Burton J. Kushner

Silicone Intubation for Obstruction of the Nasolacrimal Duct in Children

We performed 63 intubations with silicone tubing for nasolacrimal duct obstruction in children in whom nasolacrimal duct probings had failed. Fifty-nine (93.7%) obstructions were congenital and four (6.3%) were acquired. The average length of intubation was 4.3 months. The final results for both congenital and acquired obstructions combined were good in 52 cases (82.5%), fair in three (4.8%), and poor in eight (12.7%). Complications, with the exception of some with infection, were easily treated or minimal and did not affect the outcome significantly. We recommend silicone intubation as the procedure of choice for congenital or acquired nasolacrimal duct obstructions in children after failure of medical therapy and nasolacrimal duct probings.

Intralesional corticosteroid injection for infantile adnexal hemangioma.

I treated ten patients who had adnexal hemangioma with intralesional injections of corticosteroid. A marked and lasting regression of the hemangioma occurred in eight of the patients and one had a moderate response. This treatment also proved effective in preventing amblyopia in infants who had large hemangiomas that occluded the visual axis, and often resulted in a reversal of the astigmatism induced by these tumors. There were no complications. The advantages of intralesional corticosteroid injection include ease of administration, speed of action, apparent freedom from adverse side effects, and repeatability.

Restriction of elevation in abduction after inferior oblique anteriorization

PURPOSE Inferior oblique anteriorization is gaining popularity for the treatment of dissociated vertical divergence associated with inferior oblique overaction. This procedure is based on the theory that moving the insertion of the inferior oblique muscle anterior to the equator changes its vector of force from one of elevation to one that opposes elevation. The purpose of this investigation is to describe, investigate the cause, and outline treatment for a complication I observed after inferior oblique anteriorization. This postoperative syndrome consists of a motility pattern that resembles marked residual inferior oblique overaction associated with a Y or V pattern. It is probably caused by a restriction of elevation of the abducting eye causing fixation duress, with a resultant upshoot of the contralateral adducting eye. METHODS A retrospective chart review was conducted for all patients on whom I performed bilateral inferior oblique anteriorization for inferior oblique overaction associated with dissociated vertical divergence. Patients in whom this postoperative syndrome developed were compared with those in whom it did not with respect to type and extent of surgery. In addition, cases of patients I treated or examined for this complication but whose inferior oblique anteriorization had been performed by other ophthalmologists were also analyzed. RESULTS I performed bilateral inferior oblique anteriorization in 77 patients. In 29 patients the inferior oblique muscles were placed level with the insertions of the inferior rectus muscles, in 31 patients they were placed 1 mm anterior to the insertions of the inferior rectus muscles, and in 17 patients they were placed 2 mm anterior. The postoperative syndrome described here developed in two of the 77 patients; both had the inferior oblique muscles placed 2 mm anterior to the insertions of the inferior rectus muscle. These were also the only two patients in this series in whom the new insertion of the inferior oblique muscle was spread out laterally at the time of anteriorization. I have seen an additional six patients in whom this syndrome developed after undergoing operations by other ophthalmologists. In four, the inferior oblique muscles were placed 2 mm anterior to the insertions of the inferior rectus muscles, and in two they were placed 3 mm anterior. Of the eight patients I have observed with this complication, I reoperated on six. The surgical procedure consisted of denervation or extirpation of both inferior oblique muscles in four patients and conversion to standard recessions of the inferior oblique muscles in two patients. In all six patients,the versions were markedly improved and the Y orV pattern was eliminated after reoperation. CONCLUSIONS Anteriorization of the inferior oblique muscles more than 1 mm anterior to the insertions of the inferior rectus muscle may cause a limitation of elevation in abduction, resulting in a Y or V pattern that mimics inferior oblique overaction. This may be more likely to occur if the new insertions of the inferior oblique muscles are spread out laterally at the time of anteriorization.

The management of nasolacrimal duct obstruction in children between 18 months and 4 years old.

PURPOSE Success with nasolacrimal duct probing has been shown to be inversely correlated with age. Consequently, several authors have suggested that the older child with a previously untreated nasolacrimal duct obstruction should undergo silicone intubation or a balloon catheterization as the primary surgical procedure because older children are more likely to have complicated obstructions that will not respond to simple probing. The purpose of this study was to investigate the hypothesis that older children with uncomplicated nasolacrimal duct obstruction can be successfully managed with simple probing. METHODS A 14-year prospective study was conducted of consecutive patients older than age 18 months with nasolacrimal duct obstruction. All were treated (subject to certain exclusion criteria) with a simple nasolacrimal duct probing. Careful attention was paid to the type of obstruction encountered at surgery. Outcome evaluation included a standard ophthalmologic examination plus a dye disappearance test at 6 weeks after surgery. A follow-up examination or telephone interview was conducted 1 year after surgery. RESULTS Of 378 children undergoing nasolacrimal duct probing, 23 met the inclusion criteria of being older than age 18 months (18 to 48 months). Seventy percent of the 23 children had a good outcome from the probing procedure. When analyzed by the type of obstruction, 12 of the 12 children (100%) with a simple membrane at the valve of Hasner had a good outcome. This contrasted with a success rate of 4 of 11 children (36%) who had complicated obstructions (p < 0.01). Complicated nasolacrimal duct obstructions were more prevalent in older children. CONCLUSION A simple probing of the nasolacrimal duct has an excellent success rate in children up to 4 years old if an uncomplicated obstruction is found at the valve of Hasner.

Errors in the Three-step Test in the Diagnosis of Vertical Strabismus

The Parks three-step test is the standard for diagnosing which isolated cyclovertical muscle is palsied. It does not, however, tell the examiner if in fact one is dealing with a palsy of one cyclovertical muscle. Numerous other causes of vertical strabismus may have a positive Bielschowsky head tilt test. The use of the three-step test in these clinical situations may lead to incorrect diagnosis and treatment. These clinical conditions include contracture of the vertical recti, paresis of more than one vertical muscle, dissociated vertical divergence, previous vertical muscle surgery, skew deviation, myasthenia gravis, and small nonparalytic vertical deviations associated with horizontal strabismus. Several diagnostic steps in addition to the three-step test are necessary to tell if one is in fact dealing with a palsy of a single cyclovertical muscle.

Ocular Causes of Abnormal Head Postures

A prospective study was undertaken to analyze the different causes of abnormal head postures on ocular bases. Eight basic mechanisms were found in a series of 188 patients. Incomitance accounted for 62.7% of the head postures and nystagmus for 20.2%. Important diagnostic criteria for evaluating patients with head postures are discussed.

Treatment of Partly Accommodative Esotropia With a High Accommodative Convergence-Accommodation Ratio

We conducted a prospective, randomized, masked comparison of two treatments for the nonaccommodative element in esotropic patients with a high accommodative convergence-accommodation ratio. One group received symmetric medial rectus recessions with posterior fixation sutures; the other received symmetric medial rectus recessions without posterior fixation sutures but augmented according to formula taking into account the near deviation. Previous experience had suggested that our surgical formula based solely on the distance deviation would lead to excessive undercorrections. A higher percentage of the augmented recession group achieved satisfactory alignment and were able to discontinue wearing bifocals postoperatively than the posterior fixation group. The data also showed a trend (though not statistically significant) suggesting that more members of the augmented recession group were able to discontinue wearing spectacles entirely. We concluded that the posterior fixation suture technique is not as effective as the augmented recession technique for the treatment of partly accommodative esotropia with a high accommodative convergence-accommodation ratio.

A Randomized Comparison of Surgical Procedures for Infantile Esotropia

In a prospective, randomized, masked study we compared the treatment of infantile esotropia using bilateral medial rectus muscle recessions of a graded amount from the insertion to standard 10.5-mm recession from the corneoscleral limbus. Of the patients undergoing recession of the medial recti muscles 10.5 mm from the corneoscleral limbus, 33 of 39 (84%) achieved a final ocular alignment within 10 prism diopters of straight with one operation, compared to 26 of 41 (63%) of the patients undergoing a graded recession from the insertion. The difference was significant (.01 less than P less than .05 by the chi-square test).

The accuracy of experienced strabismologists using the Hirschberg and Krimsky tests.

OBJECTIVE The purpose of the study was to assess the accuracy of a group of strabismologists applying the Hirschberg and Krimsky tests. DESIGN A clinical trial. PARTICIPANTS Sixteen very experienced strabismologists participated in this study. INTERVENTION The participants were asked to evaluate slides of four different patients using the Hirschberg method and to evaluate two of the four patients with the Krimsky method. The slides included a patient with 25 delta left esotropia, a patient with 25 delta right exotropia, a patient with 80 delta esotropia with a positive angle kappa, and a patient with 75 delta infantile esotropia. Alternate prism and cover testing was performed immediately after the photograph was taken and considered to be the actual deviation of the patient. MAIN OUTCOME MEASURE Measured was the accuracy in assessing the angle of strabismus. RESULTS With the Hirschberg method, each participant underestimated at least one patient by at least 10 delta. In addition, the participants tended to underestimate both large and small angle esotropic and exotropic patients with greater errors of estimation occurring with larger angles of strabismus. With the Krimsky method, a majority of participants overestimated at least one patient by 10 delta and showed difficulty in appreciating differences of 5 delta. In addition, the authors noted inconsistent responses by each participant. CONCLUSION The Hirschberg and Krimsky methods are substantially less accurate than the alternate prism and cover test.

Observations about Objective and Subjective Ocular Torsion

OBJECTIVE To investigate the relationship between objective and subjective torsion in patients with cyclovertical strabismus and determine whether objective torsion differs according to which eye is fixing. DESIGN A prospective evaluation of tests of objective and subjective torsion. PARTICIPANTS Thirty-six patients with various types of cyclovertical strabismus. METHODS Subjective torsion was assessed with the double Maddox rod, and objective torsion was graded in a masked manner from fundus photographs. MAIN OUTCOME MEASURES Quantification of objective or subjective torsion. RESULTS Objective torsion was the same regardless of which eye was used for fixation. However, after prolonged occlusion of the nonaffected eye, there was often an increase in objective torsion in the nonaffected eye. Subjective torsion typically was absent in patients with objective torsion if they did not have bifoveal fusion but was similar to objective torsion in patients with bifoveal fusional potential. CONCLUSIONS Assessment of objective and subjective torsion are each important but play separate roles in the evaluation of cyclovertical strabismus. There is no immediate torsional motor shift when fixation switches from the nonaffected to the affected eye. However, prolonged fixation of the affected eye may possibly result in a motor torsional change in the nonaffected eye in some patients.