Marc F. Greenberg

Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis

BACKGROUND Subperiosteal abscess may accompany orbital cellulitis secondary to sinusitis. Common surgical principles include incision and drainage of all abscesses. Previous evidence suggests that some orbital abscesses may be treatable with intravenous antibiotics, especially in young children. Childrens hospital records were reviewed to determine which abscesses may be treated medically. PATIENTS AND METHODS Records of patients admitted for orbital cellulitis from 1993 to 1996 were reviewed. Patients with subperiosteal abscess on CT scan were included. Clinical outcomes for initial surgical versus medical management of medial abscesses were compared. Differences in age, hospital stay, and intracranial involvement were analyzed for medial versus nonmedial abscesses. RESULTS All patients had abscesses adjacent to infected sinuses. Eighteen young children had medial abscesses. Twelve of 13 were cured by initial medical treatment; 4 of 5 underwent successful initial drainage. Outcomes were not statistically different (P > .490). Seven children with nonmedial abscesses were older (P < .001) and had more complicated courses than those with medial abscess. Three of 6 children with superior orbital abscess also had intracranial abscess. Intracranial complication was more likely with superior versus medial orbital abscess (P < .01). CONCLUSIONS Medial subperiosteal orbital abscesses secondary to sinusitis in children 6 years of age and younger are highly amenable to treatment with intravenous antibiotics. Older children and children with nonmedial abscesses may have more complicated infections. Children with superior orbital abscesses are at higher risk for intracranial abscess.

Absence of multiple extraocular muscles in craniosynostosis

The absence of extraocular muscles, particularly the superior rectus1, 2 or superior oblique3, 4 has been recognized to cause strabismus among patients with craniosynostosis. Absence of multiple muscles is less common. In case 1 we note a patient with Pfieffers syndrome and absent left superior rectus and inferior oblique, with the presence of only a vestigial left superior oblique and an underdeveloped and misinserted left inferior rectus. In case 2 we describe a patient with Aperts syndrome with bilateral absence of the superior rectus and superior oblique muscles. Unsuspected superior rectus absence led to a bilateral elevation deficit after inferior oblique weakening. Also, during the course of treatment, all 3 remaining recti muscles in 1 eye were disinserted. To our knowledge, this is the first report of absent extraocular muscles in Pfieffers syndrome. Some evidence suggests that collateral anterior segment blood flow exists in cases of absent recti muscles. Further study is needed to determine whether all remaining muscles could be used for strabismus repair. Last, when patients with craniosynostosis require strabismus surgery, we feel that a limited exploration of all extraocular muscles should be carried out.

Adult strabismus surgery under propofol sedation with local versus general anesthesia

PURPOSE To compare operating room and hospital discharge times between adult strabismus surgeries using intravenous propofol sedation with local anesthesia versus those using general anesthesia. METHODS Thirty adult patients underwent uncomplicated strabismus procedures performed by one surgeon using propofol sedation and local subtenons anesthesia. These were retrospectively matched with adult patients undergoing similar procedures by another surgeon using general inhalational anesthesia. Only one muscle had undergone previous surgery, and no adjustable sutures were used. Times from incision closure to leaving the operating room (Out OR time), and to hospital discharge (DC time) are compared. RESULTS Propofol/local Out OR times ranged 2 to 8 minutes (mean, 4.8). General anesthesia Out OR times ranged from 3 to 28 minutes (mean, 8.8) (means differ at P<.001). At 10 minutes, 100% of propofol patients left the OR, but only 63% of general patients had done so (P<.001). Propofol/local DC times ranged from 30 to 140 minutes (mean, 64.8). General DC times ranged from 68 to 325 minutes (mean 116.5) (means differ at P<.001). At 60 minutes after completion of surgery, 53% of propofol/local patients had left the hospital, whereas none of general patients had left (P<.001). At 2.5 hours after surgery, 100% of propofol/local patients had left the hospital, but 10% of general patients remained, with two staying more than 5 hours. CONCLUSIONS Many adult strabismus surgeries may be performed more efficiently with intravenous propofol sedation and local subtenons anesthesia than with general anesthesia. Times from the end of surgery to leaving both the OR and the hospital are decreased compared with those of general anesthesia. Extreme delays are rare with propofol/local, but they occurred with general anesthesia.

The red eye in childhood.

Overall, the primary care physician can diagnose most cases of red eyes in children, if specific attention is paid to which ocular structures are involved. Accurate diagnosis allows appropriate primary care treatment for most disorders and can aid in determining which cases need referral.

Atypical Acquired Pediatric Horner Syndrome

Horner syndrome poses a challenge for the physician. Confusion in the diagnostic process may arise because some patients with Horner syndrome do not exhibit the classic findings of simultaneously occurring miosis and mild ptosis. When that is the case, the diagnosis may be missed and essential lifesaving treatment not rendered. In classic Horner syndrome findings, the physician observes mild ptosis and miosis. The less common secondary symptoms of anhydrosis and inverse ptosis of the ipsilateral lower eyelid may also be present. In Horner syndrome that is congenital or has occurred very early in life, one may see heterochromia of the iris with the lighter colored iris on the side of the Horner syndrome. The physician must not eliminate the possibility of Horner syndrome when only miosis or only mild ptosis is seen. Subsequently, both symptoms may occur at the same time, elucidating the diagnosis of Horner syndrome. Anatomically, Horner syndrome is produced when there is an interruption of the oculosympathetic pathway in 1 of 3 sites. The first site of Horner syndrome is the central neuron, which originates in the hypothalamus. The fibers leaving the hypothalamus descend ipsilaterally in the reticular formation of the brain stem. They continue in the anterolateral columns of the spinal cord in the lower cervical and upper thoracic area. They synapse in the intermediolateral column, which is also known as the ciliospinal center of Budge. From here, the second neuron, also called the preganglionic neuron, leaves the intermediolateral column via the ventral roots and joins the white rami communicantes to enter the paravertebral sympathetic chain. These fibers synapse in the superior cervical ganglion located just below the base of the skull. From this third neuronal site emerges the postganglionic neuron, which forms a plexus around the external and internal carotid arteries. The plexus around the internal carotid artery follows the artery through the foramen lacerum into the cavernous sinus. Most of the sympathetic fibers to the eye join the ophthalmic division of the trigeminal nerve, while some travel with the oculomotor nerve and the ophthalmic artery. The fibers to the eye innervate the dilator muscle of the iris and Müller muscle in the upper and lower eyelids. Horner syndrome in children is differentiated from adult Horner syndrome by the location of the involved neuron. The most frequent anatomical location of childhood Horner syndrome is the preganglionic or second-order neuron. At this site, the most common cause of acquired Horner syndrome is a neuroblastoma of the paravertebral sympathetic chain. Damage to this neuron can be caused by either birth trauma to the brachial plexus or mediastinal tumors. Often, with congenital Horner syndome, the iris on the involved side can be hypopigmented. Central, or neuron 1, lesions are primarily seen in adults and encompass tumors or hemorrhages of the brain stem. Pancoast tumor, with involvement of the apex of the lung, is one of the best-known causes of a preganglionic lesion in an adult. The third-order neuron lesion is seen mainly in adults. This lesion is often associated with a dissection of the internal carotid artery or nasopharyngeal carcinoma spreading along the internal carotid artery. Years ago, in the workup of a child with Horner syndrome, we scanned the brain, the neck, and the chest. Now, we do not routinely scan the brain because we know that neuron 1 and neuron 3 lesions occur almost exclusively in adults. In children, we currently routinely scan the neck and chest as Horner syndrome is almost always associated with neuron 2 (preganglionic) lesions. In this study, we discuss several unusual manifestations of Horner syndrome in infants. Two cases were associated with preganglionic lesions and 1 occurred with a postganglionic lesion. These manifestations were uncharacteristic in mode of appearance for several reasons. At times, miosis was present without ptosis; in other instances, ptosis appeared without miosis. Adding to the perplexity of diagnosis, we also observed a child with intermittent Horner syndrome whom we diagnosed as having a neuroblastoma.

Strabismus Precipitated by Monovision

PURPOSE To present patients who had the onset of strabismus or the recurrence of strabismus after converting to a monovision system of seeing. DESIGN Retrospective interventional case series. METHODS Clinical records of 12 patients from the private practice of the corresponding author of this paper (Z.F.P.) were reviewed. Patients obtaining monovision via contact lenses, LASIK, and cataract surgery with posterior chamber intraocular lenses were studied if their monovision produced a new strabismus or was related to the recurrence of a previous strabismus. RESULTS All patients were first treated by converting the monofixing near eye to distance vision and then using reading glasses for near work. Of the 12 patients, 7 regained their fusion by doing away with monovision and 5 required surgery to reestablish motor or sensory control. All of the surgery patients obtained an excellent alignment but 1 did not regain sensory fusion. CONCLUSION Monovision is successful for the far majority of patients who try it. However, in patients with a previous history of strabismus or those with significant phorias, caution should be used in recommending monovision, and if monovision is elected, keeping the anisometropia to small levels such as 1.25 to 1.50 diopters (D) might lessen the chance of producing strabismus post monovision. The majority of our patients developed strabismus after 2 years of monovision, telling us that while a trial of monovision with a contact lens prior to surgery may suggest that the patient could tolerate monovision, it is not a guarantee.

Results of bilateral medial rectus muscle recession in unilateral esotropic Duane syndrome.

To the Editor: We congratulate Farvardin and colleagues on their successful use of bilateral medial rectus recessions to treat patients with Duane syndrome. We disagree, however, with their statement that their result ‘‘does not support the Greenberg’’ theory on the mechanisms of strabismus in Duane syndrome. The theory is consistent with our previously published poor results and with Farvadin’s relatively successful outcomes. In our paper, we countered previous arguments, theorizing that it is the eye with limited movements (the ‘‘Duane syndrome eye’’) and not the unaffected (sound) eye that controls the head position and that the sound eye will adjust its position to align with the affected eye binocularly. We did not state that the normal medial rectus muscle should never be recessed; rather, we urged caution against certain possible outcomes. For example, consider a patient with Type 1 Duane syndrome of the left eye who fuses using a left head turn. If only the unaffected right medial rectus muscle is recessed, our theory predicts that an exoshift will be created, necessitating fusional convergence. This equal and opposite adduction of both eyes moves the affected eye further to the right, and the head must be rotated further to the left for fusion to occur. This principle can be illustrated preoperatively by placing a base out prism in front of the right eye, and observing an increase in the left head turn. We disagree with others who have suggested that creating a matching duction deficit in the sound right eye will force the affected eye to move toward the left and the head to the right. We believe that matching duction weaknesses to the left, as is done in Kestenbaum surgery, causes left, not right head turn. In the above example, if the affected medial rectus muscle is recessed but not sufficiently to correct the head turn, then a residual Duane syndrome remains. Adding a recession of the unaffected right medial rectus muscle creates the same situation described above, with fusional convergence leading to an increased left head turn. We believe that this explains poor results in some of the cases we described, and we continue to caution against undercorrection of the affected medial rectus muscle if bilateral medial rectus recessions are planned. On the other hand, if the affected left medial rectus muscle is recessed slightly more than is required to correct the head turn, then a recession of the unaffected right medial rectus muscle should restore the normal head position. Fusional convergence causing rightward movement of the affected eye in the circumstances is desirable to reverse the overcorrection. We believe this mechanism may explain many of Farvadin’s successful cases. The above examples are specific for Duane syndrome with smaller angles, in which the unaffected medial rectus

Treatment of chemotic conjunctival prolapse after pediatric craniofacial surgery: Report of a technique

Journal of AAPOS Massive conjunctival edema and prolapse occasionally occur after craniofacial surgery around the orbits in young children. A technique is described for reducing such prolapse by using a local injection of subconjunctival lidocaine with epinephrine. Ten eyes of 7 patients were followed up prospectively for resolution. In 8 eyes, prolapse resolved the day after injection, and in the remaining 2 eyes, it resolved the day after the injection was repeated. Epinephrine-induced vasoconstriction of transudating blood vessels is the presumed mechanism of fluid reduction. Conjunctival edema is often more pronounced in very young children than in adults, such as in cases of trauma, infections, or allergic reactions. Perhaps the most striking conjunctival edema occurs in the clinical setting in which a small child or infant undergoes craniofacial surgery.1 Scalp and facial swelling often surround massive eyelid and conjunctival edema, frequently leading to extreme prolapse of the forniceal conjunctiva. Often the globe cannot be fully examined, even with the use of eyelid retractors or a lid speculum. Most commonly, the upper lid is involved, although occasionally the lower lid may prolapse (Figures 1 and 2). Such conjunctival prolapse can last for days to weeks and can be associated with significant conjunctival irritation from desiccation, as well as from abrasion by pillows or bed sheets. Additionally, parents are commonly distressed by the grotesque postoperative appearance. Frequent topical lubricants and vasoconstrictor eye drops have not been successful. Surgical treatment for prolonged conjunctival prolapse after pediatric craniofacial surgery has been reported1; however, we have not found this necessary. Combination steroid/vasoconstrictor/anesthetic subconjunctival injections have been advocated for treating chemosis and conjunctival prolapse after ophthalmic surgery. The vascular effects of steroids, including sensitization of blood vessels to the effects of epinephrine, have been proposed as the mechanisms of action.2 Ten years Treatment of Chemotic Conjunctival Prolapse After Pediatric Craniofacial Surgery: Report of a Technique