Effect of preoperative stability of alignment on outcome of strabismus surgery for infantile esotropia

INTRODUCTION

Some strabismus surgeons wait until the angle of deviation stabilizes prior to operating on patients with infantile esotropia. This study evaluated whether a preoperative increase in the angle of deviation affected surgical outcomes.

METHODS

This was a retrospective comparative case series in which records of patients with infantile esotropia, who had surgery performed before age 2 years and who were followed for at least 2 years postoperatively, were reviewed to identify two groups for comparison: the first had </=5(Delta) change in the angle of deviation between the first office visit and time of surgery; the second had a >/=10(Delta) increase in the angle of deviation prior to surgery. In the latter group, surgery was performed for the angle present at the time of surgery. Outcomes were considered successful if the patients had microtropias.

RESULTS

Fifteen patients were identified in each group. The interval between the first office visit and time of surgery was the same in both groups (mean, 2 months). Outcomes were successful in 11 of 15 (73%) in each group (no significant difference, p = 0.659).

CONCLUSIONS

There was no difference in outcome between children whose angles of deviation were stable and those whose angles increased prior to surgery. This indicates that strabismus surgery does not need to be delayed while waiting for the angle of deviation to stabilize. Surgical correction may therefore be achieved at an earlier age, which may have a beneficial effect on outcome.

Pseudotumor cerebri following tapered corticosteroid treatment in an 8-month-old infant

The authors report on an 8-month-old infant with an orbital capillary hemangioma. The patient had been treated with high-dose corticosteroid therapy and had had a recent decrease in dose. The patient presented to the emergency department with increased irritability and bulging fontanelles. On lumbar puncture the opening pressure was > 55 cm H(2)O. Ophthalmological examination revealed interval development of papilledema. The child was treated with high-volume lumbar puncture, subsequent drainage of 10 ml of cerebrospinal fluid, resumption of the previous steroid dose, and acetazolomide therapy. The patient's symptoms resolved and follow-up ophthalmological examination revealed interval resolution of papilledema. The authors present the youngest reported case of pseudotumor development after corticosteroid tapering.

Outcomes in children with nasolacrimal duct obstruction: Significance of persistent symptoms while stents are in place

To evaluate the correlation between persistent symptoms while stents are in place and final outcome in children with nasolacrimal duct obstruction (NLDO). A retrospective observational case series, with medical record review that included indications for surgery, surgical procedure, presence of symptoms while stents were in place, and final outcome after stent removal. Twenty-eight children with NLDO had nasolacrimal duct stents placed in 42 eyes. Twenty-one of the 42 eyes (50%) had minimal or no signs or symptoms of NLDO while stents were in place, and 18 of 21 (86%) were symptom-free after stent removal. Twenty-one of the 42 eyes (50%) remained symptomatic while stents were in place. Eleven of these 21 eyes (52%) had good outcomes after stent removal. Ten (48%) of these patients had persistent symptoms after stent removal requiring further treatment. The prognosis for a good outcome is excellent if symptoms of NLDO resolve while stents are in place. The prognosis is poorer if symptoms of NLDO persist, but more than half of such patients still have good outcomes. Careful counseling of parents regarding these outcomes should be performed before considering additional interventions.

Strabismus surgery for elimination of bifocals in accommodative esotropia

PURPOSE

This study reports the outcomes of strabismus surgery to eliminate bifocals in patients with accommodative esotropia with a high accommodative convergence to accommodation (AC:A) ratio.

DESIGN

Retrospective interventional case series.

METHODS

Sixteen patients who wore bifocals for treatment of accommodative esotropia with a high AC:A ratio underwent strabismus surgery following prism adaptation testing (PAT) for the near angle of esotropia without bifocals. Outcomes were considered successful if patients had microtropias and maintained fusion without bifocals.

RESULTS

All patients had successful outcomes after one or two surgeries. Three of 13 (23%) patients with positive PATs required two surgeries. Two of three (67%) patients with negative PATs required two surgeries. Binocularity remained the same in 13 patients and improved in three patients. Glasses were eliminated entirely in eight of 16 (50%) patients.

CONCLUSIONS

Strabismus surgery may eliminate the need for bifocal glasses in patients with accommodative esotropia with a high AC:A ratio, with many patients able to discontinue glasses entirely. Preoperative PAT may help predict the risk of requiring more than one surgery.

Clinical ocular abnormalities in infants with trisomy 13

PURPOSE

Previous reports of ocular abnormalities associated with trisomy 13 have described pathologic abnormalities, with minimal descriptions of clinical findings. This report describes the clinical findings in four infants with trisomy 13.

DESIGN

Retrospective noncomparative case series.

METHODS

Review of medical records of four infants with trisomy 13. One patient underwent cataract surgery and treatment of Coats disease.

RESULTS

All four infants had inferonasal iris colobomas with unilateral inferonasal cataracts, primarily involving the posterior lens surface. Two patients had pigmented tissue associated with the cataracts. Cataract surgery was performed in one of the patients with good results. This patient also developed a unilateral exudative retinal detachment with peripheral telangiectatic vessels. This resolved after treatment with cryotherapy.

CONCLUSIONS

The cataracts in these infants with trisomy 13 had similar clinical features, which were different than those seen in other types of cataracts in infants. In addition, one patient had Coats disease, which has not been previously described in association with trisomy 13. The presence of inferonasal iris colobomas and adjacent sectoral cataracts in patients with other dysmorphic findings should prompt chromosomal analysis for trisomy 13.

Risk of retinopathy in children with type 1 diabetes mellitus before 2 years of age

PURPOSE

To assess the risk of diabetic retinopathy (DR) in children with type 1 diabetes mellitus (T1DM) diagnosed at a very early age.

DESIGN

Observational case series.

METHODS

The records of 51 patients were identified through the diabetes database of the Division of Pediatric Endocrinology and Metabolism at Washington University School of Medicine. The patients were diagnosed with T1DM before 2 years of age and were monitored for at least 5 years after diagnosis. The results of ophthalmic screening examinations were reviewed.

RESULTS

Fifty-one patients were identified, 33 of whom were monitored for >8 years. None of the patients developed DR.

CONCLUSIONS

Children have a negligible risk of developing DR during the first 10 years of life, even if they are diagnosed before age 2. These results indicate that screening for DR is not necessary before age 10.

The effect of initial recognition of abnormalities by physicians on outcome of retinoblastoma

PURPOSE

The purpose of this study was to assess the effect of early diagnosis by physicians on outcome of retinoblastoma.

METHODS

This was an observational case series in which the records of 36 patients with retinoblastoma were reviewed. The age at onset of first symptoms and diagnosis, identity of the individual who first recognized an abnormality, treatment, and outcome were analyzed.

RESULTS

Twenty-two patients had unilateral retinoblastoma. Both eyes were preserved in only 2 of these patients, both of whom had abnormalities first noted by their pediatricians. Fourteen patients had bilateral retinoblastoma. Both eyes were preserved in the 5 bilateral patients who were monitored from birth with serial examinations under anesthesia because of family histories of retinoblastoma. Enucleation of at least 1 eye was required in 8 of the 9 bilateral patients whose families first noted abnormalities. Enucleation of at least 1 eye was required in 27 of 28 patients (96%) in whom abnormalities were first noted by parents.

CONCLUSION

In this series, the only patients with unilateral retinoblastoma who did not require enucleation were those in whom pediatricians, rather than family members, first noted ocular abnormalities. Both eyes were preserved in all patients with bilateral retinoblastoma who underwent serial examinations under anesthesia because of family histories of retinoblastoma. The prognosis for retinoblastoma appears to be greatly improved when physicians initially detect abnormalities. Educational efforts directed at early detection of retinoblastoma by pediatricians and other primary care providers should be encouraged.

Screening for retinopathy in the pediatric patient with type 1 diabetes mellitus

Diabetic retinopathy (DR) is the leading cause of blindness in young adults in the United States. Early identification and treatment of DR can decrease the risk of vision loss in affected patients. This clinical report reviews the risk factors for the development of DR and screening guidance for pediatric patients with type 1 diabetes mellitus.

Conjunctival Pyogenic Granulomas after Strabismus Surgery

PURPOSE

To measure the incidence and evaluate treatment of pyogenic granulomas after strabismus surgery.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Four hundred seventy-nine strabismus surgical patients.

METHODS

Incidence was determined by review of 472 consecutive patients who underwent strabismus surgery from January 6, 1999 to December 29, 2000. Outcomes were evaluated in 7 additional patients who underwent surgical excision of pyogenic granulomas over a 6-year period from July 5, 1995 to September 19, 2001 (exclusive of the years 1999-2000).

MAIN OUTCOME MEASURE

Development and resolution of pyogenic granulomas.

RESULTS

Pyogenic granulomas developed in 10 of 472 patients (2.1%). None of these patients had more than 1 pyogenic granuloma, despite having had surgery before or after the event. Treatment of pyogenic granulomas with topical corticosteroids was successful in 90% of patients. Surgical excision was successful in the group of 7 additional patients who did not respond to corticosteroids.

CONCLUSIONS

Conjunctival pyogenic granulomas are a potential complication of strabismus surgery. Treatment with topical steroids is an effective initial treatment for most patients with pyogenic granulomas. Surgical excision is effective in patients who do not improve with topical medication. Patients with multiple surgeries do not seem to be at increased risk for pyogenic granulomas, and the occurrence of a pyogenic granuloma does not seem to increase the risk of developing pyogenic granulomas in future surgeries.

Severe subacute GM2 gangliosidosis caused by an apparently silent HEXA mutation (V324V) that results in aberrant splicing and reduced HEXA mRNA

We have characterized the molecular basis of beta-hexosaminidase A (HEX A) deficiency in a patient ascertained through an ophthalmologic examination that revealed cherry red spots on his retina. The absence of neurological deficit in this child until 3 3/4 years of age indicated residual HEX A must be present. Three HEXA mutations, 10T > C (S4P) and 972T > A (V324V) on the maternal allele, and 1A > T (M1L) on the paternal allele were identified. The effects of the amino acid substitutions on HEX A expressed in COS-7 cells were analyzed; as expected, no HEX A activity was associated with the M1L mutation but surprisingly, the S4P mutation resulted in 59% of the HEX A activity expressed by the wild type cDNA. The effect of the S4P change was much less than that of another HEXA mutation, G269S, associated with an adult onset form of G(M2) gangliosidosis. This indicated that the S4P change was not the cause of disease and suggested that one of the mutations on the maternal allele, 10T > C or 972T > A, had its effect at the mRNA level. This was confirmed by Northern blot analysis that showed only 7% of the normal level of HEXA mRNA in proband fibroblasts. Analysis of the residual mRNA by RT/PCR and sequencing revealed normal transcripts from both the maternal and paternal allele, as well as a low abundance aberrant transcript from the maternal allele. Sequencing of this aberrant transcript revealed a new exon 8 donor site created by the 972T > A mutation that resulted in a 17 bp deletion and destabilization of the resulting abnormal transcript. The remaining normal mRNA produced from the 972T > A allele must account for the delayed onset of clinical symptoms in this child.

Pediatric transscleral sutured intraocular lenses: efficacy and safety in 43 eyes followed an average of 3 years

PURPOSE

To report longer term results of transscleral sutured intraocular lens (TSSIOL) implantation in a sizable cohort of aphakic children, who were not suitable for contact lens wear and lacked adequate capsular support for sulcus fixation of an intraocular lens.

METHODS

Clinical outcome data were collated by retrospective review after surgery on 43 consecutive eyes in 32 aphakic children (mean age at implantation = 10 years; 33% < or = age 7 years). Outcome measures included visual acuity, postoperative refractive error, postoperative complications, and rate of reoperation. Follow-up averaged 37 months.

RESULTS

Visual acuity improved after surgery in 70% (30) of operated eyes (in 69% or 22/32 children). Fifty-one percent (22/43 eyes) improved by two lines or more. No patient suffered a loss of acuity or exacerbation of preexisting amblyopia. Postoperative refraction was within +/-2.0 D of the predicted refraction in 93% (40/43) of eyes. Complications, with the exception of one eye (2%), were minor/transient and resolved in the first week after surgery. Complications included small hyphemas (7%, 3/43 eyes), vitreous hemorrhage (5%, 2/43 eyes), and ocular hypertension or hypotony (5%). Two eyes (5%) exhibited episodes of iris capture of the IOL optic, one of which (2%, 1/43) eventually necessitated reoperation for IOL exchange. No retinal detachments or other retinal complications were encountered.

CONCLUSION

TSSIOL implantation appears to be a safe and effective method for correcting aphakia in pediatric eyes that lack adequate capsular support. Safety over a follow-up period longer than the average 3 years reported here remains to be determined. The surgery is more difficult to perform than capsular-bag or sulcus implantation and potentially carries greater risks.

Endoscopic treatment of intranasal abnormalities associated with nasolacrimal duct obstruction

PURPOSE

To report the incidence of intranasal abnormalities in children with nasolacrimal duct (NLD) obstruction and the results of treatment, which included nasal endoscopic removal of abnormal tissue.

METHODS

Nasal endoscopy was performed prospectively in 22 infants with mucoceles; in 97 children > or = 18 months at the time of initial NLD probing; and in 59 children with persistent NLD obstruction after previous probing. Endoscopic removal of abnormal tissue was performed in addition to NLD probing or balloon-catheter dilation.

RESULTS

NLD cysts were found in 22 of 22 (100%) infants with mucoceles. Cysts or other abnormalities of the distal duct were found in 6 of 97 (6.2%) children > or = 18 months at the time of initial probing and in 5 of 59 (8.5%) children whose previous NLD probing was unsuccessful. Surgery was successful in 91% of patients.

CONCLUSION

Nasal endoscopy identified intranasal anatomic abnormalities of the distal nasolacrimal duct uniformly in infants with mucoceles and in 6% to 9% of older children with complicated NLD obstruction. Treatment, including endoscopic removal of abnormal tissue, was successful in most patients. The use of nasal endoscopy may improve the treatment of patients with these disorders.

Head tilt-dependent esotropia associated with trisomy 21

OBJECTIVE

To describe a series of patients who used a head tilt to control esotropia.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Seven children with esotropia that decreased with their compensatory abnormal head tilt. Six of the patients had trisomy 21. The patients had no other identifiable etiology for their head tilt, including no oblique muscle dysfunction, nystagmus that changed with head tilt, or uncorrected refractive error.

INTERVENTION

Six patients underwent horizontal extraocular muscle surgery. Preoperative evaluation in 4 patients included assessment of the change in head position with either monocular occlusion or prisms.

MAIN OUTCOME MEASURES

Ocular alignment in primary position and improvement in abnormal head tilt after surgery.

RESULTS

In the 4 patients who underwent preoperative testing, the abnormal head tilt resolved with either monocular occlusion or prisms. The head tilt and esotropia were eliminated or improved in all patients who underwent strabismus surgery.

CONCLUSIONS

Abnormal head tilt may be used as a compensatory maneuver to improve purely horizontal strabismus. This finding appears to be associated with trisomy 21. Horizontal extraocular muscle surgery may improve the head tilt in such patients.

Choroidal neovascular membrane associated with optic nerve coloboma in a patient with CHARGE association

PURPOSE

To report a patient with CHARGE association (coloboma, heart disease, choanal atresia, growth retardation, genital hypoplasia, and ear abnormalities) who developed a choroidal neovascular membrane in association with an optic nerve coloboma.

DESIGN

Interventional/observational case report.

METHOD

A 21-month-old boy with CHARGE association developed a grayish choroidal neovascular membrane associated with lipid exudation, subretinal fluid, and retinal hemorrhage at the temporal edge of his right optic nerve coloboma.

RESULTS

The patient underwent transpupillary diode laser of the choroidal neovascular membrane. Five months later, it and the serous retinal detachment had resolved.

CONCLUSIONS

Patients with CHARGE association may develop choroidal neovascular membrane with serous retinal detachments in association with optic nerve colobomas. These neovascular membranes may be treated successfully with transpupillary diode laser.

Balloon catheter dilation for treatment of older children with nasolacrimal duct obstruction

OBJECTIVES

To describe the outcomes of balloon catheter dilation of the lacrimal duct as the first surgical treatment for older children (>or=18 months) with nasolacrimal duct (NLD) obstruction and to examine the effect of the type of obstruction on outcome.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Seventy-six children 18 months or older with NLD obstruction who had not undergone previous surgery.

INTERVENTION

The patients underwent NLD probing, infracturing of the inferior turbinate, and balloon catheter dilation of the distal NLD. The type of obstruction was noted at surgery.

MAIN OUTCOME MEASURES

Outcomes were considered excellent if the patient had complete resolution of epiphora and dacryocystitis and normal tear drainage on examination, good if the patient had only minimal residual symptoms or a minimally delayed dye disappearance test result, fair if the patient had moderate residual symptoms or delayed tear drainage, and poor if there was no improvement.

RESULTS

Seventy-six children were treated. Overall, results were excellent in 28 (37%) patients, good in 30 (39%), fair in 13 (17%), and poor in 5 (7%). Forty-eight (63%) of the patients had simple membranous obstruction at the Hasner valve. Results were good or excellent in 35 (73%) of these patients. Twenty-eight (37%) patients had stenosis that extended along the length of the distal NLD. Results were good or excellent in 23 (82%) of these patients.

CONCLUSIONS

Balloon catheter dilation is probably more effective than simple probing for older children with NLD obstruction because of stenosis that extends along the distal NLD. The procedure does not provide a significant advantage over simple NLD probing in patients with typical membranous obstruction at the Hasner valve.

The effect of an eyelid speculum on intraocular pressure measurement in children

PURPOSE

To assess the effect of a pediatric eyelid speculum on the measurement of intraocular pressure (IOP) in children.

DESIGN

Observational case series.

METHODS

Intraocular pressure measurements were performed during examination under anesthesia immediately after induction. The measurements were made with and without a pediatric eyelid speculum in place.

RESULTS

Intraocular pressure measurements were made in 77 eyes of 45 consecutive children. The mean IOP without the speculum was 16.33 mm Hg in the right eye and 16.55 mm Hg in the left eye. With the lid speculum in place the mean IOP was 20.26 mm Hg in the right eye and 20.05 mm Hg in the left eye (P <.05).

CONCLUSIONS

The presence of an eyelid speculum raised IOP an average of 4 mm Hg. This effect should be considered when interpreting IOP measurements in children.