Gad Dotan

Congenital nasolacrimal duct obstruction: common management policies among pediatric ophthalmologists.

PURPOSE To study common management policies of congenital nasolacrimal duct obstruction (CNDLO) among pediatric ophthalmologists. METHODS A 21-question survey was sent to members of the American Association for Pediatric Ophthalmology and Strabismus in April 2014. The questions focused on treatment of CNLDO during the first year of life, primary and secondary surgical interventions, surgical techniques, and amblyopia assessment. RESULTS One hundred twenty-seven members completed the survey and 121 responses were analyzed after replies of 6 candidates in training were excluded. Eighty-two percent of respondents instructed caregivers to massage the nasolacrimal duct during the first year of life; however, 55% did not perform the Crigler massage in the office. Outpatient probing was done by 17% of pediatric ophthalmologists who took the survey, almost all of whom (95%) have been in practice more than 10 years. Ninety-one percent recommended surgery for CNLDO close to the age of 1 year and 79% performed probing as initial treatment at that age. If treatment is delayed to the age of 2 years, 53% favored silicone tube intubation and/or balloon dacryoplasty. Following failed probing, silicone tube intubation was performed by 51% of practitioners. Ninety-one percent of respondents routinely checked refraction of infants with CNLDO and recommended reexamination even if initial assessment was entirely normal. CONCLUSIONS This study highlights the striking lack of consensus among pediatric ophthalmologists in many aspects of management of CNLDO and allows practitioners to compare their practice patterns regarding CNLDO management with those of their peers; however, because it provides only the opinions of a limited group of pediatric ophthalmologists, it does not imply that less common practices are wrong.

Long-term retinal nerve fiber layer changes following nonarteritic anterior ischemic optic neuropathy

Background In cases of nonarteritic anterior ischemic optic neuropathy (NAION), retinal nerve fiber layer (RNFL) thickness changes have been described during the first 12 months following the acute event. The purpose of this study was to report on the long-term RNFL changes in these eyes beyond the first year following onset of NAION. Methods Fourteen eyes of 13 patients with NAION were analyzed in this retrospective observational case series study. Uninvolved eyes served as controls. All patients underwent a complete neuro-ophthalmological examination and repeat measurements of peripapillary RNFL thickness using Stratus optical coherence tomography. Results On optical coherence tomography scan performed on average 6 months following onset of NAION, the mean global RNFL thickness (59.8 ± 11.8 μm) was significantly thinner (P < 0.001) compared with uninvolved eyes (95.1 ± 13.9 μm). In a second optical coherence tomography scan performed on average 13 (range 12–23) months later, the mean global RNFL thickness (58.9 ± 6.5 μm) was not significantly different (P = 0.702) from the first scan. Conclusion There appears to be no further RNFL loss beyond the first 6 months following an acute event of NAION.

Pediatric Pseudotumor Cerebri Associated With Low Serum Levels of Vitamin A

The aim of this study was to describe the association between pediatric pseudotumor cerebri and low serum vitamin A levels. We retrospectively reviewed the charts of 6 children (5 boys, 1 girl; mean age 8 years) with increased intracranial pressure and low serum vitamin A levels (mean 16.0 ± 8.8 µg/dL). The etiology of the vitamin A deficiency was a restricted diet (2 children), intestinal malabsorption caused by celiac disease (2 children), and undetermined cause (2 children). Only 1 child had ocular signs of xerosis. Poor visual acuity at presentation and lower serum vitamin A levels were associated with a poor visual outcome and development of optic atrophy. In conclusion, pseudotumor cerebri in children can be associated with vitamin A deficiency even when other manifestations of xerophthalmia do not exist. Early recognition of this condition and appropriate therapy can prevent blindness.

Spontaneous cerebrospinal fluid otorrhea and rhinorrhea in idiopathic intracranial hypertension patients.

W e thank Vaphiades et al for their interesting comments. Our manuscript (1) describes 4 patients with idiopathic intracranial hypertension (IIH) and increased intracranial pressure (ICP) (range, 270–370 mm H2O) that developed an unusual complication of spontaneous rhinorrhea or otorrhea (one as the initial chief complaint and the others later in the clinical course). Our study does not address the issue of whether most cases of spontaneous cerebrospinal fluid (CSF) leak occur in patients with high ICP or not. In a recent publication by Chaaban et al (2), it was reported that the majority of spontaneous CSF leaks are secondary to increased ICP, and that successful treatment of elevated ICP together with endoscopic repair can provide cure for most patients. This conclusion contradicts an earlier publication by Shugar et al (3) who have reported that 55% of cases of nontraumatic rhinorrhea described in the literature are associated with normal ICP and 45% with elevated pressure. Spontaneous rhinorrhea or otorrhea is rare in patients with IIH. One goal of our report was to raise awareness among clinicians to these unusual manifestations.

The efficacy of asymmetric bilateral medial rectus muscle recession surgery in unilateral, esotropic, type 1 Duane syndrome

BACKGROUND Many patients with esotropic, type 1 Duane syndrome adopt a head turn to gain binocular vision. Numerous surgical procedures have been performed to correct this condition, including asymmetric bilateral medial rectus muscle recession, first proposed by Jampolsky. However, few publications reported on the efficacy of this procedure. METHODS The medical records of patients with unilateral, esotropic Duane syndrome who had asymmetric medial rectus muscle recession for correction of their abnormal head turn were retrospectively reviewed with attention to head turn, ductions, and motor alignment at near and distance fixation. Surgery was considered successful when preoperative head turn was completely eliminated. RESULTS A total of 28 patients (18 females; mean age, 8 years) were included. In 24 patients (86%), the left eye was involved. Medial rectus recession averaged 4.7 mm (range, 3.25-6.0 mm) in the affected eye, with a recession larger by 1.0 mm in the unaffected eye. Average esotropia in the forced primary position improved from 32(Δ) preoperatively to 6(Δ) postoperatively, with a mean 22° improvement in head position (24°-2°). Twenty-four patients (86%) achieved complete resolution of their head turn postoperatively; the other 4 patients experienced partial improvement, with a residual head turn of 10°; a second re-recession of the medial rectus muscle in the affected eye of 1 patient resulted in complete resolution of head turn. CONCLUSIONS Our study showed that asymmetric bilateral medial rectus recession eliminated the head turn in most of our patients with unilateral esotropic Duane syndrome.

Outcomes of an Inner-City Vision Outreach Program: Give Kids Sight Day

IMPORTANCE Low-socioeconomic urban children often do not have access to ophthalmic care. OBJECTIVE To characterize the demographic characteristics and ophthalmic conditions in children attending Give Kids Sight Day (GKSD), an outreach ophthalmic care program held annually in Philadelphia, Pennsylvania, providing vision screening and immediate treatment when needed. DESIGN, SETTING, AND PARTICIPANTS Retrospective case-series study of children attending GKSD in 2012 (GKSD 2012) at an ophthalmology center in Philadelphia. Registration forms and records of all children attending GKSD 2012 were reviewed. MAIN OUTCOMES AND MEASURES Demographic characteristics, insurance status, spoken languages, reasons for attending, prior failure of vision screening, and attendance pattern of previous events were analyzed. The ophthalmological findings of these children were examined, including refractive errors, need for optical correction, and diagnoses for which continuous ophthalmic care was necessary. For children who needed ophthalmic follow-up, the rate of return to clinic and barriers for continuous care were analyzed. RESULTS We studied 924 children (mean age, 9 years; age range, 0-18 years; 51% female; 25% speaking a non-English language) coming from 584 families who attended GKSD 2012, of whom 27% were uninsured and 10% were not aware of their insurance status. Forty-two percent of participants had public insurance, which covered vision care and glasses, but 35% did not know their benefits and did not realize vision care was covered. Forty-nine percent of children attended because they failed community vision screening. Provision of free glasses and failure of previous vision screening were the most common reasons families elected to attend GKSD (64% and 49%, respectively). Eighty-five percent of children attended GKSD 2012 for the first time, whereas 15% attended prior events. Glasses were provided to 61% of attendees. Ten percent of the attendees needed continuous ophthalmic care, most commonly for amblyopia. Ten children needed ocular surgery for cataract, strabismus, nystagmus, ptosis, or nasolacrimal duct obstruction. With the assistance of a social worker, 59% of children requiring continuous treatment returned to the clinic, compared with 2% in prior years before social worker intervention. CONCLUSIONS AND RELEVANCE Programs such as GKSD can bridge the gap between successful vision screening and ophthalmic treatment, a gap that often occurs in low-socioeconomic urban populations. Those with public insurance coverage for vision services may not realize these services are covered. Social worker intervention is useful in overcoming common barriers to follow-up care.

Do Intraocular Pressure Measurements Under Anesthesia Reflect the Awake Condition

Background: Anesthesia or sedation is needed when intraocular pressure (IOP) measurement is required in certain circumstances. The effect of different anesthetic regimens on the IOP is still debatable. We aimed to evaluate alterations in the IOP under anesthesia with either propofol or different end-tidal concentrations of sevoflurane, when compared with the awake state. Methods: The IOP was measured in both eyes of 20 adult patients undergoing extraocular ophthalmic surgeries at 5 timepoints: before the induction of general anesthesia (under topical anesthesia), after the induction using propofol target-controlled infusion, and under 3 end-tidal concentrations of sevoflurane (0.5%, 2%, and 5%), either in a decreasing (group A) or an increasing (group B) concentration order. Results: With either propofol or sevoflurane anesthesia, the IOP did not differ significantly from the measurement performed during the awake state (no anesthesia), regardless of the concentration of sevoflurane used (in the range of 0.5% to 5%) or the order of sevoflurane administration (from low to high concentration or vice versa). Conclusions: These data suggest that propofol and sevoflurane are valid anesthetic agents for the evaluation of IOP in adults when anesthesia is needed.

Bilateral Sequential NAION following Cataract Extraction: Case Report and Review of the Literature.

We report a 64-year-old patient who developed nonarteritic ischemic optic neuropathy (NAION) in both eyes following cataract extraction. The cataract surgeries in both eyes were uneventful and performed within a year, and NAION occurred a few months postoperatively in both eyes. A review of the literature on this rare complication is provided. This case report serves to raise awareness among cataract surgeons about this potential complication associated with irreversible visual loss, and especially about its high risk of bilaterality.

Comparison of Ishihara Booklet with Color Vision Smartphone Applications.

Purpose To compare the standard Ishihara booklet with color-vision-testing smartphone applications. Methods A prospective observational diagnostic study on 42 normal trichromats and 38 color-deficient subjects. Patients were presented with three color vision tests in random order: an Ishihara test booklet and two color-vision-testing smartphone applications: Eye2Phone and the Color Vision Test application (CVT app). Sensitivity and specificity of the electronic tests was compared with Ishihara results, and in each one of these applications every plate was individually analyzed for success/failure rate. Results Average age was 42.7 ± 12.9 years. There were 57 males (71.2%). Sensitivity and specificity of each test was 100% (38/38) and 95.2% (40/42) for the Eye2Phone, and 100% (38/38) and 54.8% (23/42) for the CVT app. There was no significant difference between the Ishihara booklet and the Eye2Phone (p = 0.500), with a high kappa measure of agreement (0.950, p < 0.001). The CVT app was significantly different than both other tests (p < 0.001) with a low kappa measure of agreement (0.535 with the Ishihara and 0.575 with the Eye2Phone). Of the 21 tested plates, color-deficient subjects failed 11.8 ± 3.1 plates in the Ishihara booklet and 14.1 ± 2.1 plates in the Eye2Phone (p < 0.001). Significant plate-specific differences for the color-deficient group were found in plate numbers 3, 6, 7, 8, 9, 15, and 16. Both tests were poorly able to give an indication of the specific dichromatism type. The Ishihara booklet was rated more comfortable and clearer than the Eye2Phone in color-deficient subjects. The CVT app was rated lowest for comfort and clarity in both groups. Conclusions Smartphone applications testing for color vision deficiency are readily available; however, users of these apps should be aware that some may have different sensitivity for detection of color vision deficiency compared to Ishihara booklet, limiting their usefulness for clinical use. Therefore, further validation of these applications is required.

Surgical Outcome of Strabismus Surgery in Patients With Unilateral Vision Loss and Horizontal Strabismus

PURPOSE To report on the surgical outcome of horizontal strabismus surgery in patients diagnosed as having unilateral vision loss. METHODS Medical records of all patients with unilateral vision loss who underwent surgical repair of horizontal strabismus between 2008 and 2013 at three medical centers were reviewed. Data collected included age at time of surgery, type of strabismus, preoperative and postoperative deviation, procedure performed, and length of follow-up. Surgical success was defined as final alignment of 10 prism diopters (PD) or less unless more than one surgery was required to realign the eyes. RESULTS Twenty-one patients (9 children) were reviewed. Mean age at time of surgery was 28.3 years (range: 3 to 64 years) and mean follow-up was 20 months (range: 6 months to 5 years). Mean preoperative logMAR visual acuity in the deviating eyes (14 right eyes) was 1.4 ± 0.7 (range: 1.0 to 2.8) and mean deviation was 33 PD (range: 15 to 90 PD). All procedures were performed only on the deviating eye (13 recessions and 8 recession-resection procedures). Mean postoperative deviation was 6.4 PD (range: 0 to 25 PD) and 81% of patients had a manifest ocular deviation of 10 PD or less. Surgical success was comparable in children versus adults (P = .603), in patients with esotropia versus exotropia (P = 1.000), in patients with preoperative deviations larger than 30 PD compared to patients with smaller deviations (P = .521), and in patients in whom one muscle was operated on compared to all other patients (P = .617). CONCLUSIONS Strabismus surgery in patients with unilateral vision loss is often successful in correcting ocular misalignment.