Forrest D. Ellis

The Trochlea: A Study of the Anatomy and Physiology

Trochleas obtained from fresh surgical specimens, autopsy material, and cadavers were studied by means of dissection, light microscopy, and electron microscopy (scanning and transmission). A bursa-like structure that has not previously been described lines the inner surface of the cartilagenous trochlea. A fibrillar, vascular sheath surrounds the intratrochlear superior oblique tendon. This portion of the superior oblique tendon consists of discrete fibers with few, interfibrillar connections. Each superior oblique tendon fiber is thought to move through the trochlea by means of a sliding action with the central fibers undergoing the maximum excursion.

Incidence of strabismus in neonates

In an attempt to learn whether esotropia is present at birth or develops later in infancy, we observed 1,219 alert infants in a normal newborn nursery at a city hospital. Of these, 593 (48.6%) had orthotropic findings; 398 (32.7%) had exotropia, 40 (3.2%) had esotropia (intermittent in 17 with 14 varying between esotropia and exotropia and nine with a variable esotropia), and 188 (15.4%) were not sufficiently alert to permit classification. No infant displayed typical signs of congenital esotropia. We concluded that congenital-infantile esotropia is not connatal but rather develops in the first few weeks or months after birth.

Large Recession of the Horizontal Recti for Treatment of Nystagmus

Ten patients had large recession of four horizontal recti at one procedure for treatment of nystagmus. Six patients had congenital motor nystagmus, two had oculocutaneous albinism, and two had optic nerve hypoplasia. Anomalous head posture with null point was also present in five patients. The rectus muscles were placed at or behind the equator in all but one case. Three patients with both esotropia and nystagmus had the medial recti placed 1 mm behind the equator and the lateral recti or at 1 mm anterior to the equator. Visual acuity improved an average of 1 line at distance and/or near in 8 patients who cooperated for testing. Although nystagmus was not eliminated in any patient, its its amplitude decreased in eight of ten patients, and anomalous head posture improved in three of five patients. In all patients, near vision was better than distance vision both preoperatively and postoperatively. Ductions were diminished minimally after the large recession and there were no other complications from surgery.

A new classification of superior oblique palsy based on congenital variations in the tendon.

BACKGROUND Superior oblique palsy is the most frequent isolated cranial nerve palsy seen in strabismus practice. It is traditionally diagnosed according to etiology as acquired, congenital, or idiopathic, but surgical treatment is based on deviation not etiology. Observations at surgery led to speculation that the superior oblique tendon is different in congenital compared with acquired superior oblique palsy and that this difference should be considered in surgical treatment. METHODS The authors reviewed the charts of 82 patients (89 eyes) undergoing surgery on the superior oblique tendon for superior oblique palsy. In each case, the palsy had been diagnosed preoperatively as acquired, congenital, or idiopathic, and, at surgery, characteristics of the tendon anatomy were described. RESULTS Thirty-eight superior oblique tendons (36 patients), diagnosed as congenital superior oblique palsy, included 33 abnormal tendons and 5 normal tendons. Twenty-four tendons (21 patients), diagnosed as traumatic superior oblique palsy, included 22 normal and 2 abnormal tendons. Twenty-seven tendons (25 patients), diagnosed as idiopathic, included 19 normal and 8 abnormal tendons. Abnormal tendons were divided into 4 categories: (1) redundant, (2) misdirected, (3) inserted in posterior Tenons capsule, and (4) absent. CONCLUSIONS The authors conclude that congenital superior oblique palsy is usually associated with a structural abnormality of the superior oblique tendon (87%). Whereas acquired superior oblique palsy usually has a normal tendon (92%). Superior oblique underaction in acquired superior oblique palsy results from a neural deficit. Potential variance in anatomy of the superior oblique tendon should be considered when undertaking surgery for superior oblique palsy.

Persistent Binocular Diplopia After Cataract Surgery

We reviewed the records of 38 consecutive patients who had persistent binocular diplopia after cataract surgery. The patients were divided into ten categories based on the suspected conditions underlying the diplopia. Of 16 patients who underwent strabismus surgery, five achieved the therapeutic goal of single binocular vision in the primary and reading position, and four attained this with prismatic or botulinum toxin therapy in addition to surgery. Seven patients continued to have diplopia despite strabismus surgery and adjunctive therapy. Even small residual deviations were often intolerable, because of highly diminished fusional amplitudes.

Surgical Treatment of Congenital Esotropia

We conducted a retrospective study of 133 children (69 boys and 64 girls) who underwent bilateral medial rectus muscle recession (most by the augmented or en-bloc technique) for congenital esotropia. Esotropia was diagnosed before the age of 6 months in 84 patients and after the age of 6 months in the other 49. A total of 27 children underwent surgery before the age of 12 months; of these, three required second procedures. A total of 106 children underwent surgery after the age of 12 months; of these, eight required second procedures. The mean preoperative deviation was 40 prism diopters. Two patients had significant A pattern deviations and 17 had significant V pattern deviations. Six patients had dissociated vertical deviations. Five to 60 days after surgery, 52 patients had no deviation and 99 were within +/- 10 prism diopters of no deviation. Two months after surgery, 67 patients had no deviation and 114 were within +/- 10 prism diopters of no deviation. Final alignments (five months to seven years postoperatively) showed that 51 patients had no deviation and 109 were within +/- 10 prism diopters of no deviation. Despite adequate alignment, none of 13 patients whose esotropia was diagnosed before the age of 6 months, who underwent surgery before the age of 12 months, and who cooperated with testing achieved stereopsis. This suggested that there may be two types of congenital esotropia--one without fusion potential and one in which fusion is possible but lost secondarily because of peripheral esotropic factors.

Capsular management and refractive error in pediatric intraocular lenses.

BACKGROUND Guidelines for intraocular lens (IOL) implantation in children regarding patient selection, age limitations, operative techniques, including management of the posterior capsule, and refractive goals are not universally agreed on. METHODS The authors placed posterior chamber IOLs in the capsular bag of 79 eyes in 57 children. Patient age ranged from 10 months to 17 years. Follow-up averaged 2 years. Patients were selected on the basis of age, cataract morphology, laterality, and lack of potential complicating factors. In general, postoperative refractions were intended to be mildly hyperopic with the magnitude dependent on patient age. RESULTS Seventy-nine percent of patients able to report a postoperative visual acuity showed 20/40 or better visual acuity. Vision was limited by amblyopia in the remaining patients. There were no significant complications. The posterior capsule opacified on average 2 years after surgery regardless of patient age. CONCLUSIONS Implantation of posterior chamber IOLs in carefully selected children appears to be effective and safe. Consideration should be given to primary posterior capsulectomy-anterior vitrectomy at the time of lens implant in children who are not expected to be candidates for yttrium aluminum garnet (YAG) capsulotomy within 18 months of surgery.

Linear Subcutaneous Fat Atrophy After Corticosteroid Injection of Periocular Hemangiomas

Two children developed evidence of subcutaneous fat atrophy after corticosteroid injection of periocular hemangiomas. The atrophy appeared at the site of injection and followed the expected course of lymphatic channels to the vicinity of regional lymph nodes.

Treatment of congenital glaucoma.

We reviewed 37 consecutive patients who had undergone at least one goniotomy, filtering surgery, and patching for amblyopia because of congenital glaucoma between 1969 and 1979. Of 32 eyes treated for uncomplicated congenital glaucoma, 25 (78%) achieved satisfactory control of intraocular pressure. Seven of the 12 eyes (58%) for which Snellen visual acuities could be obtained had visual acuities of 6/15 (20/50) or better. Of eight eyes treated for complicated congenital glaucoma, four (50%) achieved satisfactory control of intraocular pressure, but the visual acuities of these patients could not be tested.

Stereopsis in normal infants and infants with congenital esotropia

We used electro-oculographic recordings of eye movement responses to a dynamic random-dot stereogram to assess stereopsis in normal infants and in infants with congenital esotropia. Normal infants showed an onset of stereopsis at about 4 months of age, consistent with previous reports. Four of nine infants with congenital esotropia demonstrated stereopsis when tested within two weeks of surgical alignment. No patient with congenital esotropia showed evidence of stereopsis when tested at a postoperative interval of more than two weeks.