John D. Baker

Early-Onset Accommodative Esotropia

Twenty-one patients had esotropia diagnosed before age 12 months. In all of these patients esotropia was eliminated, at least initially, by antiaccommodative therapy consisting of either full hypermetropic spectacles or miotics, or both. Clinical findings evaluated in these patients were comparable to similar clinical factors studied in a larger series of patients with accommodative esotropia, most with onset after 12 months of age. In approximately 50% of these patients early-onset accommodative esotropia deteriorated to a nonaccommodative esotropia that required surgery despite aggressive antiaccommodative therapy. All but one of the surgically treated patients continued to need hypermetropia spectacles postoperatively to maintain alignment.

Refractive Changes following Strabismus Surgery

A retrospective study of two hundred ninety-two surgical strabismus charts was accomplished, looking for changes in refraction following strabismus surgery. A greater than one diopter change in ast...

Accommodative esotropia following surgical correction of congenital esotropia, frequency and characteristics*

This study was undertaken to look at the development of accommodative esotropia, which occurs following the surgical correction of congenital esotropia. A restrospective review was done on all congenital esotropia patients operated on by one of the authors from 1974 through mid-1984. The criterion of a minimum of 3 years postsurgical follow-up was met by 101 patients. Of these patients, 52 developed accommodative esotropia, 25 within 3 months of surgery and 27 from 3 to 60 months after surgery. The average preoperative refractive error in the early group was +3.90 and +1.95 in the later group. The average time to develop accommodative esotropia in this group with later onset was 27 months following the initial surgery. It would appear that if the preoperative refractive error is +3.00 or more, and especially if the preoperative deviation responds to spectacles with a reduction of 15 prism diopters or more, then it is very likely that glasses will be required for accommodative esotropia very soon following surgery. There appear to be no clues as to which patients will need glasses later for accommodative esotropia.

The medial rectus muscle insertion site in infantile esotropia

The distance from the corneoscleral limbus to the insertion site of the medial rectus muscle was measured at several stages of medial rectus recession surgery in 20 patients (40 eyes) with infantile esotropia. Disinsertion of the medial rectus muscle resulted in a mean reduction in the distance from the muscle insertion site to the corneoscleral limbus of 0.903 mm (P less than .001), whereas the use of fixation forceps on the insertion to abduct the eye resulted in an additional mean reduction of 0.306 mm (P less than .01). The strabismus surgeon often uses the muscle insertion site as a reference point in determining the desired location for recessing a muscle. Our results suggest that this method of measurement is unreliable in infantile esotropia because the position of the medial rectus muscle insertion site varies considerably during surgery.

The role of the random dot Stereo Butterfly test as an adjunct test for the detection of constant strabismus in vision screening.

BACKGROUNDnA goal of vision screening is the detection of amblyopia risk factors, including strabismus. The random dot Stereo Butterfly test requires no instruction, has a simple pass/fail response with no monocular clues, and is easily administered. The purpose of this study was to determine whether this test could be used as a cost-effective and reliable component of preschool vision screening.nnnMETHODSnThe Stereo Butterfly was presented to children with no previous history of ocular problems or treatment. The test was presented with the use of polarized glasses at a 16-inch testing distance. A pass was recorded if the patient reported seeing a butterfly; a refer was denoted otherwise. Vision and motility measurements were recorded, and the patient underwent a complete eye examination with cycloplegic refraction.nnnRESULTSnA total of 281 children 3 to 6 years of age were tested: 221 children passed the test. Of those who passed, 7 (3.2%) had intermittent strabismus, 1 had a small-angle constant strabismus, 60 failed screening for constant strabismus (of whom 24 [40%] had constant strabismus), and 6 were false-negative results. The sensitivity of the Stereo Butterfly for detecting constant strabismus was 96%; the specificity, 86%.nnnCONCLUSIONSnThe Stereo Butterfly test may be a valuable adjunctive tool in vision screening programs for the detection of manifest strabismus because it is easy to administer and effectively detects constant strabismus. It has a high specificity for detection of constant strabismus but, if used alone, the low positive predictive value would allow for many false-positive results.

Improved infection control compliance using isolation signs that incorporate standardized colors, visual cues, and sequenced instructions.

To the Editor: Maintaining isolation precautions is an important component of hospital infection control. This is especially true on pediatricwards, where the high prevalence of viral infections, diapering, and lack of proper respiratory etiquette contribute to nosocomial infections. Unfortunately, compliance with infection control guidelines is often low, and caregivers frequently fail to follow proper isolation practices. Improved infection control compliance can be achieved in the pediatric setting by monitoring adherence and providing onsite education. Here we report increased compliance with isolation precautions in a children’s hospital following a quality improvement study that resulted in the introduction of isolation signs incorporating standardized colors, visual cues, and sequenced instructions (Fig 1). The Cleveland Clinic Children’s Hospital is a 95-bed hospital comprising 6 pediatric units. The study began byassessingbaseline compliancewithcontactanddroplet precautions between June 23, 2008 and October 6, 2008on thepediatric intensive care unit, neonatal intensive care unit, and 4 general floors of the Children’s Hospital. When isolation precautions were ordered, a white sign with a red stop sign was placed on the door. Words andpictures described the appropriate precautions to be taken.Baseline compliancewaspoor, as definedbycompleting the following steps: performing hand hygiene before donning appropriate personal protective equipment (PPE), wearing PPE before entering the room, removing PPE before exiting the room, and performing hand hygiene after removing PPE. Informal discussions with caregivers revealed confusion about the specific requirements of different types of isolation precautions and the failure of isolation signs to clarify this confusion. To determine whether improved isolation signs would enhance infection control compliance, we worked with a graphic designer to create a new set of isolation precaution signs that incorporated standardized colors, visual

Orbital sonography in children

Orbital sonography with color-flow Doppler imaging is a relatively new technology with significant application in the pediatric patient. This review stresses the primary indications for pediatric ophthalmic ultrasound and also discusses those instances where the use of ultrasound supplements other imaging studies.