A protocol for measuring ophthalmologic morbidity and recovery after cranial base surgery

Patients with cranial base tumors often have impairment in visual function, either due to the pathologic process itself or as a result of surgical treatment of the lesion. We conducted a pilot study in which we performed ophthalmologic evaluations on patients before and after cranial base surgery. The results of the study were used to develop a protocol and reporting form for longitudinal assessment of visual function in these patients. Use of the protocol and reporting form for the past 2(1/2) years has shown that they are easy for physicians to use and that the results provide a representative evaluation of the patient's ability to function visually in everyday life. The authors propose implementation of the protocol and reporting form as a means of collecting data for further research into visual function in patients with cranial base tumors.

The aetiology in paediatric aphakic glaucoma

PURPOSE

To investigate the causes of glaucoma in children following removal of cataracts.

METHODS

In total, 24 patients (37 eyes) with uncomplicated congenital cataracts who developed glaucoma following cataract removal were studied retrospectively. Cataract morphology, surgical technique, postoperative complications, time to glaucoma onset, gonioscopic findings, the presence of microcornea, and the histopathologic characteristics of the filtration angle in one case were the studied parameters.

RESULTS

We found a bimodal onset of glaucoma. Early-onset glaucoma occurred at a mean age of 6 months in 15 eyes and delayed-onset glaucoma at a mean age of 12 years in 22 eyes. Early-onset glaucoma was significantly (P=0.018) more likely to be due to angle closure. With delayed-onset glaucoma, the filtration angle is open in 86% of eyes and significantly (P=0.006) more eyes in the delayed-onset group had microcornea.

CONCLUSIONS

Performing cataract surgery very early in life in microphthalmic eyes and leaving residual lens material increases the risk for glaucoma. We recommend a prophylactic iridectomy in eyes at risk for pupillary block. Eyes with delayed-onset glaucoma have open filtration angles but with findings consistent with incomplete development of filtration structures. Early age at cataract extraction and microcornea are risk factors for delayed-onset glaucoma.

The prevalence of uveitis in juvenile rheumatoid arthritis

BACKGROUND

Because asymptomatic uveitis has been an important cause of visual loss in children with juvenile rheumatoid arthritis, periodic ophthalmologic screenings of such patients have been recommended. Recently, some authors have found a decreased prevalence of uveitis in children with juvenile rheumatoid arthritis.

METHODS

We studied a total of 76 patients (63 girls and 13 boys, aged 1 to 16 years), referred to 3 pediatric ophthalmology practices between March 1976 and October 1999. Follow-up examinations were performed at intervals of 3 to 6 months according to current guidelines, during the following 6 months to 23 years (mean, 55 months).

RESULTS

Uveitis developed in 10 children (13%). Of these 10 children, 2 were symptomatic (blurred vision, discomfort) and 7 were diagnosed with uveitis at the initial visit. Only 1 patient had asymptomatic uveitis after initial negative findings on screening examination. Final visual acuity for all the compliant children in the uveitis group was better than 20/30.

DISCUSSION

The prevalence of uveitis in our study is similar to rates found by other recent authors. This decrease may reflect a tendency for systemic medications to prevent the development of ocular inflammation. We believe that screening guidelines should be reevaluated, especially for asymptomatic children with negative findings on initial examinations.

High levels of binocular function are achievable after removal of monocular cataracts in children before 8 years of age

OBJECTIVE

To investigate the visual acuity and binocular function results achieved in children who had monocular cataracts removed before 8 years of age.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Clinical records of 171 patients who underwent a unilateral cataract removal between January 1986 and 1996 were reviewed retrospectively. Seventy-four eyes were included in the study: 19 congenital, 11 developmental, 19 posterior lenticonus, 19 traumatic, and 6 complicated cataracts. Patients with less than 2 years of follow-up; eyes with cataracts resulting from retinoblastoma; prematurity; and those associated with dense corneal scars, lens dislocation, and persistent hyperplastic primary vitreous were excluded.

INTERVENTION

Visual acuity was measured by means of age-appropriate tests such as the fixation pattern, Allen object recognition cards, isolated optotypes with the Sheridan Gardiner test, and Snellen letters. Sensory fusion was assessed with the Worth 4-dot test, and stereo acuity was assessed with the Titmus stereo test.

MAIN OUTCOME MEASURES

Cataracts were classified regarding type, extent, age at onset, duration of the opacity, age at surgery, method of removal, development of secondary membrane, form of optical rehabilitation, and presence of strabismus. Visual acuity levels between 6/6 and 6/12 were considered "good." Fusion of the Worth 4-dot test at distance and near, and presence of stereo acuity of 100 seconds of arc or better were considered "good" binocular function. Multiple logistic regression analysis was used to define factors that correlated with achieving good visual outcome.

RESULTS

Visual acuity was 6/12 or better in 27 (36.5%) eyes. However, good binocular function was achieved in only 11 of these 27 patients. Results of univariate analysis showed that later age at onset of cataract and absence of strabismus were significant for good visual acuity and binocular function. The presence of strabismus increases the risk of not achieving good visual acuity by 5.45-fold.

CONCLUSIONS

Good visual acuity and binocular function can be achieved after removal of monocular cataracts in visually immature children. Patients with strabismus at presentation or during the follow-up period have the least chance of achieving a good sensory result.

Third cranial nerve palsy in children

PURPOSE

To report the causes and the sensory, motor, and cosmetic results after treatment for oculomotor (third cranial nerve) palsy in children.

METHODS

Review of the clinical records of children with a diagnosis of third cranial nerve palsy followed up in a university-based pediatric ophthalmology practice between 1981 and 1996.

RESULTS

Forty-nine children with 53 affected eyes were followed up for a mean of 5.5 years. Third cranial nerve palsy was partial in 31 children (32 eyes) and complete in 18 children (21 eyes). The palsy was congenital in 20 eyes and caused by postnatal trauma in 17 eyes. Seventeen eyes had aberrant regeneration and four eyes with partial third cranial nerve palsy had spontaneous resolution. Thirty-six children (38 eyes) were affected before visual maturation (age 8 years), and 25 (27 eyes) had amblyopia. Of the five amblyopic eyes with quantifiable visual acuity, none had measurable improvement of Snellen visual acuity during the follow-up period. Overall, visual acuity was between 6/5 and 6/12 at the last follow-up visit in 31 eyes (58%). Ocular alignment was greatly improved after strabismus procedures, with a mean of 1.5 procedures for patients with partial third cranial nerve palsy and 2.3 procedures for those with complete palsy. Binocular function was difficult to preserve or restore but was achieved for some patients with partial third cranial nerve palsy.

CONCLUSIONS

Surgical treatment of third cranial nerve palsy is frequently necessary, especially in cases of complete palsy. Multiple strabismus procedures are often needed to maintain good ocular alignment. Surgery can result in cosmetically acceptable alignment of the eyes, but it rarely results in restoration or achievement of measurable binocular function. Treatment of amblyopia is effective in maintaining the level of visual acuity present at the onset of the third cranial nerve palsy, but improvement in visual acuity is difficult to achieve.

Long-term outcome of cyclocryotherapy for refractory pediatric glaucoma

OBJECTIVE

To evaluate the success rate and long-term outcome of cyclocryotherapy for refractory pediatric glaucoma.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

A total of 64 eyes of 49 patients from 2 institutions with pediatric glaucomas resistant to conventional medical and surgical therapies treated with cyclocryotherapy from 1975 to 1996 were included in this review.

INTERVENTION

Cyclocryotherapy was performed on eyes with pediatric glaucoma resistant to maximal medical and surgical interventions. Each cyclocryotherapy session was evaluated in terms of area treated, temperature, and number of applications placed.

MAIN OUTCOME MEASURES

Criteria for success included intraocular pressure (IOP) of 21 mmHg or less without devastating complications or need for further glaucoma surgery.

RESULTS

The mean baseline pretreatment IOP of all eyes was 30.0 +/- 8.1 mmHg. Six months after their last treatment, 42 eyes (66%) were successes. Longer term follow-up (mean, 4.8 +/- 3.3 years) yielded a lower final success rate in 28 eyes (44%). For these 28 eyes, mean IOP was reduced from 30.3 +/- 7.8 mmHg pretreatment to 16.8 +/- 4.0 mmHg after their last cyclocryotherapy treatment session (P < 0.001). The average number of cyclocryotherapy sessions for successful eyes was 4.1 +/- 4.0 (range, 1-17). The mean follow-up time for these successful eyes was 4.9 +/- 3.4 years. Devastating complications attributable to cyclocryotherapy included phthisis (5 eyes) and retinal detachment (5 eyes). Devastating complications occurred more frequently among eyes with aniridia than among all other eyes (nonaniridics) (50% vs. 11%, respectively; P < 0.05).

CONCLUSION

Cyclocryotherapy is an effective means of lowering IOP and is a reasonable treatment option in selected pediatric patients with refractory glaucoma. Eyes with aniridia experienced a very high rate of phthisis after cyclocryotherapy and may be poor candidates for this treatment.

Results following treatment of third cranial nerve palsy in children

PURPOSE

To investigate the etiology, sensory, motor, and cosmetic results of treatment for oculomotor (CNIII) palsy in children.

METHODS

We conducted a retrospective review of the clinical records of children with a diagnosis of CNIII palsy who were followed up in our practice between 1981 and 1996.

RESULTS

During the 15-year period, 49 children with 53 affected eyes were followed for a mean of 5.5 years. CNIII palsy was congenital in one third of cases and secondary to postnatal trauma in another third. Thirty-three of the eyes were affected before visual maturation (age 8 years) and 27 eyes developed amblyopia. None of the 6 eyes with amblyopia in which visual acuity could be quantitated had measurable improvement of Snellen acuity after treatment. Overall, visual acuity was between 6/5 and 6/12 at the last follow-up visit in 56% of affected eyes. Ocular alignment was greatly improved after recess-resect procedures on the horizontal rectus muscles, but binocular function was difficult to preserve or restore. Blepharoptosis improved after levator palpebrae muscle resection or eyelid suspension procedures.

CONCLUSIONS

CNIII palsy may undergo partial resolution in children, but surgical treatment is frequently necessary. Although surgery can result in cosmetically acceptable alignment of the eyes, it rarely results in restoration or achievement of binocular function. Multiple procedures are often necessary to maintain good ocular alignment. Several surgical procedures may be needed to correct related blepharoptosis and maintain an acceptable eyelid position. Treatment of amblyopia is only effective in maintaining the level of visual acuity present at the onset of the CNIII palsy, and improvement in acuity is difficult to achieve.

Secondary intraocular lens implantation after cataract surgery in children

PURPOSE

To report results of secondary intraocular lens implantation after cataract surgery in children.

METHODS

We reviewed clinical records for a 5-year period of patients who had cataract surgery in childhood and received a secondary intraocular lens implant. We studied indications for secondary intraocular lens placement; surgical procedures for intraocular lens implantation; preoperative and postoperative visual acuity, refractive error, and binocular status; and complications of the procedure.

RESULTS

A secondary intraocular lens was placed in 28 eyes of 25 patients who had cataract surgery in childhood. In 20 eyes, the lenses were placed in the ciliary sulcus. The other eight eyes had insufficient capsular support for an intraocular lens; in two, the intraocular lens was placed in the anterior chamber and, in six, in the posterior chamber with suture fixation to the sclera. Twenty of 28 eyes (71%) had measurable improvement in visual acuity; only one eye had a decrease in visual acuity of 2 lines. Fifteen patients (54%) had a final refraction within 1.50 diopters of the fellow eye; 21 (75%) were within 3.00 diopters. During follow-up, two eyes developed glaucoma. One had transient pressure elevation; one required two filtration procedures. Three patients required Nd:YAG capsulotomy. Six patients demonstrated Worth fusion at distance and near; three demonstrated 200 seconds of arc or better stereo visual acuity.

CONCLUSION

Secondary placement of an intraocular lens in the posterior chamber appears to be a safe, effective alternative for correction of aphakia in the contact lens- or spectacles-intolerant child or young adult.

Scleral fixation of posterior chamber intraocular lenses in children

BACKGROUND AND OBJECTIVE

Children with monocular aphakia who become contact lens intolerant require an intraocular lens (IOL) for visual rehabilitation. When there is inadequate support from the posterior lens capsule, use of an anterior chamber IOL or a sclerally fixated posterior chamber IOL may be considered. The authors report their experience with scleral fixation of posterior chamber IOLs in children.

PATIENTS AND METHODS

Seven posterior chamber IOLs were sutured in the ciliary sulcus of children who could not wear contact lenses. In each eye, the lens capsule remnants were inadequate to provide sufficient support for the haptics of a posterior chamber lens.

RESULTS

Six of seven patients had improved visual acuity, with an average improvement of 4 lines. Complications related to scleral fixation included exposure of the scleral fixation suture in one eye, lens decentration in one eye, and lens tilt in one eye. Follow-up ranged from 3 to 38 months, averaging 26 months.

CONCLUSION

Implantation of a posterior chamber sclerally fixated IOL offers an alternative to placement of an anterior chamber lens in children who cannot wear contact lenses and who lack capsular support. Continued follow-up of these patients will help determine the long-term safety of this technique.

Infantile exotropia

BACKGROUND

Exotropia is uncommon in healthy children between 6 months and 1 year old.

METHODS

The charts of patients treated in our practice between January 1980 and August 1994 were reviewed for a diagnosis of infantile exotropia. All of them had an exodeviation during the first year of life. Children with neurologic defects, prematurity, trauma, craniofacial syndromes, or orbital abnormalities or ocular defects that would reduce vision were eliminated.

RESULTS

Sixty-six healthy patients with normal eyes had an exodeviation of 15 prism diopters (delta) or more that persisted through the first year of life. Fifty-four were eliminated because the diagnosis had not been confirmed by a pediatric ophthalmologist before they were 1 year old or they had not been followed for more than 4 years. The 12 remaining patients were followed for at least 4 years (mean, 7.9 years). The mean age at the first examination was 7.8 months (range, 4 to 12 months). On early evaluation, exotropia was intermittent in four and constant in eight. Three had amblyopia. Ten required surgical correction. Exotropia was corrected with one operation in six patients; four required additional procedures, mostly to correct oblique muscle overaction and dissociated vertical deviation (DVD). At the most recent visit, all 12 patients had equal visual acuity in both eyes and satisfactory ocular alignment. Five had fusion at distance and near, but only two had stereo acuity of 100 seconds of arc or better.

CONCLUSION

Infantile exotropia is rare. But, like patients with infantile esotropia, those with exotropia can be expected to have good visual acuity but unstable ocular alignment. Also, as with early-onset esotropia, although surgical intervention is usually required, high levels of binocular function develop in some patients with exotropia. Oblique muscle overaction and DVD are common, often becoming manifest by the first year of age. Unlike infantile esotropia, nystagmus is rare.

Early retinal vessel development and iris vessel dilatation as factors in retinopathy of prematurity. Cryotherapy for Retinopathy of Prematurity (CRYO-ROP) Cooperative Group

OBJECTIVE

To determine whether the extent of retinal vessel development present on early screening examinations for retinopathy of prematurity has prognostic value?

DESIGN

The prospectively collected data from the Multicenter Trial of Cryotherapy for Retinopathy of Prematurity were used to compare the development of acute retinopathy of prematurity and long-term structural and visual outcomes for eyes with differing extents of retinal vessel development.

PATIENT

Study patients had eyes with the following vessel development. In zone I eyes, vessels extended from the disc less than twice the distance from the disc to the macula. In zone II eyes, vessels extended beyond zone I but not to the nasal ora serrata. Transitional eyes had vessels partly in zone I and partly in zone II.

RESULTS

The chance of developing threshold retinopathy of prematurity was inversely related to the early degree of vessel development: 54% for zone I eyes, 25% for transitional eyes, and 8% for zone II eyes. The presence of prominent iris vessels at 34 to 35 weeks of postmenstrual age was associated with increased risk for all three groups; zone I eyes almost always needed treatment (94%). The chance of having an unfavorable anatomic alteration of the posterior fundus, or poor vision at the ages of 1 year and 3 1/2 years, was also inversely related to the degree of early vessel development. Vessel development was an independently important factor even when birth weight, gestational age, and race were considered.

CONCLUSIONS

The degree of early retinal vessel development is a significant predictor of outcome from retinopathy of prematurity. Iris vessel dilatation is an important indication for greater vigilance in following these infants.

Results following secondary intraocular lens implantation in children

BACKGROUND

Placement of a secondary intraocular lens (IOL) in a child may be considered in children with congenital monocular cataracts who have had complete opacities removed early in life and who later become contact lens intolerant, in eyes that have received trauma which precluded placement of a primary IOL, and in young adults who have bilateral aphakia who become resistant to use of contact lenses or spectacles.

METHODS

Clinical records of all children in our practice who received a secondary IOL between January 1988 and December 1994 were reviewed. Indications, biometry, type of procedures, preoperative and postoperative acuity, refractive error, binocular status, and complications were studied.

RESULTS

During the 7-year period, 242 cataract operations were performed. Fifty-nine eyes received a lens implant, and 28 of these were secondary implants. There was a mean interval between the initial cataract operation and the procedure for the secondary implant of 77 months. The mean follow-up was 35 months (range, 3 to 71) for the 28 eyes that received a secondary implant. Two received anterior chamber implants. Eight eyes had insufficient capsular support for an IOL. Six implants were placed in the posterior chamber and required suture fixation to the sclera. Twenty of 28 eyes had a measurable improvement in visual acuity. Only 1 eye had a decrease in visual acuity of 2 lines. Fifteen patients (54%) had a final refraction within 1.50 diopters of the fellow eye, and 75% were within 3.00 diopters. During the follow-up period, 2 eyes developed glaucoma. One had a transient pressure elevation, and the second has required 2 filtration procedures. Three patients required a Nd: YAG capsulotomy. Six patients demonstrated Worth fusion at distance and near, but only 3 patients demonstrated 200 seconds of arc or better stereo acuity.

CONCLUSION

Placement of contemporary-style, secondary intraocular lenses in children and young adults appears to provide a safe and effective alternative for correction of aphakia in children who become contact lens or spectacle-intolerant.

Incidence of increased intracranial pressure after early surgical treatment of syndromic craniosynostosis

The late development of intracranial hypertension after an aesthetically successful cranial vault expansion has been noted anecdotally in children with syndromic synostosis. If untreated, this process can lead to neurological and visual deterioration; however, the frequency of this problem is uncertain. In an attempt to detect this process before the onset of irreversible impairment, the authors have since 1991 incorporated routine ophthalmological evaluations into the multidisciplinary follow-up protocol for all patients with complex craniosynostosis. These examinations were performed at initial evaluation and at 6-month intervals thereafter. The present report focuses on the results in 22 consecutive infants with syndromic synostosis who underwent initial surgery between 1991 and 1994. All but 4 children underwent initial cranial reconstruction at 6-18 months of age. Four patients had papilledema preoperatively which in each instance resolved postoperatively. During the follow-up period, 8 children manifested evidence of late intracranial hypertension at a median of 16.5 months after initial operation(s): 4 developed asymptomatic papilledema, 1 had progressive proptosis, and 3 had other subtle clinical signs of increased intracranial pressure (ICP). Further evaluation disclosed a Chiari 1 malformation in 2 children; 4 had a 'beaten copper' appearance on skull radiographs, and 4 underwent lumbar puncture, which in each case demonstrated an opening pressure above 20 cm H2O. Only 3 children exhibited symptoms from the ICP elevation. Six children with a head size < or = the 25th percentile underwent a repeat cranial expansion; after the cranial vault expansion, one child who initially had slit-like ventricles developed ventriculomegaly and, because of persistent papilledema, underwent insertion of ventriculoperitoneal (VP) shunt. Two other patients with a head circumference above the 50th percentile and the development of moderate ventriculomegaly underwent VP shunt insertion alone. All children have had complete resolution of papilledema as well as other symptoms and signs of increased ICP without evidence of optic atrophy or neurological sequelae. This study indicates that the incidence of delayed, asymptomatic increases in ICP among children with complex craniosynostosis is higher than previously estimated. The pathophysiologic bases for this process are discussed. Because the detection of this problem at a presymptomatic stage should optimize the likelihood of a good functional outcome, we strongly recommend close ophthalmological and clinical follow-up as a part of the comprehensive care of all young children with complex craniosynostosis, even after a cosmetically successful cranial expansion.

Strabismus associated with meningomyelocele

INTRODUCTION

Strabismus occurs frequently in patients with spina bifida or meningomyelocele.

PATIENTS AND METHODS

I performed 1544 eye examinations in 298 patients with spina bifida over a period of 15 years. The patient records were retrospectively reviewed for visual acuity, binocular function, and strabismus. Select patients with A-pattern strabismus were recalled for neuroimaging.

RESULTS

Visual acuity was correctable to 20/40 in 85% of the patients. One hundred and eighty-three patients (61%) had strabismus at some time over the study period. Sixty-three percent had an esodeviation; 37% an exodeviation. A-pattern strabismus was more common in patients with exotropia (39%) than in those with esotropia (27%). Defects on neuroimaging in the region of the vertical gaze pathways in the brain stem were correlated with A-pattern strabismus.

CONCLUSION

With increased longevity of the patient with spina bifida, quality-of-life issues become increasingly important. Amblyopia, strabismus, and other acquired defects in the visual system related to hydrocephalus should be closely monitored and treated when indicated.

The results of surgery for benign tumors of the cavernous sinus

CAVERNOUS SINUS SURGERY has been performed increasingly in the last 2 decades because of new knowledge and technologies. With increasing international expertise in cavernous sinus surgery, the results must be analyzed critically to search for accurate prognosticators of outcome. We performed a retrospective review of 124 patients (40 male, 84 female; mean age, 45 years) who underwent cavernous sinus surgery for benign tumors from 1983 to 1992. Sixty-five percent had tumors encasing the internal carotid artery. Mean follow-up was 29 months (median, 26 mo). Gross total or near-total resection was possible in 80%. Patients with neurilemomas, angiofibromas, epidermoids, chondroblastomas, and hemangiomas were more likely to have total or near-total resection (100% versus 75%, P < 0.025). Disabling complications (five cerebral infarctions, two meningitis, and one hydrocephalus with chiasmal prolapse) occurred only in patients with meningiomas or pituitary adenomas. On follow-up, excellent/good binocular vision was achieved in 53% of patients entering surgery with excellent/good function versus 25% who entered surgery with fair/poor binocular vision (P < 0.025). Ninety-three percent of patients had a Karnofsky score > or = 70 on follow-up. There were a total of 12 recurrences (10%), 6 in patients with meningiomas, 2 in patients with angiofibromas, 2 in patients with craniopharyngiomas, 1 in a patient with a pituitary adenoma, and 1 in a patient with an osteoblastoma. Patients with tumor growth or neurological symptoms indicative of progressive cavernous sinus involvement should undergo cavernous sinus exploration. This surgery has acceptable morbidity and mortality and, if the tumor can be removed easily, the surgeon should try to perform radical tumor resection. To avoid major complications, the surgeon must exercise utmost care to preserve the neurovascular structures of the cavernous sinus, with special attention to tumors that extend into the petroclival region. Better results from surgery can be expected in those patients with neurilemomas, hemangiomas, or epidermoids than in patients with meningiomas, craniopharyngiomas, or pituitary adenomas. Good functional outcome can be expected, particularly if the patient's preoperative clinical status is good. Particular attention must be paid to the reconstruction of anatomic barriers in order to prevent cerebrospinal fluid leakage and subsequent meningitis.

Episcleral osteocartilaginous choristoma

PURPOSE/METHOD

A 31-year-old woman had a hypertropia and an episcleral choristoma in the superotemporal quadrant of the globe. The choristoma was examined.

RESULTS/CONCLUSIONS

Gross and histopathologic examination showed bone and cartilage components in the tumor, which refutes the previously accepted membranous growth pattern of episcleral osseous choristomas.

Intracranial hypertension after cranial vault decompression for craniosynostosis

A 3-year-old boy with chronic papilledema, bilateral coronal synostosis and Pfeiffer syndrome underwent an orbitofrontal advancement. One month postoperatively, his papilledema had resolved, however, his vision progressively deteriorated over the ensuing 3 months to legal blindness. He had no symptoms or signs of increased pressure. Multiple imaging studies were unremarkable except for dilatation of the optic nerve sheaths. A lumbar puncture revealed intracranial hypertension, which resolved after treatment with a lumboperitoneal shunt. Intracranial hypertension may persist after craniofacial reconstruction. In patients who have progressive neurological deterioration after craniofacial reconstruction, direct measurement of intracranial pressure is indicated, despite a lack of clinical signs or symptoms of intracranial hypertension and normal imaging studies.

Control of eyelid retraction associated with Graves' disease with botulinum A toxin

Two patients had satisfactory control of eyelid retraction associated with thyroid orbitopathy with repeated treatment of the levator palpebrae superioris muscle with botulinum A toxin. The effects of the toxin lasted for 3 to 4 months.

Serum antibody production to botulinum A toxin

PURPOSE

Conflicting data have been reported regarding development of serum antibodies to botulinum A toxin. The purpose of this study is to determine conclusively whether antibody production to this toxin occurs in humans, and, if so, to determine its relationship, if any, to length of treatment, total cumulative dose, and clinical response to treatment.

METHODS

Sixty-five sera samples from 42 adults treated with botulinum A toxin for essential blepharospasm, hemifacial spasm, or spasmodic torticollis were analyzed via a sphere-linked immunodiagnostic assay for antibody production. Results were plotted against length of treatment, number of injections, cumulative dose, and treatment effect produced.

RESULTS

Twenty-four (57%) of the 42 patients produced antibodies in all three diagnostic groups. No significant differences were found between antibody producers and nonproducers with respect to age (P = 0.216), length of treatment (P = 0.586), number of injections (P = 0.619), or total cumulative dose (P = 0.286). Within the antibody-producing group, there was no significant correlation between amount of antibody and length of treatment (P = 0.081), number of injections (P = 0.134), or cumulative dose (P = 0.250). The presence of demonstrable antibodies in serum did not affect the clinical responsiveness to injection.

CONCLUSION

Antibody production is present in a majority of patients treated with botulinum A toxin. The sphere-linked immunodiagnostic assay is a reliable and reproducible method for detecting and quantifying these antibodies. When antibody production occurs, it is likely due to variations in individual immune responsiveness and appears to have no direct effect on the patient's clinical response to treatment.

A prospective, randomized, controlled comparison of retrobulbar and general anesthesia for strabismus surgery

A prospective, randomized controlled study (n = 95) was conducted to compare the morbidity and length of hospital stay associated with retrobulbar neuromuscular blockade (LA) with that associated with general anesthesia (GA) for monocular strabismus surgery in adult patients. A scoring system was developed to assess postoperative nausea and vomiting, pain, level of consciousness, oral intake, and activity while in the hospital and for the first 3 postoperative days. There was no significant difference in the postoperative nausea and vomiting associated with the two anesthetic techniques. Although patients receiving LA experienced less immediate postoperative discomfort (P < .01) and had greater levels of activity (P < .0001) while in the hospital, the discomfort and activity levels of the two groups were similar at home. The LA group was discharged from the hospital sooner (mean, 135 minutes vs 250 minutes; P < .001), allowing more efficient use of hospital resources. Both techniques provided excellent anesthesia for monocular strabismus surgery.

Risk factors for complications following pediatric epikeratoplasty

We studied the prevalence and types of complications that occurred in children treated with epikeratoplasty to identify risk factors. A review of the clinical records of 88 consecutive patients (106 eyes; 114 procedures) revealed that no complications occurred in 58 grafts (54%). Refractive complications (refractive error greater than 3.00 diopters spherical equivalent from emmetropia or astigmatism greater than 3.00 diopters) occurred in 30 eyes (28%). Medical complications occurred in 22 eyes (19%); these included epithelial defects (14 grafts), interface opacities (six grafts), graft vascularization (eight grafts), graft infection (two grafts), graft necrosis (five grafts), graft haziness (four grafts) or opacification (11 grafts), and graft dehiscence (three grafts). Eleven grafts (10%) were removed and five eyes received new grafts. Epikeratoplasty in children will be more successful if risk factors such as patient age less than one year, microcornea, corneal endothelial cell dysfunction, mental retardation, and combining the procedure with cataract surgery are avoided.

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.