Kathryn M Brady McCreery

Use of augmented rectus muscle transposition surgery for complex strabismus

PURPOSE Full tendon rectus muscle transposition surgery augmented with posterior fixation sutures has been shown to be effective in the treatment of abducens palsy and Duanes syndrome. The purpose of this study is to summarize our experience with the use of this procedure and a three fourths partial tendon transposition modification of this procedure for a variety of complex vertical and horizontal paralytic eye movement disorders. DESIGN Retrospective noncomparative interventional consecutive case series. PARTICIPANTS Eighteen patients with paralytic strabismus. INTERVENTION Full tendon rectus muscle transposition procedure augmented with posterior fixation sutures (13 patients) or a three fourths partial tendon transposition augmented with posterior fixation sutures (5 patients). MAIN OUTCOME MEASURES Resolution of diplopia in the primary position and improved ocular alignment. RESULTS Comparing preoperative to postoperative status, presence of primary position diplopia decreased from 64% to 14%, anomalous head posture decreased from 56% to 6%, and primary position alignment improved in all patients. CONCLUSIONS Full tendon rectus muscle transposition surgery augmented with posterior fixation sutures and the vessel-sparing three fourths partial tendon transposition modification of this technique are effective for the treatment of a variety of complex vertical and horizontal paralytic ocular motility disorders.

Epithelial healing and ocular discomfort after photorefractive keratectomy in children

Objective: To document the rate of healing of the corneal epithelial defect created by photorefractive keratectomy (PRK) and the degree of discomfort experienced by children treated with PRK. Setting: Baylor College of Medicine, Texas Childrens Hospital, Houston, Texas, USA. Methods: Ten patients between 3 and 10 years of age were treated with PRK for severe anisometropia. All had anisometropic amblyopia refractory to conventional therapy with glasses or contact lenses and occlusion therapy. The size of the corneal epithelial defect was documented daily until the defect healed completely. Postoperative discomfort was documented daily using a pain‐assessment scale until the epithelial defect healed completely. Results: Two children were treated with PRK for hyperopic anisometropia; the rest were treated for myopic anisometropia. Cumulatively, the corneal epithelium had healed completely by day 3 in 6 patients (60%), by day 4 in 9 patients (90%), and by day 5 in all patients. The mean healing time was 3.5 days. Patients experienced mild discomfort on the day of surgery and on the first postoperative day. They had minimal pain on day 2. After day 2, no patient reported pain or other discomfort. Conclusion: The corneal epithelial defect created by PRK healed promptly and was associated with minimal postoperative discomfort in children treated with the protocol described.

Nasolacrimal outflow drainage anomalies in down’s syndrome ☆

PURPOSE To describe structural abnormalities of the lacrimal drainage system and outcomes after treatment for lacrimal outflow obstruction in children with Downs syndrome. DESIGN Retrospective comparative interventional case series. PARTICIPANTS Thirty-eight eyes of 22 consecutive Downs syndrome patients who underwent surgical treatment for nasolacrimal drainage obstruction (mean age, 32 months) and 59 eyes of 44 non-Downs syndrome patients who underwent surgical treatment after 2 years of age. MAIN OUTCOME MEASURES Resolution of symptoms after surgery and presence of anatomic abnormalities of the lacrimal drainage system other than persistent Hasners membrane. RESULTS Among the Downs syndrome eyes, complete or partial resolution was noted in 34 (89%) of 38 eyes; 7 (18%) eyes underwent more than 1 procedure. Twenty-eight (74%) of 38 eyes had anatomic anomalies other than persistent Hasners membrane; anomalies proximal to the nasolacrimal sac predominated. In comparison, 50 (85%) non-Downs syndrome eyes experienced complete or partial resolution, and 19 (32%) had anatomic abnormalities other than persistent Hasners membrane; anomalies distal to the nasolacrimal sac predominated. CONCLUSIONS Compared with older non-Downs syndrome patients, nasolacrimal outflow obstruction in Downs syndrome patients is more often complicated by anomalies of the lacrimal drainage system proximal to the lacrimal sac. Despite this, surgery can be similarly successful. Awareness of the possible peculiarities of lacrimal outflow obstruction in Downs syndrome patients may allow better selection and use of available treatment options.

Successful implementation of a protocol for photorefractive keratectomy in children requiring anesthesia

Purpose: To describe a protocol for treating children with photorefractive keratectomy (PRK) under general anesthesia and to review intraoperative and postoperative complications. Setting: Institutional academic practice. Methods: Nine patients between 3 years and 9 years of age were treated with PRK under general anesthesia for anisometropia with unilateral high myopia or high hyperopia and amblyopia of the affected eye. Induction of anesthesia and the surgical procedure were carried out in separate rooms. The laser beam was centered on the entrance pupil, and eye position was monitored throughout the procedure. Specific precautions were taken before and during the procedure to prevent unwanted effects of inhalational anesthetic agents on laser performance. Results: All children did well, with no anesthesia‐related or treatment‐related complications. Conclusions: Our protocol for PRK under general anesthesia was effective and efficient in children who were unable to cooperate for the procedure using local anesthesia. It can be adapted for laser in situ keratomileusis and other refractive surgical procedures in children and uncooperative adults.

Acquired cataracts after diode laser photocoagulation for threshold retinopathy of prematurity

PURPOSE To report the incidence of acquired cataract after diode laser photocoagulation for threshold retinopathy of prematurity at our institution. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS One hundred fifty-three infants (293 eyes) with threshold retinopathy of prematurity. INTERVENTION Transpupillary diode laser photocoagulation. MAIN OUTCOME MEASURE Acquired cataract formation. RESULTS One cataract (0.003%) in 293 eyes occurred after transpupillary diode laser photocoagulation. This cataract consisted of peripheral cortical punctate lenticular opacities that were not progressive or visually significant. CONCLUSIONS The risk of acquired cataract after transpupillary diode laser photocoagulation for threshold retinopathy of prematurity is low. Transpupillary diode laser photocoagulation may be safer than argon laser photocoagulation for treatment of threshold retinopathy of prematurity.

Surgical management of the lens and retrolenticular fibrotic membranes associated with persistent fetal vasculature.

Purpose: To evaluate a surgical technique that allows safe, effective, near‐total removal of retrolenticular fibrotic membranes in eyes with persistent fetal vasculature syndrome (PFVS). Setting: Pediatric ophthalmologists academic practice. Methods: This retrospective review comprised 5 children (6 eyes) who had excision of a retrolenticular fibrovascular membrane during cataract surgery over a 6‐month period. Long, spoke‐like radial incisions of the membrane were made to the ciliary processes, resulting in wedge‐shaped segmentation of the membrane. A vitrector was used to excise each wedge and perform an anterior vitrectomy. Results: The mean age at time of surgery was 8 months (range 1 to 24 months) and the mean follow‐up, 9 months (range 2 to 13 months). The membrane was successfully removed in all eyes. One eye of a patient who did not comply with the postoperative medical regimen or follow‐up developed pupillary block glaucoma requiring pupilloplasty and trabeculectomy. Conclusion: This anterior surgical technique to remove tenacious retrolenticular membranes associated with PFVS was effective, allowing near‐total removal of the offending fibrovascular membrane.

Migration to aphakia and contact lens treatment is the trend in the management of unilateral congenital cataract in Britain and Ireland

BackgroundThe Infant Aphakia Treatment Study (IATS) compared the treatment of unilateral cataract in infants aged 1–6 months with primary intraocular lens (IOL) implantation vs aphakia with contact lens (CL) correction.AimsThis study aims to assess the current trends in the treatment of unilateral congenital cataract in infants less than 6 months at surgery in the UK and Ireland.MethodsAn anonymous survey was emailed to the 200 members of the BIPOSA mailing list with 14 questions to assess treatment choice (primary intraocular lens (IOL) vs aphakia with contact lens (CL)), reasons for this choice, and assessment of local CL services.ResultsThere were 56 respondents, 39 of whom completed the entire survey. Aphakia with CL was the treatment choice for 74.4% of respondents. A quarter (25.6%) of respondents said they were performing primary IOL implantation prior to the publication of the Infant Aphakia Treatment Study (IATS), but now choose aphakia with CL. Amongst the 20.5% (n = 8) of respondents who chose primary IOL implantation, 5 attributed their choice to “inadequate CL service”. The majority (84.6%) of respondents rated their infant CL service as either “good” or “very good”.ConclusionAphakia with CL rehabilitation was the most common approach to the treatment of unilateral congenital cataract in infants less than 6 months in this study. The results of the IATS appear to have influenced a change in practice from primary IOL implantation to aphakia and CL visual rehabilitation in approximately one quarter of those surveyed.