Martin S. Cogen

Eyelid depigmentation following corticosteroid injection for infantile ocular adnexal hemangioma.

We report an unusual case of development of upper eyelid depigmentation in a child 4 months following corticosteroid injection of a periocular capillary hemangioma. Depigmentation has been described with local steroid injections for other dermatologic conditions, but has not been reported previously with treatment of infantile ocular adnexal hemangiomas.

Circumferential trabeculotomy with an illuminated microcatheter in congenital glaucomas.

Purpose:To determine the safety and efficacy of circumferential trabeculotomy for congenital glaucomas using an illuminated microcatheter. Methods:This was a retrospective chart study involving 11 eyes from 7 patients with primary or secondary congenital or juvenile glaucoma who underwent circumferential trabeculotomy performed with an illuminated microcatheter over a 2-year period. Data from eyes with 6 or more months of follow-up intraocular pressure (IOP) data were included in the analysis. Mean IOP was determined along with a survival analysis. Unqualified success was defined as an IOP<21 mm Hg and at least a 30% reduction in IOP without the use of IOP-lowering agents and a qualified success when medications were needed to reach this goal. Results:Mean IOP (mm Hg) was reduced from 33.8±6.3 preoperatively to 18.3±3.5 at the final postoperative visit (P-value<0.001). Length of follow-up was 8 to 12 months (mean of 11 mo). A qualified success was seen in 90.1% of eyes and an unqualified success in 81.8%. If eyes with previous angle surgery were excluded, the unqualified success was 87.5% and the qualified success was 100%. Transient hyphema was seen in all cases. No long-term surgical complications were seen. Conclusions:Circumferential trabeculotomy performed with an illuminated microcatheter provided significant IOP lowering in all patients with unqualified success in the majority of eyes and no significant complications. Further study with even longer follow-up is needed.

Goniotomy versus circumferential trabeculotomy with an illuminated microcatheter in congenital glaucoma.

PURPOSE To compare circumferential trabeculotomy performed with an illuminated microcatheter with standard goniotomy for the treatment of congenital glaucoma. METHODS The short-term results of catheter-assisted trabeculotomy with an illuminated microcatheter were retrospectively compared with those of goniotomy in patients treated for congenital glaucoma. Success with either approach was defined as an intraocular pressure (IOP) <21 mm Hg with at least a 30% reduction from preoperative pressure levels at 12-month follow-up. Complete success was defined when the target IOP levels were reached without the use of antiglaucoma medication, and qualified success was defined when antiglaucoma drops were required to meet this level of IOP. RESULTS A total of 24 eyes of 20 patients were included. Microcatheter-assisted circumferential trabeculotomy demonstrated a 91.6% qualified and 83.3% unqualified success rate with 12-month follow-up that exceeded the 53.8% qualified and 46.2% unqualified success rate of conventional goniotomy. CONCLUSIONS In congenital glaucoma, during the first year after surgery, trabeculotomy performed with an illuminated microcatheter appears to be more effective than ab interno goniotomy. No complications were seen in either group; however, the follow-up was relatively short.

Masked trial of topical anesthesia for retinopathy of prematurity eye examinations

PURPOSE To observe the effect of a topical anesthetic on pain and corneal clarity in premature infants undergoing eye examinations for retinopathy of prematurity (ROP). METHODS ROP examinations were performed on premature infants who were randomized to receive either proparacaine 0.5% or an artificial tear solution in the right eye. All infants received an artificial tear solution in the left eye. Assessment of discomfort was performed by use of the Premature Infant Pain Profile (PIPP) during examination of the right eye, with a painful event defined as a PIPP score≥11. The left eye was then examined and a comparison of corneal clarity was made between the 2 eyes. RESULTS A total of 39 examinations were performed on 34 infants: artificial tear solution was administered 17 times and topical proparacaine anesthetic 22 times. The mean PIPP score for those receiving artificial tears was 10.4 compared with 8.8 for the anesthetic group (p=0.17). Of the examinations without anesthetic, 65% were painful, compared with 27% with anesthetic (p=0.04). No effect on corneal clarity was observed in any examination. CONCLUSIONS The use of a topical anesthetic appears to marginally decrease pain and has no adverse effect on subjectively assessed corneal clarity during examination of premature infants for ROP.

Combined superior oblique tuck and adjustable suture recession of the ipsilateral superior rectus for long-standing superior oblique palsy

PURPOSE Unilateral long-standing superior oblique palsy may lead to superior rectus overaction/contracture requiring surgery of multiple extraocular muscles to correct the hypertropia. We review our technique of tucking the superior oblique combined with immediate postoperative adjustable suture recession of the ipsilateral superior rectus. METHODS Twelve patients during the course of 2.5 years with longstanding vertical diplopia unrelated to closed head trauma or systemic disease who underwent our surgical technique were identified. The hypertropia in all patients was largest across the lower field (Knapp class 5) or nasal and lower fields (Knapp class 4). Outcome measures were primary-position hypertropia and vertical diplopia. RESULTS The mean preoperative hypertropia in primary gaze measured 17.8 PD (range, 4 to 30). The mean 2-week postoperative vertical deviation was 1.3 PD (range, 4 PD hypotropic to 6 PD hypertrophic). The mean 6-week postoperative vertical deviation was 1.9 PD (range, 2 PD hypotropic to 12 PD hypertrophic). Diplopia in primary and down gaze, which was universally present before surgery, resolved in 11 of the 12 patients (92%). CONCLUSIONS This combination of procedures appears to be a highly successful choice for treatment of unilateral long-standing superior oblique palsy. Advantages for both patient and surgeon include adequate exposure through a single conjunctival incision, elimination of risks to the contralateral eye, and immediate intraoperative suture adjustment of the ipsilateral superior rectus.

Effects of Myo-inositol on Type 1 Retinopathy of Prematurity Among Preterm Infants <28 Weeks’ Gestational Age: A Randomized Clinical Trial

Importance Previous studies of myo-inositol in preterm infants with respiratory distress found reduced severity of retinopathy of prematurity (ROP) and less frequent ROP, death, and intraventricular hemorrhage. However, no large trials have tested its efficacy or safety. Objective To test the adverse events and efficacy of myo-inositol to reduce type 1 ROP among infants younger than 28 weeks’ gestational age. Design, Setting, and Participants Randomized clinical trial included 638 infants younger than 28 weeks’ gestational age enrolled from 18 neonatal intensive care centers throughout the United States from April 17, 2014, to September 4, 2015; final date of follow-up was February 12, 2016. The planned enrollment of 1760 participants would permit detection of an absolute reduction in death or type 1 ROP of 7% with 90% power. The trial was terminated early due to a statistically significantly higher mortality rate in the myo-inositol group. Interventions A 40-mg/kg dose of myo-inositol was given every 12 hours (initially intravenously, then enterally when feeding; n = 317) or placebo (n = 321) for up to 10 weeks. Main Outcomes and Measures Type 1 ROP or death before determination of ROP outcome was designated as unfavorable. The designated favorable outcome was survival without type 1 ROP. Results Among 638 infants (mean, 26 weeks’ gestational age; 50% male), 632 (99%) received the trial drug or placebo and 589 (92%) had a study outcome. Death or type 1 ROP occurred more often in the myo-inositol group vs the placebo group (29% vs 21%, respectively; adjusted risk difference, 7% [95% CI, 0%-13%]; adjusted relative risk, 1.41 [95% CI, 1.08-1.83], P = .01). All-cause death before 55 weeks’ postmenstrual age occurred in 18% of the myo-inositol group and in 11% of the placebo group (adjusted risk difference, 6% [95% CI, 0%-11%]; adjusted relative risk, 1.66 [95% CI, 1.14-2.43], P = .007). The most common serious adverse events up to 7 days of receiving the ending dose were necrotizing enterocolitis (6% for myo-inositol vs 4% for placebo), poor perfusion or hypotension (7% vs 4%, respectively), intraventricular hemorrhage (10% vs 9%), systemic infection (16% vs 11%), and respiratory distress (15% vs 13%). Conclusions and Relevance Among premature infants younger than 28 weeks’ gestational age, treatment with myo-inositol for up to 10 weeks did not reduce the risk of type 1 ROP or death vs placebo. These findings do not support the use of myo-inositol among premature infants; however, the early termination of the trial limits definitive conclusions.

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