Phoebe D. Lenhart

Augmented Hummelsheim procedure to treat complete abducens nerve palsy

BACKGROUND Horizontal strabismus due to a weak rectus muscle can be treated with an augmented Hummelsheim procedure, in which both vertical rectus muscle tendons are split, resected by 4 mm, and reattached to the sclera adjacent to the weak rectus muscle. Compared with vertical rectus transposition, the procedure spares two ciliary vessels and does not require placement of augmentation sutures. In this study, we evaluated binocular alignment and ocular motility in patients with abducens nerve palsy treated with an augmented Hummelsheim procedure. METHODS The medical records of consecutive patients with complete abducens nerve palsy who underwent the augmented Hummelsheim procedure, usually combined with medial rectus muscle recession, were retrospectively reviewed. Binocular alignment, ocular motility, and complications were analyzed. RESULTS Ten patients (age range, 12-57 years) met inclusion criteria for the study, of whom 9 of 10 had simultaneous medial rectus recession. Follow-up ranged from 1 week to 24 months. The augmented Hummelsheim procedure improved esotropia from 43(Δ) ± 5(Δ) preoperatively to 6(Δ) ± 7(Δ) postoperatively (P < 0.0001) and reduced abduction deficits from -4 to -3 (P < 0.0001). One patient with coexisting oculomotor nerve palsy developed consecutive exotropia; 2 had induced vertical deviations. There were no cases of anterior segment ischemia. CONCLUSIONS The augmented Hummelsheim procedure combined with medial rectus muscle recession reduced mean primary position esotropia and improved abduction in patients with complete abducens nerve palsy.

Congenital Fibrovascular Pupillary Membranes: Clinical and Histopathologic Findings

PURPOSE To report the clinical and histopathologic findings associated with congenital fibrovascular pupillary membranes. DESIGN Case series. PARTICIPANTS Seven infants were included, 6 with a unilateral congenital pupillary membrane and 1 with classic persistent fetal vasculature (PFV). METHODS Patients underwent a membranectomy, pupilloplasty, or lensectomy. Histopathologic examination was performed on the excised membranes. MAIN OUTCOME MEASURES Visual acuity and pupil size. RESULTS Four of the 6 patients with a unilateral congenital pupillary membrane had 1 or more recurrences after a membranectomy and pupilloplasty. The most recent pupil size ranged from 2 to 5 mm in the affected eye. When last tested, the vision in the affected eye was excellent in 4 of the 6 patients. The 2 patients without recurrences of the pupillary membranes underwent multiple iris sphincterotomies at the time of the initial surgery. Histopathologic examination of 2 primary pupillary membranes showed fibrovascular tissue that did not stain for neuron-specific enolase. Smooth muscle actin was only present in vascular walls. In contrast, histopathology of a recurrent pupillary membrane revealed collagenized fibrovascular tissue that was immunoreactive for smooth muscle actin. Finally, histopathology of the retrolenticular membrane excised from an infant with classic PFV was similar to the latter aside from hypercellularity. CONCLUSIONS Congenital fibrovascular pupillary membranes in infants are likely a variant of PFV that may recur if incompletely excised. The risk of these membranes recurring may be reduced by excising as much as the membrane as possible and enlarging the pupil with iris sphincterotomies. A lensectomy should be avoided if possible.

The Role of Magnetic Resonance Imaging in Diagnosing Optic Nerve Hypoplasia

PURPOSE To establish objective lower limits of normal optic nerve (ON) size in children based on high-resolution orbital magnetic resonance imaging (MRI). DESIGN Case-control study of patients with ON hypoplasia vs normal controls. METHODS A neuroradiologist made 4 measurements of each ON at 2 locations (5 mm posterior to the optic disc and just posterior to the optic canal) in patients with ON hypoplasia and controls aged 0-17 years from an academic eye center and childrens hospital. Primary analyses were performed using mixed linear models. RESULTS Measurements were made in 26 cases of clinically confirmed ON hypoplasia and 31 controls (median age: ON hypoplasia, 1 year; controls, 5.5 years). Nine of 26 cases (35%) and 19 of 31 controls (61%) underwent high-resolution T2-weighted imaging of the orbits. Mean ON diameter was 1.36 mm (95% CI: 1.19-1.54; P < .001) smaller for clinically hypoplastic ONs than for controls. Optic nerve diameter increased by 0.05 mm per year of age (95% CI: 0.03-0.07; P < .001). A lower bound to the 95% prediction interval for normal optic nerves was (2.24 mm + 0.052 × [age in years]) mm and excluded all but 1 case. CONCLUSIONS Age was independently associated with normal ON size by MRI and should be taken into consideration when evaluating ON hypoplasia, based on MRI criteria. We have provided a formula to assist clinicians in objectively determining if ON hypoplasia is present.

Global challenges in the management of congenital cataract: proceedings of the 4th International Congenital Cataract Symposium held on March 7, 2014, New York, New York.

Childhood cataracts have become a leading cause of preventable childhood blindness in many areas of the world. Here we summarize regional focus group discussions from the 4th Annual International Congenital Cataract Symposium on the current situation, challenges, and recommendations for the management of congenital cataracts in sub-Saharan Africa, the Middle East and North Africa, South Asia, Central America, South America, and developed nations. Strategies for managing congenital cataracts must be adapted and developed according to regional conditions. A basic framework for acceptable outcomes must focus on developing systems to address the critical components of education, access, quality care, and good follow-up.

A cost analysis of pediatric cataract surgery at two child eye health tertiary facilities in Africa

PURPOSE To determine the direct cost of pediatric cataract surgery at two child eye health tertiary facilities (CEHTFs) in Africa. METHODS The direct cost of pediatric cataract surgery was determined by reviewing data collected from two CEHTFs in Zambia and Malawi. Inventory, cost, and usage data of all durable medical equipment, consumable equipment, personnel, and medications were collected and the direct cost per child calculated. RESULTS For cataract surgery and related treatment during 2011, the total cost per child was calculated to be

Partial coherence interferometry versus immersion ultrasonography for axial length measurement in children

202 for Malawi and

Functional and Motor Outcomes of Strabismus Surgery for Chronic Isolated Adult Sixth Nerve Palsy

277 for Zambia using figures derived from estimating labor cost allocation proportional to employee time devoted to pediatric cataract management. The one-time equipment cost totaled

Cataract secondary to self-inflicted blunt trauma in children with autism spectrum disorder.

178,121 for Malawi and

Predictors of Good Motor and Sensory Outcomes Following Strabismus Surgery for Patients with Third Nerve Palsies

179,832 for Zambia. CONCLUSIONS These cost estimates may serve as a basis for economic decisions aimed at improving access to care, management, and follow-up for children with cataract and provide useful insights for programs dedicated to promoting organizational and financial sustainability for CEHTFs in Africa.

Concordance between child and parent-proxy report on a new self-report tool of vision related quality of life for children with JIA-associated uveitis – “Effects of Youngsters’ Eyesight on QOL -EYE-Q”

PURPOSE: To determine whether measurements obtained by partial coherence interferometry (PCI) correlate well with measurements obtained using immersion ultrasound (US) in children. SETTING: Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA. DESIGN: Evaluation of a diagnostic test or technology. METHODS: The charts of pediatric patients who had cataract surgery from August 2008 to September 2009 were reviewed. Axial length (AL) measurements in the operative eye were obtained using PCI at the preoperative clinic visit and then using immersion US in the operating room before surgery. The data were compared to determine the degree of agreement. RESULTS: The charts of 18 patients (27 eyes) were reviewed. Preoperative AL measurements by PCI were obtained in 21 eyes (78%). On average, the PCI‐measured ALs were 0.1 mm less than the immersion US values (95% confidence interval, −0.2 to −0.1; P = .002). All eyes with an AL of 23.5 mm or less had lower PCI values than immersion US values. There was no systematic pattern of 1 measurement being greater or less than the other in eyes with an AL longer than 23.5 mm. CONCLUSIONS: There was a systematic difference in AL measurement between PCI and immersion US, with PCI tending to give lower values, particularly in eyes with an AL of 23.5 mm or less. Depending on the length of the eye, a 0.1 mm error in AL measurement could result in a 0.25 to 0.75 diopter difference in intraocular lens calculation that could be clinically significant in some patients. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.