Zane F. Pollard

Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis

BACKGROUND Subperiosteal abscess may accompany orbital cellulitis secondary to sinusitis. Common surgical principles include incision and drainage of all abscesses. Previous evidence suggests that some orbital abscesses may be treatable with intravenous antibiotics, especially in young children. Childrens hospital records were reviewed to determine which abscesses may be treated medically. PATIENTS AND METHODS Records of patients admitted for orbital cellulitis from 1993 to 1996 were reviewed. Patients with subperiosteal abscess on CT scan were included. Clinical outcomes for initial surgical versus medical management of medial abscesses were compared. Differences in age, hospital stay, and intracranial involvement were analyzed for medial versus nonmedial abscesses. RESULTS All patients had abscesses adjacent to infected sinuses. Eighteen young children had medial abscesses. Twelve of 13 were cured by initial medical treatment; 4 of 5 underwent successful initial drainage. Outcomes were not statistically different (P > .490). Seven children with nonmedial abscesses were older (P < .001) and had more complicated courses than those with medial abscess. Three of 6 children with superior orbital abscess also had intracranial abscess. Intracranial complication was more likely with superior versus medial orbital abscess (P < .01). CONCLUSIONS Medial subperiosteal orbital abscesses secondary to sinusitis in children 6 years of age and younger are highly amenable to treatment with intravenous antibiotics. Older children and children with nonmedial abscesses may have more complicated infections. Children with superior orbital abscesses are at higher risk for intracranial abscess.

Bilateral Superior Oblique Muscle Palsy Associated With Apert’s Syndrome

Eleven children had Aperts syndrome and bilateral superior oblique muscle palsy. Of seven patients who underwent surgical exploration of the superior oblique muscle area, five had no superior oblique tendon in either eye and two had only a small fibrous band as a remnant in each eye. All 11 patients had a significant horizontal deviation in primary gaze and downgaze, in addition to a vertical imbalance. The findings led to the conclusion that all patients with craniofacial anomalies, especially those with Aperts syndrome, should be examined for the presence of vertical muscle palsies and particularly bilateral superior oblique muscle palsy.

Absence of multiple extraocular muscles in craniosynostosis

The absence of extraocular muscles, particularly the superior rectus1, 2 or superior oblique3, 4 has been recognized to cause strabismus among patients with craniosynostosis. Absence of multiple muscles is less common. In case 1 we note a patient with Pfieffers syndrome and absent left superior rectus and inferior oblique, with the presence of only a vestigial left superior oblique and an underdeveloped and misinserted left inferior rectus. In case 2 we describe a patient with Aperts syndrome with bilateral absence of the superior rectus and superior oblique muscles. Unsuspected superior rectus absence led to a bilateral elevation deficit after inferior oblique weakening. Also, during the course of treatment, all 3 remaining recti muscles in 1 eye were disinserted. To our knowledge, this is the first report of absent extraocular muscles in Pfieffers syndrome. Some evidence suggests that collateral anterior segment blood flow exists in cases of absent recti muscles. Further study is needed to determine whether all remaining muscles could be used for strabismus repair. Last, when patients with craniosynostosis require strabismus surgery, we feel that a limited exploration of all extraocular muscles should be carried out.

Adult strabismus surgery under propofol sedation with local versus general anesthesia

PURPOSE To compare operating room and hospital discharge times between adult strabismus surgeries using intravenous propofol sedation with local anesthesia versus those using general anesthesia. METHODS Thirty adult patients underwent uncomplicated strabismus procedures performed by one surgeon using propofol sedation and local subtenons anesthesia. These were retrospectively matched with adult patients undergoing similar procedures by another surgeon using general inhalational anesthesia. Only one muscle had undergone previous surgery, and no adjustable sutures were used. Times from incision closure to leaving the operating room (Out OR time), and to hospital discharge (DC time) are compared. RESULTS Propofol/local Out OR times ranged 2 to 8 minutes (mean, 4.8). General anesthesia Out OR times ranged from 3 to 28 minutes (mean, 8.8) (means differ at P<.001). At 10 minutes, 100% of propofol patients left the OR, but only 63% of general patients had done so (P<.001). Propofol/local DC times ranged from 30 to 140 minutes (mean, 64.8). General DC times ranged from 68 to 325 minutes (mean 116.5) (means differ at P<.001). At 60 minutes after completion of surgery, 53% of propofol/local patients had left the hospital, whereas none of general patients had left (P<.001). At 2.5 hours after surgery, 100% of propofol/local patients had left the hospital, but 10% of general patients remained, with two staying more than 5 hours. CONCLUSIONS Many adult strabismus surgeries may be performed more efficiently with intravenous propofol sedation and local subtenons anesthesia than with general anesthesia. Times from the end of surgery to leaving both the OR and the hospital are decreased compared with those of general anesthesia. Extreme delays are rare with propofol/local, but they occurred with general anesthesia.

The red eye in childhood.

Overall, the primary care physician can diagnose most cases of red eyes in children, if specific attention is paid to which ocular structures are involved. Accurate diagnosis allows appropriate primary care treatment for most disorders and can aid in determining which cases need referral.

Strabismus Precipitated by Monovision

PURPOSE To present patients who had the onset of strabismus or the recurrence of strabismus after converting to a monovision system of seeing. DESIGN Retrospective interventional case series. METHODS Clinical records of 12 patients from the private practice of the corresponding author of this paper (Z.F.P.) were reviewed. Patients obtaining monovision via contact lenses, LASIK, and cataract surgery with posterior chamber intraocular lenses were studied if their monovision produced a new strabismus or was related to the recurrence of a previous strabismus. RESULTS All patients were first treated by converting the monofixing near eye to distance vision and then using reading glasses for near work. Of the 12 patients, 7 regained their fusion by doing away with monovision and 5 required surgery to reestablish motor or sensory control. All of the surgery patients obtained an excellent alignment but 1 did not regain sensory fusion. CONCLUSION Monovision is successful for the far majority of patients who try it. However, in patients with a previous history of strabismus or those with significant phorias, caution should be used in recommending monovision, and if monovision is elected, keeping the anisometropia to small levels such as 1.25 to 1.50 diopters (D) might lessen the chance of producing strabismus post monovision. The majority of our patients developed strabismus after 2 years of monovision, telling us that while a trial of monovision with a contact lens prior to surgery may suggest that the patient could tolerate monovision, it is not a guarantee.

Accommodative Esotropia After Ocular and Head Injury

Five children lost their ability for motor fusion after traumatic injury to either the eye or head. All patients had the onset of accommodative esotropia within two months of the traumatic episode. The ocular alignment of each child was controlled by the use of spectacles that corrected the accommodative requirements. These patients are unique because they did not show any evidence of accommodative esotropia before their injuries. One child developed accommodative esotropia with a high ratio of accommodative convergence to accommodation. The use of bifocal spectacles controlled the deviation for this child.

Treatment of chemotic conjunctival prolapse after pediatric craniofacial surgery: Report of a technique

Journal of AAPOS Massive conjunctival edema and prolapse occasionally occur after craniofacial surgery around the orbits in young children. A technique is described for reducing such prolapse by using a local injection of subconjunctival lidocaine with epinephrine. Ten eyes of 7 patients were followed up prospectively for resolution. In 8 eyes, prolapse resolved the day after injection, and in the remaining 2 eyes, it resolved the day after the injection was repeated. Epinephrine-induced vasoconstriction of transudating blood vessels is the presumed mechanism of fluid reduction. Conjunctival edema is often more pronounced in very young children than in adults, such as in cases of trauma, infections, or allergic reactions. Perhaps the most striking conjunctival edema occurs in the clinical setting in which a small child or infant undergoes craniofacial surgery.1 Scalp and facial swelling often surround massive eyelid and conjunctival edema, frequently leading to extreme prolapse of the forniceal conjunctiva. Often the globe cannot be fully examined, even with the use of eyelid retractors or a lid speculum. Most commonly, the upper lid is involved, although occasionally the lower lid may prolapse (Figures 1 and 2). Such conjunctival prolapse can last for days to weeks and can be associated with significant conjunctival irritation from desiccation, as well as from abrasion by pillows or bed sheets. Additionally, parents are commonly distressed by the grotesque postoperative appearance. Frequent topical lubricants and vasoconstrictor eye drops have not been successful. Surgical treatment for prolonged conjunctival prolapse after pediatric craniofacial surgery has been reported1; however, we have not found this necessary. Combination steroid/vasoconstrictor/anesthetic subconjunctival injections have been advocated for treating chemosis and conjunctival prolapse after ophthalmic surgery. The vascular effects of steroids, including sensitization of blood vessels to the effects of epinephrine, have been proposed as the mechanisms of action.2 Ten years Treatment of Chemotic Conjunctival Prolapse After Pediatric Craniofacial Surgery: Report of a Technique