Judy H. Seaber

Management of the Posterior Capsule During Pediatric Intraocular Lens Implantation

One of the major obstacles in pediatric intraocular lens implantation has been the subsequent dense opacification of the posterior capsule. We used a modification of the standard pediatric cataract surgical procedure, which involved endocapsular cataract extraction, posterior chamber intraocular lens implantation, pars plana posterior capsulotomy, and pars plana anterior vitrectomy in 20 consecutive patients with unilateral traumatic, radiation-induced, and developmental cataracts. Visual axes were rapidly restored in all patients without further intervention for posterior capsule opacification. Visual acuity returned to 20/40 or better in all patients and 75% of all patients (15 patients) reached maximum improvement by five weeks. No complications attributed to intraoperative removal of the posterior capsule occurred.

Unilateral pseudophakia in children under 4 years

PURPOSE We examined the efficacy of intraocular lens implantation (IOL) in children younger than 4 years of age for unilateral aphakic visual rehabilitation. METHODS Twenty-one patients underwent unilateral cataract extraction, IOL placement, posterior capsulotomy, and anterior vitrectomy between 1990 and 1994. Postoperative vision, refractive change, and complications were monitored prospectively. Two cataract subgroups were analyzed: 12 patients with infantile (congenital and developmental) cataracts, and nine patients with posttraumatic cataracts. RESULTS Overall age at surgery averaged 26 months (range 9 to 44 months), with follow up of 5 to 55 months. Fifty-two percent achieved 20/40 or better vision: 42% in the infantile group and 67% in the traumatic group. IOL power averaged 22.6 diopters (D). The difference between predicted and actual postoperative refraction was less than 1 D in 70%. After 6 months, the average change in refraction was 0.50 D (21 patients). An increasing myopic shift of 1.10 D at 12 months (14 patients), 1.80 D at 18 months (nine patients), and 2.90 D after 24 months (eight patients) was noted. This trend was greater in the infantile group. Amblyopia treatment was implemented in 18 patients. Half have completed occlusion successfully, one third continue therapy, 17% are treatment failures, and 11% (two patients) were lost to follow up. Six patients required strabismus surgery; five had infantile cataracts. Postoperative complications occurred in four eyes, two infantile and two traumatic; they consisted of posttraumatic temporal IOL dislocation, corectopia, partial pupillary capture of an IOL, and partial pupillary membrane. CONCLUSION Primary IOL implantation is an effective way to rapidly achieve aphakic visual rehabilitation in preschool children. We continue to evaluate the long-term safety and effects of pediatric pseudophakia.

Traumatic Superior Oblique Palsies

The differences in the clinical and diagnostic characteristics of 33 consecutive traumatic unilateral (21 patients, 62%) and bilateral (12 patients, 38%) superior oblique palsies were studied. The unilateral palsies had a large hypertropia in primary position, more vertical than torsional diplopia, a compensatory head tilt to obtain fusion, and a positive Bielschowsky head tilt test. In contrast, the bilateral palsies had small hypertropias in primary gaze that alternated on right and left gaze, a large V-pattern esotropia with excyclotorsion that was frequently bilateral, and a compensatory head position with fusion in upgaze. The results of the study indicate that a V-pattern in excess of 25 prism diopters, an excyclotorsion of greater than 10 degrees, or head trauma severe enough to cause loss of consciousness should also signal bilateral involvement. Torsional diplopia was present in only 20% of unilateral palsies vs 75% of bilateral palsies. The Bielschowsky head tilt test was diagnostic in 100% of the patients with unilateral palsy and 83% of the patients with bilateral palsy. It was undiagnostic in the supine position in all patients. Spontaneous resolution occurred in 65% of the unilateral palsies but in only 25% of the bilateral palsies. Surgical correction was successful in relieving persistent symptoms.

Adaptation to monocular torsion after macular translocation

Abstract• Purpose: To document the functional outcome of two patients following successful macular translocation for the treatment of severe subretinal hemorrhage in age-related maculopathy. • Methods: The retina was surgically rotated around the optic nerve with translocation of the fovea either upward or downward to an area of healthy retinal pigment epithelium. In the postoperative period, visual function was carefully studied with emphasis on adaptation to torsion. • Results: Visual acuity in one patient improved from 2/200 to 20/80 and the other patient remained at 20/200. Both patients developed horizontal and vertical strabismus with torsion of up to 55°. After a prolonged period of occlusion of the unoperated eye, both patients were subjectively able to adapt to monocular torsion. However, adaptation under binocular conditions did not occur. • Conclusion: Macular translocation was successful in improving visual acuity in one patient, with no improvement in the second. Both patients had significant ocular torsion and strabismus, but under monocular conditions they were successful in perceptually adapting to the change in the visual environment. Fear of cyclotorsion should not be a deterrent to considering macular translocation as a possible treatment option for severe subretinal macular hemorrhage if the patient is willing to accept monocular vision.

Secondary Posterior Chamber Intraocular Lens Implantation in Pediatric Patients

PURPOSE To report results of secondary posterior chamber intraocular lens (IOL) implantation in previously aphakic pediatric patients. METHODS In 19 pediatric patients, 19 aphakic eyes (11 after infantile and eight after traumatic cataract surgery) received secondary sulcus-fixated posterior chamber IOL implants. RESULTS Visual acuity of 20/40 or better was achieved with IOL implantation and overrefraction in three of 11 infantile (27%) and six of eight traumatic cataract patients (mean follow-ups, 18.1 months [range, 8 to 29 months] and 18.0 months [range, 6 to 28 months]), respectively. Eighteen of 19 patients (95%) demonstrated postoperative vision equal to or better than preoperative levels; 15 of 19 patients (79%) showed improved vision after IOL implantation. The mean +/- SD difference between actual and predicted postoperative refraction at 1 month was -0.97 +/- 0.96 diopter. Average refractive error at last examination was -0.40 +/- 2.43 diopters. Amblyopia therapy was performed in 14 patients. One IOL required repositioning 8 months postoperatively. Strabismus was present in 14 patients before and 13 patients after IOL implantation, requiring surgery in four patients. CONCLUSIONS Secondary IOL implantation can be performed successfully in carefully selected pediatric patients. Visual acuity results are better in eyes with a history of traumatic cataract and are influenced by patient compliance. The short-term risks of the procedure appear no greater than those of primary IOL implantation, and complications resemble those seen in adults.

Comparison of ocular motor effects of unilateral stereotactic midbrain lesions in man

A series of 22 patients with stereotactic lesions in the rostral dorsolateral mesencephalon are presented. Lesion I was larger than Lesion II. more irregular in size. and extended further laterally and dorsally at the level of the superior colliculus. Lesion II was maller and placed within 5 mm of the midline aqueduct and 5 mni caudally from the posterior commissure. Lesion I created paralysis of elevation. depression. and convergence and induced pupillary miosis in all patients. Lesion II appeared to spare elevation in all patients but one, and it tended to produce skew deviation in conjunction with divergence pnralysis in three patients and an associated convergence paralysis in only one patient. Three patients suffered a paralysis of convergence. Pupils were symmetrically miotic in three patients out of the six with Lesion II. Conclusions from this indicate that perhaps Lesion I at the posterior commissure was interfering with the crossing fibers subserving vertical gaze, convergence and pupillary reac...

Dyskinetic Strabismus as a Sign of Cerebral Palsy

We found dyskinetic strabismus in 66 patients with cerebral palsy. The most striking feature of dyskinetic strabismus is the fluctuation from esotropia to exotropia under the same accommodative conditions with a slow tonic deviation similar to a vergence movement. With increasing age, exodeviation becomes more prevalent. Dyskinetic strabismus is seen exclusively in cerebral palsy patients. Many of these patients have an athetoid component to their disorder. The association of dyskinetic strabismus with athetosis and upward gaze palsy suggests that the basal ganglia may be the site of the malfunction. The strabismus responds poorly to surgery and the associated athetosis is important in the diagnosis and treatment of cerebral palsy.

Strabismus after retinal detachment surgery: etiology, diagnosis, and treatment.

Between 5% and 25% of patients may experience persistent diplopia after surgery for retinal detachment. The complexity of the presentation poses a distinct challenge to both the retinal and the strabismus surgeon. Careful evaluation to determine factors contributing to the strabismus and assessment of fusional capabilities are essential before treatment. A combination of the appropriate surgical approach with nonsurgical adjuncts such as prisms or botulinum toxin is often successful in relieving symptoms.

What is an Orthoptist

The role of the Orthoptist has expanded greatly over the years from the traditional areas of binocular vision disorders and problems with eye coordination such as strabismus (turned eye) and amblyopia (reduced vision). Now Orthoptists may be found working in diverse areas such as: Ophthalmic clinics in Public Hospitals and the Private sector Early Childhood and Community Health including vision screening Rehabilitation and Low Vision clinics Private Orthoptic practises and “sports” vision Centres caring for the developmentally delayed, handicapped and visually impaired

Monocular Cues Control Binocular Alignment

By haploscopic presentation of lines in various orientations, holding overall binocular percept constant, it was experimentally demonstrated that monocular cues control the stability of the alignment of the eyes.