = 2), and altered facial expression (n = 11). Systemic side effects were not observed. Select chemodenervation of facial muscles with graded injections of botulinum toxin is a useful adjunct to control blepharospasm, hemifacial spasm, and facial spasm due to aberrant regeneration of the facial nerve.

Ophthalmologic features of Prader-Willi syndrome

Forty-six patients with Prader-Willi syndrome were examined to determine the incidence and character of ocular abnormalities. All patients met clinical criteria for this syndrome including infantile hypotonia, hypogonadism, truncal obesity, intellectual impairment, dysmorphic facies, and short stature. Thirty-two patients had best corrected visual acuities between 6/6 and 6/9 in each eye. Seven patients (15%) had myopia greater than -3.75 diopters. Nineteen (41%) patients had astigmatism of 1.25 diopters or greater. Amblyopia of strabismic, anisometropic, or ametropic etiology was present in 11 (24%) of the patients. Strabismus was present in 25 (54%) patients: 22 (48%) patients had esotropia and three (7%) had exotropia. Nine patients either received or required strabismus surgery. Thirty-three percent of the patients examined for iris transillumination defects had this finding. This study represents the first large series of patients with Prader-Willi syndrome to undergo detailed ophthalmologic evaluation. Recognition of this syndrome is important because of the high incidence of potentially treatable ocular problems.

Screening criteria for the detection of retinopathy of prematurity in patients in a neonatal intensive care unit

We examined the eyes of 2986 neonates admitted to the Magee-Womens Hospital Neonatal Intensive Care Unit from January 1, 1977, through December 31, 1985, who weighed less than 2000 g at birth or were exposed to added oxygen and later discharged. Fifty-six of these patients had grade III, IV, or V retinopathy of prematurity as defined by Kingham (stage III or IV in the International Classification of Retinopathy of Prematurity system) in at least one eye. All 56 patients were exposed either to added oxygen for more than 50 days or had a birthweight less than 1600 g. We propose that these are more realistic screening criteria than those proposed by the American Academy of Pediatrics (exposure to any added oxygen, birthweight less than 2000 g). Their use will avoid many unnecessary eye exams, while allowing detection of all significant retinopathy of prematurity.

Retinopathy of prematurity. Risk factors in a five-year cohort of critically ill premature neonates

We studied the importance of exposure to an elevated partial pressure of carbon dioxide (PCO2) in the development of scarring retinopathy of prematurity (SROP) in a cohort of 92 neonates with chronic lung disease (greater than or equal to 14 days of respiratory therapy, greater than or equal to 30 days of oxygen therapy, and greater than or equal to 70 days in the hospital), 31 of whom had SROP. This cohort was chosen to avoid confounding prolonged respiratory failure with the presence of SROP and because such a cohort was expected to contain approximately 85% of all patients with SROP. Patients with SROP had a lower PCO2 and spent more time on a respirator at higher respirator pressures during the first 70 days of life. In addition, infants with SROP had a lower mean arterial pressure and had a higher prevalence of seizures (97% vs 43%) and intraventricular hemorrhage (52% vs 26%). We conclude that an elevated PCO2 is not associated with SROP in this group of critically ill premature neonates but that the presence of a seizure disorder or an intraventricular hemorrhage is strongly associated with SROP.

Treatment of facial spasm with Oculinum (C. botulinum toxin)

Forty-six consecutive adult patients with facial spasm were treated with one or more Botulinum toxin (Oculinum) injections to control muscle spasm. During the follow-up period of 6.6 months (one week-12 months), 27 patients required retreatment with a mean time interval of 3.4 months between treatments. Control of facial spasm was achieved in all patients. Complications included occasional bruising around the injection site and a transient blepharoptosis in one patient. No systemic effect was observed. This preliminary report suggests that treatment with Botulinum toxin (Oculinum) is an acceptable alternative to surgical management in select patients.

Absence of antibody production in patients treated with botulinum A toxin

To test the possibility of the formation of an antibody to botulinum A toxin after multiple injections of this potent neurotoxin, we collected serum samples from 28 patients who received 57 doses. These injections over a nine-month period with as much as 50 units per injection formed no detectable antibody.

Masked blepharoptosis

The eyelid of a patient with apparent unilateral blepharoptosis and a preference for fixation with the contralateral eye, was corrected surgically. However, postoperatively when the preferred (unoperated) eye was used for fixation, the ptosis appeared to have been overcorrected. When the non-preferred (operated) eye was forced to take up fixation, the overcorrected lid position resolved, but ptosis of the unoperated eyelid was unmasked. Surgical correction of this previously masked ptosis ultimately produced a satisfactory result. Our experience emphasizes the importance of ocular fixation preference when evaluating patients with blepharoptosis.

Results following surgical management of oculomotor nerve palsy with a modified Knapp procedure

Thirteen patients with oculomotor nerve palsy had their strabismus managed with a recess/resect procedure on the horizontal recti of the affected eye. A simultaneous graded supraplacement of both horizontal recti in the affected eye was used to manage the hypotropia in 9 of 11 patients with unilateral palsies. If some medial rectus function exists, correction of III nerve palsy is best achieved with a recess/resect procedure with supraplacement of the horizontal recti, 1 mm for each 2 prism diopters of hypotropia in primary position. Eight of 13 patients required additional procedures. Four of 13 patients did achieve high levels of binocular function.