Uveal effusion syndrome: clinical features, surgical treatment, histologic examination of the sclera, and pathophysiology

PURPOSE

To clarify clinical features and pathophysiology and to evaluate surgical outcome of subscleral sclerectomy for primary uveal effusion syndrome.

DESIGN

Prospective, consecutive noncomparative case series.

PARTICIPANTS

Nineteen eyes of 16 patients diagnosed with uveal effusion syndrome treated in our clinic between 1989 and 1998.

METHODS

Patients were examined by routine ophthalmologic examinations, fluorescein and indocyanine green angiography; measurement of the axial length of the eyeball; magnetic resonance imaging; and echography. Subscleral sclerectomy (sclerectomy under the scleral flap) was performed at the equator on all patients. Histologic examination of excised sclera was carried out on all samples. Patients were followed for outcome over time.

MAIN OUTCOME MEASURES

Reattachment of the choroid and retina with resolution of the serous fluid.

RESULTS

Three subgroups were identified: In type 1, nanophthalmic eye; the eyeball is small (average axial length 16 mm) and high hypermetropic (average +16 diopters); in type 2, the eyeball size is normal (average axial length 21 mm) with small refractive error; and in type 3, the eyeball size is normal. Histologically, types 1 and 2 demonstrated abnormal sclera with disorganization of collagen fiber bundles and deposits of proteoglycans in the matrix, whereas type 3 showed normal sclera. Subscleral sclerectomy was effective for types 1 and 2, inducing postoperative resolution of the subretinal fluid. However, type 3 eyes were not helped by this technique.

CONCLUSIONS

Primary uveal effusion syndrome is caused by abnormalities of the sclera and increased resistance to transscleral fluid outflow as subscleral sclerectomy is an effective treatment in types 1 and 2 only, correct preoperative classification is essential for early surgical management.

From hair to cornea: toward the therapeutic use of hair follicle-derived stem cells in the treatment of limbal stem cell deficiency

Limbal stem cell deficiency (LSCD) leads to severe ocular surface abnormalities that can result in the loss of vision. The most successful therapy currently being used is transplantation of limbal epithelial cell sheets cultivated from a limbal biopsy obtained from the patient's healthy, contralateral eye or cadaveric tissue. In this study, we investigated the therapeutic potential of murine vibrissae hair follicle bulge-derived stem cells (HFSCs) as an autologous stem cell (SC) source for ocular surface reconstruction in patients bilaterally affected by LSCD. This study is an expansion of our previously published work showing transdifferentiation of HFSCs into cells of a corneal epithelial phenotype in an in vitro system. In this study, we used a transgenic mouse model, K12(rtTA/rtTA) /tetO-cre/ROSA(mTmG) , which allows for HFSCs to change color, from red to green, once differentiation to corneal epithelial cells occurs and Krt12, the corneal epithelial-specific differentiation marker, is expressed. HFSCs were isolated from transgenic mice, amplified by clonal expansion on a 3T3 feeder layer, and transplanted on a fibrin carrier to the eye of LSCD wild-type mice (n = 31). The HFSC transplant was able to reconstruct the ocular surface in 80% of the transplanted animals; differentiating into cells with a corneal epithelial phenotype, expressing Krt12, and repopulating the corneal SC pool while suppressing vascularization and conjunctival ingrowth. These data highlight the therapeutic properties of using HFSC to treat LSCD in a mouse model while demonstrating a strong translational potential and points to the niche as a key factor for determining stem cell differentiation.

Long-term results of corneal graft survival in infants and children with peters anomaly

OBJECTIVE

To determine the long-term results of corneal graft survival after penetrating keratoplasty for Peters anomaly and to identify risk factors for graft failure.

DESIGN

Noncontrolled interventional case series: a single-center retrospective review of a consecutive surgical series.

PARTICIPANTS

The records of all children 12 years of age or younger who underwent penetrating keratoplasty for Peters anomaly between January 1971 and December 1992 were reviewed. All study eyes had completed a minimum of 3 years of follow-up from the date of first keratoplasty and had undergone most of their corneal surgery at Emory University.

INTERVENTION

Characteristics of the recipient, the eye, the donor, and the surgical procedure were analyzed for their influence on survival of the first graft. Survival probabilities were estimated using the Kaplan-Meier method. Multivariate regression analysis was performed to estimate relative risks and adjusted survival probabilities.

MAIN OUTCOME MEASURE

Graft clarity.

RESULTS

One hundred forty-four penetrating keratoplasties were performed in 72 eyes of 47 patients. The median age at first keratoplasty was 4.4 months. The median follow-up was 11.1 years. Fifty-four percent of eyes received one graft, 18% received two grafts, and 28% received three or more grafts. The overall probability of maintaining a clear first graft was 56% at 6 months, 49% at 12 months, 44% at 3 years, and 35% at 10 years. The probability of second or subsequent grafts surviving for 3 years was less than 10%. Thirty-nine percent of eyes had a clear graft at the time of review; 36% of eyes had a clear first graft. Multivariate analysis identified disease severity, donor cornea size, coexisting central nervous system abnormalities, and quadrants of anterior synechiae as the strongest risk factors for graft failure. Supplemental multivariate analysis, restricted to observable preoperative variables, identified stromal vessels, total limbal opacification, and preoperative glaucoma as independent preoperative predictors of graft failure. Allograft rejection was the most frequently identified cause of graft failure. Major complications after keratoplasty were phthisis, retinal detachment, cataract, and glaucoma.

CONCLUSIONS

The overall long-term probability of maintaining a clear graft after initial penetrating keratoplasty for Peters anomaly is 35% +/- 0.06%, with subsequent grafts rarely surviving. Eyes with severe disease, larger donor corneas, coexisting central nervous system abnormalities, and anterior synechiae have significantly poorer outcomes than eyes without these factors. These data should be carefully considered before recommending corneal transplantation for Peters anomaly, particularly after previous graft failure.

Surgical results of persistent hyperplastic primary vitreous

PURPOSE

To evaluate the surgical success of patients with persistent hyperplastic primary vitreous (PHPV) and to identify preoperative indicators of visual outcome.

DESIGN

Noncomparative case series.

METHODS

The diagnosis of PHPV was made in 35 eyes of 27 patients from 1982 to 1994. In each case, anterior and/or posterior PHPV findings, preoperative testing, surgical procedures, and visual outcomes were documented. Twenty-nine of 35 eyes were managed surgically. Follow-up ranged from 2 months to 12 years.

RESULTS

Of the 35 eyes, 2 (5.7%) had strictly anterior PHPV, 8 (22.9%) had strictly posterior PHPV, and 25 (71.4%) had components of both anterior and posterior disease. Initial lensectomy and vitrectomy was performed in 24 eyes (68.6%). Surgery was withheld in four eyes secondary to severity of disease with an unrecordable visual-evoked potential (VEP). Reoperation rate was 32.3% for membrane reproliferation, glaucoma, vitreous hemorrhage, retinal detachment, or strabismus. Best-corrected final visual acuity ranged from 20/60 to no light perception. Six eyes (17%) maintained Snellen visual acuity despite posterior PHPV with some degree of retinal dysplasia.

CONCLUSIONS

Surgical treatment of PHPV can result in functional visual outcome despite posterior segment involvement. The degree of ocular malformation, however, will ultimately limit the amount of visual improvement. Preoperative testing, including VEP, may aid in determining surgical candidates.

Outcomes in persistent hyperplastic primary vitreous

AIMS

To report outcomes in cases of persistent hyperplastic primary vitreous (PHPV) and examine factors predictive of visual acuity in patients selected for surgery.

METHODS

Retrospective case series of 55 eyes in 50 patients presenting between 1990 and 2001 at the Children's Hospital, Westmead. 33 eyes underwent surgery aimed at visual rehabilitation.

RESULTS

In surgical patients, median age at surgery was 77 days, and median age at final follow up was 28 months. Six (18%) achieved a visual acuity at final follow up of 6/60 or better and eight (24%) achieved acuity of less than 6/60 to counting finger vision inclusive. Those undergoing surgery before 77 days were approximately 13 times more likely to obtain a visual acuity of counting fingers or better than those operated later (p = 0.01). Neither posterior segment PHPV nor post-surgical glaucoma was a significant predictor of outcome in this selected group.

CONCLUSION

Early surgery aimed at rehabilitation markedly improves the likelihood of useful visual outcome in selected eyes with PHPV.

Rare craniofacial clefts: Tessier no. 4 clefts

A major difficulty in understanding rare craniofacial clefts arises from the fact that previous reports have focused on a single case or have grouped together different types of rare clefts. Less than 50 Tessier no. 4 clefts have been reported. This paper examines our experience with eight patients treated primarily or secondarily for Tessier no. 4 clefts. A treatment plan is recommended. The primary early concern is protection of the eye. Early correction of soft-tissue deformities should include skin, muscle, and lining of the orbit, cheek, and oral cavity. Contrary to the dictum that all soft tissue must be preserved, the medial portion of the upper lip from the cleft to the philtral ridge must be resected to prevent poorly camouflaged scars, muscle deficiency, and macrostomia. Bone grafting should be undertaken at an early age using calvarial bone. Late operations will be necessary for correction of medial and lateral canthal position, epiphora, lower eyelid skin deficiency, and further bony augmentation.

Visual outcomes following lensectomy and vitrectomy for combined anterior and posterior persistent hyperplastic primary vitreous

OBJECTIVE

To determine the visual outcome after surgery for persistent hyperplastic primary vitreous using modern vitreoretinal techniques.

DESIGN

Retrospective medical record review during a 5-year period (June 1992 to June 1997). Information recorded for each patient included age, medical history, sex, results of preoperative ocular examination, age at diagnosis, procedure performed, intraoperative and postoperative complications, location and number of sclerotomy sites, type of aphakic rehabilitation, amblyopic therapy given, final visual acuity, and length of follow-up.

RESULTS

Fourteen patients who underwent surgical management of combined anterior and posterior persistent hyperplastic primary vitreous were identified. Eleven patients underwent aphakic rehabilitation and aggressive amblyopic therapy consisting of occlusive therapy for several waking hours each day. One additional older patient received aphakic rehabilitation only. Ten eyes (71%) achieved a visual acuity of 20/300 or better, and 8 (57%) obtained a final visual acuity of 20/100 or better. Average length of follow-up was 22 months (range, 4-57 months). Nine patients were fitted with an aphakic soft contact lens, 2 older patients had a posterior chamber intraocular lens placed at the time of vitrectomy, and 1 patient wore aphakic spectacles.

CONCLUSIONS

With modern vitreoretinal techniques, aphakic rehabilitation, and aggressive amblyopic therapy, useful vision can be obtained in the majority of patients with combined anterior and posterior persistent hyperplastic primary vitreous.

Optical coherence tomography in optic pit maculopathy managed with vitrectomy-laser-gas

BACKGROUND

Optic disc pit (ODP) maculopathy has a poor visual prognosis if left to its natural course. Several therapeutic approaches have been attempted. The cases of 11 patients evaluated with optical coherence tomography (OCT) and treated with vitrectomy-laser-gas and their functional and anatomical outcomes are presented.

METHODS

Retrospective interventional consecutive case series, including 11 eyes with ODP maculopathy. Pre- and postoperative best-corrected visual acuity (BCVA), OCT and angiography were recorded. All patients underwent pars plana vitrectomy, posterior hyaloid dissection peripapillary diode laser prior to retinal reapplication and C(3)F(8) 15% injection.

RESULTS

Mean preoperative BCVA was 20/126. Median preoperative BCVA was 1.0 LogMAR (range 1.3-0.4) . Eighty-two per cent of patients gained 2 or more Snellen lines of vision (mean 4.4 lines gained). Mean final BCVA was 20/32, and median final BCVA was 20/30 in Snellen VA and 0.2 in LogMAR (range 0.7-0) Preoperative OCT in all but one case confirmed the bilaminar structure of the macular detachment. Postoperative OCT helped in monitoring reabsorption of the macular detachment, which was achieved in all cases after an average of 6.5 months post-surgery. BCVA increased progressively as the subretinal fluid was reabsorbed (P=0.006). Mean duration of postoperative follow-up was 15 months. Recurrence was observed in two cases.

CONCLUSIONS

In our series, the vitrectomy-laser-gas procedure for ODP maculopathy improved vision and achieved satisfactory anatomic results in all 11 cases. OCT was useful in the diagnosis and follow-up of this pathology. However, the low incidence of this entity makes it difficult to obtain series large enough to determine the efficacy of the vitrectomy-laser-gas procedure and other treatment modalities and be able to suggest a procedure of choice.

Unilateral persistent hyperplastic primary vitreous: course and outcome

PURPOSE

Improved surgical techniques enable more favorable results in the management of persistent hyperplastic primary vitreous (PHPV). The purpose of our study was to evaluate the outcome of PHPV eyes managed conservatively or after surgery (with or without intraocular lens implantation).

METHODS

A total of 89 children (37 boys, 52 girls) with PHPV in one eye (mean follow-up of 6.3 +/- 5.7 years) were included. The children were subgrouped according to treatment modality. Twenty-eight (31.5%) children were managed conservatively (nonoperated). Cataract extraction combined with vitrectomy and removal of embryonic remnants was carried out in 61 eyes (68.5%). Intraocular lenses were implanted in 30 of the operated eyes (pseudophakic) and 31 eyes remained without lens (aphakic).

RESULTS

Final evaluated visual acuity in the entire group was 6/15 or better in 12.6% (11 of 87) of the eyes. A total of 11.5% (10 of 87) had a visual acuity of 6/21 to 6/60, 46.0% (40 of 87) obtained 6/90 to light perception and 26 of 87 (29.9%) had no light perception in the involved eye. The rate of no light perception was significantly lower in patients with pseudophakia (10.0%) compared to those with aphakia (43.3%) or nonoperated (37.0%) eyes (P =.009). Intraocular pressure was adequately assessed repeatedly in 72 eyes. High intraocular pressure and glaucomatous changes were observed in 7 of 31 (22.6%) patients with aphakia, 2 of 24(8.3%) patients with pseudophakia and in 2 of 17(11.8%) nonoperated eyes (P =.34). Poor cosmetic outcome was seen in 12 of 31 (38.7%) children with aphakic eyes and 5 of 30 (16.7%) children with pseudophakic eyes (P =.08). Prosthesis or cosmetic shells were needed for 8 of 31 patients with aphakia, for none of the patients with pseudophakia and for 2 of 28 of the nonoperated children (P =.003).

CONCLUSION

PHPV eyes have a potential for developing useful vision with favorable cosmetic outcome after surgery. Intraocular lens implantation may be a favorable and beneficial option for the management of children with unilateral PHPV.

Anomalous orbital structures resulting in unusual strabismus

Anomalous orbital structures are a rare cause of strabismus. These structures attach to the globe and produce a mechanical restriction, resulting in incommitant motility disorders. Three types of anomalous structures have been described. The first arise from the extraocular muscles themselves and insert in abnormal locations. The second are fibrous bands located beneath the rectus muscles. The third are discrete anomalous muscles that originate in the posterior orbit and insert in abnormal locations on the globe. These structures have been associated with unusual patterns of strabismus. Clinical findings that suggest the presence of anomalous orbital structures include globe retraction not associated with Duane retraction syndrome, very large vertical strabismus, and an elevation deficit that is worse in abduction. When looking for anomalous orbital structures in patients with atypical strabismus, imaging studies should be considered.

Visual acuity outcomes with and without surgery in patients with persistent fetal vasculature

PURPOSE

To investigate visual acuity outcomes in patients with persistent fetal vasculature (PFV) left untreated or treated with vitreoretinal surgical techniques and to investigate clinical features associated with prognosis.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

All patients with PFV examined at the Bascom Palmer Eye Institute from January 1, 1983 through December 31, 1998.

INTERVENTION

All patients in the study had unilateral PFV. Of 42 PFV patients identified, 30 patients underwent vitreoretinal surgery. Indications for surgery included media opacity (e.g., cataract), vitreoretinal traction, and retinal detachment.

MAIN OUTCOME MEASURES

Final best postoperative visual acuity, prognostic ocular clinical features, and surgical complications.

RESULTS

In the surgical group of patients, median age at diagnosis was 8 weeks, and median length of follow-up was 32 months, with all patients having at least 1 year of follow-up. Two patients had clinical and echographic findings consistent with anterior PFV, 2 patients had strictly posterior PFV, and the remaining 26 patients had components of both anterior and posterior PFV. Fourteen eyes (47%) achieved a final visual acuity of 20/400 or better at last follow-up. Risk factors for a poor visual acuity outcome (<20/400) included microphthalmia (28% of patients with microphthalmia versus 67% of patients with normal axial length achieved a final vision of 20/400 or better; P = 0.061) and preoperative retinal detachment or retinal or optic nerve abnormalities, or both, such as hypoplasia, folds, or indistinct macula with hypopigmentation (25% of patients with any of these anomalies versus 61 % of patients without these findings achieved a final vision of 20/400 or better; P = 0.072). After surgery, retinal detachment developed in three eyes, chronic hypotony in two other eyes, and neovascular glaucoma in one eye. In the nonsurgical group there were 6 male and 6 female patients. Two patients with posterior PFV had minimal disease and were not considered surgical candidates, whereas 10 patients with combined anterior and posterior PFV had advanced pathologic features, and it was believed that surgery would not offer significant visual improvement; median age at diagnosis was 9.5 months, and median length of follow-up was 36 months, with all patients having at least 1 year of follow-up. At last follow-up, 3 eyes (25%) had a final visual acuity of 20/400 or better. During follow-up, retinal detachment developed in 2 eyes and chronic hypotony in an additional 2 eyes.

CONCLUSIONS

The current study indicates that approximately 50% of patients undergoing surgery for PFV will achieve useful vision. Visual acuity outcomes in patients with PFV are correlated with the nature and extent of ocular risk factors. Some patients may not be candidates for surgery because of either minimal changes or advanced disease that limit the potential of visual improvement.

Optical coherence tomography in optic disk pit maculopathy treated by the macular buckling procedure

PURPOSE

To report optical coherence tomography in optic disk pit maculopathy treated with macular scleral buckling procedure.

METHODS

Twenty six eyes (26 patients) with optic disk pit maculopathy were treated with macular buckling procedure and evaluated with optical coherence tomography. In group 1, five eyes were evaluated with optical coherence tomography before and after macular buckling procedure. In group 2, 21 eyes were evaluated with optical coherence tomography after macular buckling procedure. With optical coherence tomography, cross-sectional, horizontal retinal images were obtained through the fovea and optic disk pit.

RESULTS

In group 1, four of five eyes showed absorption of intraretinal fluid 7 to 9 months after macular buckling procedure. After absorption of fluid, retinal thickness in the foveal center ranged from 128 to 178 microm. In one eye the channel from optic disk to fovea reopened and fluid reappeared. In group 2, 20 of 21 eyes showed absorption of intraretinal schisis and subretinal fluid after macular buckling procedure. After absorption of fluid, retinal thickness in the foveal center ranged from 119 to 216 microm.

CONCLUSIONS

In optic disk pit maculopathy, optical coherence tomography enabled morphologic assessment of the retina before and after macular buckling procedure. In the successfully treated cases the permanent closure of the connection between the optic disk pit and the intraretinal schisis was demonstrated. Eventual disappearance of schisis and subretinal fluid was depicted. It was also proved that the thickness of the macula returned to normal and visual acuity improved.

Epibulbar complex choristoma associated with nevus sebaceus

We encountered an infant with nevus sebaceus of Jadassohn who was born with a striking pedunculated mass on the superotemporal aspect of the anterior sclera and limbus of the left eye. In addition, two small choroidal colobomas were seen in the papillomacular bundle area of the same eye. Histopathologic examination of the excised mass revealed a mixture of ectodermal and mesodermal elements, including cartilage and bone. These findings led to the rare diagnosis of epibulbar complex choristoma.

Computed tomography of the lacrimal drainage system: retrospective study of 107 cases of dacryostenosis

PURPOSE

To evaluate the role of computed tomography in patients with dacryostenosis.

METHODS

One hundred seven cases of dacryostenosis (94 patients) were assessed by thorough clinical and lacrimal history and examination, and lacrimal region computerized tomography (CT). The lacrimal drainage system examination included the state and position of the puncta; Jones testing; lacrimal syringing; and, in the latter half of the study, telescopic nasal endoscopy. The patients were drawn from the hospital outpatients and private office of the operating lacrimal surgeon in this series (I.C.F.). Of the 107 cases, 79 either underwent dacryocystorhinostomy surgery or had this planned.

RESULTS

In 14 of the 107 cases (12 patients), preoperative CT led to an alteration of patient management, usually referral to an otolaryngologist for further evaluation or treatment. In addition to the detection of two tumors extrinsic to the sac, conditions such as ethmoiditis, lacrimal sac mucoceles, soft tissue opacity in the nasolacrimal duct, gross nasal polyposis, fungal sinusitis, and a dacryolith were observed by CT.

CONCLUSION

Similar to the role of functional endoscopic sinus surgery in otolaryngology, CT imaging will become increasingly important in the assessment of many patients with symptoms of lacrimal drainage obstruction.

Ten-year follow-up of excimer laser surface ablation for myopia in thin corneas

PURPOSE

To evaluate the long-term outcomes of excimer laser surface ablation performed on thin corneas.

DESIGN

Retrospective study.

METHODS

We included in the study 75 eyes (49 patients) with a preoperative central corneal thickness (CCT) thinner than 500 mum that had undergone surface ablation to correct their myopia and that had at least 10 years of follow-up. We evaluated the stability of visual acuity (VA) and refraction, the predictability, corneal keratometry, safety, efficacy, and postoperative complications at the examinations 3 months and 1, 2, 5, and 10 years after surgery.

RESULTS

Preoperative CCT was 481.54 +/- 15.7 microm (range, 438 to 499 microm). Preoperative spherical equivalent was -6.12 +/- 2.67 diopters (D) (range, -2 to -14 D). The best spectacle-corrected VA significantly improved (P < .01) during the follow-up. The uncorrected VA showed significant improvement in all visits when compared with the 3-month postoperative visit. Both the sphere and cylinder showed a slight but significant regression (P < .01) only in the comparison between 3 months and 10 years after the surgery. Ten years after the surgery, 30 eyes (40%) were within 0.50 D and 43 eyes (57.33%) were within 1.00 D of emmetropia. The safety index improved over the 10 year period and was always higher than 0.9. The efficacy index remained stable around 0.8. The topography did not show signs of corneal ectasia and the keratometry showed no increase in corneal power. Thirty eyes (40%) needed enhancement.

CONCLUSION

Surface ablation seems to be safe and effective to correct myopia in corneas thinner than 500 microm, with stable visual and refractive outcomes in a 10-year follow-up.

Surgical management of glaucoma in infants and children with Peters' anomaly

OBJECTIVE

To determine the long-term outcome of surgery for congenital glaucoma in infants and children with Peters' anomaly.

DESIGN

Retrospective review of a consecutive interventional case series.

SETTING

An urban academic tertiary referral institution.

PARTICIPANTS

Thirty-four eyes of 19 children are subjects of this report. Included are all children 12 years of age or younger with Peters' anomaly who underwent surgery for primary congenital glaucoma between January 1971 and December 1992 and completed a minimum of 3 years of follow-up from the date of the first glaucoma surgery.

INTERVENTION

The surgical procedures performed were trabeculectomy, trabeculotomy, goniotomy, Molteno shunt implantation, cyclodialysis, and cyclocryotherapy.

MAIN OUTCOME MEASURES

Primary outcome measures were intraocular pressure (IOP) control and final postoperative visual acuity. Intraocular pressure control was defined as complete success (IOP</=21 mmHg without antiglaucoma medication), qualified success (IOP</=21 mmHg with antiglaucoma mediation), or failure (IOP>21 mmHg with or without antiglaucoma medication, inoperable retinal detachment, phthisis, or chronic hypotony, defined as an IOP of </=6 mmHg).

RESULTS

A total of 126 glaucoma procedures were performed on 34 eyes of 19 patients. The median age at time of first glaucoma surgery was 2.1 months (range, 2 days to 8.5 years). The median follow-up was 11.0 years (range, 3.2 to 22.8 years) from the time of first glaucoma surgery. Intraocular pressure control with or without antiglaucoma medication was achieved in 11 eyes (32%) after 1 or more surgical procedures. Major postoperative complications included graft failure in 26 eyes (76%), cataract in 6 eyes (18%), inoperable retinal detachment with phthisis in 12 eyes (35%), and phthisis alone in 6 eyes (18%). Final vision was 20/200 or better in 3 eyes (9%), 20/400 to hand motion in 12 eyes (35%), light perception in 7 eyes (21%), and no light perception in 12 eyes (35%).

CONCLUSIONS

Glaucoma surgery, combined with medical therapy, may result in adequate, long-term IOP control in 32% of eyes with glaucoma associated with Peters' anomaly. Visual results are poor due to uncontrolled glaucoma, amblyopia, neurologic impairment, and other anterior and posterior segment anomalies that may accompany Peters' anomaly. Postoperative complications, including graft failure, cataract, inoperable retinal detachment, and phthisis, also contribute to decreased visual acuity.

Nasolacrimal outflow drainage anomalies in Down's syndrome

PURPOSE

To describe structural abnormalities of the lacrimal drainage system and outcomes after treatment for lacrimal outflow obstruction in children with Down's syndrome.

DESIGN

Retrospective comparative interventional case series.

PARTICIPANTS

Thirty-eight eyes of 22 consecutive Down's syndrome patients who underwent surgical treatment for nasolacrimal drainage obstruction (mean age, 32 months) and 59 eyes of 44 non-Down's syndrome patients who underwent surgical treatment after 2 years of age.

MAIN OUTCOME MEASURES

Resolution of symptoms after surgery and presence of anatomic abnormalities of the lacrimal drainage system other than persistent Hasner's membrane.

RESULTS

Among the Down's syndrome eyes, complete or partial resolution was noted in 34 (89%) of 38 eyes; 7 (18%) eyes underwent more than 1 procedure. Twenty-eight (74%) of 38 eyes had anatomic anomalies other than persistent Hasner's membrane; anomalies proximal to the nasolacrimal sac predominated. In comparison, 50 (85%) non-Down's syndrome eyes experienced complete or partial resolution, and 19 (32%) had anatomic abnormalities other than persistent Hasner's membrane; anomalies distal to the nasolacrimal sac predominated.

CONCLUSIONS

Compared with older non-Down's syndrome patients, nasolacrimal outflow obstruction in Down's syndrome patients is more often complicated by anomalies of the lacrimal drainage system proximal to the lacrimal sac. Despite this, surgery can be similarly successful. Awareness of the possible peculiarities of lacrimal outflow obstruction in Down's syndrome patients may allow better selection and use of available treatment options.

Optical Coherence Tomography Before and After Vitrectomy with Internal Limiting Membrane Removal in a Child with Optic Disc Pit Maculopathy

BACKGROUND

The pathogenesis of optic disc pit maculopathy is still unknown, although recent optical coherence tomographic (OCT) analyses have made a great contribution to clarifying its morphological appearance. The best treatment for this disease is also controversial.

CASE

We report on a 7-year-old girl with optic disc pit maculopathy associated with a separation of the internal limiting membrane (ILM) near the optic disc.

OBSERVATIONS

The OCT images before treatment showed a conduit from the perineural space to the schisislike separation of the sensory retina with a dome-shaped separation of the ILM. A serous detachment (SD) in the macula, centered on the fovea, was also present. In OCT images after laser photocoagulation, the conduit appeared to be closed, but the SD was still present. Vitrectomy with ILM removal and gas tamponade resulted in a marked reduction of the SD in the macular area. Focal macular electroretinograms and visual acuity demonstrated a recovery of macular function.

CONCLUSION

The dome-shaped separation of the ILM suggested that the vitreous might be exerting a tractional force on the optic disc pit, and vitrectomy with ILM peeling released the traction on the optic disc pit.

Surgical treatment of advanced chronic angle closure glaucoma in Weill-Marchesani syndrome

PURPOSE

To describe the surgical treatment of advanced chronic angle closure glaucoma in Weill-Marchesani syndrome.

PATIENTS AND METHODS

Two children with Weill-Marchesani syndrome (4 eyes) undergoing lensectomy, anterior vitrectomy, and sutured intraocular lens (IOL) and Molteno tube shunt surgery at Wills Eye Hospital were prospectively studied. Visual acuity and intraocular pressure (IOP) were recorded.

RESULTS

Both patients presented with increasing myopia and advanced glaucomatous damage. Laser iridotomy was ineffective in deepening the anterior chamber. The first patient developed a flat anterior chamber after trabeculectomy. At the 12-month follow-up visit, all 4 eyes had an important decrease in IOP and cupping after combined lensectomy, anterior vitrectomy, and sutured IOL and Molteno tube shunt placement. One eye had a transitory postoperative choroidal effusion and retinal detachment that resolved spontaneously.

CONCLUSIONS

Advanced chronic angle closure glaucoma in Weill-Marchesani syndrome may be treated with a combination of lensectomy, anterior vitrectomy, and sutured IOL and Molteno tube shunt surgery. In early cases, prophylactic peripheral iridotomies should be stressed.

Peters' anomaly. A synopsis of surgical management and visual outcome

Peters' anomaly is not an isolated anterior segment abnormality, but occurs as a diverse, phenotypically heterogeneous condition associated with multiple underlying ocular and systemic defects. Surgical treatment of Peters' anomaly is a complex and challenging undertaking. The broad spectrum of disease severity, the lack of uniformity in clinical features, the differences and overlap of preoperative risk factors, and the variability in the numbers and types of intraocular procedures that are performed on individual eyes, as well as postoperative complications all contribute to the difficulties involved in surgical management. This article discloses useful information pertaining to keratoplasty for Peters' anomaly. The study by Yang et al showed that long-term graft clarity could be achieved in 36% of eyes. However, 93% of all clear grafts were first grafts, whereas only 7% were second grafts. All third or subsequent grafts failed. Other important findings were: (1) the significantly greater chance of maintaining a clear graft with initial grafts, compared with subsequent grafts; (2) the disclosure of periods of differential risk for graft failure; and (3) the identification of risk factors for graft failure. Surgical intervention involving one or more procedures is effective in controlling IOP in 32% of eyes with associated congenital glaucoma. Still, multiple procedures and adjunctive medical therapy are often required to achieve and maintain adequate IOP control. The visual outcome is guarded in children with Peters' anomaly. Achieving a satisfactory visual outcome and preventing further visual loss is impeded by the presence of congenital anterior and posterior segment anomalies, structural defects of the CNS, cognitive dysfunction and amblyopia, as well as postoperative complications such as graft failure, cataract, inoperable retinal detachment, and phthisis.

Diagnosis and management of congenital cataract with preexisting posterior capsule defect

PURPOSE

To establish and evaluate the diagnostic signs, intraoperative performance, and postoperative outcomes in children with congenital cataract with a preexisting posterior capsule defect (PCD).

SETTING

Iladevi Cataract & IOL Research Centre, Ahmedabad, India.

METHODS

This study evaluated 400 consecutive eyes that had congenital cataract surgery, of which 27 (20 children) had a confirmed preexisting PCD. Seven children had bilateral defects. The preoperative diagnostic signs of PCD under maximum pupil dilation included well-demarcated, thick defect margins; white dots on the posterior capsule; and white dots in the anterior vitreous that moved with the degenerated vitreous like a fish tail (fish-tail sign). Hydrodissection was not attempted. Bimanual irrigation/aspiration and 2-port anterior vitrectomy were performed. The mean follow-up was 17.9 months +/- 16.96 (SD).

RESULTS

The mean age of the 16 boys and 4 girls with a PCD was 21.98 +/- 33.33 months. Nineteen eyes (70.3%) had total white mature cataract. In 7 eyes (25.92%), the preexisting PCD was converted into a posterior capsulorhexis. Twenty eyes (74.07%) had an AcrySof MA30BA intraocular lens (IOL) implanted in the bag and 4 eyes (14.81%), in the sulcus. Three eyes (11.11%) were left aphakic. The visual axis remained clear in all eyes, and the IOL was well centered in 24 eyes (88.88%).

CONCLUSION

Establishing the diagnostic signs of PCD with the eye fully dilated and carefully planning the surgery produced satisfactory technical and visual outcomes.

Bilateral congenital corneal keloids and anterior segment mesenchymal dysgenesis in a case of Rubinstein-Taybi syndrome

PURPOSE

To report the unusual association of bilateral corneal keloids and anterior segment mesenchymal dysgenesis in a child with Rubinstein-Taybi syndrome.

METHODS

Case report of a 2-year-old boy.

RESULTS

Excision of the epicorneal mass in the right eye was followed by recurrence of the lesion. Multiple penetrating keratoplasties were unsuccessful in reconstructing the anterior segment because of recurrent corneal epithelial breakdown, suggesting limbal stem cell insufficiency. Histopathology and electron microscopy of the excised mass lesion showed features typical of a corneal keloid: thickened keratinized epithelium, absent Bowman's layer, and fibrovascular hyperplasia, with haphazard orientation of the collagen lamellae. Ultrasound biomicroscopy and intraoperative findings suggested a diagnosis of Peter anomaly, but genetic analysis did not show a PAX6 mutation.

CONCLUSION

The findings in our patient add to the spectrum of ocular changes described in Rubinstein-Taybi syndrome and confirm earlier reports of poor ocular prognosis in corneal keloids and Rubinstein-Taybi syndrome.

Unusual posterior hyaloid strand in a young child with optic disc pit maculopathy: intraoperative and histopathological findings

BACKGROUND

The mechanism responsible for optic disc pit maculopathy is unclear, but abnormal vitreous structures, including the anomalous Cloquet's canal at the optic disc pit, have been suggested as important factors.

CASE

We report the intraoperative and ultrastructural findings of an unusual posterior vitreous strand in the eye of an 8-year-old girl with optic disc pit maculopathy.

OBSERVATIONS

The patient presented with decreased vision in the left eye. Examination of the left eye revealed a best-corrected visual acuity (VA) of 0.08 and a macular detachment associated with an optic disc pit. Vitrectomy was performed with the adjunctive use of triamcinolone acetonide intraoperatively. The presence of an unusual posterior hyaloid strand tightly attached to the margin of the optic disc pit was noted. An unusual movement of this strand was observed during the surgery. The strand was excised, and fluid-gas exchange was performed using gas tamponade with 20% SF(6). After 12 months, a complete macular reattachment was obtained, with the VA improving to 1.2. Electron microscopic examination of the removed strand revealed abundant thick collagen fibrils with a frame of fine fibrils.

CONCLUSION

The unusual posterior vitreous strand connected to the optic disc pit may have contributed to the pathogenesis of maculopathy in this young child.

Multicenter study of pars plana vitrectomy for optic disc pit maculopathy: MACPIT study

PurposeTo evaluate surgical intervention with pars plana vitrectomy (PPV) for correction of optic disc pit maculopathy (ODP-M).Patients and methodsRetrospective chart review from 13 centres of 51 eyes of 50 patients with ODP-M who underwent PPV between 2002-2014. Anatomic and final best-corrected visual acuity (BCVA) outcomes were evaluated for all cases with different adjuvant techniques.ResultsThere were 23 males and 27 females with median age 25.5 (6-68) years. Preoperative median foveal thickness was 694.5 (331-1384) μm and improved to 252.5 (153-1405) μm. Median BCVA improved from 20/200 (20/20000 to 20/40) to 20/40 (20/2000 to 20/20) with 20/40 or better in 31 eyes. Complete retinal reattachment was achieved in 44 eyes (86.3%) at 7.1 (5.9) months. The good surgical outcomes were achieved in different adjuvant groups. Median follow-up was 24 (6 to 120) months.ConclusionsThese results confirm the long-term effectiveness of PPV for ODP-M. Prospective studies are needed to determine the effectiveness of any adjuvant technique in improving the success of PPV for ODP-M.