Tamara Wygnanski-Jaffe

Long-term results of esotropia surgery in children with developmental delay

PURPOSEnTo assess the long-term results of esotropia surgery in children with developmental delay who were operated on with reduced surgical dosages.nnnMETHODSnThis was a retrospective analysis of children with developmental delay who had undergone surgery for esotropia during a 16-year period. The pre- and postoperative angle of deviation was calculated for each subject as the mean of distant and near angles measured by a cover test or the Krimsky measurement. The main outcome measure was surgical success, categorized as esotropia or exotropia of ≤ 10(Δ).nnnRESULTSnThe chart review identified 24 children who met inclusion criteria, with a mean age of 2.8 ± 2.5 years (range, 0.8-10 years). The mean angle of preoperative esotropia was 49.8(Δ) ± 13.3(Δ). All patients had bilateral medial rectus muscle recessions, with a mean surgical dosage of 5.1 ± 0.7 mm per muscle, on average 0.75 mm less than the standard amount. The average postoperative follow-up was 5.3 ± 3 years (range, 1-13 years). Surgical success was achieved in 9 of 24 children (37.5%) after one operation. Among the 15 failures, 10 (66.6%) were undercorrected, and 5 (33.3%) developed consecutive exotropia. Of these, 8 (53%) agreed to a second procedure. The overall surgical success rate for all patients after all procedures was 63%.nnnCONCLUSIONSnAlthough the initial success rate is low with reduced surgical amounts in children with developmental delays, and some children become exotropic on long-term follow-up, satisfactory results may be achieved with additional procedures.

Do children and adolescents with attention deficit hyperactivity disorder have ocular abnormalities

Purpose. To investigate visual function and ocular features in children with attention deficit hyperactivity disorder (ADHD). Methods. Fifty-one children underwent a detailed ophthalmologic evaluation. Thirty-two were diagnosed with ADHD, and 19 children with attention deficit disorder (ADD). The mean age was 9.9±3.1 years. Results. The average best-corrected visual acuity of the better-seeing eye was 1 (range 0.9-1.25) and 0.96 (range 0.5-1.25) for the fellow eye. Eighteen percent (10) had amblyopia in one or both eyes (3 had strabismic and 7 had ametropic amblyopia). Heterotropia was found in 5 (10%), and absent stereoacuity was found in 3 (6%). Subnormal convergence amplitude was noted in 2 patients (4%). The mean spherical equivalent (SE) of the eyes in this study was 0.17±1.73 (range −5.5 to +7). Twenty-two subjects (43%) had a myopia of −0.50 D or higher. Hyperopia higher than 3.5 D was seen in 10 cases (20%), and astigmatism larger or equal to 1.0 D was observed in 10 patients (20%). With-the-rule astigmatism was by far most common type in the 29 eyes with an astigmatic refractive error (59%). Significant ametropia was detected in 42 (83%) of the patients. In contrast to other studies, we did not find a higher rate of convergence insufficiency or heterotropia. Conclusions. Children diagnosed with either ADHD or ADD can present with significant ametropia but infrequent heterotropia.

The effect of oral propranolol on intraocular pressure in infants with Sturge-Weber syndrome glaucoma.

Purpose To report the effect of oral propranolol on intraocular pressure (IOP) in infants newly diagnosed with unilateral Sturge-Weber syndrome (SWS) glaucoma receiving no other treatment. Methods This was a prospective, nonrandomized interventional case series. Four infants presenting with unilateral SWS glaucoma with no prior treatment were treated with oral propranolol at a dose of 2 mg/kg and followed thereafter. Results Propranolol had a temporary IOP-lowering effect in 3 of 4 children after 1 week of treatment. This effect diminished thereafter and 3 of 4 children required additional medical or surgical treatment. Conclusions Oral propranolol has a temporary effect on IOP in SWS glaucoma and is not effective as a single treatment in this syndrome, yet can serve to delay surgical treatment for a short period of time. In one case, the glaucoma was well-controlled on this medication.

Epileptic seizures induced by cycloplegic eye drops

Abstract Objective: To assess the incidence of seizures induced by cycloplegic ophthalmic drops. Materials and methods: A survey among members of the American Association for Pediatric Ophthalmology and Strabismus yielded five patients who received cycloplegic eye drops between 1998 and 2010 and who consequently developed a seizure. Results: The median age of the patients was 5 years (range 3 months to 12 years). Cyclopentolate hydrochloride 1% was the only causative agent. The seizure happened on average 12u2009min after the instillation of dilating eye drops. Three were generalized convulsions, and two patients had a focal seizure. Past medical history was unremarkable in four cases. In total, 16 previous cases of seizures induced by cycloplegic drugs were identified in reports published between 1890 and 2004, implicating atropine in nine reports, tropicamide and phenylephrine eye drops in one and cyclopentolate in six. Discussion: A small amount of cyclopentolate drops could induce convulsions in young children after only minutes to less than an hour, while a larger dosage of atropine over the span of several hours could cause this rare and unpredictable complication. Predisposing factors were rare and those developing the seizures were healthy subjects. Generalized seizures were much more frequent than focal convulsions. Conclusions: Seizures after instillation of cycloplegic drops are extremely rare.

The relationship between patient age and astigmatism magnitude after congenital cataract surgery.

Purpose To evaluate the magnitude of refractive astigmatism after congenital cataract surgery and to define its correlation with patient age. Methods The authors retrospectively reviewed the charts of all pediatric patients who underwent congenital cataract extraction with intraocular lens (IOL) implantation through a 3.0-mm clear corneal incision from 1998 to 2003, and had no suture removal for 5 months afterward. Thirty-four children were included, aged 2 months to 15 years. Refractive astigmatism was assessed manually 1 week, 3 months, and 5 months after surgery by an experienced optometrist. The paired t test was used to compare the magnitude of postoperative astigmatism at different postoperative periods. Spearman correlation was used to determine the correlation between patient age and the postoperative refractive astigmatism. Results Mean refractive astigmatism in all patients was 1.8±1.5 diopters (D) at 1 week post-operatively. It significantly decreased to 1.0±0.7 D at 3 months postoperatively (p=0.001), and to 0.8±0.7 D at 5 months postoperatively (p=0.03). The change in astigmatism was significantly greater during the first 3 postoperative months than during the following 2 months (p=0.04). Patient age was significantly correlated with 1 week postoperative astigmatism (Spearman coefficient, r = −0.46; p=0.006) and with 3 months postoperative astigmatism (Spearman coefficient, r =–0.37; p=0.03). Conclusions Congenital cataract surgery using a small, clear corneal incision for IOL implantation caused high early postoperative astigmatism, which spontaneously regressed thereafter. Younger patients had higher early postoperative astigmatism.

Traumatic pediatric cataract in southern Ethiopia—results of 49 cases

PURPOSEnTo report the experience of two tertiary care facilities in southern Ethiopia in the treatment of traumatic pediatric cataract for a period of more than 1 year.nnnMETHODSnThe medical records of consecutive traumatic pediatric cataract patients who underwent surgery at the Hawassa University and the Yirgalem University schools of medicine from July 2007 to August 2008 were retrospectively reviewed. All patients with a follow-up of at least 12 months were included.nnnRESULTSnA total of 49 children were included. Mean patient age was 8.6 ± 0.3 years (range, 5-15 years). Of the 49 cases, 32 (65%) were caused by blunt trauma. Average follow-up period was 15 months. Postoperative visual acuity of counting fingers or better was achieved in 43 (88%) eyes compared with 5 (10%) at presentation (P < 0.0001). Better visual acuity at presentation and blunt trauma were associated with better final visual acuity. Only blunt trauma was found by multivariate analysis to influence final visual acuity (P = 0.0001).nnnCONCLUSIONSnVisual acuity of counting fingers or better visual can be achieved in most cases. Blunt trauma is a good independent prognostic factor for visual acuity.

Long-Term Results of Bilateral Medial Rectus Muscle Recession in Children with Developmental Delay

ABSTRACT Purpose: To assess the long-term results of a reduced amount of medial rectus recession in children with esotropia and developmental delay. Methods: A retrospective chart analysis of 42 children with developmental delay who had undergone surgery for esotropia during a 20-year period in a large referral center was performed. The pre- and postoperative angle of deviation was calculated for each subject as the mean of distant and near angles measured by a cover test or the Krimsky measurement. Surgical success was categorized as esotropia or exotropia of ≤10 prism diopters (PD). The main outcome measure was a stable surgical result after several years of follow-up. Results: The chart review identified 42 children who met inclusion criteria, with a mean age of 2.9 years (range, 0.8-10 years). The mean angle of esotropia prior to surgery was 44.29 ± 13.9 PD (range 20-80 PD). All patients had bilateral medial rectus muscle recessions, with a mean surgical dosage of 5.04 ± 0.62 mm per muscle, on average 0.66 mm less than the standard amount. The average postoperative follow-up was 4.6 years (median 3.67 years, range 8 months-15 years). Twenty-four children (57%) achieved surgical success, 13 (31%) were undercorrected, and 5 (12%) were overcorrected. Ten of the 18 with an unsuccessful surgical outcome underwent a second procedure. The overall surgical success rate for all patients after all procedures was 71%. Conclusions: The main reason for surgical failure after bilateral medial rectus muscle recession (BMR) in developmentally delayed children remains residual esotropia. However, with time, more patients demonstrated consecutive exotropia. Although it is difficult to achieve a stable long-term ocular alignment in children with developmental delay, satisfactory results may be achieved with additional surgical procedures. The optimal amount of primary recession and whether to perform the surgical schedules according to the Parks tables or to reduce the amount of the recession when operating on children with developmental delay is still debatable.

A comparison of plusoptiX A12 measurements with cycloplegic refraction.

PURPOSEnTo test the accuracy and reliability of the plusoptiX A12 in detecting amblyogenic risk factors.nnnMETHODSnWe prospectively collected data on children undergoing screening with the plusoptiX A12, cycloplegic refraction, and complete ophthalmic examination. American Association for Pediatric Ophthalmology and Strabismus (AAPOS) 2013 guidelines for the detection of amblyogenic risk factors were used for plusoptiX A12 screening and comparison of the results of both examination modes.nnnRESULTSnData on 402 eyes of 201 children (mean age, 7.63xa0±xa03.41 years) was collected. Mean (with standard deviation) cycloplegic refraction results were as follows: sphere, 0.88xa0±xa01.5 D; cylinder, -0.61xa0±xa00.74 D; axis, 71.17xa0±xa071.04; and spherical equivalent, 0.68xa0±xa02.63. The plusoptiX A12 measurements were as follows: sphere, 0.58xa0±xa01.4 D; cylinder, -0.66xa0±xa00.77 D; axis, 77.3xa0±xa068.9; and spherical equivalent, 0.25xa0±xa01.3. We found a strong correlation (Pearson) for sphere (rxa0=xa00.91), cylinder (rxa0=xa00.81), and axis (rxa0=xa00.7). The mean difference of the myopic spherical component between the plusoptiX and cycloplegic refraction was -0.048xa0±xa00.55 (95% LoA, +1.04 to -1.14 D); for the hyperopic spherical component, 0.37xa0±xa00.93 (LoA, +2.20 to -1.45 D); and for the cylindrical component, 0.05xa0±xa00.32 (LoA, +0.68 to -0.57D). The sensitivity, specificity, positive and negative predictive values for myopia were, respectively, 86%, 93%, 82%, and 94%; for astigmatism, 85%, 98%, 88% and 98%; and for hyperopia, 40%, 100%, 100%, and 98%.nnnCONCLUSIONSnThe plusoptiX A12 accuracy is high in all subgroups but better in the myopic, astigmatic, and anisometropic subgroups. Reliability was lower in the hyperopic eyes, possibly resulting in underestimation of hyperopic refractive error.

Progressive-Addition Lenses for Accommodative Esotropia with a High Accomodative Element.

Abstract Purpose: Accommodative esotropia with a high accommodative element has been typically treated with bifocal lenses. This study assessed the age-dependent efficacy of progressive-addition lenses (PAL) for a high accommodative element in improving motor and sensory performance. Methods: We evaluated PAL as an initial treatment modality or after initiating treatment with bifocals at various ages. Thirty-two patients, who did not undergo eye muscle surgery, were included in this retrospective study. Subjects were divided into 2 subgroups: 7 subjects who received PAL treatment only (median age 4.5 years), and 25 children treated with bifocals (median age 4.5 years) and then switched to PAL at the mean age of 9 years. Measurement of the deviation was performed by the alternate prism cover test. The Stereo fly test and Randot stereo test were used to assess stereoacuity. The mean follow-up periods for the subgroups were 57 and 46 months, respectively. Results: The deviation at near decreased in the PAL-only group from an average of 28 prism diopters (PD) without correction at diagnosis to zero PD with correction. Stereopsis in the PAL first group improved from an average of 113” to 54” and in the bifocals first group improved from 541” to 141. Conclusion: PAL treatment for accommodative esotropia with a high accommodative achieved good sensory and motor results. PAL and bifocals were equally beneficial as the initial treatment of young children with convergence excess esotropia.

Association of orbital decompression and the characteristics of subsequent strabismus surgery in thyroid eye disease

OBJECTIVEnTo examine the association of orbital decompression and the characteristics and outcome of subsequent strabismus surgery in patients with thyroid eye disease (TED).nnnMETHODSnData on patients with TED who underwent orbital decompression at the Goldschleger Eye Institute, Sheba Medical Center, Israel, between January 1990 to December 2011 were extracted. The characteristics of decompression and strabismus surgeries were recorded. The outcomes and association of both surgical procedures were analyzed. Statistical analysis included distribution, Pearson correlation, and matched paired tests.nnnRESULTSn145 eyes underwent orbital decompression, of which 45 eyes (31.0%) underwent strabismus surgery. Esotropia developed in 70% of the patients. Men and smokers underwent strabismus surgeries after decompression procedures more frequently than women and nonsmokers (χ2 test, p = 0.07, 0.002). Moreover, patients who complained of diplopia before the decompression surgery underwent strabismus surgery more frequently (χ2 test, p = 0.005). Seventy-seven percent of the patients who underwent medial wall decompression developed esotropia (χ2 test, p = 0.004).nnnCONCLUSIONSnTo the best of our knowledge, this is the largest series in the literature examining the association between decompression and strabismus surgeries. The patients characteristics and the orbital walls involved in the decompression procedures are associated with the characteristics of subsequent strabismus that develops thereafter. These findings may have significant implications in planning TED management.