Masked trial of topical anesthesia for retinopathy of prematurity eye examinations

PURPOSE

To observe the effect of a topical anesthetic on pain and corneal clarity in premature infants undergoing eye examinations for retinopathy of prematurity (ROP).

METHODS

ROP examinations were performed on premature infants who were randomized to receive either proparacaine 0.5% or an artificial tear solution in the right eye. All infants received an artificial tear solution in the left eye. Assessment of discomfort was performed by use of the Premature Infant Pain Profile (PIPP) during examination of the right eye, with a painful event defined as a PIPP score≥11. The left eye was then examined and a comparison of corneal clarity was made between the 2 eyes.

RESULTS

A total of 39 examinations were performed on 34 infants: artificial tear solution was administered 17 times and topical proparacaine anesthetic 22 times. The mean PIPP score for those receiving artificial tears was 10.4 compared with 8.8 for the anesthetic group (p=0.17). Of the examinations without anesthetic, 65% were painful, compared with 27% with anesthetic (p=0.04). No effect on corneal clarity was observed in any examination.

CONCLUSIONS

The use of a topical anesthetic appears to marginally decrease pain and has no adverse effect on subjectively assessed corneal clarity during examination of premature infants for ROP.

Congenital oculomotor nerve synkinesis associated with fetal retinoid syndrome

INTRODUCTION

Isotretinoin (RA), used for the treatment of cystic acne, is a powerful teratogen, causing craniofacial dysmorphisms and neural tube defects. We present two patients with RA embryopathy and oculomotor nerve synkinesis.

METHODS

Retrospective review of patient records.

RESULTS

Two patients presented with third nerve synkinesis and fetal RA exposure. Both had marked elevation of the upper eyelids on adduction such that the lid fissures alternately opened and closed on gaze from side to side. Both patients showed typical dysmorphisms of RA embryopathy. The first patient had complete agenesis of the cerebellar vermix and died at 2 years. The second patient had restricted extraocular muscles in one eye and was exotropic and hypotropic.

DISCUSSION

Both patients demonstrated simultaneous innervation of the medial rectus and levator palpebrae muscles causing coincident lid elevation in adduction. This evidence of oculomotor nerve synkinesis is consistent with animal studies showing abnormalities in the formation of cranial nerve ganglia following fetal RA exposure.

CONCLUSION

RA is a powerful teratogen. These patients provide additional clinical evidence of its influence on neural migration during early development.

Augmenting surgery for sensory esotropia with near/distance disparity with a medial rectus posterior fixation suture

Ten esotropic patients with near/distance disparity and diminished vision in one eye had monocular horizontal strabismus surgery combined with a posterior fixation suture placed on the medial rectus. Before surgery, all patients were at least 20 prism diopters (delta) more esotropic at near than at distance fixation. The disparity in the near/distance deviation was reduced by 18 delta.

Topical treatment of periocular capillary hemangioma

Five patients with vision-threatening periocular capillary hemangiomas were treated with topical clobetasol propionate cream. Two received steroid eye drops. All experienced a decrease in the size of their hemangioma. Topical treatment of periocular capillary hemangioma appears to be well tolerated and, in selected cases, may eliminate the need for intralesional injection of corticosteroids.

A cluster of patients with inferior rectus restriction following local anesthesia for cataract surgery

During a 5-month period, four patients developed contracture of the inferior rectus muscle following local anesthesia for cataract surgery in the practice of one ophthalmologist. Two anesthesiologists administered retrobulbar anesthesia. All patients had persistent vertical diplopia caused by a large hypotropia of the operated eye. Forced duction testing revealed marked restriction to elevation of the eye. In two patients, MRI demonstrated segmental thickening of the inferior rectus muscle, just posterior to the globe. All patients had normal thyroid function tests. No patient had a previous history of strabismus. Three of the four have had strabismus surgery consisting of recession of the markedly restricted inferior rectus muscle on an adjustable suture. These three patients have regained fusion and are now asymptomatic.

Synthetic polypeptide sleeve for strabismus surgery

A synthetic polypentapeptide sleeve was placed around the superior rectus muscle of five New Zealand white rabbits in hopes of preventing postoperative fibrous scarring. Two forms of the polypentapeptide were used. No significant inflammation or scarring occurred with either form of the polypentapeptide when compared to controls. One form elicited a fibrous membrane surrounding the sleeve within 2 weeks. The other elicited no such reaction after 2 months. The latter form of the polypentapeptide may be useful in preventing scarring following strabismus surgery.

Occult Duane syndrome: co-contraction revealed following strabismus surgery

Three patients presented in infancy with large angle esotropia and limited abduction. Narrowing of the lid fissures with globe retraction on horizontal gaze became apparent only after recession of the medial recti. Abduction remained limited. Two of the three exhibited dissociated vertical deviations, and seemed to have both congenital esotropia and Duane syndrome. The third had an unusual pattern of apparent co-contraction in which the eye attempting abduction actually adducted. Although rare, Duane syndrome may occur in children with large angle esotropia, and its presence may not be revealed until after strabismus surgery.

Primary rhabdomyosarcoma of the iris

We describe herein a 4-year-old girl with primary rhabdomyosarcoma of the right iris. Malignant cells were aspirated from the aqueous humor, and the eye was enucleated 7 months after the tumor appeared. To our knowledge, only two cases of primary rhabdomyosarcoma of the iris have been reported. Both of these patients received radiation therapy prior to enucleation.

Strabismus following endoscopic intranasal sinus surgery

Two patients developed exotropia with limited medial rectus function following endoscopic intranasal ethmoid sinus surgery. In both patients, fractures occurred in the medial orbital wall. The first patient required horizontal rectus muscle surgery to regain ocular alignment. The second required no surgery, but was left with limited horizontal motility secondary to scarring at the fracture site. While endoscopic techniques improve the surgeon's view of sinus anatomy, they do not eliminate the risk of entering the orbit and causing ocular complications.

Visual acuity in monocular pediatric aphakia: does epikeratophakia facilitate occlusion therapy in children intolerant of contact lens or spectacle wear?

Twenty-two children had a monocular cataract extracted between 1981 and 1986. Twelve of these patients eventually tolerated a monocular contact lens or anisometropic spectacle wear. Eleven patients initially would not tolerate conventional therapy, and epikeratophakia was performed. Of the 12 patients tolerating a contact lens or spectacles, eight (67%) now see 20/60 or better, and six (50%) see 20/40 or better. Only one (10%) of the patients maintaining the epikeratophakia graft developed vision as good as 20/70. Epikeratophakia did not facilitate occlusion therapy for amblyopia. The critical factor in the development of good vision following monocular cataract extraction was the patient's willingness to patch the better eye, not the method of correcting the refractive error.

Eyelid depigmentation following corticosteroid injection for infantile ocular adnexal hemangioma

We report an unusual case of development of upper eyelid depigmentation in a child 4 months following corticosteroid injection of a periocular capillary hemangioma. Depigmentation has been described with local steroid injections for other dermatologic conditions, but has not been reported previously with treatment of infantile ocular adnexal hemangiomas.

Vertical effect of the adjustable Harada-Ito procedure

The adjustable Harada-Ito procedure, as described by Metz, was performed on four patients. A hypotropia of 10 to 12 prism diopters (PD), in addition to incyclotorsion, was induced in two patients in whom the superior oblique tendon was split 8 mm, only enough to permit mobilization to its new location. Splitting the tendon for 15 mm eliminated the induced hypotropia while preserving incyclotorsion.

Familial aniridia with preserved ocular function

Of 76 members of a large pedigree with familial aniridia, 61% of the 38 affected patients had visual acuity of 6/9 (20/30) or better and only 5% had acuity of 6/60 (20/200) or worse. Cataracts were present in 18% of affected patients; glaucoma in 13%; and strabismus in 34%. Sixteen percent of affected patients had strabismic amblyopia. No patient had nystagmus or corneal pannus. The good visual acuity in this family, as compared to that in others, indicates that the absence of iris tissue alone cannot account for the severe visual problems usually associated with aniridia.

Lid lesions of childhood: a histopathologic survey at the Wilmer Institute (1923-1974)

This study reports 398 excised eyelid lesions in 385 children from birth through age 15. This study analyzes and discusses the clinical and histological features of the 34 types of lesions which were encountered. This tabulation serves as a guide to the physician when confronted with lid lesions in children as to the types of lesions which may be found. More importantly, however, this study is the first comprehensive clinco-pathologic evaluation of eyelid lesions in children, a topic which had previously been written and discussed in a fragmentary manner. This study analyzes data from the Wilmer Institute during 1923-1974.

Epibulbar tumors in childhood

Three hundred two cases of epibulbar tumors in children were retrospectively reviewed histologically and examined by diagnostic categories over a 49-year period. Of the 302 cases, 33% were choristomas; 29% nevi; 11%, epithelial inclusion cysts; 7%, papillomas; 6%, pyogenic granulomas; and 5% granulomas. Three cases of sqamous-cell carcinoma and one of rhabdomyosarcoma occurred as well as a variety of benign lesions.

Late syphilis in the primate

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