Persistent hyperplastic primary vitreous: diagnosis, treatment and results

While the great majority of patients with persistent hyperplastic primary vitreous never obtain useful vision, it is encouraging that 18.07% of all the patients in this series did achieve 20/200 vision or better (Table V). In the whole group, 12 of 83, or 14.45%, obtained 20/70 vision or better with treatment. All of these successful results were in eyes with the purely anterior PHPV only. In fact, when looking at the results of the anterior PHPV cases alone, 15 of 21 achieved 20/200 or better, which was 71.4% of the patients with anterior presentation only. In this anterior group, 12 of 21 (57.1%) attained 20/70 vision or better with treatment. The goals of treatment with PHPV should always be kept in mind when confronted with an infant who has this entity. First, an effort should be made to save the eye from glaucoma or phthisis, which are the most devastating results of untreated PHPV. A lensectomy will usually prevent the secondary glaucoma, which results from the lens-iris diaphragm being pushed forward to cause a secondary angle-closure glaucoma. A secondary glaucoma can also be produced from recurrent hyphema, which scars the outflow passageways in the angle. By removing the PHPV membrane and reducing the tractional forces applied to the ciliary body by the membrane, one can lessen the possibility of phthisis. Surgery reduces the centripetal, as well as axial, forces generated by the membrane. The second goal is to produce a black pupil for cosmetic reasons, and the third goal of obtaining useful vision is reasonable to expect if the entity presents with only anterior involvement. Bilaterality, while rare in this series (2:83 cases, or 2.4%), was a very poor prognosis for vision, since both patients had only light perception to hand motion vision in both eyes. With the exception of the eye problems, these two children were otherwise normal in their physical and mental development. No measurable stereopsis or binocularity has been achieved in any of these patients. This was primarily because 100% of the patients had strabismus and secondarily to the fact that in the patients with good surgical results, aggressive and prolonged patching may have precluded the development of binocular vision. Two patients have uncontrolled glaucoma with only light perception vision. Both of these patients are comfortable and pain-free. Two patients have, in time, developed phthisis and wear a cosmetic shell. No cases have required enucleation in this series. (The pathological specimen from Figs 1 and 2 represents an enucleated eye during my residency.) Two patients developed an extensive cyclitic membrane after surgery, which completely occluded the pupillary space. Both patients had originally undergone extensive membrane removal of their PHPV with the production of a nice clear pupillary space. The first patient developed the cyclitic membrane only 3 weeks after the original surgery. A second surgery has been successful in clearing the pupillary opening, but the patient has only hand motion vision at 1 foot due to amblyopia. The second patient had been fitted with a gas-permeable hard contact lens after original surgery for an anterior PHPV. An extensive cyclitic membrane developed 4 months later and required a secondary procedure to clear the pupillary space. The patient's pupillary space has remained open after this second procedure, and the patient is currently wearing a contact lens and undergoing amblyopia therapy. The most important factor in the prognosis of patients with persistent hyperplastic primary vitreous is the extent of the membrane. Families should be told that if their child has only an anterior presentation, then surgical and amblyopia therapies offer a good chance for useful vision. Patients with a combination of anterior and posterior PHPV, or patients with only a posterior PHPV, should be advised that there is a reasonable opportunity to save the eye from glaucoma and phthisis, but that useful vision is usually not

Acute rectus muscle palsy in children as a result of orbital myositis

OBJECTIVE

Acute rectus muscle palsy caused by orbital myositis is often confused with infectious orbital cellulitis. The purpose of this article is to clarify the former condition by explaining how it is manifested and treated.

METHODS

The seven children less than age 11 years in this study were examined after having an acute onset of ocular pain. Physical examination indicated a loss of motility in the field of action of the involved extraocular rectus muscle. Computed tomographic examination confirmed the existence of orbital myositis. Treatment consisted of intravenous or oral administration of corticosteroids.

RESULTS

In all the initial evaluations, computed tomography showed the isolated rectus muscle to be enlarged. In four of the patients in whom the lateral rectus was involved, esotropia was present in the primary position. In the fifth patient with lateral rectus involvement, esotropia was seen only in the field of gaze of the involved lateral rectus muscle. The patient with medial rectus involvement had exotropia, and the patient with superior rectus involvement had hypotropia on the involved side. Each had injection and chemosis of the conjunctiva and Tenon fascia only in the quadrant overlying the involved rectus muscle.

CONCLUSIONS

Children with orbital myositis can have an acute rectus muscle palsy. The inflammation and strabismus are exquisitely sensitive to systemic corticosteroid therapy, which produces a rapid resolution of symptoms. If the steroid therapy is discontinued abruptly, the myositis can recur.

Diagnosis and treatment of inferior oblique palsy

We present the work-up and treatment for 25 patients with inferior oblique palsy, including 2 with bilateral inferior oblique palsy and 23 with unilateral inferior oblique palsy. Nineteen patients were adults over the age of 21 years, and six were children under the age of 10 years. Sixteen adults and two children underwent CT scanning of the head. All scans were normal. Eight adults also underwent MRI evaluation of the head. These also were all normal. All adults had a negative Tensilon test for myasthenia gravis. The majority presented with a head tilt to the side of the paretic muscle. None of these patients complained of tilting images, but incyclotorsion was measurable in all cases that were tested. The most important conclusion from this study is that inferior oblique palsy is a benign entity, with none of these patients having a brain tumor or myasthenia gravis.

Treatment of acute dacryocystitis in neonates

Twenty-five newborns with acute dacryocystitis underwent probing of the nasolacrimal duct. All had a resolution of the acute dacryocystitis. Only one continued to have epiphora and had to undergo a subsequent probing with silicone intubation at 9 months of age. All were probed without anesthesia, being mummified and held by nurses while the author performed the probing. Only five were treated with parenteral and topical antibiotics for a week prior to probing while 20 were probed without any prior antibiotic therapy. Additionally, five of six mucoceles of the lacrimal sac which did not resolve in the 1st 2 weeks of life with massage were successfully probed without anesthesia. Four of the five mucoceles had developed an acute dacryocystitis on conservative management. Probing of the nasolacrimal duct in the newborn period is a safe and successful approach for acute dacryocystitis. It is a highly successful procedure for the treatment of acute dacryocystitis with a very low morbidity rate.

Treatment of persistent hyperplastic primary vitreous

Persistent hyperplastic primary vitreous (PHPV) will usually lead to a cataract and secondary glaucoma if not treated. At least a lensectomy should be performed to reduce the frequent incidence of glaucoma. In the purely anterior form, the cataract should be removed as well as the PHPV, as this gives a clear media that can be rehabilitated visually. Eyes with a posterior PHPV have poor visual results due to posterior pole abnormalities.

Results of treatment of persistent hyperplastic primary vitreous

The records of 48 patients with persistent hyperplastic primary vitreous (PHPV) were reviewed. Approximately 17% had vision of 20/100 or better after surgery, contact lens fitting, and amblyopia therapy. Only eyes with a purely anterior presentation had successful visual outcomes. Lensectomy alone prevented glaucoma, but a membranectomy as well was required to ensure a successful visual result. Eyes with a posterior PHPV had poor visual results because of posterior pole abnormalities. I recommend that an attempt be made to visually salvage eyes with an anterior presentation. Eyes with a posterior or a combination anterior-posterior PHPV can be successfully treated for glaucoma, but the visual results will be poor.

Accommodative esotropia after ocular and head injury

Five children lost their ability for motor fusion after traumatic injury to either the eye or head. All patients had the onset of accommodative esotropia within two months of the traumatic episode. The ocular alignment of each child was controlled by the use of spectacles that corrected the accommodative requirements. These patients are unique because they did not show any evidence of accommodative esotropia before their injuries. One child developed accommodative esotropia with a high ratio of accommodative convergence to accommodation. The use of bifocal spectacles controlled the deviation for this child.

Bilateral superior oblique muscle palsy associated with Apert's syndrome

Eleven children had Apert's syndrome and bilateral superior oblique muscle palsy. Of seven patients who underwent surgical exploration of the superior oblique muscle area, five had no superior oblique tendon in either eye and two had only a small fibrous band as a remnant in each eye. All 11 patients had a significant horizontal deviation in primary gaze and downgaze, in addition to a vertical imbalance. The findings led to the conclusion that all patients with craniofacial anomalies, especially those with Apert's syndrome, should be examined for the presence of vertical muscle palsies and particularly bilateral superior oblique muscle palsy.

Long-term follow-up in patients with ocular toxocariasis as measured by ELISA titers

Twenty patients with ocular toxocariasis were followed-up with serial elisa titers. Eighty-five percent showed a decrease in serum titers, 10% showed an increase, and 5% were stable. One should not be dissuaded from making the diagnosis clinically of ocular toxocariasis because of low titers, as the patient may have had higher titers previously. In the past, results were reported as positive if a titer of at least 1:32 was present and negative if below this level. Exact titers should be requested, as any positive titer (even as low as 1:2) with clinical correlation is believed to be significant.

Inferior oblique paresis: a benign entity

Eleven cases of inferior oblique palsy are presented. The benign nature of this entity is stressed. The etiologies of this group were congenital, trauma, and presumed vascular. No cases of CNS tumor, infection, or myasthenia gravis were seen. All of these patients have been followed for at least six months, and some for four years, without any other major illness presenting other than the inferior oblique palsy.

Treatment of persistent hyperplastic primary vitreous

Thirty-two patients with persistent hyperplastic primary vitreous were examined by the author over a 10-year period. Two patients have been followed with conservative management. Thirty patients were treated with surgery involving lensectomy with anterior vitrectomy being performed as the minimal treatment, with a few patients being treated with a full vitrectomy and dissection of the PHPV stalk from the posterior lens surface to the retina. The only eyes which obtained a good visual result were those eyes which contained only the anterior PHPV without the posterior segment being involved. While surgery on the posterior segment was anatomically successful, poor visual results were obtained due to retinal abnormalities. No eye has been removed. Five eyes have useful vision. Early treatment is advised in order to prevent underdevelopment of the orbit secondary to early enucleation as well as to treat amblyopia in those visually salvageable eyes.

Classification and treatment of bilateral superior oblique palsy

Twenty-one patients with bilateral superior oblique palsy were studied in order to classify them into five major categories. By classifying the presentations, an orderly approach to the diagnosis as well as the treatment of bilateral superior oblique palsy is made.

Lensectomy for Secondary Angle-closure Glaucoma in Advanced Cicatricial Retrolental Fibroplasia

A study of 15 patients with secondary angle-closure glaucoma associated with advanced cicatricial retrolental fibroplasia is presented. Eight patients developed glaucoma acutely, while 7 showed a chronic course. In four patients the fellow eye became involved acutely within 1 month of the first eye. Seven others were also bilateral, but on a chronic basis. Twelve of the 15 presented after age 2. All were treated with lensectomy which cured the glaucoma. All have extremely poor vision in the range of light perception to hand motion, but have retained their eyes on a pain-free basis.

The pupil in congenital third nerve misdirection syndrome

The involved pupil in the syndrome of aberrant regeneration of the oculomotor nerve usually remains larger than the uninvolved side, or approaches equality in size. A 4-year-old child was seen with congenital aberrant regeneration of the right third nerve. The right pupil was consistently smaller than the left, but particularly so in dim illumination. The question can be raised as to whether relative pupillary miosis more commonly follows third nerve misdirection in children than adults.

Asymmetry in retrolental fibroplasia

Ten cases of asymmetry in retrolental fibroplasia vary from patients with unilateral to those with bilateral involvement. In the bilateral cases, one eye was always more severely affected. This article encourages the treatment of amblyopia when present in patients with retinopathy of prematurity.

Familial bilateral posterior lenticonus

Posterior lenticonus usually occurs sporadically and only in one eye. However, in three families bilateral posterior lenticonus occurred in more than one member. When the defect appears bilaterally, genetic counseling should be considered to educate the family about the possibility that future offspring might have this disorder.

Ocular and testicular abnormalities in alopecia areata

Ocular abnormalities similar to those usually found in patients with vitiligo occurred in nine patients with alopecia areata and one patient with poliosis. Exophthalmos, iris color change, discrete depigmentation, and, frequently, associated pigment hyperplasia of the choroid and retinal epithelium were found in the ten patients. Four patients had had a bilateral iris color change from dark brown to blue-green. Hypogonadism, thyroid disease, and poliosis may frequently be associated with pigmentary disturbances of the eye, as well as hair loss. Testicular dysfunction with oligospermatism to aspermatism, hypoandrogyny, hyperretractable testes, and epididymal cyst is reported. Two patients had unilateral and one patient had bilateral testicular atrophy.

Results of surgery for ocular Toxocara canis

It has been shown that the diagnosis of ocular Toxocara canis is highly accurate when the typical clinical findings are associated with a positive ELISA titer in the serum of 1:8 or greater. The inflammatory reaction in this disorder can be devastating and not infrequently leads to a tractional detachment of the posterior pole or a rhegmatogenous detachment and/or a progressive cyclitic membrane leading to phthisis bulbi. We have recently performed vitreoretinal surgery on 17 patients with complications secondary to ocular T canis. Fifteen patients had stability or improvement in visual acuity, and one patient had a decrease in visual acuity. There were no surgical complications present. The clinical features, operative techniques used, and postoperative course are summarized, and the indications for the used of various surgical procedures are presented.