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Journal: Journal of pediatric ophthalmology and strabismus

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PURPOSE:Inferior oblique (IO) myectomy can result in self-adjustment; the greater the preoperative hyperdeviation, the larger the postoperative correction. This study estimated the effect of IO recession in primary position and in contralateral gaze. METHODS:Records of 43 patients with IO muscle overaction associated with congenital unilateral superior oblique palsy were reviewed retrospectively. Seventeen patients who had a unilateral 10-mm recession (IO attached at 2 mm temporal and 3 mm posterior from the inferior rectus muscle insertion) and 26 patients who had a standard 14-mm recession were evaluated at 3 months postoperatively. The effect of the recession was measured by preoperative hyperdeviation minus postoperative hyperdeviation. RESULTS:The average preoperative hyperdeviation was 13.4 ± 4.83 prism diopters (PD) in primary position and 16.2 ± 6.32 PD in contralateral gaze in the 10-mm group and 8.0 ± 3.48 PD in primary position and 12.76 ± 4.55 PD in contralateral gaze in the 14-mm group. The average deviation at 3 months postoperatively was 2.1± 3.03 in primary position and 2.6 ± 3.95 PD in contralateral gaze in the 10-mm group and 0.8 ± 1.21 in primary position and 1.8 ± 1.95 PD in contralateral gaze in the 14-mm group. The range of self-adjusting effect at 3 months postoperatively was 3 to 20 PD in primary position and 5 to 30 PD in contralateral gaze in the 10-mm group and 3 to 15 PD in primary position and 4 to 24 PD in contralateral gaze in the 14-mm group. The self-grading effect was large and displayed no significant differences at 3 months postoperatively in the 10- and 14-mm groups (P = .104 and .560, respectively). CONCLUSION:Both IO recession procedures were largely self-grading and no significant differences were evident at 3 months postoperatively.

Concepts: Superior oblique muscle, Superior rectus muscle, Inferior oblique muscle

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PURPOSE:Surgical management of superior oblique palsy (SOP) is challenging because of combined vertical, horizontal, and torsional misalignment. The authors report the surgical results of patients with large primary position hypertropias (> 20 prism diopters [PD]) due to unilateral SOP. METHODS:Criteria for success included correction of the anomalous head posture, primary position alignment between orthotropia and 6 PD of undercorrection, and no reoperation required for residual deviations in any direction of gaze. RESULTS:Forty-five patients met inclusion criteria. Mean preoperative alignment in primary gaze was 26.5 ± 6.5 PD compared to 3.0 ± 4.4 PD postoperatively (P < .001). Twenty-three (51%) cases met the criteria for success with one operation. Of the patients who had single muscle surgery, 14% had a successful outcome, with a mean 67% (17.3 PD) reduction in hypertropia. Of patients who underwent simultaneous multiple muscle surgery, 58% met the criteria for a successful result, with a mean 92% (24.6 PD) reduction in primary gaze hypertropia. Success was the highest in patients who underwent ipsilateral inferior oblique combined with contralateral inferior rectus recessions with (60% success) or without (65% success) a Harada-Ito procedure. CONCLUSION:Undercorrections are frequent following surgery for unilateral SOP with preoperative deviations greater than 20 PD in primary position, especially after single-muscle surgery. Simultaneous multiple muscle surgery rarely results in overcorrection and is recommended in patients with SOP and more than 20 PD of hypertropia in primary position.

Concepts: Superior oblique muscle

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PURPOSE:To determine whether children tolerate cyclopentolate 1% spray better than drops and to assess the adequacy of cycloplegia achieved by spray for objective refraction. METHODS:The effects of cyclopentolate 1% drops and spray on distress levels were assessed prospectively using a guardian questionnaire in consecutive patients 10 years of age or younger. Distress was graded at various points during the appointment using a Likert scale of 1 to 10 (1 = no distress, 10 = severe distress). The adequacy of cycloplegia in children receiving cyclopentolate spray and the waiting times were assessed via a Likert questionnaire completed by the examining physician. RESULTS:The guardians of 72 and 77 children who received cyclopentolate 1% drops or spray, respectively, completed the questionnaire. The children were divided in three age groups: 1 to 4 years, 5 to 7 years, and 8 to 10 years. Children 7 years or younger were significantly less distressed by administration of cyclopentolate 1% spray (P < .005). There was no statistical difference in distress levels in children older than 7 years (P = .9719). Thirteen of the 77 children who received cyclopentolate 1% spray did not have adequate cycloplegia to allow objective refraction. CONCLUSION:The results demonstrate cyclopentolate 1% spray is less distressing at the time of administration than cyclopentolate 1% drops for children 7 years or younger. However, the cycloplegia achieved is not adequate in a high percentage of children.[J Pediatr Ophthalmol Strabismus 20XX;XX(X):XX-XX.].

Concepts: Physician, Assessment, Psychometrics, Ophthalmology, Scale, Likert scale, Distressing, Distress

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PURPOSE:To evaluate the visual outcome and corneal endothelial cell density after Artisan aphakic intraocular lens (IOL) implantation (Ophtec, Groningen, the Netherlands) in pediatric eyes with subluxated lenses. METHODS:Artisan aphakic IOLs were implanted in 18 eyes of 11 children with subluxated lenses. Idiopathic subluxations and ectopia lentis due to Marfan syndrome were included, whereas subluxations due to trauma or buphthalmos were excluded. Best-corrected visual acuity (BCVA) and endothelial cell density were monitored. Mean postoperative BCVA and endothelial cell density at last follow-up visit were calculated. RESULTS:The age of children at the time of Artisan aphakic IOL implantation ranged from 8 to 16 years (mean: 11.58 ± 2.9 years). Mean follow-up was 9.12 ± 4.30 months. Mean postoperative logarithm of the minimum angle of resolution BCVA was 0.26 ± 0.13 (P = .001) and mean postoperative endothelial cell density was 2,860 ± 435 cells/mm(2) (P = .000). Mean endothelial cell loss was 17.1%. CONCLUSION:Artisan aphakic IOL implantation is a safe surgical choice in the management of ectopia lentis in the pediatric age group. It has minimal complications and is less traumatic to pediatric eyes. However, long-term follow-up of these children is required.

Concepts: Eye, Cornea, Marfan syndrome, Lens, Contact lens, Intraocular lens, Corneal endothelium, Ectopia lentis

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The authors report two cases with vertical deviations. The first patient had right exotropia and hypotropia and left inferior oblique overaction and was treated with left inferior oblique muscle weakening and bilateral lateral rectus muscle recession. The second patient had chin-up posture and right dissociated vertical deviation and was treated with bilateral superior oblique posterior tenotomy. [J Pediatr Ophthalmol Strabismus 2014;51:e78-e81.].

Concepts: Superior oblique muscle, Superior rectus muscle, Inferior oblique muscle, Lateral rectus muscle, Annulus of Zinn, Trochlea of superior oblique

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The authors retrospectively evaluated the use of botulinum toxin injections to treat epiphora in children secondary to proximal obstruction of the nasolacrimal drainage system. Three patients (ages 8, 9, and 16 years) received botulinum toxin injections in the palpebral portion of the lacrimal gland. Two patients experienced symptomatic relief immediately following botulinum toxin injection. Both required subsequent injections, with an average symptomatic relief lasting 7 months. The only noted side effect was papillary conjunctivitis in one patient that resolved without treatment. The third patient was lost to follow-up. Although conjunctival dacryocystorhinostomy with Jones tube is the surgical procedure of choice for treating proximal lacrimal system obstruction, complication rates in children are high. Botulinum toxin injections provide a safe and effective alternative. [J Pediatr Ophthalmol Strabismus 2014;51:e75-e77.].

Concepts: Ophthalmology, Conjunctiva, Lacrimal nerve, Tears, Botulinum toxin, Lacrimal apparatus, Nasolacrimal duct, Nasolacrimal canal

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A 17-month-old girl referred for a suspected ciliary body medulloepithelioma was found to have persistent fetal vasculature. Fluorescein angiography showed perfused hyaloid artery posterior tunica vasculosa lentis with brittle star appearance and nonperfused anterior pupillary membrane. Ultrasound biomicroscopy confirmed absence of iris or ciliary body solid tumor. [J Pediatr Ophthalmol Strabismus 2014;51:e69-e71.].

Concepts: Oncology, Blood, Tumor, Eye, Cardiovascular system, Iris, Ciliary body, Tunica vasculosa lentis

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Myopia is an important public health issue, and high myopia may lead to severe complications if left untreated. Orthokeratology lenses, worn overnight to reshape the cornea, are one of many recent modalities used to slow down the progression of myopia in children. This treatment has been proven successful, as evidenced by decreased spherical refractive error and axial length relative to the control at interval follow-up ranging from 6 months to 5 years. In this systematic review, the authors collected published controlled studies that analyzed the efficacy of orthokeratology lens wear and calculated longitudinal relative changes in axial length, revealing a weighted average of -45.1% change in axial length at the 2-year follow-up. The exact mechanism by which orthokeratology lenses reduce myopia progression is unknown, but research shows that the corneal reshaping decreases peripheral hyperopic defocus and therefore increases peripheral myopic defocus to likely reduce stimuli for axial elongation and subsequent development of myopia. Use of orthokeratology lenses is generally safe, but cases of associated infectious keratitis may have a higher incidence of virulent organisms such as Pseudomonas, Acanthamoeba, and antibacterial-resistant strains of Staphylococcus, partially due to the required overnight use of these lenses. Orthokeratology is regarded as one of the most effective non-pharmacologic measures to slow progression of myopia in children and, with regular follow-up to ensure safety, continues to be one of the most effective treatments for myopia management around the world. [J Pediatr Ophthalmol Strabismus. 201X;XX(X):XX-XX.].

Concepts: Cornea, Myopia, Refractive surgery, Lens, Astigmatism, Orthokeratology, Contact lens, Glasses

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To evaluate the usefulness of the Plus Lens (Goodlite Company, Elgin, IL) test and the Spot Vision Screener (Welch Allyn, Skaneateles Falls, NY) in detecting high hyperopia in a pediatric population.

Concepts: Eye