Ronit Friling

Diode laser treatment of retinopathy of prematurity: anatomical and refractive outcomes.

Purpose: To examine the anatomical and refractive outcomes of infrared diode laser photocoagulation (DLPC) for the treatment of threshold retinopathy of prematurity (ROP). Methods: The charts of all consecutive premature neonates with ROP treated by DLPC at our tertiary center from December 1, 1996, to December 31, 2004, were reviewed. Results: The group included 100 neonates (194 eyes) with a mean birth weight ± SD of 833.9 ± 250.3 g and a mean gestational age ± SD of 26 ± 1.9 weeks. Sixty-two percent of neonates had zone I or posterior zone II ROP. Each eye received a mean ± SD of 1,740 ± 990 laser applications, and 21% of eyes received an additional 1 to 2 rows posterior to the ridge. Neonates treated after December 2003 (cutoff date of the Early Treatment of Retinopathy of Prematurity study) underwent a significantly greater number of laser applications (mean ± SD, 2,286 ± 1,087) than did neonates treated earlier. Anatomical results of laser treatment were favorable for 179 eyes (92.3%) at a mean follow-up ± SD of 33.6 ± 27.2 months. After vitreoretinal surgery, partial or total retinal detachment was documented for 2.5% of patients who received posterior-to-the-ridge laser treatment and 3.8% of patients treated only on the avascular retina. Refractive data were available for 134 eyes: 55.2% had myopia of −5 diopters (31.3%) or greater (23.9%). Strabismus was found in 21 (28.8%) of 73 neonates tested. Gestational age was correlated with corrected age at treatment, zone of ROP, number of laser applications, and spherical equivalent. Snellen visual acuity of 6/12 or more occurred in 17 of 24 patients who complied with testing. Conclusion: DLPC is a safe and effective treatment for ROP. Neonates of lower gestational age and birth weight require earlier and more aggressive laser treatment and may have a higher refractive error.

Intravitreal Bevacizumab As Supplemental Treatment Or Monotherapy For Severe Retinopathy Of Prematurity

Purpose: To investigate the benefit of intravitreal bevacizumab as supplemental or primary treatment for retinopathy of prematurity. Methods: The files of nine consecutive infants treated with intravitreal bevacizumab for bilateral severe posterior retinopathy of prematurity were reviewed. Results: Gestational age was 24 weeks to 27 weeks, and birth weight was 660 g to 1,131 g. Indications for treatment were retinopathy of prematurity progression from Stage 3 to 4A or 2 to 3 with extraretinal neovascularization despite laser treatment; active neovascular Stage 4A disease after laser and cryo-treatment; anterior segment neovascularization and bleeding after laser treatment; and aggressive posterior disease with tunica vasculosa lentis and vitreous haze, which prevented laser treatment. One patient (two eyes) underwent lens-sparing vitrectomy after bevacizumab treatment; one eye acquired macular fold. One patient underwent bilateral scleral buckle. Bevacizumab treatment was associated with subsidence of the active vascular component in all eyes. Anatomical results were favorable in 17 eyes. There were no local or systemic complications. Conclusion: Intravitreal bevacizumab may serve as a supplemental therapeutic agent for severe laser-refractory retinopathy of prematurity or as monotherapy when media opacities preclude diode laser photocoagulation or the patient is too sick for lengthy laser treatment.

Elevated intraocular pressure associated with steroid treatment for infantile spasms

PURPOSE To evaluate the ocular changes and medical and surgical therapy after high-dose systemic steroid treatment in babies with infantile spasm and hypsarrhythmia. DESIGN Retrospective, noncomparative, interventional case series. PARTICIPANTS In 5 of the 9 (55%) babies with infantile spasm exposed to systemic corticosteroid treatment, an increase in intraocular pressure (IOP) and optic disc cupping was observed. INTERVENTION Ophthalmic examination under mild sedation was conducted 3 to 4 weeks after initiation of systemic therapy. Antiglaucoma treatment was given to the patients found to have high IOPs and cup-to-disc ratio changes. Routine follow-up was continued until systemic therapy was completed. MAIN OUTCOME MEASURES Controlled IOP with a decrease in cupping damage after antiglaucoma therapy. RESULTS Five patients required antiglaucoma treatment; one also underwent augmented trabeculectomy. Mean IOP decreased in this subgroup from 30.1 +/- 9.5 mmHg to 15.4 +/- 4.2 mmHg in the right eye (P = 0.043) and from 32.6 +/- 7.4 mmHg to 15.2 +/- 1.8 mmHg in the left eye (P = 0.043). Mean cup-to-disc ratio improved from 0.53 +/- 0.2 to 0.37 +/- 0.04 in the right eye (P = 0.06) and from 0.57 +/- 0.12 to 0.35 +/- 0.05 in the left eye (P = 0.042). CONCLUSIONS The rapid onset of IOP and cup-to-disc ratio changes in patients with infantile spasm and hypsarrhythmia treated by high-dose corticosteroids necessitates early and intensive monitoring to prevent anatomic ocular damage and visual impairment in the future.

Sub-Tenon’s Ropivacaine Block for Pain Relief After primary Strabismus Surgery

Purpose: Pain is the main cause of patient distress/dissatisfaction after strabismus surgery. The aim of the study was to evaluate the effect of sub-Tenon’s block with ropivacaine at the end of strabismus surgery on post-operative pain. Methods: A prospective trial was conducted in 79 patients (age 1.0–65 years) scheduled for outpatient primary strabismus surgery with fixed sutures under general anesthesia (GA) at a major tertiary hospital. Half the patients were randomly allocated to receive sub-Tenon’s block with ropivacaine 0.2% at conclusion of the operation. Primary outcome measures were visual analog scale (VAS) scores at arrival to the post-anesthesia care unit (PACU), at discharge 3 hr later, 12–16 hr post-operatively, and 24 hr post-operatively. Supplemental analgesia requirements and patient satisfaction were recorded as well. Data were presented as median (range). Mann–Whitney test, Pearson χ2-test or Fisher’s exact test was used for statistical analysis; p ≤ 0.05 was considered significant. Results: There were no between-group differences in median VAS scores at arrival to the PACU and at discharge, with a borderline difference at 24 hr post-operatively (p = 0.06). At 12–16 hr post-operatively, the median score was 0.0 (range 0–5) in the study group and 4.0 (range 0–6) in the controls (p < 0.001). The lower VAS score in the study group was associated with a lower rate of supplemental analgesia use (21.9% versus 57.9%, p = 0.001), fewer doses of supplemental analgesia (10 doses versus 35, p = 0.03), and higher patient satisfaction (p < 0.001). Conclusions: Sub-Tenon’s block with ropivacaine 0.2% at the completion of outpatient primary strabismus surgery with fixed sutures under GA reduces pain 12–16 hr post-operatively and analgesia requirements 4–23 hr post-operatively.

Z-tenotomy of the superior oblique tendon and horizontal rectus muscle surgery for A-pattern horizontal strabismus.

PURPOSE Few studies have investigated combined surgeries for horizontal deviation and A pattern caused by superior oblique overaction (SOOA). This study presents our experience with combined surgery and examines the effect of the type of strabismus and prior surgery on outcome. METHODS The medical records of patients who underwent combined surgery for horizontal deviation occurring with A-pattern misalignment from 2000 through 2004 were reviewed. The procedure consisted of horizontal extraocular muscle recession or resection with superior oblique Z-tenotomy. The criteria for surgical success were horizontal deviation at primary gaze of </=10(Delta), A pattern of </=8(Delta), and SOOA of </=1.0. RESULTS The study group included 28 patients with a mean age of 13.4 years. Thirteen (46.4%) had A-pattern esotropia; 15 (53.6%) had A-pattern exotropia. Fifteen (50%) had undergone previous surgery. The success rate for the whole group was 60.7%. There was no statistically significant difference in success rate between patients with esotropia (53.8%) or exotropia (66.7%) (p = 0.48) or between patients in whom the combined procedure was the primary (71.4%) or secondary (50.0%) treatment (p = 0.246). Measurements of horizontal strabismus remained stable throughout follow-up in the esotropia group but were unpredictable in the exotropia group. CONCLUSIONS The success rate of combined horizontal deviation/A-pattern surgery is unaffected by type of horizontal deviation or prior surgery.

Postoperative Lomefloxacin 0.3% Prophylaxis in Strabismus Surgery

Purpose: To evaluate the efficacy of topical lomefloxacin 0.3% versus chloramphenicol 0.2% with polymyxin B 2500 U/ml in the treatment of patients after strabismus surgery. Methods: Seventy-nine consecutive patients who underwent strabismus surgery from April through October 2006 were randomized to receive topical lomefloxacin 0.3% (n = 45, 58 eyes) or chloramphenicol 0.2% with polymyxin B 2500 U/ml (n = 34, 40 eyes) postoperatively, in addition to topical dexamethasone 0.1% and diclophenac 0.1%. The groups were compared for clinical signs of local cellulitis and findings on conjunctival cultures. Results: From postoperative day 1 to day 28, rates of chemosis decreased from 96% to 9.5% in the lomefloxacin group and from 94% to zero in the chloramphenicol group; rates of hyperemia decreased from 100% to zero in both groups. Accordingly, rates of a cumulative clinical sign score (CCSS) decreased from 60% to zero in the lomefloxacin group and 50% to zero in the chloramphenicol group. Rates of positive bacterial cultures dropped from 59.6% preoperatively to 48.3% on day 14 in the lomefloxacin group and from 63% to 47% in the chloramphenicol group. Conclusions: Topical lomefloxacin is a potent alternative to topical chloramphenicol eye drops after strabismus surgery for the control of pain, infection and discharge, chemosis, hyperemia, and conjunctival hemorrhage.

Uveitic Glaucoma: Long-term Clinical Outcome and Risk Factors for Progression

ABSTRACT Purpose: To study the long-term clinical outcomes of uveitic glaucoma and to identify risk factors for progression. Methods: Retrospective study of uveitic glaucoma patients in two tertiary medical centers in 2003–2015. Patient- and disease-related data was retrieved. Clinical parameters and visual fields measured at predetermined time points were recorded. Outcome measures included maintaining intraocular pressure ≤21 mmHg and preserving visual fields. Results: Included were 34 patients (53 eyes), with a mean follow-up of 7 years. Idiopathic anterior uveitis and open-angle glaucoma were most common. In total, 62% of eyes were steroid responders. Higher IOP was associated with posterior synechiae, peripheral-anterior synechiae, steroidal, and immunomodulatory therapy (p<0.05). Glaucomatous field defects developed in 49%, with most showing no progression, despite elevation of cup-to-disc ratio (p<0.05). Conclusions: Chronic severe uveitis, expressed by structural complications and immunomodulatory therapy, was associated with high IOP and the need for more IOP lowering medications, but was unrelated to glaucomatous damage.

Evaluation of ocular motility deviation changes in exotropic patients after cycloplegic eye drops versus prism adaptation test

Purpose: To evaluate changes in ocular motility deviation with cycloplegic eye drop examination compared to the prism adaptation test in patients with strabismus. Methods: The medical charts were reviewed of all patients who underwent primary strabismus surgery in our center from December 2013 to July 2015. Data collected included demographics, medical history, and findings on pre-operative ophthalmic/orthoptic examination. Ocular motility deviation was measured before instillation of cycloplegic eye drops, immediately after maximal dilation (end point), and 10 and 20 min later. Prism adaptation test readings were taken at baseline, immediately after prism removal (end point), and 10 and 20 min later. Results: A total of 43 patients had complete pre- and post-operative evaluations. Our analysis focused only on the exotropic patients (n = 33). On cycloplegics, there was no significant difference in ocular motility deviation between baseline and end point for distance and near (p = 0.584, p = 0.468, respectively). On prism adaptation test, comparison of ocular motility deviation between baseline and end point was statistically significant for distance and near (p = 0.002, p = 0.001, respectively). Changes remained significant 10 min after the end point for near (p = 0.011). Comparison at the end points between the tests revealed statistical significance for distance and near, favoring the prism adaptation test (p = 0.001 and p < 0.001, respectively). This significance was maintained even after 10 min for near (p = 0.036). Conclusion: The prism adaptation test is preferred over cycloplegic eye drops for the evaluation of maximal reserve of distance/near motility before surgical correction of exotropia.

Systemic corticosteroids may be beneficial for managing severe or refractory orbital cellulitis in children

Orbital cellulitis infects the orbital tissues, with chemosis and periorbital swelling accompanied by limited eye movements, proptosis or decreased visual acuity (1). The most common cause is rhino-sinusitis extending into the orbit, especially when the ethmoidal sinuses are involved (1). Reported complications have included subperiosteal abscesses, orbital abscesses and cavernous sinus thrombophlebitis (1). This article is protected by copyright. All rights reserved.

Horizontal Deviations in Congenital Brown Syndrome

PURPOSE To report the incidence of horizontal deviations requiring surgical correction in patients with congenital Brown syndrome. METHODS In a retrospective study, the medical records of all children who underwent a surgical correction of congenital Brown syndrome at Schneider Childrens Medical Center of Israel from 1998 to 2016 were reviewed, analyzing the presence of preoperative primary position horizontal misalignment. RESULTS Overall, 19 eyes (8 right and 11 left eyes) of 16 patients (7 males, 9 females; mean age: 4.2 ± 2.6 years) were included in this study. Fourteen patients (88%) had surgery for correction of a compensatory head position, including 8 patients (50%) with a head tilt and 6 patients (38%) with a chin-up position, and 2 patients had surgery for primary position hypotropia. All of them underwent a weakening procedure of the superior oblique tendon, by either Z-tenectomy (81%, n = 13) or suture elongation of the superior oblique tendon (19%, n = 3). Fifty-six percent of patients (n = 9) had primary position horizontal deviation before surgery, including 50% (n = 8) exodeviations, ranging from exophoria of 4 prism diopters (PD) to exotropia of 30 PD, and one esotropia of 14 PD. Fifty percent of patients (n = 8) had surgery to correct the horizontal deviation by a recession of either one (31%, n = 5) or two (19%, n = 3) muscles. Mean preoperative horizontal deviation (9.3 ± 3.4 PD) decreased significantly following surgery (1.7 ± 1 PD, P = .001) (paired t test). CONCLUSIONS Significant horizontal misalignment is often present in patients with congenital Brown syndrome and its correction should be considered at the time of surgery. [J Pediatr Ophthalmol Strabismus. 2018;55(2):113-116.].