Albert W. Biglan

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 patients 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.

Visual Results after Early Surgical Treatment of Unilateral Con enital 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 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.

Risk factors for secondary membrane formation after removal of pediatric cataract

Purpose: To evaluate the incidence of secondary membrane formation, factors that lead to its development, and the frequency of procedures to treat these membranes in children after cataract surgery. Setting: Department of Pediatric Ophthalmology, Childrens Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA. Methods: Clinical records of 152 patients (190 eyes) who had cataract extraction between January 1986 and 1996 were reviewed retrospectively. The mean follow‐up was 6 years (range 2 to 13 years). Cataract surgery was performed through a limbal incision in all cases. Twenty‐eight eyes had a primary posterior capsulectomy, and 120 eyes had posterior capsulectomy combined with an anterior vitrectomy. In 42 eyes, the posterior capsule was left intact. Nineteen eyes received a primary intraocular lens (IOL), 15 eyes received a secondary IOL, and 156 eyes were rehabilitated with spectacles or contact lenses. Results: Seventy‐two eyes (37.9%) developed secondary membrane a mean of 8.9 months postoperatively (range 3 weeks to 53 months). Membranes occurred in 78.6% of eyes with an intact posterior capsule, 42.9% with posterior capsulectomy, and 22.5% with combined posterior capsulectomy and anterior vitrectomy. Secondary membrane formation was associated with not performing a posterior capsulectomy with anterior vitrectomy (P < .001) and the presence of a primary IOL (P < .001). Younger age at surgery increased the chance of secondary membrane formation in patients who had posterior capsulectomy and anterior vitrectomy (P < .01). Conclusions: The younger the child at cataract surgery, the greater the risk of secondary membrane. Primary posterior capsulectomy combined with an anterior vitrectomy decreased but did not eliminate the incidence of secondary membrane.

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 patients clinical response to treatment.

Long-term outcome of cyclocryotherapy for refractory pediatric glaucoma1

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.

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.

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.

Congenital Lacrimal Sac Mucoceles

Seven infants had tense, blue-gray swellings inferior to the medial canthal tendon with otherwise normal-appearing eyelids and puncta. All lacrimal sacs transilluminated and A-scan ultrasonography performed in one case demonstrated a nonloculated cystic cavity. Four (57%) infants had uncomplicated mucoceles. One was treated with massage, and has remained asymptomatic for 14 months. The other three were cured with a single probing and irrigation of the entire lacrimal system. Three (43%) infants had developed erythema of the tissues overlying the swollen lacrimal sacs by the time of referral. Because none of the mucoceles could be decompressed by massage, prompt probing and irrigations were performed in each case. Cultures from the aspirates of all three sacs yielded Staphylococcus organisms. In contrast to the uncomplicated cases, two patients developed recurrences that necessitated additional treatment.

Central Corneal Endothelial Cell Counts in Children

Our data indicate that corneal endothelial cell density in a normal eye remains essentially unchanged from ages five to 20. Changes in cell density and morphology during the first five years of life need further investigation. In this study, the mean endothelial cell count of a normal population of children was 2696 cells/mm2. Children undergoing cataract aspiration had a mean cell loss from the normal of 7.2%. The cell loss rates for push-pull aspiration-irrigation or phacoemulsification cataract extraction were not statistically different. The implantation of an intraocular lens was associated with a 33.3% endothelial cell loss when compared to the control or normal population of eyes. A mean loss of 38.0% was noted when the IOL eyes were compared to their normal fellow eyes.