John D. Roarty

Long-term Visual Morbidity of Cytomegalovirus Retinitis in Patients with Acquired Immune Deficiency Syndrome

BACKGROUND Patient survival with the acquired immune deficiency syndrome (AIDS) and cytomegalovirus (CMV) retinitis is increasing because of earlier diagnosis and improved medical therapy. Visual morbidity that occurs with prolonged survival has not been well described. METHODS To evaluate the progression of retinitis, ocular complications, and visual morbidity, the authors retrospectively reviewed the records of 22 patients who had tested positive for human immunodeficiency virus since December 31, 1987. Each patient had an ophthalmologic diagnosis of CMV retinitis and had survived for a minimum of 6 months after diagnosis of retinitis. Patients were treated with intravenous ganciclovir alone, ganciclovir followed by foscarnet, or foscarnet alone (1 patient). RESULTS Mean survival was 16.7 months after the diagnosis of retinitis. The retinitis progressed in 74% of eyes during therapy. Visual acuity of 20/70 or worse occurred in 79% of eyes at a mean of 7.6 months from diagnosis of CMV retinitis. No light perception occurred in 49% of eyes after a mean of 15 months patient survival. Eleven patients with visual acuity of 20/70 or worse in both eyes survived a mean of 11 months. In 39 eyes with CMV retinitis, the following complications occurred: retinal detachment (33%), papillitis (32%), branch retinal artery occlusion (10%), persistent iritis (5%), and cataract (2.5%). CONCLUSION Improved modalities of therapy will continue to increase the survival of patients with AIDS and CMV retinitis. Progression of the retinitis occurs with current therapeutic regimens in the majority of patients. As survival increases, significant visual loss and ocular complications may compromise patient care and quality of life.

Improvement of Compensatory Head Postures after Strabismus Surgery

PURPOSE To determine the incidence and relative frequencies of orientations of compensatory head postures (CHP) and success in surgically treating the CHP seen in patients with pure lateral rectus paresis (group I), superior oblique paresis (group II), Duane syndrome (group III), Brown syndrome (group IV), and congenital motor nystagmus (group V). METHODS The authors retrospectively reviewed all patients assessed and treated between 1985 and 1991 with these five conditions. Frequencies and orientations of the CHP were determined in all patients in each group. The success of surgery in eliminating the CHP in the subgroups of patients who underwent surgery to treat the CHP also was determined. RESULTS The frequencies of CHP were 29.0% of 93 group I cases, 71.2% of 139 group II cases, 68.1% of 91 group III cases, 17.4% of 35 group IV cases, and all 23 group V cases, for an overall incidence of 56.7% of 381 patients. For patients who underwent surgery to eliminate a CHP, success rates were 85.7% of 21 group I cases, 75.6% of 41 group II cases, 87.2% of 47 group III cases, 100% of 5 group IV cases, and 78.3% of 23 group V patients, for an overall success rate of 82.5% of 137 surgical cases. CONCLUSION Because CHP is seen frequently in strabismus and nystagmus disorders, ocular causes must be ruled out in any case of an anomalous head posture. Appropriately planned surgery for CHP caused by incomitant strabismus or eccentric nystagmus null zones has a high rate of success in eliminating CHP.

Management of Complicated Facial Hemangiomas with β-Blocker (Propranolol) Therapy

Hemangiomas are the most common tumors of childhood, affecting 5 to 10 percent of infants.1 They have a predilection for the head and neck region, affect girls more than boys, are seen in premature infants more than in fullterm infants, and are present in Caucasians more than in other ethnicities. These benign tumors have a classic histologic appearance, with plump, proliferative endothelial cells, and often have GLUT-1 positivity. Although having a somewhat predictable natural history evidenced by periods of proliferation, plateau, and involution, the timing of these distinct stages, the presence of complications, and the response to therapy are best characterized as unpredictable.2,3 Often, expectant observation is all that may be requisite for managing uncomplicated infantile hemangiomas. However, lesions in the facial region may result in ocular or airway complications in addition to permanent aesthetic facial disfigurement or deformity and impart significant psychological distress to caregivers.4 A variety of medical and surgical methods to manage these lesions have been described. Recent reports have espoused propranolol therapy for the treatment of infantile hemangiomas, although treatment guidelines to date have not been elucidated.5–8 The present report describes the successful management of two patients with large facial amblyogenic infantile hemangiomas with the use of propranolol in the setting of failed oral corticosteroid therapy.

Efficacy of brinzolamide and levobetaxolol in pediatric glaucomas: A randomized clinical trial

PURPOSE To describe the safety and clinical response on elevated intraocular pressure (IOP) of brinzolamide and levobetaxolol in pediatric patients under 6 years of age. METHODS A double-masked, randomized design. Pediatric patients were randomized to brinzolamide suspension, 1%, or levobetaxolol suspension, 0.5%, both dosed twice daily. IOPs at 9 AM were taken at screening, baseline, and weeks 2, 6, and 12. A descriptive study with mean change from baseline IOP, the primary efficacy parameter. RESULTS Seventy-eight evaluable patients (32 brinzolamide and 46 levobetaxolol). Patients on no prestudy IOP-lowering therapy randomized to brinzolamide had mean IOP change from baseline ranging from -4.1 mm Hg (week 2) to -5.0 mm Hg (week 6). When all brinzolamide patients are considered, there was little mean change from baseline IOP due to the large number of patients enrolled without a washout of prior IOP-lowering therapy. Levobetaxolol patients had mean change from baseline, ranging from -1.8 mm Hg (week 6) to -2.9 mm Hg (week 2). Levobetaxolol patients on no prestudy therapy had mean IOP change from baseline ranging from -2.9 mm Hg (week 12) to -4.0 mm Hg (week 2). Brinzolamide was more efficacious for glaucoma associated with systemic or ocular abnormalities and less efficacious for primary congenital glaucoma. Levobetaxolol was most efficacious for primary congenital glaucoma. Adverse events were predominantly nonserious and did not interrupt patient continuation in the study. CONCLUSIONS Both brinzolamide and levobetaxolol were well tolerated. Both drugs provided clinically relevant IOP reductions for patients not on a previous medication, although efficacy is, in part, contingent upon diagnosis.

Bilateral idiopathic Brown's syndrome with delayed onset in the second eye.

PURPOSE We describe 6 cases of a previously unreported variation of bilateral Browns syndrome that presented in congenital form in one eye and developed later in the fellow eye with no underlying cause. METHODS We reviewed the clinical records of 6 patients from 6 separate practices to determine whether there were any common clinical features on presentation or in their clinical courses. RESULTS All 6 patients were diagnosed with unilateral congenital Browns syndrome at the first ophthalmologic assessment but showed no evidence of the syndrome in the fellow eye. In 5 cases the contralateral syndrome developed in the second eye after surgery was performed on the first eye, and in 1 case it developed before any surgery was done. The ages at onset of the syndrome in the second eye ranged from 2 to 8 years. None of the children had any evidence of systemic illness or local orbital disease to explain an acquired Browns syndrome. CONCLUSION To our knowledge, this is the first reported series of cases of bilateral Browns syndrome that manifested sequentially in the eyes with no known causes for an acquired syndrome in the second eye. This finding supports the premise that congenital and acquired Browns syndrome are on a continuum with a common pathophysiology of restriction of free movement of the superior oblique tendon in the trochlea.

Masked bilateral superior oblique palsy in children

PURPOSE Following surgery on an eye for unilateral superior oblique palsy, it is a well-recognized postoperative occurrence for the unoperated eye to develop superior oblique palsy, commonly referred to as masked bilateral superior oblique palsy. The purpose of this study was to describe this postoperative finding in children following unilateral inferior oblique weakening surgery. METHODS A retrospective review of records of children who underwent unilateral inferior oblique weakening surgery at Childrens Hospital of Michigan, Detroit, Michigan, from 1987 to 2005, including information on the development of masked bilateral superior oblique palsy with contralateral inferior oblique overaction requiring a second surgical intervention. RESULTS Of 50 children (25 boys and 25 girls, mean age: 5.6 years) who underwent unilateral inferior oblique weakening surgery (47 recessions and 3 myectomies), 9 (18%) manifested masked bilateral superior oblique palsy postoperatively, requiring subsequent surgical weakening of the inferior oblique muscle in the unoperated eye. Preoperative primary position hypertropia in children who were eventually diagnosed as having masked bilateral superior oblique palsy (5.56±4.22 prism diopters [PD]) was significantly smaller compared to children with unilateral superior oblique palsy (10.4±6.5 PD, P=.012), and preoperative primary position hypertropia of less than 5 PD was associated with an odds ratio of 8.2 (95% confidence interval: 1.7 to 38.5, P=.008) for requiring reoperation. CONCLUSIONS Masked bilateral superior oblique palsy is a possible outcome after surgery for the correction of pediatric unilateral superior oblique palsy. Parents should be informed of this possible outcome, especially when primary position hypertropia is less than 5 PD.

The Role of Stereopsis and Binocular Fusion in Surgical Treatment ofIntermittent Exotropia

Background/Aims: The purpose of this study is to identify the appropriate timing for surgical treatment of intermittent exotropia (XT) in the pediatric population by examining several parameters that may contribute to surgical planning. Methods: A retrospective chart review was conducted on patients between the ages of 3 and 17 years undergoing surgical management for intermittent XT. Preoperative and postoperative data regarding age, past medical history, visual acuity, stereopsis, magnitude of deviation and control was recorded. Medical records were reviewed and analyzed to determine if preoperative control of near misalignment, stereopsis, or presence of amblyopia may play a role in surgical outcome. Results: Ninety-five patients met inclusion criteria. Mean age was 6.71 years. Mean follow up period was 10.79 months. At least 140 sec arc of stereopsis using Titmus testing was present in 39.5% of patients preoperatively, while 55.8% of patients had less than 140 sec arc preoperatively, indicative of poor fusion at near. 47.2% of patients had good control of the near misalignment preoperatively, while 52.7% of patients had fair to poor control preoperatively. There was no statistically significant difference in surgical outcomes when comparing preoperative level of control of misalignment at near (P=0.2284) and stereopsis (P=0.2537). Presence of amblyopia preoperatively also had no association with surgical outcome (P=1.00). Conclusion: The use of worsening stereopsis and/or alignment control at near as parameters to determine the appropriate time for surgical intervention does not predict improved outcomes in patients with intermittent XT.