Hilda Capo

Ipsilateral Hypertropia after Cataract Surgery

BACKGROUND Reports of acquired strabismus caused by injection of local anesthetics during cataract surgery have increased recently. The authors proposed a mechanism to explain the occurrence of strabismus with apparent overactive muscles after cataract surgery. METHODS The authors studied 19 patients in whom strabismus developed after cataract surgery. Prism and cover test in the diagnostic positions of gaze and forced-duction testing were used to identify the affected muscles. RESULTS The deviation was greater in the field of action of the presumed tight muscle in 16 of 19 patients. An ipsilateral hypertropia with superior rectus muscle overaction subsequently developed in two patients with an initial hypotropia. An overaction of the ipsilateral lateral rectus muscle causing an exotropia developed in one patient with initially limited abduction. CONCLUSIONS Myotoxicity from direct injection of local anesthetics into an extraocular muscle probably causes transient paresis followed by segmental contracture of the involved muscle. Mild contractures result in strabismus with a motility pattern of an overactive muscle. Larger amounts of contracture lead to restrictive strabismus. The risk of strabismus may be decreased by administering the local anesthetic into sub-Tenon space using a blunt-tipped cannula when performing cataract surgery.

Validity of the convergence insufficiency symptom survey: a confirmatory study.

Purpose. The objectives of the present study were to evaluate whether investigator bias influenced the Convergence Insufficiency Symptom Survey (CISS) scores of children with normal binocular vision (NBV) in our original validation study, reevaluate the usefulness of the cutoff score of 16, and reexamine the validity of the CISS. Methods. Six clinical sites participating in the Convergence Insufficiency Treatment Trial (CITT) enrolled 46 children 9 to <18 years with NBV. Examiners masked to the child’s binocular vision status administered the CISS. The mean CISS score was compared with that from the children with NBV in the original, unmasked CISS study and also to that of the 221 symptomatic convergence insufficiency (CI) children enrolled in the CITT. Results. The mean (±standard deviation) CISS score for 46 subjects with NBV was 10.4 (±8.1). This was comparable with our prior unmasked NBV study (mean = 8.1 (±6.2); p = 0.11) but was significantly different from that of the CITT CI group (mean = 29.8 ± 9.0; p < 0.001). Eighty-three percent of these NBV subjects scored <16 on the CISS, which is not statistically different from the 87.5% found in the original unmasked study (p = 0.49). Conclusions. Examiner bias did not affect the CISS scores for subjects with NBV in our prior study. The CISS continues to be a valid instrument for quantifying symptoms in 9 to <18-year-old children. These results also confirm the validity of a cut-point of ≥16 in distinguishing children with symptomatic CI from those with NBV.

Microbial Keratitis in Childhood

BACKGROUND Microbial keratitis occurs infrequently in childhood. The leading ocular predisposing factors are trauma and preexisting corneal disease. Many of the age-related risk factors in adults play a minor role in children. METHODS The authors retrospectively studied 51 eyes with ulcerative keratitis in 50 children younger than 16 years of age. This includes all patients treated at Bascom Palmer Eye Institute during an 11 1/2-year period from January 1, 1980, to June 30, 1991. The criterion for inclusion in the study was a discharge diagnosis of microbial (nonviral) keratitis. RESULTS The principal risk factors identified in this study were trauma (44%), prior corneal surgery (24%), systemic illness (14%), and contact lens wear (12%). Systemic illness or an immunocompromised state existed in 7 (47%) of the 15 children younger than 3 years of age. There was a large male preponderance (68%). Forty-four (86.3%) of the 51 eyes were culture-positive; six (11.7%) were polymicrobial. Five of seven culture-negative patients had received prior topical antibiotic therapy. Pseudomonas aeruginosa (34%), Staphylococcus aureus (20%), and fungi (18%) were the most common organisms isolated. Seven (14%) eyes required surgery. CONCLUSION This study presents important differentiating factors between adult and childhood nonviral microbial keratitis. Identification of principal risk factors in children may aid in early recognition and treatment of microbial keratitis.

A strabismus susceptibility locus on chromosome 7p

Strabismus has been known to have a significant genetic component, but the mode of inheritance and the identity of the relevant genes have been enigmatic. This paper reports linkage analysis of nonsyndromic strabismus. The principal results of this study are: (i) the demonstrated feasibility of identifying and recruiting large families in which multiple members have (or had) strabismus; (ii) the linkage in one large family of a presumptive strabismus susceptibility locus to 7p22.1 with a multipoint logarithm of odds score of 4.51 under a model of recessive inheritance; and (iii) the failure to observe significant linkage to 7p in six other multiplex families, consistent with genetic heterogeneity among families. These findings suggest that it will be possible to localize and ultimately identify strabismus susceptibility genes by linkage analysis and mutation screening of candidate genes.

Foveal Structure–Function Correlation in Children With History of Retinopathy of Prematurity

PURPOSE To correlate visual acuity to macular spectral-domain optical coherence tomography (SD OCT) anomalies detected in children with a history of retinopathy of prematurity (ROP). DESIGN Retrospective cohort study. METHODS All charts of children with a history of ROP between 2 and 18 years of age and with SD OCT performed between 2010 and 2012 were reviewed. Central foveal thickness was measured and correlated with visual acuity. Secondary outcome measures included temporal parafoveal thickness, presence of the inner nuclear layer and outer segment, gestational age at birth, sex, spherical equivalent, history of laser treatment, and developmental delay. RESULTS The study included 44 better-seeing eyes of 44 patients. Sixty-four percent (28/44) of patients in our study had 20/40 or better visual acuity despite an abnormal foveal morphology in 91% of total eyes. CONCLUSION Patients with a history of ROP demonstrate a high frequency of macular morphologic abnormalities, including retention of inner retinal layers and absent foveal depression, on SD OCT. These structural changes do not always correlate to visual acuity. Instead it appears that cone maturation may be a better indicator of visual acuity. In addition, there is a significant correlation between best-corrected visual acuity and myopia.

Surgical technique, visual outcome, and complications of pediatric intraocular lens implantation.

PURPOSE To evaluate retrospectively the surgical technique, visual outcome, and complications of pediatric cataract extraction (CE) and intraocular lens (IOL) implantation. METHODS Forty-three patients ages 2 to 12 underwent CE with IOL implantation with a minimum follow up of 1 month. RESULTS All IOLs were implanted in the posterior chamber with 17 (40%) in the bag, 25 (58%) sulcus fixated, and one (2%) partially in the bag (one haptic in the bag, one in the sulcus). Primary posterior capsulectomy was performed in 12 (28%) cases. A final visual acuity of at least 20/40 was achieved in 26 (60%) and at least 20/80 in 32 (74%). Posterior capsule opacification developed in 18 (42%) and pupillary capture in 7 (16%). Seventeen (40%) patients had postoperative visual acuity worse than 20/40. Of these, nine (53%) had this visual outcome as a result of presumed amblyopia. CONCLUSIONS Posterior chamber IOL implantation affords a safe and effective method of visual rehabilitation for cataractous children 2 years of age and older. Amblyopia and antecedent posterior segment trauma, rather than IOL-related or surgical complications, are the limiting factors in final visual outcome.

Diplopia after glaucoma drainage device implantation

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.

The Use of Titanium T-Plate as Platform for Globe Alignment in Severe Paralytic and Restrictive Strabismus

PURPOSE To evaluate the long-term effectiveness of improved ocular alignment using a suture/T-plate anchoring platform system. DESIGN Retrospective, noncomparative, interventional case series. METHODS setting: Institutional. study population: Seven consecutive patients with large angle deviations attributable to paralytic and/or restrictive strabismus managed jointly by orbital and strabismus surgeons. intervention procedure: The T-plate base is anchored to the orbital rim with the shaft projecting toward the orbital apex to simulate the origin of the affected muscle. A nonabsorbable suture serves as the coupling element linking the muscle insertion to the tip of the T-plate such that the suture coincides with the axis of the dysfunctional muscle and yields a pull vector to simulate the passive tensile force of the muscle. Information analyzed included patient demographics, etiology of strabismus and characteristics, prior muscle surgeries, secondary interventions, subjective appraisal of diplopia, and final ocular alignment measurements. main outcome measures: Subjective appraisal of diplopia, final ocular alignment in primary gaze, and late stability. RESULTS All 7 patients showed marked reduction in ocular deviation with a median change of 33 prism diopters (PD) and a range of 7 to 72 PD. For the 6 patients with medial rectus dysfunction, the final ocular alignment ranged from 6 to 18 PD of residual exotropia in primary gaze. The patient with sixth nerve palsy had 5 PD of residual esotropia. There were no failures after an average of 59.4 months of follow-up. CONCLUSIONS A globe tethering technique using a suture/titanium T-plate anchoring platform system effectively treats refractory cases of paralytic and restrictive strabismus with large angles of deviation.

Distinguishing torpedo maculopathy from similar lesions of the posterior segment.

Torpedo maculopathy is a congenital solitary, oval-shaped lesion typically located temporal to the center of the macula. Congenital hypertrophy of the retinal pigment epithelium (RPE), RPE lesions of Gardner syndrome, and other lesions can present with similar characteristics. Because of its unique clinical and imaging features, torpedo maculopathy generally can be differentiated from other posterior segment lesions.

Optical coherence tomography findings of pigmented fundus lesions in familial adenomatous polyposis

The pigmented fundus lesions associated with familial adenomatous polyposis (FAP) often resemble those characteristic of congenital hypertrophy of the retinal pigment epithelium (CHRPE). However, some fundus lesions in FAP resemble hamartomatous lesions of the retinal pigment epithelium (RPE). Intraretinal extension of the RPE is a feature not seen in CHPRE lesions that may be unique to some of the pigmented lesions of FAP. The authors report the spectral-domain optical coherence tomography findings of the pigmented ocular lesions associated with FAP in a 10-year-old boy.