Restoration of fusion in children with intracranial tumors and incomitant strabismus

A Comparison of Chemodnervation to Incisional Surgery for Acute, Acquired, Comitant Esotropia: An International Study

PURPOSE

To compare the efficacy of botulinum toxin injections to strabismus surgery in children with acute, acquired, comitant esotropia (ACE), and to investigate factors predicting success.

DESIGN

International, multi-center nonrandomized comparative study METHODS: Setting: Cloud-based survey.

STUDY POPULATION

Children aged 2 to 17 years who underwent a single surgical intervention for ACE.

INTERVENTIONS

Botulinum toxin injection ("chemodenervation" group) or strabismus surgery ("surgery" group).

MAIN OUTCOME MEASURES

Primary measure: success rate at 6 months in propensity-matched cohort, defined as total horizontal deviation of 10 prism diopters or less with evidence of binocular single vision. Secondary measure: Risk factors for poor outcomes in the full cohort.

RESULTS

Surgeons from 19 centers contributed. There were 74 patients in the chemodenervation group and 97 patients in the surgery group. In the propensity-matched data (n = 98), success rate was not significantly different at 6 months (70.2% vs 79.6%; P = .2) and 12 months (62.9% vs 77.8%; P = .2), but was significantly lower in the chemodenervation group at 24 months (52% vs 86.4%; P = .015). Irrespective of treatment modality, treatment delay was associated with lower success rates at 6 months, with median time from onset to intervention 4.5 months (interquartile range (IQR): 2.1, 6.7) in the success group and 7.7 months (IQR: 5.6, 10.1) in the failure group (P < .001).

CONCLUSIONS

In children with ACE, success rate after chemodenervation was similar to that of surgery for up to 12 months but lower at 24 months. Those with prompt intervention and no amblyopia had the most favorable outcomes, regardless of treatment modality.

Visual function in children with primary brain tumors

PURPOSE OF REVIEW

To review the recent advances in understanding how primary brain tumors affect vision in children.

RECENT FINDINGS

Children with primary brain tumors may have vision loss due to involvement of their afferent visual pathways or from papilledema. These vision deficits may go unrecognized until later in life, years after treatment of the primary lesion. Strabismus and cranial nerve palsies may occur as a result of brain tumors. Ophthalmologists can monitor and treat young children at risk for vision loss from amblyopia as a result of effects from their underlying lesion. Advances in imaging techniques have made it possible to quantify damage to the visual pathways with objective tests.

SUMMARY

Systematic referrals for evaluation by an ophthalmologist should occur early in the course of treatment of primary brain tumors as these evaluations may improve visual outcomes and quality of life.

Visual Complications of Pediatric Posterior Fossa Tumors: Analysis of Outcomes

OBJECTIVE

Visual abnormalities are common among children with posterior fossa tumors, resulting from disruption of ocular afferent and efferent systems due to the tumor or surgery. This study describes the visual complications and outcomes associated with these tumors.

METHODS

Clinical and radiographic data of patients who underwent index surgery for resection of posterior fossa tumor from 2007 to 2016 were reviewed. Descriptive statistics, univariate, and multivariate regression were performed to assess factors contributing to visual acuity and postoperative strabismus.

RESULTS

There were 182 patients who underwent posterior fossa craniotomy for neoplasm were included. Ophthalmologic symptoms were the fourth most common presenting complaint; initial ophthalmologic examination was abnormal in 40% of patients. Evaluation of visual acuity demonstrated a good outcome in 88% of patients following treatment. The most common postoperative oculomotor finding was esotropia (29%) which resolved spontaneously in more than half of patients. A good outcome was obtained in all patients who underwent surgery for esotropia. Hypertropia was noted in 14% of the cohort and less than half resolved spontaneously; less than half undergoing strabismus surgery for hypertropia had a good outcome. Multivariate analysis confirmed the association between cerebellar mutism and postoperative esotropia and hypertropia. Clinically significant pathological nystagmus was seen in 8% of the cohort.

CONCLUSIONS

Our results indicate a good visual outcome in the majority of pediatric patients undergoing resection of posterior fossa tumors. Ophthalmologic complications should be appropriately evaluated and addressed to allow for the best possible vision to survivors of posterior fossa tumors.

Effects of Brain Tumors on Vision in Children

Central nervous tumors are the leading cause of death from cancer in the pediatric population. Advances in care for pediatric neuro-oncology patients have led to improved survival rates. As survivorship increases, care of the sequelae of the tumor and its treatment become more important for long-term quality of life. A significant portion of the brain is involved in vision. Pediatric brain tumors can distort, damage, and destroy portions of the brain involved in both the afferent and efferent vision pathways. This interruption of normal visual pathways can lead to permanent vision loss or other morbidities such as strabismus and nystagmus. This article reviews the presenting symptoms and signs of brain tumors in children and adolescents, as well as the effects of the tumor and its treatment on the afferent and efferent visual pathways. Strategies for monitoring during treatment, and management of sequelae are reviewed. Through systematic evaluation and monitoring of pediatric neuro-oncology patients, those at risk for vision loss or tumor progression can be identified.

A Review of Visual and Oculomotor Outcomes in Children With Posterior Fossa Tumors

Tumors of the posterior fossa represent the most common solid malignancy of childhood and can affect the visual system in several ways. This article outlines the relevant visual anatomy affected by these tumors and reviews the visual and oculomotor outcomes associated with the following 3 most common tumor types-medulloblastoma, juvenile pilocytic astrocytoma, and ependymoma. The available data suggest that the rate of permanent vision loss is low (5.9%-8.3%), with patients having juvenile pilocytic astrocytoma demonstrating the best outcomes. The rate of long-term strabismus (25%-29.1%) and nystagmus (12.5%-18%) is higher and associated with significant morbidity.