Leonard B Nelson

RESULTS OF LATE PROBING FOR CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION

One hundred four consecutive patients (138 eyes) with congenital nasolacrimal duct obstruction were probed after the age of 13 months. One hundred twenty-nine eyes (93.5) were cured after the first probing. Based on this study and others showing the effectiveness of medical management, it is the current practice of the authors to delay probing until the patient is at least 13 months of age.

Persistent strabismus presenting after cataract surgery.

To determine causative factors of persistent strabismus presenting after cataract surgery, the surgical techniques and subsequent motility findings of eight patients who had persistent postoperative strabismus were studied. In two of the eight patients, complications related to the placement of the bridle suture were believed causative based on subsequent surgical findings. A similar etiology could be speculated in an additional three patients. An isolated vascular accident coincident to the cataract operation could account for a sixth case. The final two patients were believed to have a decompensated congenital fourth nerve palsy. In no patients could the myotoxic effect of a local anesthetic or the hypoxic effect of an ocular pressure-reduction device plausibly account for the deviation.

Surgical management for abnormal head position in nystagmus: the augmented modified Kestenbaum procedure.

Patients with nystagmus and an eccentric null point in lateral gaze may assume an abnormal head position to maximise visual acuity. Surgical procedures for this condition can result in significant undercorrection of the head turn. A follow-up of 15 patients for an average of 33 months revealed a sustained improvement in head position with the use of the augmented modified Kestenbaum procedure.

Primary Glaucoma Associated with Iridotrabecular Dysgenesis and Ectropion Uveae

We present nine patients with unilateral congenital ectropion uveae (hyperplasia of the iris pigment border), iris hypoplasia, characteristic gonioscopic findings, and glaucoma. A majority of these patients also demonstrated mild ptosis. In none of these patients were there any associated systemic abnormalities. The apparent ectropion uveae results from spread of the iris pigment epithelium beyond the iris ruff and onto the anterior surface of the iris. In two patients with this abnormality, histopathologic and electron microscopic findings are presented. All patients with congenital ectropion uveae should be carefully examined periodically to detect glaucoma.

Silsoft Extended Wear Contact Lenses in Pediatric Aphakia

Fifty pediatric aphakic patients, ranging in age from 7 days to 11 years, were fitted with the Silsoft extended wear contact lens. Compared to other extended wear lenses, the Silsoft lens has several advantages. These include easier handling, a less traumatic fitting procedure for the child, the use of fluorescein for evaluation of the lens-cornea relationship and a low loss rate. This lens appears to be safe, with no permanent adverse effects on the cornea.

Acute acquired comitant esotropia.

Acute acquired comitant esotropia has been used to describe a dramatic onset of a relatively large angle of esotropia with diplopia and minimal refractive error. We describe six children aged 5 to 11 years who developed an acute non-accommodative esotropia with diplopia. Neurological examination, including CT scan, in each of these children gave negative results. We suggest that this is an unusual presentation of esotropia of undetermined aetiology. The diagnosis, clinical characteristics, and management are discussed.

Surgical management of large angle congenital esotropia.

Ninety-seven patients with congenital esotropia with deviations of 50 prism dioptres or greater underwent large (6 and 7 mm) bimedial rectus recessions. The overall success rate with one operation was 83.5%. Judgment of final alignment was made at the last follow-up examination, six to 61 months (average 23.4 months) postoperatively. Large bimedial rectus recessions for congenital esotropia are an effective surgical treatment which does not significantly alter adduction.

An Alternative Approach to the Surgical Management of Exotropia-The Unilateral Lateral Rectus Recession

Fifty-five patients with moderate angle exotropia of 15 to 20 prism diopters were surgically treated with a unilateral lateral rectus recession of 7.0, 7.5, or 8.0 mm. The mean age at surgery was 14.5 years. The mean preoperative deviation was 18.0 delta. The mean lateral rectus recession was 7.6 mm. At the initial postoperative follow up, all patients were either a small-angle exotropia or esotropia, or orthophoric. Twenty-eight of the 55 patients (51%) were orthophoric at their most recent follow up. Twenty-four patients (44%) were undercorrected, with 22 of these having residual exodeviations less than 8 delta. Three patients (5%) were overcorrected.

Simultaneous Surgery for Bilateral Congenital Cataracts

In about one third of patients congenital cataracts are bilateral. If the cataracts are dense, and the patient an infant, bilateral simultaneous cataract removal reduces anesthetic risk, hospital stay, and cost and allows earlier optical correction. This study represents a retrospective survey of 32 eyes (16 cases) with simultaneous surgery for bilateral congenital cataracts. Bilateral simultaneous surgery can be performed to avoid a second general anesthesia in infants who have bilateral dense congenital cataracts.

Peribulbar Anesthesia for Strabismus Surgery

We prospectively studied 76 patients to analyze the effectiveness of peribulbar anesthesia during strabismus surgery. The patients, ranging in age from 14 to 77 years, were given anesthesia with standard preoperative medication and a peribulbar injection of a mixture of 2% mepivacaine hydrochloride and hyaluronidase. Only one of the 76 patients required an additional injection of anesthetic to achieve adequate anesthesia. No morbidity was associated with the peribulbar anesthesia. Local anesthesia, particularly retrobulbar anesthesia, has been used as an alternative technique in an attempt to reduce the morbidity and mortality associated with general anesthesia in ocular surgery, particularly in those patients with high-risk characteristics. Even with retrobulbar anesthesia, however, there is a risk of morbidity and, in rare cases, mortality. Our results suggest that the use of peribulbar anesthesia is a safe and effective means of anesthesia in strabismus surgery because of minimal associated morbidity.