Yi Ning J. Strube

Amniotic Membrane Transplantation for Restrictive Strabismus

PURPOSE To report the use of amniotic membrane transplant in patients with restrictive strabismus. DESIGN Retrospective, interventional case series. PARTICIPANTS Patients with restrictive strabismus treated with amniotic membrane transplantation. METHODS Chart review of 7 consecutive patients (8 eyes) who developed restrictive strabismus after periocular surgery and were treated with surgical removal of restrictive adhesions and placement of an amniotic membrane transplant. MAIN OUTCOME MEASURES Intraoperative findings to explain the mechanism of restrictive strabismus, and clinical postoperative results, including ocular alignment, ductions and versions, symptom relief, and resolution of diplopia. RESULTS Restrictive strabismus occurred after surgery for pterygium, retinal detachment, orbital floor fracture, dermoid cyst, and dermatochalasis. Restrictive strabismus was due to a combination of conjunctival contracture, fat adherence, or rectus muscle contracture. All patients developed postoperative scarring, with failed additional standard surgery to remove the adhesions, including 1 patient treated with mitomycin C for recurrent scarring after pterygium. Reoperation using amniotic membrane transplantation was associated with improvement of ocular motility in 6 of the 7 patients; 1 patient had recurrence of scarring with persistent diplopia. The remaining 6 of 7 patients had no significant recurrence of scarring, and motility remained stable during the follow-up period of 5 to 13 months. CONCLUSIONS Amniotic membrane transplantation seems to help prevent recurrence of adhesions in patients with restrictive strabismus caused by conjunctival scarring, fat adherence syndrome, or rectus muscle contracture. Use of an amniotic membrane transplant should be considered as a treatment option for these difficult cases of restrictive strabismus. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Fourth-generation fluoroquinolones in the treatment of mycobacterial infectious keratitis after laser-assisted in situ keratomileusis surgery

CASE REPORT Infectious keratitis after laser-assisted in situ keratomileusis (LASIK) is a rare complication that may be challenging to diagnose and treat. We discuss some of the reasons for difficulties diagnosing postoperative atypical or nontuberculous mycobacterial infection and establishing an effective treatment, with reference to reports of comparative antibacterial activity of the most commonly used antibiotics. COMMENTS To the best of our knowledge, we are the first to report the use of the fourth-generation fluoroquinolone moxifloxacin in combination therapy for the successful treatment of this condition.

Strabismus surgical subspecialization: a population-based analysis.

IMPORTANCE The growing complexity of medical and surgical care has resulted in increasing subspecialization. To date, data have been lacking regarding the degree to which subspecialization has affected the provision of strabismus surgical services. This gap is important to address given the implications for health care human resources planning and educational programs. OBJECTIVE To investigate the effect of subspecialization on the provision of strabismus surgery services. DESIGN, SETTING, AND PARTICIPANTS Population-based study in Ontario, Canada, which provides universal health care coverage to the provincial population. Participants included all ophthalmologists in Ontario and the provincial population of approximately 12 million persons from January 1, 1994, through December 31, 2011. MAIN OUTCOMES AND MEASURES Surgeon-level rates of strabismus surgery. RESULTS From January 1, 1994, through December 31, 2011, the percentage of ophthalmologists who provided strabismus surgery decreased from 37.7% (156 of 414 surgeons) to 12.5% (54 of 432 surgeons; difference, 25.2%; 95% CI, 19.3%-30.9%; P < .001), a 66.8% decline from the baseline level. Of ophthalmologists who provided strabismus surgery during the same period, the mean number of strabismus procedures per surgeon grew from 16.2 to 55.3 per year, a 241.4% increase (95% CI, 20.4%-461.6%; P < .001). These trends occurred at all career stages. CONCLUSIONS AND RELEVANCE Strabismus surgery has evolved into a subspecialized field of ophthalmology during the past 15 years. These findings may have important implications for health care professionals and health care system leaders, including the need to account for subspecialization in physician human resources decisions to ensure access to quality strabismus surgery across regions. Furthermore, residency education programs and their governing organizations may need to account for strabismus subspecialization when designing curriculum and accreditation requirements.

Pediatric adenoid cystic carcinoma of the lacrimal gland treated with intra-arterial cytoreductive chemotherapy

Adenoid cystic carcinoma (ACC) of the lacrimal gland is the most common primary malignant tumor of the lacrimal gland. It typically affects patients in the fifth decade of life and presents with rapid progression of pain, ptosis, motility disturbances, and sensory deficits of less than 1 years duration. ACC is rare in children. Due to early, aggressive perineural and bony spread, there is a high risk of intracranial extension. Additionally, due to frequent hematogenous and lymphatic spread, there is a high rate of distant metastases even after treatment, which can occur late up to a decade or more. The currently accepted treatment for ACC is radical exenteration with orbitotomy and adjuvant chemotherapy and/or radiation therapy. Recently, intra-arterial cytoreductive chemotherapy (IACC) has been investigated as a neoadjuvant treatment modality. It has the advantage of increasing local concentration at the target tissue and decreasing systemic distribution. We report the first known pediatric case of ACC treated with IACC, followed by exenteration, radiation, and adjuvant intravenous chemotherapy. The patient was followed for 4 years, with no recurrence and no known complications.

Relationship between feeding schedules and gastric distress during retinopathy of prematurity screening eye examinations

PURPOSE To determine whether a relationship exists between the timing of feeding before retinopathy of prematurity (ROP) eye examinations and gastric side effects or distress associated with this examination. METHODS A prospective, randomized, single-masked study was conducted involving infants in the neonatal intensive care unit who required an ROP eye examination and who received normal or full enteral feeding over a 1 year period. Infants were randomly assigned to 1 of 2 study arms: feeding 1 hour before examination (arm 1) or feeding schedule adjusted to ensure no feeding within 2 hours before examination (arm 2). Physiological data, including blood pressure and pulse rate, before, during and after examination, crying time during the examination, presence of vomiting and gastric aspirates, and gastric aspirates volume 24 hours after the examination, were recorded. RESULTS A total of 34 infants were enrolled, with 57 separate eye examinations conducted. There was 19% less crying (p = 0.016) in arm 1 versus arm 2. Vomiting was 3-fold less in arm 1 versus arm 2 (4.2% vs 12.5%, p = 0.38). Gastric aspirates was less in arm 1 versus arm 2 (p = 0.18). Diastolic blood pressure was lower and respiratory rate greater during the examination in arm 1 (p < 0.05), whereas pulse rate was greater at the start of the examination in arm 1 (p < 0.05). CONCLUSIONS Feeding neonatal intensive care unit infants 1 hour before compared with withholding feeding 2 or more hours before ROP examinations may reduce stress during the examination, as measured by percentage crying during the examination, with no increased incidence of vomiting or gastric aspirates.

Rectus Muscle Tightening Procedures

The two most useful rectus muscle tightening procedures are the rectus muscle resection and the rectus muscle plication. Rectus muscle tucking has not proven reliable, as it tends to loosen over time. A tuck is a muscle-to-muscle union. Because the muscle fibers are longitudinal and the transverse fibers are weak, the sutures tend to pull out and slip. The rectus muscle plication, however, involves securing posterior muscle to sclera, and this procedure is as stable as a resection.

Principles of Strabismus Surgery

Prior to strabismus surgery, an important and seemingly obvious question should be asked: “Why are we operating?” Is our treatment goal to establish binocular fusion, eliminate diplopia, expand the field of binocular vision, correct a compensatory head posture, or simply to improve cosmetic appearance? Establishing the goals prior to surgery helps us clarify indications for surgery, and formulate a logical treatment plan. The plan that is made should be the one that is best for the patient—not just the plan that is best for correcting the angle of deviation.

Inferior Oblique Muscle Weakening Procedures

Historically, inferior oblique surgery was considered extremely difficult and was fraught with complications such as fat adherence, ciliary nerve damage with pupillary dilatation, and intraoperative hemorrhage. More recently, however, the management of inferior oblique overaction has improved substantially. The late Dr. Marshall Parks pioneered meticulous techniques that all but eliminated these complications. Another important advance has been the anteriorization procedure.

A child with rapidly progressive necrotizing group a streptococcal Tenon's capsule infection one day after strabismus surgery.

Periorbital infections after strabismus surgery are rare. We describe the first reported case of necrotizing group A streptococcal infection of the conjunctiva and Tenons capsule complicating uneventful strabismus surgery in a 23-month-old boy, successfully managed with conservative intraoperative debridement and with targeted local and systemic antibiotics.

Transposition Surgery for Rectus Muscle Palsy

Transposition surgery is based on changing the location of the muscle insertion so the muscle pulls the eye in a different direction (i.e., changes the vector of forces). Transposition surgeries can be used to treat a rectus muscle paresis, a lost muscle, A and V patterns ( Chap. 15), small vertical tropias ( Chap. 15), and torsion ( Chap. 15). Three transposition procedures are described in this chapter: Knapp, Jensen, and Hummelsheim.