Mary Lou McGregor

Pseudotumor cerebri in children receiving recombinant human growth hormone

PURPOSE This article represents the first report in the ophthalmology literature of an association between pseudotumor cerebri (PTC) and recombinant human growth hormone (rhGH). DESIGN Noncomparative case series. PARTICIPANTS Three children receiving rhGH for short stature with Turner syndrome, Jeune syndrome, or Down syndrome. METHODS Children underwent full ocular examination. After papilledema was identified, patients underwent lumbar puncture and imaging with either magnetic resonance imaging or computerized tomography. Treatment was under the guidance of the primary physician or neurosurgeon. The rhGH was discontinued in all children. MAIN OUTCOME MEASURES Visual acuity and evaluation of the optic nerve for resolution of papilledema were followed at each examination. RESULTS In all three cases, papilledema resolved with the cessation of rhGH, and treatment with acetazolamide or prednisone. Visual acuity was unchanged in case 1, decreased by two to three lines in case 2, and was inconsistent in case 3. One child (case 2) required a ventriculoperitoneal shunt for persistent elevation of intracranial pressure. CONCLUSION There appears to be a causal relationship between the initiation of rhGH with the development of PTC. Children should have a complete ophthalmic evaluation if they report headache or visual disturbances. Baseline examination with routine follow-up should be instituted when children cannot adequately communicate.

Occlusion and levodopa-carbidopa treatment for childhood amblyopia

PURPOSE The purpose of the current study was to compare the effects of levodopa-carbidopa with and without part-time occlusion on visual function in older amblyopic children. METHODS Thirteen older amblyopic children were randomly assigned to receive or not receive part-time occlusion (3 h/day) combined with 7 weeks of oral dosing with levodopa-carbidopa (1.02 mg/0.25 mg/kg body weight three times daily). Visual acuity, contrast sensitivity, and fusion were measured at baseline; 1, 3, 5, and 7 weeks during the treatment regimen; and 4 weeks after termination of all treatment. At these same times health status was assessed with standard laboratory blood tests, physical examination, and subjective questionnaire. RESULTS From baseline to the follow-up test trial, both groups improved in visual acuity in the amblyopic eyes (occlusion group 20/116 to 20/76, P < .001; no occlusion group 20/90 to 20/73, P < .01) and dominant eyes (occlusion group 20/18 to 20/15, P > .05; no occlusion group 20/20 to 20/16, P < .01). The occlusion group exhibited a significant decrease in the difference in acuity between the dominant and amblyopic eyes of 1.3 lines (P < .02), whereas the no occlusion group revealed no significant effect. A comparison between groups revealed a significantly greater improvement in visual acuity in the amblyopic eye in the occlusion group compared with the no occlusion group (P = .01). In contrast, there was no significant difference between groups in terms of the change in visual acuity in the dominant eye (P = .15). Mean log contrast sensitivity in the amblyopic eye significantly improved in the occlusion group and did not significantly change in the no occlusion group. Fusion changed similarly in both groups. The improvements in visual function were maintained 4 weeks after the termination of all treatment. Adverse side effects were minimal in both groups. CONCLUSION The combination of levodopa-carbidopa and occlusion improves visual function more than levodopa-carbidopa alone in older amblyopic children.

Levodopa/carbidopa treatment for amblyopia in older children

The purpose of the present study is to determine how long visual function improves during levodopa/carbidopa with part-time occlusion treatment in older amblyopic children. A 7-week open clinical trial of levodopa (0.55 mg/kg, three times daily) with 25% carbidopa combined with part-time occlusion (3 hours/day), was undertaken in 15 older (mean age, 8.87 years) amblyopic children. Visual acuity, fusion, and stereo acuity were measured at baseline, at weeks 1, 3, 5, and 7 during treatment, and 6 weeks following the end of all treatment. Health status was assessed by physical examination, questionnaire, and standard laboratory tests (CHEM 20, complete blood cell count [CBC], and differential). The results revealed that visual acuity in the amblyopic eye improved for 5 weeks, from 20/170 at baseline to 20/107, then stabilized for the last 2 weeks. Visual acuity also improved in the dominant eye by 0.6 lines, from 20/19 to 20/16. At the 6-week follow up, visual acuity in the amblyopic eye remained at 20/107 (paired t = 4.78, df = 14, P < .001), a 37% improvement. Thirty-three percent of the subjects demonstrated improved fusion from baseline to the 7-week trial that was maintained at follow up (chi 2 = 3.97, P < .05). Stereo acuity did not significantly change. Physical exam (blood pressure, body temperature, respiration, heart rate) and standard laboratory tests remained normal and side effects were minimal.(ABSTRACT TRUNCATED AT 250 WORDS)

Longitudinal Study of Levodopa/Carbidopa for Childhood Amblyopia

To determine the tolerability and efficacy of levodopa/carbidopa combined with occlusion therapy for childhood amblyopia, a double-masked placebo-controlled randomized longitudinal study was performed on 10 amblyopic children between 6 and 14 years of age. Subjects received, on average, 20/5 mg levodopa/carbidopa or 20 mg of placebo three times per day combined with part-time occlusion over a 3-week period. Visual function was assessed by Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity charts and by contrast sensitivity. Tolerability was assessed by questionnaire, SMAC (standard laboratory tests; consists of a chem 20 and complete blood count [CBC]) analysis, and physical examination. Compliance with occlusion and capsule consumption were assessed by questionnaire and by capsule count, respectively. At the end of the dosing regimen, the levodopa/carbidopa group significantly improved in visual acuity by 2.7 lines and in mean contrast sensitivity by 72% in the amblyopic eye. The placebo group improved in visual acuity by 1.6 lines in the amblyopic eye. Tolerability and occlusion compliance were similar between groups; however, capsule ingestion compliance was significantly lower in the levodopa/carbidopa group. One month after the termination of treatment, the levodopa/carbidopa group maintained a significant 1.2-line improvement in visual acuity and 74% improvement in contrast sensitivity in the amblyopic eye. The placebo group did not maintain an improvement in visual acuity between the eyes. It is concluded that levodopa/carbidopa, at an average of 0.48/0.12 mg/kg, is well tolerated and, when combined with part-time occlusion, is efficacious in improving visual function in amblyopic children.

Treatment of symptomatic convergence insufficiency with a home-based computer orthoptic exercise program

PURPOSE To determine the efficacy of a home-based computer orthoptic program to treat symptomatic convergence insufficiency. METHODS A retrospective review of consecutive patients with symptomatic convergence insufficiency treated with a home-based computer orthoptic program was performed. Symptomatic convergence insufficiency was defined as: near point of convergence (NPC) >6 cm, decreased positive fusional vergence, exophoria at near at least 4(Δ) greater than at far, and documented complaints of asthenopia, diplopia, or headaches with reading or near work. The Computer Orthoptics CVS program was used for this study. Before beginning the computer orthoptic program, patients with an NPC >50 cm were given 4 base-in prisms and push-up exercises (NPC exercises with an accommodative target) for 2 weeks. RESULTS A total of 42 patients were included. Mean treatment duration was 12.6 weeks; mean follow-up, 8.5 months. Of the 42 patients, 35 were treated with the home-based computer orthoptic program and push-up exercises; the remaining 7 only used the computer orthoptic program. Because of a remote NPC, 5 patients were given base-in Fresnel prism before starting treatment. Baseline mean NPC was 24.2 cm; posttreatment mean NPC improved to 5.6 cm: 39 patients (92.8%) achieved an NPC of ≤6 cm (p < 0.001). Positive fusional vergence improved in 39 patients (92.8%). Fourteen patients reduced their near exophoria by ≥5(Δ). A total of 27 patients (64.2%) reported resolution of symptoms after treatment. CONCLUSIONS In our study, home-based computer orthoptic exercises reduced symptoms and improved NPC and fusional amplitudes. The computer orthoptic program is an effective option for treating symptomatic convergence insufficiency.

A comparison of cryotherapy versus diode laser retinopexy in 100 consecutive infants treated for threshold retinopathy of prematurity.

PURPOSE The purpose of this paper is to present a series of patients who were treated for threshold retinopathy of prematurity with either cryotherapy or diode laser. Complications and unfavorable outcomes during the first year after treatment will be compared for the two procedures. METHODS The clinical courses of a consecutive series of 100 infants (192 eyes) were reviewed. All infants had their threshold status confirmed by a second examiner. Infants were treated with cryotherapy through 1993 and with diode laser thereafter. One hundred two eyes of 54 patients were treated with cryotherapy. Ninety eyes of 46 patients were treated with laser retinopexy. Two of the patients who were treated with laser (4 eyes) did not survive to the 3-month follow-up visit, and their results are not included here. The two groups of infants were comparable in their birth weight, adjusted gestational age at treatment, and severity of disease as determined by zone and sectors of stage 3 retinopathy of prematurity. RESULTS Unfavorable outcome (total retinal detachment) was seen in 25.4% of eyes treated with cryotherapy (26 of 102), as compared with 15% of eyes treated with laser (13 of 86). Two cataracts were seen in our patients: one patient 22 weeks after cryotherapy, and the other 7 months after diode laser. CONCLUSIONS No statistically significant difference was found in the rate of retinal detachments in the two groups (X2 = 3.05; P = .08).

Retinopathy of Prematurity in Discordant Twins

Discordant twins may be at increased risk for retinopathy of prematurity (ROP) because of factors related to their unequal growth. Discordancy is defined as a difference of 15% or more in the birth weights of the two infants. We examined the data in 26 sets of discordant twins from six NICUs, including birthweight, gestational age, sex, and highest grade of ROP. Thirty-eight percent (10) of the lower birthweight infants had higher grades of ROP than their twin. Twenty-three percent (6) of the heavier birthweight twins had higher grades of ROP than their smaller siblings. Three infants reached threshold, and five were prethreshold. In every case, their twin siblings had mild or no ROP. Thirty-eight percent of the twins (10) had the same ROP outcome.

Increased Intracranial Pressure in Patients with Cystinosis

Patients with cystinosis have risk factors known to be associated with secondary increased intracranial pressure. The authors report a series of patients with cystinosis and describe their experience in the diagnosis and management of increased intracranial pressure in this population. The ophthalmologist should be aware of this vision-threatening association.

Corneal power measurements in fixating versus anesthetized nonfixating children using a handheld keratometer

PURPOSE To compare keratometry measurements on a fixating patient with readings from the same nonfixating patient intraoperatively using the Nidek KM-500 handheld keratometer. METHODS Consecutive patients who were scheduled for strabismus or nasolacrimal surgery between 5 and 11 years of age were included in the study. Handheld keratometry was performed preoperatively on both eyes with the child fixating and intraoperatively with the child anesthetized. Three readings were taken on each eye. The steepest and flattest corneal meridians were recorded. Intraclass correlation coefficients were calculated to assess reliability, and interchangeability was assessed by the use of the Bland-Altman method. RESULTS Included in the study were 55 eyes of 28 patients. The average fixating keratometry reading was 44.10 +/- 1.45 D for right eyes and 44.12 +/- 1.42 D for left eyes. The average nonfixating keratometry reading was 44.06 +/- 1.62 D for right eyes and 44.02 +/- 1.54 D for left eyes. The intraclass correlation coefficient for the average keratometry obtained fixating versus nonfixating was 0.96 for right eyes and 0.95 for left eyes. The Bland-Altman analysis showed fairly large limits of agreement between readings, but most readings fall within the limits of variability. The mean time to obtain the intraoperative measurements was 4.26 minutes. CONCLUSIONS In our study the Nidek KM-500 handheld keratometer provided reliable readings when used intraoperatively on anesthetized nonfixating children and required minimal time to perform.

Diagnostic criteria in pediatric intracranial hypertension

BACKGROUND The modified Dandy criteria and the newer diagnostic criteria for pseudotumor cerebri syndrome (PTCS) are both used to diagnose intracranial hypertension (IH). In comparison to the modified Dandy criteria, the PTCS criteria stratify the IH diagnosis into definite, probable, and suggested categories, exclude clinical symptoms, and use radiologic evidence for diagnosis. There is a lack of consensus on which criteria should be used in the pediatric population. The purpose of this study was to compare the diagnostic criteria for PTCS to the modified Dandy criteria and to identify limitations within both sets of criteria. METHODS The PTCS criteria were retrospectively applied to 50 patients originally diagnosed with IH under the modified Dandy criteria. RESULTS Of the 50 patients, 31 (62%) met diagnostic criteria for definite PTCS, 10 (20%) met criteria for probable PTCS, and 9 patients (18%) failed to meet sufficient PTCS criteria for diagnosis. CONCLUSIONS Although the PTCS criteria use objective data to make the IH diagnosis, we found subjective symptoms to be useful indicators of disease in this group of patients. Additionally, distinguishing probable from definite IH may not have clinical relevance, because both groups were treated similarly. The absence of radiographic evidence of IH should not preclude a diagnosis of the condition, as it was present in a minority of patients included in this study. Further research is needed to clarify the disease process in patients who present with signs and symptoms of elevated intracranial pressure but lack ocular pathology.