Mohamed A.W. Hussein

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.

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.

Use of the RetCam 120 for fundus evaluation in uncooperative children.

PURPOSE To report our experience using the RetCam 120 to evaluate suspected retinal pathology in children who did not cooperate for standard in-office examination. DESIGN Interventional case series. METHODS We reviewed charts of eight consecutive uncooperative children with suspected fundus abnormalities that were photographed using the RetCam 120 as a routine part of patient care. RESULTS Three uncooperative children with suspected pathology required RetCam 120 photos because of inadequate fundus examination. Five had pathology or suspected pathology that required more detailed examination. In all of these children, we were able to reach or rule out a diagnosis. CONCLUSION The Retcam 120 digital fundus camera has utility as an in-office diagnostic tool for fundus examination of poorly cooperative children and may be a good alternative to examination under anesthesia or sedation in selected cases.

Migration and apparent disappearance of silicone tube following treatment of nasolacrimal duct obstruction

PURPOSE To describe the unusual complication of migration and apparent disappearance of silicone tubes following intubation of the lacrimal drainage system. DESIGN Interventional case reports. METHOD Report of two patients with an unusual tube migration process. RESULTS Silicone stents migrated nasally, with healing of the erosion tract in the wake of the migrating tube. One tube became completely internalized. CONCLUSIONS Meticulous inspection of the medial canthal area in patients with suspected spontaneous extrusion of silicone stents from the lacrimal drainage system is warranted. Examination under anesthesia and nasal endoscopy may help locate tubes in cases of suspected nasal migration.

Evaluating the association of autonomic drug use to the development and severity of retinopathy of prematurity

PURPOSE To explore the association of autonomic agents with the development and severity of retinopathy of prematurity (ROP). METHODS The medical records of all preterm infants screened for ROP were retrospective reviewed. The association between development and severity of ROP and the use and dose(s) of autonomic agents was analyzed, after adjustment for the covariates gestational age, weight, development of septicemia, intraventricular hemorrhage, and respiratory distress syndrome. RESULTS A total of 350 infants were screened. Caffeine was used in 338 infants; dopamine in 98 infants. There was a significant association between the use of dopamine and development of ROP (P < 0.001; relative risk [RR] = 1.6 [95% CI, 1.23-2.06]) and the need for ROP treatment (P = 0.001; RR = 4.63 [95% CI, 1.82-11.79]). The number of dopamine doses was significantly associated with the development of any ROP (P < 0.001; RR = 1.07 [95% CI, 1.03-1.1]), the severity of ROP (P < 0.001; RR = 1.09 [95% CI, 1.05-1.14]), and the need for treatment (P < 0.001; RR = 1.09 [95% CI, 1.05-1.14]). The total dose of caffeine was significantly associated with the development of any ROP (P = 0.003; RR = 1.03 [95% CI, 1.01-1.05]) and the need for treatment (P = 0.006, RR = 1.073 [95% CI; 1.021-1.13]). CONCLUSIONS Although a causal relationship was not identified, the use of the autonomic agents caffeine and dopamine was associated with the development and severity of retinopathy of prematurity in this cohort.

Limitation of opposing ductions following augmented horizontal rectus muscle transposition

PURPOSE To report the effect on ductions in opposing gaze following augmented horizontal rectus muscle transposition to treat cyclovertical muscle palsies. METHODS Record review of 5 patients who underwent augmented horizontal rectus muscle transposition for treatment of vertical gaze misalignment secondary to cyclovertical muscle palsy. RESULTS Ductions in the direction of the palsied muscle improved in all patients. Four patients (80%) developed significant limitation of vertical gaze in the direction opposite that of the palsied muscle. CONCLUSIONS Augmented transposition surgery for vertical muscle palsy can produce considerable limitation of ductions in the direction opposite to that of the paralyzed muscle.

The long-term outcomes in children who are not compliant with spectacle treatment for accommodative esotropia

PURPOSE To evaluate the long-term motor and sensory outcomes of children who have refractive accommodative esotropia and are noncompliant with spectacle wear. METHODS The medical records of patients diagnosed with pure refractive accommodative esotropia between 1999 and 2004 were retrospectively reviewed. All patients had hyperopia of at least 3 D and at least 1 years follow-up. Patients were classified according to degree of compliance with spectacle wear as good, fair, and poor. The main outcome measures were sensory and motor outcomes. RESULTS A total of 92 patients were included. The mean follow-up period was 61.4 months (range, 12-200 months). Compared to patients with good compliance, those with fair compliance had a significantly higher risk for poor sensory outcome (odds ratio [OR] = 4.56; 95% CI 2.1 - 24.7; P = 0.0003) and poor motor outcome (OR = 4.1; 95% CI, 1.44 -11.75; P = 0.0065). Patients with poor compliance likewise had a higher risk for poor sensory outcome (OR = 12.3; 95% CI, 1.29-96.79; P = 0.0061) and poor motor outcome (OR = 11.7; 95% CI, 2.38-74.19; P = 0.0006). CONCLUSIONS Fair and poor compliance with spectacle use greatly increases the risk of poor sensory and motor outcomes in children with pure refractive accommodative esotropia.

Use of iris pattern recognition to evaluate ocular torsional changes associated with head tilt

Purpose: To describe the use of enhanced iris images and a computer software program to quantify ocular torsional changes associated with head tilt. Methods: Pixel coordinates of the pupil and different iris landmarks were obtained manually using paint program from digital images of the right and left iris of 3 subjects with normal extraocular motility. Photographs of the right eye and of the left eye were taken in the straight-ahead position and at various degrees of right and left head tilt. A computer software program converted the x- and y-pixel coordinates into angles of rotation after averaging multiple points and determining the degree and the direction of torsion for each eye. The degree of head tilt was mathematically calculated from the digital images. The degree and the direction of ocular torsion were correlated with the degree and the direction of head tilt. Results: The average degree of head tilt was 27.5 degrees (from 8 to 43 degrees). The average intorsion of the lower eye per degree of head tilt was 0.61 degrees (from 0.54 to 0.65 degrees). The average extorsion of the higher eye per degree of head tilt was 0.56 degrees (from 0.43 to 0.60 degrees). The average ocular torsional changes strongly correlated with the degree of head tilt (correlation coefficient = 0.92). Conclusions: Computer-assisted iris pattern recognition and analysis of the ocular torsional changes associated with head tilt may provide a useful and objective means of assessing ocular torsion.

Infantile Hemangiomas of the Eyelids and Orbit

Infantile hemangiomas are the most common vascular tumor seen in infants. They typically appear in the first few weeks of life [1–3] and occur in 4–12 % of infants [4]. When located in the periocular and orbital region, hemangiomas have the potential to affect the developing vision of infants, causing amblyopia. Multiple treatment modalities have been offered for treatment of infantile hemangiomas including topical, intralesional, and systemic steroids; more recently, the use of oral propranolol has been successful in treating these lesions.

Oral propranolol in the management of periocular capillary hemangiomas.

Capillary hemangiomas are benign vascular tumors that typically appear in the first few weeks of life. When located in the periocular and orbital regions, they can affect the developing vision of infants. Multiple treatment modalities have been offered including topical, intralesional, and systemic steroid use; more recently, the use of oral propranolol has been used successfully to treat these lesions.