Anterior transposition of the superior oblique tendon in the treatment of oculomotor nerve palsy and its influence on postoperative hypertropia

PURPOSE

To determine whether postoperative hypertropia after anterior transposition of the superior oblique tendon without trochleotomy could be avoided with a simplified surgical approach.

METHODS

Eight patients with oculomotor nerve palsy (one patient was bilaterally affected) were retrospectively identified as having undergone anterior transposition of the superior oblique tendon without trochleotomy or vertical rectus muscle surgery between March 1992 and September 1998. The superior oblique tendon was cut at the medial border of the superior rectus muscle and placed 1-3.5 mm anterior to the medial insertion of the superior rectus muscle in each of these patients. Resection of the superior oblique tendon was not performed. The lateral rectus muscle was weakened, and no vertical rectus muscles were resected.

RESULTS

Preoperative deviations with the uninvolved eye fixating in primary position ranged from 20-90 prism diopters (delta) of exotropia (mean: 49.3 delta) and from 0-20 delta of hypotropia (mean: 11.25 delta). Postoperative horizontal deviations in the primary gaze position ranged from 12 delta of exotropia to 20 delta of esotropia. Six cases were aligned within 10 delta of exotropia or esotropia. Postoperative vertical deviations in the primary gaze position ranged from 2 delta of hypertropia to 8 delta of hypotropia. Six cases were aligned within 2 delta of deviation. Significant postoperative restrictive hypertropia, or new postoperative paradoxical ocular movements, did not occur in any patient. Patients who underwent follow-up >4 months maintained stable eye alignment.

CONCLUSION

Transposition of the superior oblique tendon without simultaneous resection or trochleotomy, or additional surgery to the vertical rectus muscle simplifies the surgical technique and eliminates subjective decision making regarding the amount of resection.

The incidence of ophthalmologic interventions in children with birth weights less than 1251 grams. Results through 5 1/2 years. Cryotherapy for Retinopathy of Prematurity Cooperative Group

OBJECTIVE

This study aimed to report the frequency of ophthalmologic surgical and medical therapies provided to children with birth weights less than 1251 g who had all stages of retinopathy of prematurity (ROP). In addition, this study aimed to report the initial age at which such procedures are provided and to report the frequency of cerebrospinal fluid shunts.

DESIGN

Observational case series with prospective data collection.

PARTICIPANTS

Children from the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) with birth weights less than 1251 g served as subjects. Group A included 257 children from all 23 CRYO-ROP study centers who had threshold ROP, who had participated in the randomized trial of cryotherapy, and who had survived to age 1 year. Group B included 1208 children from 5 of the 23 study centers who had varying severity of ROP (69 had threshold ROP) and who had participated in a 5 1/2-year study of the natural history of ROP.

MAIN OUTCOME MEASURES

Investigators documented medical and surgical ophthalmologic interventions through age 5 1/2 years as well as cerebrospinal fluid shunting surgery for hydrocephalus through age 2 years.

RESULTS

Group A was composed of 257 children with threshold ROP who underwent 226 ocular interventions in addition to cryotherapy (0.9 intervention per child). The most common treatments performed on the randomized cohort of children were vitrectomy (26% of patients), lensectomy (18%), amblyopia therapy (20%), and strabismus surgery (10%). Cataract surgery not associated with vitrectomy was performed infrequently (2%) and was performed equally often in treated and control eyes. Amblyopia therapy was prescribed as often for treated as for control eyes. Cerebrospinal fluid shunts were placed in 11% of these children. Group B was composed of 1208 natural history patients who underwent 239 ophthalmologic interventions (0.4 intervention per child). Strabismus surgery was the most commonly performed procedure for the natural history cohort of children (6% of the children). Amblyopia therapy was prescribed for 7% of the natural history patients. Cerebrospinal fluid shunts were required by 3% of the natural history infants, more often in children with more severe ROP.

CONCLUSIONS

These premature infants underwent a large number of ophthalmologic treatments during the first 5 1/2 years of life. The long-term costs of both extreme prematurity and ROP include not only the initial ablative therapy for ROP and societal loss due to blindness that still occurs in some cases, but also the ongoing costs of caring for eye problems.

Neonatal asteroid hyalosis

Asteroid hyalosis, noted in 0.83% of routine eye examinations, is uncommon in younger patients and is more frequently seen in patients more than 60 years old. It has been considered to be related to an aging process, and when it occurs in younger patients, ocular disease is typically associated. We report a 4-week-old patient with Down syndrome and bilateral congenital cataracts who had unilateral asteroid hyalosis.

Ocular abnormalities in the mucopolysaccharidoses after bone marrow transplantation. Longer follow-up

OBJECTIVE

The purpose of the study was to provide longer follow-up of ocular findings in patients with mucopolysaccharidoses (MPS) after bone marrow transplantation (BMT).

DESIGN

The study design was a retrospective 6-year cohort evaluation.

PARTICIPANTS

Twenty-three patients with MPS (19 with MPS type I-H, 3 with MPS type III, 1 with MPS type VI) were studied.

INTERVENTION

Bone marrow transplantation was performed.

MAIN OUTCOME MEASURES

The following outcome measures were considered: vision, slit-lamp biomicroscopic and funduscopic examinations, intraocular pressure, electroretinography (ERG), and retinoscopy.

RESULTS

Thirteen (81%) of 16 patients showed ERG improvement in the first year. However, all patients showed slowly progressive decline of the ERG over longer follow-up. Other ocular findings included optic atrophy (n = 7 patients), disc edema (n = 6 patients), strabismus (n = 6 patients), nystagmus (n = 6 patients), cataract (n = 3 eyes), keratoconjunctivitis sicca (n = 4 eyes), ocular hypertension (n = 2 eyes), and glaucoma (n = 2 eyes).

CONCLUSIONS

The MPS are rare and heterogeneous disorders characterized by progressive retinal degeneration and blindness. Ocular abnormalities can occur as a result of the disease or as a consequence of BMT. Successful BMT has been shown to improve systemic health, but this may not reflect continuing ocular status and retinal function. Despite early improvement in ERG function, longer follow-up suggests progressive retinal decline.

Optic nerve neovascularization in incontinentia pigmenti

PURPOSE

To describe the presence of optic disk neovascularization in a child with incontinentia pigmenti.

METHODS

A 6-month-old infant with incontinentia pigmenti developed optic disk neovascularization in addition to vascular abnormalities in the peripheral retina. Panretinal photocoagulation was performed.

RESULT

The optic disk neovascularization regressed after panretinal photocoagulation.

CONCLUSIONS

Optic disk neovascularization is another notable retinal manifestation of incontinentia pigmenti. When optic disk neovascularization is detected, retinal ablation should be considered as treatment.

Myopia predicts better outcome in persistent hyperplastic primary vitreous

PURPOSE

Persistent hyperplastic primary vitreous (PHPV) is a congenital disorder that presents with a spectrum of ocular anomalies, including cataracts, microphthalmia, and hyaloid vessel remnants. Severe visual loss due to secondary glaucoma and retinal detachment is common. This report evaluates the visual outcome of a variant of PHPV with myopia not associated with glaucoma.

METHODS

The records of 23 consecutive patients with the diagnosis of PHPV (all unilateral) from October 1992 to August 1995 were reviewed. All but three patients had a cataract extraction procedure and all underwent amblyopia therapy. Eyes with a phakic myopic refractive error (Rx) or aphakic refractive correction < or = 8.5 diopters (D) in the immediate postoperative period were designated as myopic.

RESULTS

Six patients were in the myopic group (Group 1) and 17 in were the nonmyopic group (Group 2). The mean age of diagnosis was 21.1 months in Group 1 versus 2.0 months in Group 2, with a comparable follow-up period of 36 months. The mean preoperative Rx of Group 1 was -7.78 D. The mean aphakic Rx of Group 2 was +18.29 D. Average axial length measurement determined by echography was 22.46 mm in Group 1 and 14.03 mm in Group 2. The mean corneal diameter was 11.3 mm in Group 1 vs 8.9 mm in Group 2. In Group 2, seven eyes developed retinal detachment and four developed glaucoma. These complications did not develop in Group 1 during the follow-up period. Overall functional visual acuity was better in Group 1, with a median visual acuity at final follow up of 20/160, as compared with light perception for Group 2.

CONCLUSIONS

PHPV eyes with myopia were not detected as early as the typical PHPV eyes, primarily because of less media opacification and near-normal corneal diameters. These eyes showed a more favorable visual outcome as they were less likely to develop typical PHPV-related postoperative complications. Myopic PHPV eyes may require a different management approach.

The association of strabismus, amblyopia, and refractive errors in spasmus nutans

PURPOSE

Spasmus nutans is a condition that includes asymmetric nystagmus and occurs during the amblyogenic period. Because specific alterations in early visual experience are known to be associated with changes in visual development, relations between spasmus nutans and abnormal visual sequelae were examined.

METHODS

The records of 18 patients with spasmus nutans were reviewed retrospectively. The incidence of strabismus, amblyopia, anisometropia, and astigmatism was compared with published age-matched control subjects.

RESULTS

There was a significantly higher incidence of strabismus (10 of 18) and amblyopia (8 of 18) of the eye with the greater amplitude of nystagmus. No correlation of refractive error with lateralization of nystagmus could be established. Twelve of 18 patients required spectacles for improvement in visual acuity and for treatment of amblyopia. Best-corrected visual acuity averaged 1.20 Snellen lines poorer than age-adjusted normative values; however, loss of visual acuity was, in most cases, symmetric and not related to lateralization of nystagmus.

CONCLUSION

Early detection and treatment of anticipated abnormal visual issues in patients with spasmus nutans will optimize visual outcomes.

Office probing for congenital nasolacrimal duct obstruction: a study of parental satisfaction

PURPOSE

To determine parental satisfaction with nasolacrimal probings performed in the office without sedation for congenital nasolacrimal duct obstruction.

METHODS

We reviewed the charts of 81 consecutive children under 4 years of age who underwent nasolacrimal probings in our office. Sixty-seven caretakers of these children were contacted by telephone to determine parental satisfaction, probing effectiveness, procedural complications, and future recommendations. A comparison between parental satisfaction and patient age, probing effectiveness, and unilateral versus bilateral probings was performed.

RESULTS

Most caretakers (86%) were satisfied with the procedure and most (81%) would prefer the probing to be performed in the office rather than under general anesthesia (6% were unsure). Satisfaction rates were similar between the different age groups (P > .5 by Chi-square analysis), but were slightly lower in the unsuccessful probing and bilateral probing subgroups. Parents of children who underwent both an office procedure and a subsequent procedure under general anesthesia tended to prefer the office-based technique.

CONCLUSION

The majority of caretakers of children who underwent unilateral or bilateral nasolacrimal probings in the office without sedation were satisfied with the procedure and, when given a choice, preferred it over probings performed under general anesthesia.

Diagnosis of oculocutaneous albinism with molecular analysis

PURPOSE

To use molecular analysis to diagnose oculocutaneous albinism in a patient with an atypical clinical presentation.

METHODS

A 34-year-old woman with a history of strabismus and absent cutaneous pigment underwent comprehensive ophthalmic examination, visual-evoked potentials to detect altered optic decussation, and molecular analysis.

RESULTS

Examination showed fine nystagmus, iris transillumination, foveal hypoplasia, and corrected visual acuity of 20/25 in each eye. Misrouting of the retinostriate fibers was demonstrated with visual-evoked potentials. Mutations in the tyrosinase gene established the diagnosis of oculocutaneous albinism 1 even though the patient had atypical clinical features.

CONCLUSIONS

Molecular analysis can establish the diagnosis of oculocutaneous albinism 1 in the patient with atypical ocular features.

Ocular ischemic syndrome in a child with moyamoya disease and neurofibromatosis

Ocular ischemic syndrome is extremely rare in childhood. Patients with moyamoya disease may be particularly susceptible to the development of ocular ischemia due to the associated carotid occlusion. A 19-month-old boy presented with neurofibromatosis and signs of ocular ischemia. At 29 months of age, he developed dense right vitreous hemorrhage and eventually lost vision in that eye due to phthisis. At almost six years of age, he developed an acute hemiplegia and was then diagnosed with moyamoya disease. This rare instance of childhood ocular ischemia in conjunction with moyamoya disease and neurofibromatosis demonstrates the serious ocular and systemic sequelae of occlusive vascular disease.

Visual acuity of eyes after vitrectomy for retinopathy of prematurity: follow-up at 5 1/2 years. The Cryotherapy for Retinopathy of Prematurity Cooperative Group

PURPOSE

To provide long-term follow-up on the structural status and visual function at 5 1/2 years of age for 128 eyes of 98 infants who participated in the multicenter randomized clinical trial of cryotherapy for retinopathy of prematurity in whom total retinal detachment developed from retinopathy of prematurity (ROP) by the 3-month study examination. Fifty-four patients had lensectomy-vitrectomy procedures in one or both eyes before 1 year of age (n=72 eyes), and 44 patients did not (n=56 eyes).

METHODS

When the children were 5 1/2 years of age, an eye examination was performed and residua of ROP was assessed. Recognition acuity (Early Treatment of Diabetic Retinopathy Study chart) and grating visual acuity (Teller acuity card procedure) assessments were undertaken by testers who were masked to the status of each of the child's eyes.

RESULTS

At least partial retinal attachment was present at 5 1/2 years in 21% compared with 28% at 1 year of age (not significant). All except one of the eyes tested at 5 1/2 years had vision limited to light perception or no light perception, regardless of whether a vitrectomy had been performed. One eye that underwent vitrectomy had minimal pattern vision. The two eyes that were reported previously to have minimal pattern vision at 1 year of age were blind at the longer-term follow-up.

CONCLUSIONS

The poor visual outcome after a lensectomy-vitrectomy procedure for retinal detachment due to ROP demands that emphasis be placed on prevention of retinal detachment in premature infants.

Predicting visual acuity in children with colobomas involving the optic nerve

BACKGROUND

This study evaluates the relationship to visual acuity of four ophthalmoscopic features of colobomas involving the optic nerve. The goal was to identify those features that could predict potential visual acuity of children with these colobomas.

METHODS

Fundus photographs of 23 eyes with colobomas involving the optic nerve met the entry criteria and were evaluated by two masked observers. The following features were evaluated: coloboma size, optic nerve color, foveal development, and subfoveal retinal pigment epithelial changes. Simple linear regression was used to identify the feature that most closely correlated with visual acuity. Refractive status was assessed by cycloplegic refraction.

RESULTS

The only component that correlated with the development of good visual acuity was the degree of foveal involvement by the optic nerve coloboma (P = .002, R = 0.8). Significant refractive error and anisometropia were common in patients with colobomas involving the optic nerve.

CONCLUSION

Central visual acuity in children born with colobomas involving the optic nerve correlates with the development of normal foveal anatomy, regardless of the size of the coloboma, the color of the optic nerve, or the presence of subfoveal pigmentary changes. Because refractive error is common, these children should receive an accurate refraction and amblyopia treatment.

Vision in albinism

PURPOSE

The purpose of this investigation was to study vision in albinism from 3 perspectives: first, to determine the characteristics of grating acuity development in children with albinism; second, to study the effect of illumination on grating acuity; and third, to define the effect of melanin pigment in the macula on visual acuity.

METHODS

I. Binocular and monocular grating acuity was measured with the acuity card procedure in 40 children with albinism during the first 3 years of life. Recognition acuity was eventually measured in 27 of these patients. Ocular pigment was documented by a previously established method of grading iris transillumination and macular transparency. II. Grating acuity under standard and increased illumination levels was measured in 20 adults with albinism (group I) compared with that in 20 adults with nystagmus due to conditions other than albinism (group II) and 20 adults without ocular abnormalities (group III). Recognition acuity measured with the ETDRS charts was also recorded for each group. III. Best-corrected binocular acuity was measured in 29 patients with albinism who were identified with melanin pigment in their maculas by direct ophthalmoscopy.

RESULTS

I. Both binocular and monocular grating acuity was reduced 2 to 3 octaves below the norm for ages 6 months to 3 years. Limited data available in the first 6 months of life did not show failure of vision to develop. Grating acuity measurements overestimated eventual recognition acuity. Mean recognition acuity was 20/111. A relationship between grating acuity development and presence or absence of ocular pigment was not found. II. Grating acuity was significantly better for groups I and II under the condition of increased illumination (P < .03). For patients with albinism, grating acuity under standard illumination was significantly better than recognition acuity (P < .001). For all groups, grating acuity under increased illumination was significantly better than recognition acuity (P < .01). III. Mean recognition acuity in patients with albinism and melanin pigment in their maculas (20/47) was significantly better than measured recognition acuity in Project I (P < .001). All had foveal hypoplasia, but 8 patients had an incompletely developed annular reflex in the macula, 6 patients showed stereoacuity, and 3 patients had no nystagmus.

CONCLUSIONS

I. Grating acuity development in albinism seems to progress along a curve that is asymptotic to visual development in a normal population. II. Increasing illumination does not reduce grating acuity in patients with albinism. Grating acuity overestimates recognition acuity in these patients. III. Ophthalmoscopic detection of melanin pigment in the macula in patients with albinism is associated with better vision.

A prospective study of ocular hypertension and glaucoma after pediatric cataract surgery

BACKGROUND

Late-onset glaucoma can occur after pediatric cataract surgery. However, no large prospective study of the prevalence of ocular hypertension and glaucoma after pediatric cataract surgery has been performed.

METHODS

A prospective glaucoma evaluation was offered to all eligible subjects at least 5 years after automated lensectomy and vitrectomy for pediatric cataracts.

RESULTS

Sixty-two (58%) of 107 eligible subjects received a glaucoma evaluation. One (4.5%) of 22 patients with bilateral cataracts had glaucoma, and a much higher percentage (45%) had ocular hypertension. Five (12.5%) of 40 patients with unilateral cataracts had glaucoma, and an additional 32.5% had ocular hypertension. For patients with monocular cataracts, the age and corneal diameter at the time of cataract surgery were related to the subsequent development of ocular hypertension or glaucoma. The majority of subjects were able to cooperate with a comprehensive glaucoma examination that included cycloplegic refraction, determination of intraocular pressure, examination of the optic nerve, and fundus photography, without requiring sedation.

CONCLUSIONS

There is a high prevalence of ocular hypertension after pediatric cataract surgery. Children who are 5 years of age and older usually are able to cooperate with a glaucoma evaluation. The natural history of ocular hypertension after pediatric cataract surgery will be determined with longitudinal studies in the future.

Effect of acute-phase retinopathy of prematurity on grating acuity development in the very low birth weight infant. The Cryotherapy for Retinopathy of Prematurity Cooperative Group

PURPOSE

To examine the development of grating acuity in four groups of eyes in the Multicenter Study of Cryotherapy for Retinopathy of Prematurity (CRYO-ROP): eyes with no ROP; eyes with less-than-prethreshold ROP; eyes with prethreshold ROP; and eyes with threshold ROP that were randomized to serve as controls (not treated with cryotherapy).

METHODS

Subjects were 1398 children with birth weights < 1251 g whose acute-phase ROP was documented as part of the CRYO-ROP study. Monocular grating acuity was measured using the Teller acuity card procedure when children reached 1, 2, 3 1/2, and 4 1/2 years of age.

RESULTS

Eyes in the no-ROP and less-than-prethreshold groups showed nearly identical acuity development. Eyes with prethreshold ROP showed mean acuity similar to the no-ROP group at 1 and 2 years, but slightly below the no-ROP group at 3 1/2 and 4 1/2 years. Only 50% of eyes in the threshold untreated ROP group had measurable acuity. These eyes showed mean acuity scores that were approximately 1 octave below those of the no-ROP group at all four test ages. When data from eyes with ROP residua or other ocular abnormalities, and data from eyes of children who were unable to pass the study developmental screening items, were excluded, acuity development was similar among groups.

CONCLUSIONS

Mild (less-than-prethreshold) ROP has no effect on the development of grating acuity in children between 1 and 4 1/2 years of age. Moderate (prethreshold) ROP is associated with reduced acuity at 3 1/2 and 4 1/2 years. In general, severe (threshold untreated) ROP results in moderate to severe reductions in acuity at all ages between 1 and 4 1/2 years. However, a small number of children with severe ROP show normal acuity development.

Ophthalmic features of minimal pigment oculocutaneous albinism

PURPOSE

The purpose of this study is to describe the heterogeneous phenotype of individuals with an unusual type of albinism--minimal pigment oculocutaneous albinism.

METHODS

Nine patients with minimal pigment oculocutaneous albinism were identified and followed for up to 11 years. The criteria were the presence of oculocutaneous albinism in association with low hairbulb tyrosinase activity in the patient and disparate activity in the parents with one parent having normal activity and the other having low tyrosinase activity. Changes in skin, hair, and ocular pigment were followed as the patients matured. As a measure of ocular pigment, iris transillumination and macular transparency were graded according to a previously published scheme.

RESULTS

Patients were born with white scalp hair and skin, and nystagmus developed. Visual acuity was reduced to 20/50 to 20/200 for the group, but in one patient vision improved with maturity. Irides were blue. In seven patients, iris pigment developed, which was detected by transillumination with slit-lamp biomicroscopy, including the one patient with improved visual acuity. All patients had foveal hypoplasia, and melanin pigment in the fundi could not be detected by clinical examination. Visual acuity in the group did not correlate directly with the presence or development of iris transillumination or macular transparency. The pedigrees were consistent with an autosomal recessive inheritance pattern.

CONCLUSION

This unique type of oculocutaneous albinism has heterogeneous clinical features. Minimal pigment oculocutaneous albinism appears to represent a new type of tyrosinase-related oculocutaneous albinism (OCA1MP).

Dense peripheral corneal clouding in Scheie syndrome

A 28-year-old woman with Scheie syndrome (MPS I-S) presented with the unusual feature of extremely dense peripheral corneal clouding, allowing maintenance of good central visual acuity. Characteristic systemic features, an abnormal electroretinogram result, and absent alpha-L-iduronidase activity confirmed the diagnosis despite the unusual corneal pattern of clouding.

Analysis of tyrosinase gene mutations using direct automated infrared fluorescence DNA sequencing of amplified exons

The ability to correctly diagnose the molecular cause of genetic diseases is becoming increasingly important in medicine. This requires an efficient method for the analysis of the DNA sequence of specific genes and the detection of mutations in affected individuals. We report a method to determine the mutations responsible for tyrosinase related albinism (OCA1) using a combination of polymerase chain reaction-single stranded conformational polymorphism (PCR-SSCP) analysis and direct DNA cycle sequencing using fluorescently labeled oligonucleotides and an automated DNA sequencer based on infrared fluorescence technology. This method allows DNA from several individuals to be sequenced quickly and simultaneously so that the specific location of each mutation and the carrier status of family members can be determined.

The effect of grating orientation on resolution acuity in patients with nystagmus

The acuity card procedure is an effective method for the assessment of grating acuity in preverbal and nonverbal patients. However, the effect of nystagmus on this acuity assessment has not been well-described. We studied the effect of grating orientation on the measurement of resolution acuity in a group of nystagmus patients, a group of patients with albinism and nystagmus, and a normal control group. The resolution acuity was significantly (P < or = .01) better with horizontal grating orientation in both the nystagmus and the albino groups, but grating orientation did not affect resolution acuity in the control group. This study suggests that grating orientation must be taken into account when using the acuity card procedure in patients with nystagmus.