Pamela J. Kutschke

20th Annual Frank Costenbader Lecture-Adult Strabismus

BACKGROUND A retrospective analysis of adults with strabismus was done to examine the potential risks and the possible benefits of surgical treatment and to describe the types of adult strabismus. METHODS Eight hundred ninety-two patients were analyzed. Age at time of surgery ranged from 9 years to 89 years. The average follow up was 34 months. Major types of strabismus were grouped by their original diagnoses. The group of patients with horizontal strabismus, which usually had an onset before 9, was termed the before visual maturity (BVM) group. The group of patients with paretic or restrictive strabismus usually had the onset of strabismus after age 9 and was termed the after visual maturity (AVM) group. RESULTS Patients with adult strabismus can gain restoration of alignment, as well as binocular function. At the last postoperative visit, 74% of the BVM group were aligned within 15 prism diopters. Not only was restoration of alignment accomplished, many of them gained some degree of sensory fusion as measured by the Worth 4-Dot (W4D) or Titmus stereoacuity. Twenty-nine percent of patients with congenital esotropia had some sensory fusion. The other subtypes in the BVM group had even higher percentages of patients with postoperative stereoacuity. In the AVM group, 92% had fusion at the last postoperative visit. CONCLUSIONS The outcomes of adult strabismics in our study show that certain benefits can be gained from correction of ocular alignment. Restoration of alignment, elimination of diplopia and sensory fusion are functional benefits that can be obtained through strabismus surgery in the adult patient. It is clear that adult strabismus is more than just a cosmetic problem and treatment is worthwhile.

Upper Age Limit for the Development of Amblyopia

The medical records of 64 patients between 1 and 11 years old with known onset of an amblyopia-inducing condition were retrospectively reviewed to determine the upper age limit for the development of amblyopia. Thirty seven patients (group 1) developed amblyopia and 27 patients (group 2) did not. The mean patient age at the onset of the amblyopia-inducing condition was 41.0 months (2.90 SE) for group 1 and 92.3 months (4.02 SE) for group 2. The difference was statistically significant (P = .0001). No patient developed amblyopia after 73 months of age. The duration of the amblyopia-inducing condition and the type of amblyopia-inducing condition were not significantly different between the two groups. The age of the patient when exposed to an amblyopia-inducing condition is the most important determinant for the development of amblyopia. Patients 6 years or older with a normal visual system have a low probability of developing amblyopia following the onset of an amblyopia-inducing condition.

Prism Adaptation for Esotropia With a Distance-Near Disparity

A series of 64 patients who had surgery for esotropia with a distance-near disparity of at least 10 prism diopters was reviewed. Thirty-three patients were prism adapted for their distance deviation (PA distance). Thirty-one patients were prism adapted for near deviation (PA near). Both groups were divided into responders and nonresponders. In the PA distance group, 22 (67%) patients were responders. All responders had surgery for their prism-adapted angle. Postoperatively, 19 (86%) responders had fusion. Thirteen (68%) required bifocals to maintain fusion. In the PA near group, 21 (68%) patients were responders. All responders had surgery for their prism-adapted angle. Ninety-four percent of responders had fusion postoperatively. None needed bifocals for fusion postoperatively and none were overcorrected. The results show that those patients who were prism adapted for their near angle, responded with fusion, and had surgery for their full amount of esotropia at prism response obtained better postoperative fusion, without the need for a bifocal at near and without overcorrection at distance.

Postoperative results in inferior oblique palsy

PURPOSE Although rare, the entity of isolated inferior oblique palsy has been discussed in past literature. The purpose of this study is to expand on the number of cases as well as the surgical options. Postoperative clinical findings, especially head-tilt measurements also are discussed. METHODS The charts of patients were retrospectively reviewed following surgical correction of unilateral inferior oblique palsy. Data analyzed included type of surgical correction, pre- and postoperative measurements in all fields of gaze, torsion, and sensory status. RESULTS Twenty-eight patients were studied. Patients were separated into groups based on the type of procedure performed. Indications for each type of procedure will be discussed. Twenty-three patients had a single surgical procedure. Of these, 16 had excellent surgical results. Five patients required reoperation with four achieving an excellent surgical result. Head-tilt testing at the last postoperative visit was positive for iatrogenic superior oblique palsy (4) and residual inferior oblique palsy (3). CONCLUSIONS In the largest series of unilateral inferior oblique palsy to date, the results appear to be good if the indications for the proper surgical procedure are followed. The number of cases of iatrogenic superior oblique palsy appear to be consistent with that discussed in previous literature, but not higher than the incidence of residual inferior oblique palsy. Postoperative head-tilt measurements were consistent with the deviation found in other fields of gaze.

Endophthalmitis Following Pediatric Strabismus Surgery with Good Visual Result

A 3-year-old child underwent bilateral medial rectus recession for partially accommodative esotropia. No recognized complications occurred at the time of surgery. Six days following surgery, she presented with increasing ocular redness, pain, and discharge. The clinical picture was consistent with endophthalmitis. The patient underwent trans pars plana vitrectomy and lensectomy, combined with a course of intravitreal, periocular, and systemic antibiotics. Four years following surgery, after aggressive occlusion therapy for amblyopia, her visual acuity improved to 20/30 with aphakic correction.

The gradient filter test to assess amblyopia

A new technique, the gradient filter test, was developed for evaluating changes in the visual acuity of preverbal children undergoing treatment for amblyopia. The gradient filter test consists of a series of calibrated photographic fog filter and prism lenses. The combined prism-filter lenses are placed in front of the normal fixing eye. The greatest density (fogging value) filter that causes a switch in fixation from the amblyopic to the normal eye is noted. In both normal eyes of 20 nonamblyopic patients and the fellow (non-amblyopic) eyes of 20 amblyopic patients, visual acuity decreased as the density of the prism-filter lens increased. The gradient filter test accurately detected an improvement in visual acuity when compared with optotype measurements in eight patients undergoing occlusion therapy. The gradient filter test is a useful clinical tool that can assess changes in visual acuity in preverbal children who are being treated for amblyopia.

PEDIG Results in Perspective: Concerns

Introduction The treatment of amblyopia is a large part of the pediatric ophthalmology and orthoptic practice. The Amblyopia Treatment Studies (ATS) have tried to answer questions about which treatments work for different types of amblyopia and which treatments work the best. Methods Each of the ATS articles were examined for strengths and weaknesses with particular emphasis on the ATS1, patching versus atropine study. Results Many strengths and weaknesses were found. As indicated by this articles title, the weaknesses were emphasized. Conclusions These studies had, as all prospective studies do, strict inclusion criteria that hampered the study by limiting the included patients. However, in some areas the studys methodology was not strict enough, making the results subject to question.

Symposium: Vision Screening in Children Conclusion

Vision screening for amblyopia concerns all of us in the eye community. Everything from public health concerns that amblyopia poses to the natural history of the disease has been discussed by authorities on the subject. The various types of screening in the community and in the schools have been described and compared. Pediatricians, optometrists, ophthalmologists, and even politicians have gotten into the heated debate of what is best for the child. Considering the health dollars involved, this is no surprise. The debate rages on. It is our hope that you have enjoyed and learned new information from this symposium concerning a very critical topic.

Preverbal Assessment for Amblyopia

Purpose To describe and compare the different methods of preverbal assessment of amblyopia. Results Each method of visual assessment has its plusses and minuses. Conclusion There is no “best” method for assessment for amblyopia. The best method may be a combination of the various described tests.

Minimizing undercorrection in strabismus surgery.

Unfortunately, undercorrections are sometimes the outcome of strabismus surgery. Some preoperative strabismic tests allow the examiner to determine the appropriate surgery to minimize undercorrections. Some strabismic conditions exhibit features that can be determined preoperatively and that will decrease the chances of postoperative undercorrection.