Journal of AAPOS

There's more to ROP than ROP

Alistair R. Fielder — 2013-04-01

See accompanying articles on pages 124 and 129. The infant born preterm is at risk of developing a number of ophthalmic problems, not just in the eye but along the entire visual pathway and even beyond. Some are the result solely of being born too soon, whereas others are complications of prematurity and its management. Finally, there are those ophthalmic problems that are generated by these complications or their management. Teasing out the relative contributions made by each of these to an individual child in the clinic can be difficult and sometimes impossible. Recently, investigators from the Early Treatment for Retinopathy of Prematurity (ETROP) study have reported on such diverse topics as cataract, myopia, retinopathy of prematurity (ROP), nystagmus, cerebral vision impairment, glaucoma, and strabismus.

Progression of myopia and high myopia in the Early Treatment for Retinopathy of Prematurity Study: Findings at 4 to 6 years of age

2013-04-01

Purpose: To report the prevalence of myopia and high myopia in children <6 years of age born preterm with birth weights <1251 g who developed high-risk prethreshold retinopathy of prematurity and who participated in the Early Treatment for Retinopathy of Prematurity trial.Methods: Surviving children from the cohort of 401 participants who had developed high-risk prethreshold ROP in one or both eyes underwent cycloplegic retinoscopy at 6 and 9 months corrected age and yearly between 2 and 6 years postnatal age. Eyes were randomized to receive treatment at high-risk prethreshold ROP or conventional management with treatment only if threshold ROP developed. Myopia (spherical equivalent ≥0.25 D) or high myopia (≥5.00 D) in eyes at 4-, 5-, and 6-year examinations was reported.Results: At ages 4, 5, and 6 years, there was no difference in the percentage of eyes with myopia (range, 64.8%-69.9%) and eyes with high myopia (range, 35.3%-39.4%) between earlier treated and conventionally managed eyes.Conclusions: Approximately two-thirds of eyes with high-risk prethreshold ROP during the neonatal period are likely to be myopic into the preschool and early school years. In addition, the increase in the proportion of eyes with high myopia that had been observed in both earlier-treated and conventionally managed eyes between ages 6 months and 3 years does not continue between ages 3 and 6 years.

Clinical characteristics of children with severe visual impairment but favorable retinal structural outcomes from the Early Treatment for Retinopathy of Prematurity (ETROP) study

2013-03-25

Purpose: To describe visual function and associated characteristics at the 6-year examination in children enrolled in the Early Treatment for Retinopathy of Prematurity Study who had unfavorable visual outcomes despite favorable structural outcomes in one or both eyes.Methods: The clinical examination records of children completing the 6-year follow-up examination were retrospectively reviewed. Eligible subjects were those with visual acuity of ≤20/200 in each eye (where recordable) and a normal fundus or straightening of the temporal retinal vessels with or without macular ectopia in at least one eye. Data regarding visual function, retinal structure, presence of nystagmus, optic atrophy, optic disk cupping, seizures/shunts, and Functional Independence Measure for Children (ie, WeeFIM: pediatric functional independence measure) developmental test scores were reviewed.Results: Of 342 participants who completed the 6-year examination, 39 (11%) met inclusion criteria. Of these, 29 (74%) had normal retinal structure, 18 (46%) had optic atrophy, and 3 (8%) had increased cupping of the optic disk in at least one eye. Latent and/or manifest nystagmus occurred in 30 children (77%). The presence of nystagmus was not related to the presence of optic atrophy. Of the 39 children, 28 (72%) had a below-normal WeeFIM score.Conclusions: In 25 participants (7%) completing the 6-year examination, cortical visual impairment was considered the primary cause of visual loss. The remainder likely had components of both anterior and posterior visual pathway disease. Clinical synthesis of ocular anatomy and visual and neurologic function is required to determine the etiology of poor vision in these children.

An Eye on the Arts

2013-04-01

In truth, Dear Reader, it was as if one eye were watching the play for the first time. The headache that was always with me had settled, as was its wont, behind my right eye with such intensity that I expected the back of my eyeball to hiss the way a pitcher of good grog does when the boy thrusts in a white-hot rod to heat it. I could also feel the pressure of the scarab there. Sometimes I believed that it burrowed forward precisely so that it could peer out through one of my eyes.

Comparison of fentanyl and morphine in laser surgery for retinopathy of prematurity

Faruk H. Örge, Tamara J. Lee, Michele Walsh, Kimberly Gordon — 2013-04-01

Purpose: To compare complication rates of the analgesics fentanyl and morphine in preterm infants undergoing laser therapy for retinopathy of prematurity (ROP).Methods: In this observational study, the medical records of consecutive preterm neonates undergoing laser treatment of ROP from June 2007 through September 2010 were retrospectively reviewed. Because a fentanyl-based infusion protocol was initiated in November 2009, there was approximately the same number of treatment sessions with morphine and with fentanyl. In both groups, midazolam was used additionally on a case-by-case basis. Analgesia type, complications, and vital signs were documented at 5-minute intervals for all surgeries. The primary outcome was change in ventilation status. Secondary complications included change in temperature and incidence of apneic, bradycardic, and desaturation events.Results: A total of 35 patients were included, with 17 in the morphine group (mean gestational age, 24.8 weeks; mean birth weight, 661 g) and 18 in the fentanyl group (mean gestational age, 24.4 weeks; mean birth weight, 681 g). Overall worsening of ventilation status was noted in 29% of patients in the morphine group and 6% of patients in the fentanyl group (P = 0.08; 95% confidence interval, −2% to 48%). Temperature instability (outside of 36.5° to 37.4°C range) was noted in 6% of patients in the morphine group and no patients in the fentanyl group. Apneic events were 3.2 times more common and bradycardic events 1.5 times more common in the morphine group.Conclusions: We found no difference in safety parameters for fentanyl infusion or morphine for analgesia in preterm infants undergoing ROP laser therapy in the neonatal intensive care unit setting. Although estimates of complication rates suggest that fentanyl may be safer, further study is needed to confirm this premise.

First Person

2013-04-01

My first patient yesterday is a now high school senior, a lovely young lady with von Hippel-Lindau disease whom I have cared for since she was about 5 years old. She and I and her family have become friends over the years as we worked through the systemic complexities of her disease and the enucleation of her right eye. Back for an annual check-up yesterday, she is preparing for college and sought my advice about her future career, the directions of her education, and a future occupation. I explained the many twists in my career, including at least four changes of specialty during my medical school education. I encouraged her to start with as diverse a basic plan as possible, reminding her that many things that she thinks that she likes may fade, and other things that don't seem appealing at first may turn into real interests. As she and her Mom left the examination room, I reminded them of my father's aphorism: “If you are good at something, keep doing it!” “Oh”, replied her Mom, “please don't say that, Dr. Lewis. She's very good at whining!”

The challenges to ophthalmologic follow-up care in at-risk pediatric populations

2013-04-01

Purpose: To identify barriers to ophthalmological follow-up in high-risk children who are identified by vision screening and eye examination.Methods: The records of patients identified as needing follow-up through two free eye care programs (organized optometric and ophthalmologic screening sessions aimed at identifying and treating ocular pathology) targeted toward inner-city youths of low socioeconomic status were reviewed. Parents were contacted by phone, and a questionnaire on barriers to follow-up was administered. Callers attempted to schedule appointments at that time. Data were assessed by means of descriptive analysis.Results: Of 93 patients, 54 (58%), were successfully contacted. Of these, 23 (25%) were eventually scheduled. Five (5%) patients elected follow-up elsewhere. Twenty (22%) with working phones were still unable to be scheduled. Additional obstacles included families' lack of awareness of the need for follow-up (13%), assumption by families that they would be contacted (5%), scheduling conflicts (4%), concerns about insurance, and difficulty finalizing referrals (2%). A total of 39 patients (42%) were not successfully contacted because of inoperable phone services, and none of the families responded to the mailed questionnaire.Conclusions: Inability to contact families was the greatest barrier to follow-up. Our findings suggest that immediate arrangement of follow-up care, on-site visual assessment, and a program director may be useful in increasing follow-up for high-risk children.

Intraobserver reliability of contact pachymetry in children

2013-04-01

Background: Central corneal thickness (CCT) is an important measurement in the treatment and management of pediatric glaucoma and potentially of refractive error, but data regarding reliability of CCT measurement in children are limited. The purpose of this study was to evaluate the reliability of CCT measurement with the use of handheld contact pachymetry in children.Methods: We conducted a multicenter intraobserver test–retest reliability study of more than 3,400 healthy eyes in children aged from newborn to 17 years by using a handheld contact pachymeter (Pachmate DGH55; DGH Technology Inc, Exton, PA) in 2 clinical settings—with the use of topical anesthesia in the office and with the patient under general anesthesia in a surgical facility.Results: The overall standard error of measurement, including only measurements with standard deviation ≤5 μm, was 8 μm; the corresponding coefficient of repeatability, or limits within which 95% of test–retest differences fell, was ±22.3 μm. However, standard error of measurement increased as CCT increased, from 6.8 μm for CCT less than 525 μm, to 12.9 μm for CCT 625 μm and greater. The standard error of measurement including measurements with standard deviation >5 μm was 10.5 μm. Age, sex, race/ethnicity group, and examination setting did not influence the magnitude of test–retest differences.Conclusions: CCT measurement reliability in children via the Pachmate DGH55 handheld contact pachymeter is similar to that reported for adults. Because thicker CCT measurements are less reliable than thinner measurements, a second measure may be helpful when the first exceeds 575 μm. Reliability is also improved by disregarding measurements with instrument-reported standard deviations >5 μm.

Corneal thickness measured by Scheimpflug imaging in children with Down syndrome

2013-03-25

Purpose: To measure corneal thickness via the use of a Scheimpflug imaging system (OCULUS Optikgeräte GmbH, Wetzlar, Germany) in children with Down syndrome.Methods: This prospective, nonrandomized, clinical trial included children with Down syndrome and age- and sex-matched healthy controls. All subjects received a complete ophthalmologic examination. Corneal topography measurements were acquired by means of Scheimpflug imaging. Central corneal thickness (CCT), thinnest point of cornea (TP), and corneal volume (CV) were analyzed.Results: A total of 27 children with Down syndrome and 37 control subjects were included in the study. In children with Down syndrome, the mean CCT was 494.27 ± 47 μm, the mean TP was 487 ± 49 μm, and the mean CV was 56.2 ± 6. In the controls, the mean CCT was 539.3 ± 40 μm, the mean TP was 538.0 ± 40.8 μm, and the mean CV was 61.3 ± 4. For all 3 parameters, the difference was statistically significant (P < 0.001). In the Down syndrome group, the CCT was <500 μm in 16 subjects (59.2%) and <450 μm in 5 (18.5%). In the control group, the CCT was <500 μm in 14 subjects (37.8%) and <450 μm in 2 (5.4%).Conclusions: In this study, corneal thickness was less in children with Down syndrome than in healthy control subjects. Decreased corneal thickness may be an early sign of a degenerative corneal disease such as keratoconus in children with Down syndrome.

An Eye on the Arts

2013-04-01

Abd al-Karim didn't remember how he lost his left eye. He got used to living with only one eye, to seeing everything, without ever feeling that his left eye was blind. His aunt said his eye bled when he was forty days old. The mother died, and blood gushed from the baby's eye. His aunt took him to Sheikh Ibrahim, the village doctor who squeezed an herbal mixture into his eye, but it never got better. It became inflamed and covered with black spots. She took him to a Bedouin who was known for treating incurable cases. He said the eye should be cauterized and so he heated a nail, cauterized it, and blinded it.

Reanalysis of refractive growth in pediatric pseudophakia and aphakia

Susan Whitmer, Aurora Xu, Scott McClatchey — 2013-03-25

Background: The current model of refractive growth in children (RRG2) is calculated as the slope of aphakic refraction at the spectacle plane versus the logarithm of adjusted age. However, this model fails in infants because of the optical effect of vertex distance of a spectacle lens on the effective power at the cornea. In this study, we developed a new model of refractive growth (RRG3) that eliminates the optical effect of vertex distance on the RRG2 model.Methods: We calculated RRG3 values for pseudophakic and aphakic eyes previously analyzed for RRG2. Inclusion criteria were age ≤10 years at the time of cataract surgery and follow-up time between measured refractions of at least 3.6 years and at least the age at first refraction plus 0.6 years. For both pseudophakic and aphakic eyes, we compared RRG3 values in children who had cataract surgery before age 6 months with those in children aged 6 months or older.Results: A total of 78 pseudophakic and 70 aphakic eyes met the inclusion criteria. Ages at surgery ranged from 0.25 to 9 years, with a 9.5-year mean follow-up time. The mean RRG3 value was not significantly different between the surgical age groups for both pseudophakic eyes (P = 0.053) and aphakic eyes (P = 0.59).Conclusions: The RRG3 values were not significantly different between the surgical age groups for both pseudophakic and aphakic eyes. Consequently, RRG3 is theoretically applicable even in the small eyes of infants having surgery before 6 months of age.

Glaucoma after pediatric cataract surgery in a population with limited access to care

Craig Baden, Fortunate Shija, Susan Lewallen, Paul Courtright, Anthony Hall — 2013-03-25

Background: Cataract is a leading cause of childhood blindness in eastern Africa and other resource-constrained regions around the world, and high-quality surgical centers are increasingly responding to this challenge. Despite evidence concerning the ongoing risk of postoperative glaucoma after lensectomy, little is known of the incidence of glaucoma after pediatric cataract surgery in Africa. We sought to evaluate the frequency and predictors of postoperative glaucoma in this setting.Methods: The medical records of all children who underwent surgery for congenital or developmental cataract between 2003 and 2005 at the Kilimanjaro Christian Medical Centre were retrospectively reviewed to determine the incidence of postoperative glaucoma. Potential risk factors were evaluated by means of logistic regression.Results: Cumulative incidence of glaucoma at 3 years was 6.5% (95% CI, 2.5-16.0), and the annual incidence rate was 2.0 cases per 100 operated eyes (95% confidence interval, 0.74-4.37). Total time of follow-up and absence of primary intraocular lens implantation correlated with risk for postoperative glaucoma, but multivariate analysis could not confirm independent associations.Conclusions: As cataract surgical rates continue to increase and pediatric ophthalmology centers in Africa progress toward the goals of Vision 2020: The Right to Sight, renewed efforts must be directed toward the long-term postoperative care of all children undergoing operation for pediatric cataract.

Plusoptix photoscreening may replace cycloplegic examination in select pediatric ophthalmology patients

David I. Silbert, Noelle S. Matta, Kristen Andersen — 2013-03-25

Purpose: To determine whether children presenting to a pediatric ophthalmologist and found to have a normal Plusoptix photoscreener (PlusoptiX GmbH, Nuremberg, Germany) result, normal visual acuity (children age 3+), and normal alignment/motility receive additional benefit from a dilated fundus examination.Methods: The medical records of all children seen at one pediatric ophthalmology practice between 2007 and 2010 who were coded as having had a photoscreening were retrospectively reviewed. Of the total number of records identified, one-half were selected randomly for review. Patients who underwent plusoptiX screening on the first visit were included. Patients with abnormal alignment and/or abnormal vision as well as those referred for examination as determined by a medical or ophthalmic condition that required a dilated fundus examination were excluded.Results: Of 1,377 patients identified, 697 were selected randomly for record review. Of these, 451 had had an initial plusoptiX screening. A total of 222 had a normal result. Of the 190 patients analyzed, cycloplegic examination provided additional diagnostic information for only 4 children: 1 with nonvisually significant congenital cataract, 1 with refractive amblyopia from moderate astigmatism, 1 with moderate hyperopia who later was found to have accommodative esotropia, and 1 with increased cupping but normal IOP.Conclusions: A normal plusoptiX result, combined with normal alignment/motility evaluation and visual acuity was found to have a 98% negative predictive value for ophthalmic pathology, including significant refractive error. The plusoptiX and an abbreviated eye examination may obviate the need for dilation in select children.

Seeing is Believing

2013-04-01

As soon as the doctor began to cut the muscle, however, our strapping patient gave signs of restlessness; and all at once, with an actual bellow, he jerked his head on one side, carried away the doctor's hook, and shut his eye upon it with a sort of lockjaw grip, as if determined it should never be drawn out. How my hook got out I have no idea; fortunately, the doctor let his go, or the lad's eye would have been scratched out. As it was, there he sat with the bandage slipped above one eye, and the other closed upon the hook, the handle of which stood out straight. Probably at that moment he would have been willing to sacrifice pride of personal appearance, keep his squint, and go through life with his eye shut, the hook in it, and the handle sticking out; but the instrument was too valuable to be lost.

The effect of amblyopia treatment on stereoacuity

2013-04-01

Purpose: To explore how stereoacuity changes in patients while they are being treated for amblyopia.Methods: The Monitored Occlusion Treatment for Amblyopia Study (MOTAS) comprised 3 distinct phases. In the first phase, baseline, assessments of visual function were made to confirm the initial visual and binocular visual deficit. The second phase, refractive adaptation, now commonly termed “optical treatment,” was an 18-week period of spectacle wear with measurements of logMAR visual acuity and stereoacuity with the Frisby test at weeks 0, 6, 12, and 18. In the third phase, occlusion, participants were prescribed 6 hours of patching per day.Results: A total of 85 children were enrolled (mean age, 5.1 ± 1.5 years). In 21 children amblyopia was associated with anisometropia; in 29, with strabismus; and in 35, with both. At study entry, poor stereoacuity was associated with poor visual acuity (P < 0.001) in the amblyopic eye and greater angle of strabismus (P < 0.001). Of 66 participants, 25 (38%) who received refractive adaptation and 19 (29%) who received occlusion improved by at least one octave in stereoacuity, exceeding test–retest variability. Overall, 38 (45%) improved one or more octaves across both treatment phases. Unmeasureable stereoacuity was observed in 56 participants (66%) at study entry and in 37 (43%) at study exit.Conclusions: Stereoacuity improved for almost one half of the study participants. Improvement was observed in both treatment phases. Factors associated with poor or nil stereoacuity at study entry and exit were poor visual acuity of the amblyopic eye and large-angle strabismus.

An Eye on the Arts

2013-04-01

The eye is another example frequently cited by advocates of Intelligent Design as displaying a degree of complexity that stepwise natural selection could never have achieved. Darwin himself recognized the difficulty that his readers would have accepting this…. Yet Darwin, ever the impressive comparative biologist, proposed 150 years ago a series of steps in the evolution of this complex organ, which modern molecular biology is rapidly confirming.

Surgical results after one-muscle recession for correction of horizontal sensory strabismus in children

Luisa M. Hopker, David R. Weakley — 2013-04-01

Purpose: To report the success rates in children after one-muscle recession for sensory strabismus.Methods: The medical records of consecutive patients ≤18 years of age who underwent primary unilateral horizontal surgery for sensory strabismus measuring ≤30Δ from 2004 to 2010 were retrospectively reviewed. Data collected included age at surgery, sex, length of follow-up, procedure performed, pre- and postoperative deviation, and treatment of associated vertical strabismus. Success was defined as a final deviation within 10Δ of orthotropia.Results: A total of 33 patients (16 males) were included. Mean age at surgery was 5.2 years (range, 6 months to 17 years) and mean follow-up was 36 months (range, 6 months-7.4 years). Age at surgery (P = 0.37) and follow-up (P = 0.79) were comparable in patients with esotropia (n = 12) and exotropia (n = 21). Mean preoperative deviation was 23.7Δ in the esotropia group and 24Δ in the exotropia group (P = 0.875). Successful postoperative alignment was achieved in 76% of esotropic patients and 92% of exotropic patients (P = 0.379). Lateral rectus recessions resulted in a mean correction of 2.8Δ/mm of recession compared to 3.0Δ/mm for medial rectus recessions (P = 0.71).Conclusions: Advantages of one-muscle recession include a high success rate, few over-corrections, relatively short duration of surgery, and an intact muscle should reoperation be indicated.

Fusion can mask the relationships between fundus torsion, oblique muscle overaction/underaction, and A- and V-pattern strabismus

2013-04-01

Purpose: To evaluate relationships between fundus torsion, A- or V-pattern strabismus, and oblique muscle over- or underaction, and to explore the influence of stereopsis on these relationships.Methods: The medical records of patients with A or V patterns and/or abnormal ocular torsion seen at a single institution over nearly 30 years were retrospectively reviewed. Data collected were age, objective fundus torsion (estimated by indirect ophthalmoscopy), horizontal deviations in up- and downgaze, oblique muscle over- or underaction, and stereopsis.Results: A total of 396 patients were included. A patterns were observed in 121 patients (30.6%); V patterns in 90 (22.7%). Of the A-pattern patients, 73.6% had superior oblique muscle overaction, whereas 71.1% of the V-pattern patients had inferior oblique muscle overaction (P < 0.0001, r = 0.71), increasing to 78.6% and 86.3%, respectively, for patients without stereopsis (r = 0.78). Of the patients with fundus intorsion, 78.7% had superior oblique muscle overaction, whereas 74.4% of those with fundus extorsion had inferior oblique muscle overaction (P < 0.0001, r = 0.79), increasing to 83.5% and 82.8%, respectively, for patients without stereopsis (r = 0.82). Fundus intorsion occurred in 76% of the A-pattern patients, whereas fundus extorsion occurred in 71.1% of the V-pattern patients (P < 0.0001, r = 0.73), increasing to 78.6% and 86.3%, respectively, for patients without stereopsis (r = 0.79).Conclusions: Strong correlations were found between fundus intorsion, superior oblique muscle overaction, and A patterns, and between fundus extorsion, inferior oblique muscle overaction, and V patterns. These correlations increased in patients without stereopsis, suggesting that the presence of binocular fusion can partially interfere with the close correlation of these parameters.

Choice of conjunctival incisions for horizontal rectus muscle surgery—a survey of American Association for Pediatric Ophthalmology and Strabismus members

Mikel Mikhail, Rhiannon Verran, Forough Farrokhyar, Kourosh Sabri — 2013-03-25

Purpose: To assess the use of limbal versus fornix conjunctival incisions in primary and repeat horizontal rectus muscle surgeries among pediatric ophthalmologists and adult strabismus surgeons.Methods: A 2-page questionnaire was mailed to members of the American Association for Pediatric Ophthalmology and Adult Strabismus. Participants were asked about their use of limbal, fornix, or other incision types in their pediatric and adult strabismus patient population.Results: A total of 1,022 questionnaires were circulated. The net overall response rate was 27.8%. For first-time strabismus surgeries in pediatric patients, 40.8% of respondents used limbal incisions in the majority of their cases, 58.1% used fornix incisions, and 1.1% used other incision types. For reoperations, 58.1% used limbal-based incisions, 39.1% used fornix incisions, and 2.1% used other incision types. In the majority of their primary surgeries on adults, 40.1% used limbal incisions, 53.5% preferred fornix incisions, 1.4% used other incision types, and 4.9% answered “not applicable” (available for respondents who operated exclusively on either children or adults). On reoperations, limbal incisions were used by 63.4% of respondents, 29.9% used fornix incisions, 1.4% used other incision types, and 5.3% answered “not applicable.”Conclusions: Among those surveyed, limbal incisions were preferred for greater intraoperative exposure and better teaching of junior surgeons; fornix incisions were thought to cause less postoperative pain and inflammation and lead to more rapid soft-tissue healing.

First Person

2013-04-01

At an outpatient surgical facility in a rural area in Louisiana, the anesthesiologist interviewed the mother of the young patient who was there for strabismus surgery. During the interview, the anesthesiologist asked, “Has you son had any previous surgery?”

The effect of previous orbital decompression on results of strabismus surgery in patients with Graves' ophthalmopathy

Myung Hun Kim, Kyung-Ah Park, Sei Yeul Oh — 2013-03-25

Purpose: To evaluate the effect of previous orbital decompression on the success of strabismus surgery in patients with Graves' ophthalmopathy.Methods: The medical records of patients who underwent strabismus surgery for Graves' ophthalmopathy were retrospectively reviewed. Patients were divided into two groups according to whether they had previously undergone orbital decompression. Success was defined as no diplopia in primary and downgaze or no diplopia with prisms no more than 8Δ horizontally and 4Δ vertically. The effect of strabismus surgery on the amount of proptosis was also evaluated.Results: A total of 56 patients with Graves' ophthalmopathy were included. Of these, 27 had undergone orbital decompression before strabismus surgery and 29 patients had not. The two groups did not differ in terms of the average angle of preoperative horizontal or vertical deviations and the average numbers of muscle that underwent surgery. The postoperative exophthalmometric value decreased an average of 0.4 mm in the decompression group and 0.2 mm in the nondecompression group. The success rate of the surgery was 92.6% in patients who had previous decompression and 93.1% in patients who had not.Conclusions: Previous orbital decompression surgery had no significant effect on the outcomes of strabismus surgery or on postoperative change in proptosis in patients with Graves' ophthalmopathy.

An Eye on the Arts

2013-04-01

There is little that can be done about the eye with a cataract, but with glasses, the sight of his right eye is measurably improved. Hung can once again see the Cyrillic letters stamped on the canvas from which, years ago, he sewed himself a straw-filled mattress. If he leans into the scrap-metal wall of his shack, he can make out some of the headlines of the old newspapers he stuffed into the cracks to keep out the winter draft. But he has given up reading, gave that up some time ago; it just reminds him of all he has lost.

Diplopia after glaucoma drainage device implantation

2013-04-01

Purpose: To determine incidence of diplopia after glaucoma drainage device (GDD) surgery and to report treatment outcomes.Methods: Financial claims data were used to identify patients who underwent GDD surgery (CPT [Current Procedural Terminology] 66180) at the Bascom Palmer Eye Institute from January 2, 1991, through December 31, 2005. After a second claims data search, the medical records of patients diagnosed with diplopia (International Classification of Diseases, 9th Revision code 368.2) and those who underwent extraocular muscle surgery (CPT-4 code 67311-67335) after GDD implantation were reviewed retrospectively.Results: A total of 2,661 patients underwent GDD surgery during the study period. Charges were submitted for 59 patients for strabismus surgery or office visits relating to diplopia. Of these, 27 patients were excluded because medical records did not document diplopia or included pre-existing diplopia, cranial nerve palsy, or diplopia attributed to another ocular procedure. The remaining 32 patients developed diplopia secondary to GDD. Superotemporal quadrant GDDs were identified in 23 eyes and inferonasal quadrant placement in 9 eyes. The 1-year cumulative incidence of diplopia was 1.4%. No patient developed diplopia after 1 year. The mean follow-up after diagnosis for patients with diplopia was 48 ± 27 months (range, 1-124 months). The mean time of onset of diplopia after GDD implantation was 66 ± 62 days, with median onset of 42 days (range, 8-278 days). Treatment of diplopia included prisms in 17 cases (53.1%), no treatment in 13 (40.6%), other therapies in 2 (6.3%), and surgery after prismatic treatment failed in 3 (9.4%).Conclusions: The incidence of diplopia after GDD surgery is low, and most patients are treated with prisms.

A computerized version of the Lancaster red-green test

Ahmed Awadein — 2013-04-01

Purpose: To compare results from a computerized version of the Lancaster red-green test with those of the conventional test.Methods: Consecutive adult patients with noncomitant strabismus were tested with the conventional Lancaster red-green test and with a computerized version of the same. The computerized test was administered by means of a 40-inch monitor at a working distance of 50 cm or a projector and screen at a working distance of 1 meter. Agreement between the measured horizontal, vertical, and torsional deviations in the conventional test and both computerized versions was evaluated with the mountain plot, Bland-Altman plot, and Deming regression analysis models.Results: A total of 82 patients were tested. Agreement of measured horizontal deviation in the conventional test was better with the projector version of the test (limits of agreement: right eye, −4.6Δ to 3.4Δ; left eye, −4.9Δ to 3.5Δ) than the monitor version (limits of agreement: right eye, −10Δ to 4.2Δ; left eye, −8.9Δ to 4.1Δ). The measured vertical and torsional deviation in the conventional test showed good agreement with both versions of the computerized test (limits of agreement <5Δ for vertical measurements and <3° for torsional measurements). Agreement was similar for right and left eyes.Conclusions: The vertical and torsional deviations measured with both computerized versions of the test were in good agreement with those obtained with the conventional test. For measured horizontal deviations, the projector version had better agreement than the monitor version.

Pigmented choroidal nevus in a child with oculocutaneous albinism

Priya Sharma, Swathi Kaliki, Maria Soledad Peña, Carol L. Shields — 2013-01-25

We report the case of an 8-year-old white girl with albinism and a flat pigmented choroidal lesion in the left eye measuring 0.5 mm in diameter. There was no subretinal fluid, lipofuscin, or drusen. The patient later displayed 10 lightly-pigmented cutaneous nevi on her upper chest, left arm, and right leg at 8 months' follow-up. The choroidal nevus showed minimal change over 2 years.

Bilateral Candida endophthalmitis in a premature infant

2013-03-25

Endogenous infantile Candida endophthalmitis is a rare but potentially devastating condition resulting from sequestration of the fungus within the lens after systemic infection. We report the case of a 20-week-old girl with a history of Candida sepsis who presented with bilateral Candida albicans endophthalmitis 15 weeks after completing a 6-week course of intravenous antifungal therapy. Prompt vitrectomy resulted in salvage of the right eye, although a total retinal detachment occurred. Cataract extraction and administration of intravenous and intravitreal amphotericin B preserved vision in the left eye.

Candida species lens abscesses in infants with a history of neonatal Candida sepsis

2013-04-01

We report 3 patients who were delivered prematurely and who developed a lens opacity with signs of ocular inflammation at a postgestational age of 10-52 weeks. All patients had been treated for Candida sepsis as neonates. Each patient underwent lensectomy and anterior vitrectomy. In 2 infants Candida albicans was cultured from the lens/anterior chamber membrane; in 1 Candida parapsilosis was cultured from a lens aspirate. Despite eradication of the fungal infection, outcomes were poor: 2 eyes developed glaucoma, and 1 developed a retinal detachment with subsequent phthisis.

Lipodermoid in a patient with Emanuel syndrome

2013-03-25

We report an 8-month-old boy with Emanuel syndrome who also had the clinical features of Goldenhar syndrome. At birth, he was observed to have bilateral microtia with multiple auricular pits, retrognathia, and a unilateral lipodermoid. Further testing revealed cardiac defects. The finding of a lipodermoid in Emanuel syndrome demonstrates phenotypic overlap between Goldenhar and Emanuel syndromes and suggests a role for genetic analysis in all patients with clinical features that include ear anomalies and lipodermoids. Correct identification of patients with Emanuel syndrome is important for determining whether there is risk of long-term neurodevelopmental disability, and genetic testing can determine parental carrier status to aid in family planning.

Congenital iris ectropion uveae presenting with glaucoma in infancy

Debbie Laaks, Nicola Freeman — 2013-03-25

A healthy 5-month-old boy presented with a sporadic unilateral right-sided sectorial ectropion uveae, anterior insertion of the iris root, increased IOP, and glaucomatous disk changes. The absence of other additional ocular anomalies and the appearance of the angle led to a diagnosis of congenital iris ectropion syndrome. IOPs became refractory to maximal topical therapy, and trabeculotomy surgery was performed. The patient has since been stabilized on topical agents.

Ciliochoroidal metastasis as the initial manifestation of an occult soft-tissue extraosseous sarcoma in a 10-year-old girl

Swathi Kaliki, Ralph C. Eagle, Carol L. Shields, Jerry A. Shields — 2013-04-01

Uveal metastases are rare in children and metastasis from sarcoma is rare at any age. We report a purportedly healthy 10-year-old girl who developed ciliochoroidal metastasis from an occult primary extraosseous sarcoma of the ankle region. The patient died from widespread metastases 6 months after enucleation despite intensive chemotherapy.

Seeing is Believing

2013-04-01

In the early 1900s, orthoptists and ophthalmologists introduced a wide variety of techniques for the improvement of binocular function. Mary Maddox is considered the first English orthoptist. She was the first to apply knowledge of ocular motility to the practice of orthoptics as an allied health profession. The eldest daughter of the renowned English ophthalmologist Ernest Edmund Maddox (1860-1933), Mary emphasized the treatment of abnormal retinal correspondence. She was the first to organize the orthoptic clinic in London in 1919 (Roper-Hall G. Am Orthopt J 2009;59:103-10; Helveston EM. Am J Ophthalmol 2005;140:903-10). Several orthoptic societies and journals were created in those embryonic stages of the field (MacLellan AV. Orthoptics: The Early Years [2006]). Her work in orthoptic investigation and the treatment of strabismus has inspired others to take up the profession. The study of orthoptics spread from Great Britain to North America in the early 1930s, and by 1932 Legrand Hardy and Elizabeth Stark had started the first American Orthoptic Clinic in New York City (Edelman PM. Orthoptics: A Syllabus of Ocular Motility [1987], viii).

Anesthetic and airway management during laser treatment for retinopathy of prematurity: A survey of US ophthalmologists and neonatologists

Kathryn S. Klein, Susan Aucott, Pamela Donohue, Michael Repka — 2013-04-01

Ophthalmologists and neonatologists were surveyed to assess current practices for anesthetic and airway management techniques used during laser treatment for retinopathy of prematurity. Of the 351 practitioners who completed the survey, most perform fewer than 10 treatments annually. Intravenous sedation, rather than general anesthesia, is used by 60% of respondents. Routine intubation is used by 58%, whereas 36% monitor infants at their current level of respiratory support.

Modified full-thickness anterior blepharotomy for upper eyelid retraction in children

Krista J. Stewart, Gregory J. Griepentrog, Mark J. Lucarelli — 2013-03-25

Graded full-thickness anterior blepharotomy has been used to treat eyelid retraction in adult patients with thyroid eye disease. We report 2 children diagnosed with upper eyelid retraction who underwent a modified full-thickness anterior blepharotomy. In both cases, symptoms resolved and cosmetically acceptable outcomes were achieved.

Topical brinzolamide for foveal schisis in juvenile retinoschisis

Francine P. Yang, Katharina Willyasti, Seo Wei Leo — 2013-04-01

We describe a case series of 4 consecutive patients diagnosed with X-linked retinoschisis seen at a pediatric ophthalmology clinic during a 3-year period. All patients were treated with topical brinzolamide; 3 patients experienced significantly decreased severity of macular cysts on OCT in at least one eye.

Pediatric ophthalmology bids farewell to one of its founders, Leonard Apt, MD

Sherwin J. Isenberg, Joseph L. Demer, J. Bronwyn Bateman — 2013-04-01

The field of pediatric ophthalmology has lost a leader of towering professional stature. Leonard Apt, MD, the founder of academic pediatric ophthalmology in the United States, and professor of ophthalmology at the University of California Los Angeles (UCLA), died in Santa Monica at 90 years of the age on February 1, 2013, after an acute cardiac illness.