Savleen Kaur

Complications in the First 5 Years Following Cataract Surgery in Infants With and Without Intraocular Lens Implantation in the Infant Aphakia Treatment Study

PURPOSE To compare rates and severity of complications between infants undergoing cataract surgery with and without intraocular lens (IOL) implantation. DESIGN Prospective randomized clinical trial. METHODS A total of 114 infants were enrolled in the Infant Aphakia Treatment Study, a randomized, multi-center (12) clinical trial comparing the treatment of unilateral aphakia in patients under 7 months of age with a primary IOL implant or contact lens. The rate, character, and severity of intraoperative complications, adverse events, and additional intraocular surgeries during the first 5 postoperative years in the 2 groups were examined. RESULTS There were more patients with intraoperative complications (28% vs 11%, P = .031), adverse events (81% vs 56%, P = .008), and more additional intraocular surgeries (72% vs 16%, P < .0001) in the IOL group than in the contact lens group. However, the number of patients with adverse events in the contact lens group increased (15 to 24) in postoperative years 2-5 compared to the first postoperative year, while it decreased (44 to 14) in years 2-5 compared to the first postoperative year in the IOL group. If only one half of the patients in the contact lens (aphakic) group eventually undergo secondary IOL implantation, the number of additional intraocular surgeries in the 2 groups will be approximately equal. CONCLUSION The increased rate of complications, adverse events, and additional intraocular surgeries associated with IOL implantation in infants <7 months of age militates toward leaving babies aphakic if it is considered likely that the family will be successful with contact lens correction.

Postural and diurnal fluctuations in intraocular pressure across the spectrum of glaucoma

Aims To evaluate postural fluctuations (PFs) and diurnal variation (DV) of intraocular pressure (IOP) in patients with untreated glaucoma, glaucoma suspects and healthy volunteers, and study their relationship, if any, to the extent of glaucomatous damage. Methods This prospective, observational cross-sectional study was carried out in a tertiary care referral institution. The patient population included five groups of patients comprising the following: 19 with ocular hypertension (OHT), 26 with optic discs suspicious for glaucoma (DS), 18 with normal tension glaucoma (NTG), 19 with primary open angle glaucoma (POAG) and 20 normal subjects. The IOP was measured at four time periods using Perkins tonometer, in sitting and supine positions. The main outcome measures were change in IOP with posture, the DV in both postures and the relationship between PF, DV and the extent of visual field damage. Results The supine IOP was significantly higher than the sitting IOP, at all time points of the day, in all groups (p<0.001). The PF at 04:30 was significantly higher in POAG, OHT and NTG. The PF at 09:00 correlated significantly with the mean deviation (MD) on visual fields in the NTG group (r=0.735; p=0.001). The DV did not correlate with the MD in any of the five groups studied. Conclusions The significantly higher supine IOP is frequently missed in routine glaucoma practice. An early morning supine IOP measurement may reveal a peak IOP hitherto not picked up during routine office IOP measurements, and may be a useful measurement in unexplained progressive glaucoma.

Re: Long-term results after primary intraocular lens implantation in children operated less than 2 years of age for congenital cataract

Purpose: To study the long-term outcome of cataract surgery with primary intraocular lens (IOL) in children <2 years. Materials and Methods: Retrospective analysis of bilateral cases that were operated before 2 years age for congenital cataract. All underwent primary posterior capsulotomy with anterior vitrectomy and primary IOL implantation. Only those with a follow-up of at least 8 years were evaluated. Results: Twenty-six eyes of 13 children with bilateral cataract met the inclusion criteria. Average age at surgery was 14.15 months with a mean follow-up of 102 months. Average preoperative axial length (AL) was 19.93 mm. There was a refractive shift from a mean spherical equivalent of 1.64 D at 2 weeks after surgery to -1.42 D measured at last follow-up. Twenty-four eyes out of 26 (92%) achieved final visual acuity (VA) of 6/18 or more at last follow-up with 19/26 (73%) having acuity of 6/12 or greater. Raised intraocular pressure was documented in one eye only. Average AL recorded at last follow-up was 22.21 mm. Conclusion: Primary IOL implantation in children <2 years is a safe surgical procedure with excellent long-term results. The myopic shift is well-controlled and final VA achieved is reasonably good.

Outcome of Ocular Steroid Hypertensive Response in Children.

Purpose:The aim of our study was to analyze the epidemiological profile and outcome of steroid-induced ocular hypertension in children below 12 years of age in a tertiary eye center. Methods:Hospital records of patients attending the pediatric glaucoma clinic from July 2005 to December 2012 at our center were retrospectively reviewed. Steroid-induced ocular hypertension was defined as intraocular pressures (IOP)>21 mm Hg (or an increase of>6 mm from baseline) with or without associated glaucomatous optic neuropathy after intake of steroids in any form. Demographic data, management details and IOP, anterior segment, and posterior segment findings were recorded. The main outcome measure was the control of IOP after treatment. Results:Of the acquired pediatric glaucoma patients, 24% were steroid-induced ocular hypertensives (36 of 150 patients) (mean age group 9.2±2.4 y). We studied 57 eyes of 36 patients that had an IOP>21 mm Hg after steroid intake. Of the 36 patients, 22 had bilateral steroid hypertensive response. Of all the patients, 15 (41.6%) received steroids because of vernal conjunctivitis, 16 (22 eyes) could be managed by withdrawing steroids only, 13 (25 eyes) were controlled by medical therapy, and 7 (10 eyes) needed surgery. Favorable outcome (defined as<21 mm of Hg with/without topical antiglaucoma medications) was achieved in 80.5% at the last follow-up (mean 17.4±23.47 mo; range 4 mo to 8 y). Conclusions:Our paper emphasizes on the ocular hypertensive side effects of steroids in children. There are many instances where one can avoid the use of steroids and consider nonsteroidal/anti-inflammatory alternatives. Withdrawal of steroids and antiglaucoma medicines are effective in controlling IOP in majority (80.5%).

Ultrasound Biomicroscopy in Strabismus Surgery: Efficacy in Postoperative Assessment of Horizontal Muscle Insertions.

ABSTRACT Purpose: To study the efficacy of ultrasound biomicroscopy (UBM) in assessment of extraocular muscle insertion sites after strabismus surgery. Methods: This double masked prospective interventional study included 16 eyes of 15 patients with deviation <60 prism diopters (PD) who underwent primary horizontal strabismus surgery. Preoperative muscle insertion was measured by UBM and compared with measurements done intraoperatively by surgical caliper. Both measurements by surgical caliper were taken intraoperatively before and after performing the planned repositioning of the muscle insertion. Postoperatively muscle insertion was remeasured by UBM and compared with the presumed muscle insertion after surgery. Clinically limits of agreement of ± 1 mm were taken as acceptable. Results: Mean age of patients was 21 ± 3 years (range 16–28 years). Preoperative average distance of the medial rectus (MR) from limbus was 5.3 ± 0.3 mm (4.9–5.9 mm) by the UBM and 5.6 ± 0.3 (5–6 mm) by surgical caliper (p = 0.05). For lateral rectus (LR), UBM measurements from the limbus were 6.8 ± 0.7 mm (5.9–8.3 mm) and 7.1 ± 0.4 mm (6.5–8 mm) by calipers (p = 0.067). Post–op UBM at 3 months could visualize new muscle insertion for all operated MR muscles (i.e., 100% of cases) and for LR muscles in only 50% of cases. However, accuracy could be achieved only in 78.6% of cases for MR muscle and for LR in 62.5% of cases (among LR muscles that were visible post-op). Maximum distance posterior to the limbus that the UBM was able to detect MR was 11.2 mm and for LR was 13.5 mm. Conclusion: UBM does not detect the new position of LR with any consistency postoperatively. Even after detection of muscle, the new insertion is only within ±1 mm of the actual muscle insertion in 62.5% of the cases. Hence it is not a reliable tool for planning resurgery.

Outcome of primary intraocular lens implantation in infants: Complications and rates of additional surgery.

Purpose To study the requirement of additional surgery and adverse events in infants having primary intraocular lens (IOL) implantation. Setting Tertiary care institute, Chandigarh, India. Design Prospective observational noncomparative case series. Methods Infants who had phacoaspiration, primary posterior capsulotomy, anterior vitrectomy, and primary IOL implantation were evaluated for complications and the need for additional surgery over a 3‐year period. The main outcome measures were the rate of complications, adverse events, and need for additional surgery. Results Sixty infants (100 eyes) with a mean age of 7.13 months ± 2.32 (SD) (range 3 to 12 months) were studied. The mean follow‐up was 41.2 ± 3.5 months. Indication of additional surgery included visual axis opacification in 13 eyes, pupillary membrane/IOL decentration in 4 eyes, and iris prolapse in 4 eyes. Adverse events included pigment on the IOL in 14 eyes and iridolenticular adhesions in 9 eyes. Ocular hypertension was observed in 2 eyes. The IOL was placed in sulcus or by optic capture in 14 eyes. There was no difference in additional surgery and adverse events between infants aged 6 months or younger versus those older than 6 months (P = .734). Conclusion There was a low incidence of adverse events and additional surgery requirement in infants who had cataract surgery with primary IOL implantation. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Intractable Choroidal Effusion With Exudative Retinal Detachment in Sturge-Weber Syndrome

A 5-year-old boywith Sturge-Weber syndrome (SWS) and glaucoma receiving treatment since infancy elsewhere presented with raised intraocular pressure (IOP) in the right eye. Hehadundergone trabeculectomy in the right eyewithmitomycin C4years earlier. On examination, his best-corrected visual acuity was 6/60 (−2.5 diopters sphere/0.5 diopters cylinder × 90) and 6/6 (0.5 diopters sphere) OD and OS, respectively. His IOP was 36 mm Hg and 12 mm Hg OD and OS, respectively,while receiving themaximum-toleratedantiglaucomamedications. Fundus examinationwas normal (Figure 1A andB), and B-scan ultrasonography revealed nomass lesion in the right eye. The left eye was normal. He underwent Ahmed glaucoma valve implantation in the right eye. On the first postoperative day, the anterior chamber was flat with corneolenticular touch (Figure 1C) and serous choroidal effusion. The anterior chamber repeatedly flattened despite viscoelastic injection, and thechoroidal effusionpersisted.TheAhmedglaucomavalve tubewas ligated a week later, following which the IOP stabilized and choroidal effusion subsided. After 9 months, the IOP rose to 30 mm Hg, which could not be controlled medically. There was a tense fibrous capsule encapsulating the Ahmed glaucoma valve plate, which was excised. Postoperatively, it again led to hypotony and a shallow anterior chamber. The accompanying choroidal effusionwas now associatedwith exudative retinal detachment, with retina-lenticular touch (Figure 1D) and the patient did not respond to conservative management. Quiz at jamaophthalmology.com A B

Outcome of a New Acrylic Intraocular Lens Implantation in Pediatric Cataract.

PURPOSE To study the outcome of Hoya Clear Preloaded intraocular lens (IOL) (PC 60AD, AF Series; Hoya, Tokyo, Japan) implantation in children. METHODS Children who underwent phacoaspiration with primary posterior capsulotomy, anterior vitrectomy, and primary IOL implantation through a 2.8-mm incision were observed prospectively. In all cases, attempts were made to implant the IOL into the capsular bag. Parameters noted were ease of implantation, synechiae formation, IOL deposits, decentration of IOL, visual axis obscuration, haptic compression, and ovalling of the rhexis. Intraoperative complications related to the IOL were also recorded. RESULTS This series comprised 58 eyes of 38 patients with congenital/developmental cataract who underwent implantation of the Hoya IOL. Mean age of the patients was 3.27 ± 2.69 years (range: 3 months to 8 years) and mean follow-up was 24.5 ± 9.13 months. Visual axis obscuration occurred in 4 eyes, posterior synechiae in 5 eyes, IOL deposits in 6 eyes, haptic compression in 3 eyes, and IOL decentration in 1 eye. CONCLUSIONS The data suggest that implantation of the Hoya IOL is a safe option in children undergoing cataract surgery.

Isolated lateral rectus recession with Y splitting versus anchoring of the lateral rectus muscle in patients with exotropic Duane syndrome

PURPOSE To compare the outcome of two surgical procedures used to treat up- and downshoots in Duane retraction syndrome associated with exotropia. METHODS The medical records of patients with exotropic Duane retraction syndrome seen at a single tertiary care facility from 2009 to 2012 were retrospectively reviewed. Patients were divided into two groups, one comprising patients treated with Y splitting and recession of the lateral rectus muscle; the other, patients treated with anchoring of the lateral rectus muscle to the lateral palpebral ligament. Surgical outcomes were compared in terms of deviation, head turn, up- and downshoot, and duration of surgery. RESULTS A total of 15 patients were included, 7 treated by Y splitting and recession and 8 by anchoring of the lateral rectus muscle. Both groups were comparable in terms of age, sex, laterality, best-corrected visual acuity, mean deviation in primary position, and preoperative head turn to the affected side. Torticollis decreased from 27.9° ± 6.4° to 2.6° ± 4.4° in the Y-split group and from 22.5° ± 5.9° to 1.6° ± 3.1° in the anchoring group (P < 0.001 [95% CI]). Exotropia decreased from 26.4(Δ) ± 5.6(Δ) to 2.28(Δ) ± 4.07(Δ) in the Y-split group and 26.9(Δ) ± 5.3(Δ) to 1.5(Δ) ± 6.88(Δ) in the anchoring group (P < 0.001 [95% CI]). The up- and downshoots decreased markedly in the both groups (P = 0.7 for upshoots and P = 1 for downshoots). The mean operating time was 15.3 ± 2.0 minutes for Y splitting plus recession and was 8.3 ± 1.8 minutes for anchoring. CONCLUSIONS In our patient cohort, the two procedures yielded comparable results in terms of the correction of the horizontal position deviation, head posture, and up- and downshoots.

Nasal lateral rectus transposition combined with medial rectus surgery for complete oculomotor nerve palsy

Complete paralysis of the oculomotor nerve results in the lateral rectus and superior oblique muscles acting unopposed and the eye being fixed in an abducted, slightly depressed and intorted position. The goal of strabismus surgery in such cases is to achieve an acceptable alignment in primary position. Simple recession-resection procedures may not yield acceptable results, and numerous other procedures have been attempted, with limited success. We report the outcome of nasal transposition of two halves of the lateral rectus muscle combined with medial rectus surgery in 3 cases of total oculomotor nerve palsy.