SUBHYALOID HEMORRHAGE IN EVANS SYNDROME

PURPOSE

Evans syndrome is a rare disorder characterized by autoimmune hemolytic anemia and immune thrombocytopenia. We report the first case of ophthalmic involvement in a pediatric patient with Evans syndrome, in which painless vision loss was the presenting symptom.

METHOD

A 15-year-old girl presented with acute painless loss of vision in her right eye and was found to have bilateral subhyaloid hemorrhages.

RESULTS

She was treated with intravenous steroids and transitioned to hydroxychloroquine. Her retinal hemorrhages resolved and her vision improved.

CONCLUSION

Nontraumatic subhyaloid hemorrhage is a rare cause of vision loss in children. Evans syndrome should be considered in the differential diagnosis of such patients when hematologic abnormalities are present.

Congenital inner eyelid folds

BACKGROUND

We describe the ocular findings in two infants who were found to have unusual internal eyelid folds during routine probing for nasolacrimal duct (NLD) obstruction.

MATERIALS AND METHODS

Medical records review of two patients with similar eyelid folds.

RESULTS

Both children had unusual eyelid folds that began on the inner eyelid adjacent to the lacrimal canaliculi and extended to a position near the caruncle. Both children had resolution of NLDO following routine surgery, suggesting that the eyelid anomalies were an incidental finding at the time of NLDO surgery.

CONCLUSION

The etiology of these unusual inner eyelid folds is not certain but may represent schisis or incomplete separation of the inner eyelid margin.

Successful treatment of an exudative choroidal hemangioma with oral propranolol in a 10-year-old boy

A 10-year-old boy was referred for a circumscribed choroidal hemangioma with underlying exudative detachment of the left eye. To avoid general anesthetics required for laser-based therapy in a child, we began a trial of oral propranolol. The patient's exudative detachment resolved, with resulting improvement in visual acuity, and remained quiescent for 3 years.

Long-term outcomes of strabismus surgery in Mobius sequence

Purpose: Mobius sequence is a rare disorder that results from underdevelopment of the sixth and seventh cranial nerves, with subsequent facial weakness and impairment of ocular abduction. Approximately half of the affected patients have esotropia with limitation of extraocular movements. This study retrospectively reviews the long-term outcome of strabismus surgery for such patients. Methods: The long-term follow-up results in five children with Mobius sequence, who were observed after strabismus surgery for congenital esotropia, were analyzed. Results: All patients had a limitation of abduction in both eyes. Preoperative esotropia ranged from 20 to 30 prism diopters (PD) (mean 27 PD). Patient age at surgery ranged from 4.5 to 14 months. Bilateral medial rectus muscle recession was performed in all cases, ranging from 4.0 to 6.5 mm. Inferior transposition of the medial rectus muscles was performed in two patients for treatment of V-pattern, and two patients also had surgery for vertical strabismus. Follow-up ranged from 4 to 19.5 years (mean 11.7 years). The final horizontal alignment was <8 PD in all patients, and all demonstrated some binocularity. Conclusion: Bilateral medial rectus muscle recession is an effective treatment for esotropia associated with Mobius sequence, with good long-term stability.

Infantile Exotropia and Developmental Delay

PURPOSE

To evaluate a group of infants with this disorder to determine the long-term outcome of surgery and to assess the need for neurologic evaluations.

METHODS

This interventional case series reviewed the records of infants who underwent surgery for the treatment of exotropia with onset during the first year of life. The preoperative ophthalmic and systemic findings, treatment, and developmental and ophthalmic outcomes were reviewed. Surgery was considered successful if the horizontal deviation was less than 10 prism diopters (PD). Developmental assessments were obtained at each visit.

RESULTS

Twenty-six patients presented between age 2 and 10 months with exotropia ranging from 20 to 95 PD. Ten (38%) patients had a developmental delay that was recognized at the first visit, 9 of whom had a systemic diagnosis at that time; the other patients remained developmentally normal during a mean follow-up of 7 years. Age at surgery ranged from 4 to 18 months. Surgery was successful in 10 (38%) of 26 patients after 1 surgery and in an additional 13 (50%) of 26 patients after a second surgery.

CONCLUSIONS

In this study, the need for more than 1 surgery was higher in infantile exotropia when compared to other forms of childhood strabismus, but most children achieved good alignment with one or two surgeries. Developmental delay is common in patients with infantile exotropia, but this was usually recognized at the time of the initial evaluation. In the current patients, routine neurologic screening or imaging of these otherwise developmentally normal infants was not required. [J Pediatr Ophthalmol Strabismus. 2018;55(4):225-228.].

Novel retinal findings in peroxisomal biogenesis disorders

Peroxisomal biogenesis disorders are caused by disruption of long chain fatty acid metabolism due to mutations in PEX genes. Individuals with these disorders often have vision loss due to optic atrophy and pigmentary retinopathy. We report an unusual retinal manifestation of peroxisomal biogenesis disorder.

Retinal degeneration in autoimmune polyglandular syndrome type 1: a case series

BACKGROUND

Autoimmune polyglandular syndrome type 1 (APS1) is a rare autosomal recessive disorder due to mutations in the AIRE gene.

AIM

To report the ocular features and characterise the retinal phenotype in molecularly confirmed APS1.

METHOD

This retrospective case series reviewed five molecularly confirmed cases with APS1 known to have ocular involvement (age range: 19 months-44 years; mean follow-up of 8 years). The medical history, ocular history and evaluation, visual field testing, full-field electroretinogram (ERG) and antiretinal antibody results were reviewed.

RESULTS

All but one case had decreased vision at first presentation. All cases had peripheral pigmentary retinal changes; macular atrophy was noted in 80% of cases. The most common feature on spectral-domain optical coherence tomography was a disruption of the external limiting membrane and inner segment ellipsoid band (n=3). Fundus autofluorescence imaging demonstrated a parafoveal ring of hyper-autofluorescence (n=1) or a stippled and patchy autofluorescence pattern in the macula (n=1). The visual fields were constricted in all tested patients (n=3). The rod ERG was abnormal in all cases; the relative involvement of rods and cones differed. Four patients who were tested for antiretinal antibodies were found positive by immunohistochemistry (n=3) and/or western blot (n=2).

CONCLUSIONS

Photoreceptor degeneration is part of APS1 phenotype and the presence of antiretinal antibodies strongly supports an aetiology similar to that of non-paraneoplastic autoimmune retinopathy. Periodic retinal evaluation and imaging, visual field testing and ERG would assist in monitoring the retinopathy in APS1-related disease.

Orbital Causes of Incomitant Strabismus

Strabismus may result from abnormal innervation, structure, or function of the extraocular muscles. Abnormalities of the orbital bones or masses within the orbit may also cause strabismus due to indirect effects on the extraocular muscles. This paper reviews some disorders of the orbit that are associated with strabismus, including craniofacial malformations, orbital masses, trauma, and anomalous orbital structures.

Initial management of congenital canalicular atresia

PURPOSE

To evaluate the initial management of pediatric patients with lacrimal canalicular atresia (CA) involving the upper or lower eyelid.

METHODS

The medical records of 15 children with symptoms of nasolacrimal duct (NLD) obstruction and CA of either the upper or lower eyelid treated from 1994 to 2014 were retrospectively reviewed. Surgical treatment consisted of nasolacrimal probing through the patent canaliculus. Preoperative findings, treatment, and outcomes were reviewed. Outcomes were considered good if the patients had resolution of signs and symptoms of lacrimal obstruction, fair if the symptoms improved and additional surgery was not required, and poor if additional lacrimal surgery was performed.

RESULTS

CA was found in 19 eyes of 15 patients: 11 eyes had upper CA; 8 eyes, lower. All 11 eyes with upper CA improved after NLD probing through the patent lower canaliculus. Of the 8 eyes with lower CA, 4 (50%) had good outcomes and 4 eyes had poor outcomes after NLD probing through the patent upper canaliculus. All of the latter patients improved after subsequent treatment with balloon catheter dilation (BCD), monocanalicular stent placement, or both.

CONCLUSIONS

If a patient is found to have upper CA during initial surgery for NLD obstruction, NLD probing through the patent lower canaliculus has a good rate of surgical success. For patients with lower CA, the success rate of NLD probing through the upper canaliculus appears to be lower. Additional treatment during the initial surgery with either BCD or monocanalicular stent placement should be considered in these patients.

Comparison of lateral rectus muscle re-recession and medial rectus muscle resection for treatment of postoperative exotropia

PURPOSE

To compare the outcomes of unilateral lateral rectus muscle re-recession and medial rectus muscle resection for treatment of recurrent or persistent exotropia.

DESIGN

Retrospective nonrandomized clinical trial.

METHODS

setting: Hospital-based clinical practice.

PATIENT POPULATION

Forty patients with recurrent or persistent exotropia following bilateral lateral rectus muscle recessions.

INTERVENTION

Fourteen patients were treated with unilateral medial rectus muscle resection and 26 with unilateral lateral rectus muscle re-recession.

MAIN OUTCOME MEASURES

Outcomes were considered successful if the patients had deviations less than 10 prism diopters (PD) at last follow-up. All patients were followed for at least 1 year postoperatively.

RESULTS

The mean preoperative deviations were 17.4 PD in the medial rectus muscle resection group and 18.1 PD in the lateral rectus muscle re-recession group. Successful outcomes were achieved in 9 of 14 patients (64%) treated with medial rectus muscle resection and 19 of 26 patients (73%) treated with lateral rectus muscle re-recession. There was no statistically significant difference between these outcomes. Mean follow-up was 4.5 years in the medial rectus muscle resection group and 2.9 years in the lateral rectus muscle re-recession group.

CONCLUSIONS

Surgery on a single muscle can be used to treat moderate-angle recurrent or persistent exotropia. Unilateral re-recession of the lateral rectus muscle and medial rectus muscle resection have equivalent success rates.

Clinical characteristics and surgical approach to visually significant persistent pupillary membranes

BACKGROUND

Infants with hyperplastic persistent pupillary membranes (PPM) may be at risk for deprivation amblyopia due to obstructions of the visual axis. We describe the long-term visual and anatomic outcomes of a surgical technique for their removal.

METHODS

The medical records of consecutive patients <3 years of age who underwent surgical removal of PPMs between December 1998 and May 2012 were retrospectively reviewed. Each PPM was judged to be visually significant based on poor visual acuity, poor retinoscopic reflex, or inability to visualize the fundus. The surgical technique included injection of a viscoelastic agent beneath the pupillary strands to bow them anteriorly, careful peeling of residual adherent strands from the anterior lens capsule, and lysis of the strands at the pupillary margin with intraocular scissors. Pre- and postoperative visual and anatomic results were recorded.

RESULTS

This case series included 10 eyes of 6 patients: PPMs were bilateral in 4 patients and unilateral in 2. The patient age at time of surgery ranged from 2.5 months to 2.5 years (mean, 14 months). Mean postoperative follow-up was 5.3 years (range, 2.5-8 years). All patients had successful clearance of the visual axis and good visual acuity. No intraoperative complications occurred.

CONCLUSIONS

All patients in this series had excellent visual and structural outcomes, with no significant complications. The technique described here may be considered for patients with visually significant PPMs to improve visual function and pupil appearance.

Brain MRI abnormalities and spectrum of neurological and clinical findings in three patients with proximal 16p11.2 microduplication

The phenotype of recurrent ∼600 kb microdeletion and microduplication on proximal 16p11.2 is characterized by a spectrum of neurodevelopmental impairments including developmental delay and intellectual disability, epilepsy, autism and psychiatric disorders which are all subject to incomplete penetrance and variable expressivity. A variety of brain MRI abnormalities were reported in patients with 16p11.2 rearrangements, but no systematic correlation has been studied among patients with similar brain anomalies, their neurodevelopmental and clinical phenotypes. We present three patients with the proximal 16p11.2 microduplication exhibiting significant developmental delay, anxiety disorder and other variable clinical features. Our patients have abnormal brain MRI findings of cerebral T2 hyperintense foci (3/3) and ventriculomegaly (2/3). The neuroradiological or neurological findings in two cases prompted an extensive diagnostic work-up. One patient has exhibited neurological regression and progressive vision impairment and was diagnosed with juvenile neuronal ceroid-lipofuscinosis. We compare the clinical course and phenotype of these patients in regard to the clinical significance of the cerebral lesions and the need for MRI surveillance. We conclude that in all three patients the lesions were not progressive, did not show any sign of malignant transformation and could not be correlated to specific clinical features. We discuss potential etiologic mechanisms that may include overexpression of genes within the duplicated region involved in control of cell proliferation and complex molecular mechanisms such as the MAPK/ERK pathway. Systematic studies in larger cohorts are needed to confirm our observation and to establish the prevalence and clinical significance of these neuroanatomical abnormalities in patients with 16p11.2 duplications.

Comparison of the effectiveness and safety of transscleral cyclophotocoagulation and endoscopic cyclophotocoagulation in pediatric glaucoma

PURPOSE

Among the options for surgical management of pediatric glaucoma, destruction of the ciliary body reduces aqueous production and, consequently, intraocular pressure (IOP). Compared to more invasive filtering and shunt procedures, cyclodestruction is an attractive option for control of IOP in pediatric glaucomas.

METHODS

The relative reduction in IOP, duration of effect, and comparable safety and efficacy of transscleral cyclophotocoagulation (TSCP) and endoscopic cyclophotocoagulation (ECP) in pediatric patients with glaucoma was studied in this retrospective chart review.

RESULTS

A reduction in IOP of 28.6% and 33.2% with TSCP and ECP, respectively, was found. Eyes treated with ECP underwent an average of 3.24 cyclodestructive procedures; eyes treated with TSCP underwent an average of 2.29 cyclodestructive treatments. These differences were not statistically significant. A final success rate of 67.6% after TSCP and 62% after ECP failed to significantly differ between the two groups. Consequently, two-thirds of the patients were able to avoid penetrating surgery and the associated risks after one or more cyclodestructive procedures.

CONCLUSIONS

TSCP and ECP are safe, effective, and comparable treatments for pediatric glaucomas. The results suggest that TSCP and ECP may be considered first-line therapy to achieve control of IOP in all forms of pediatric glaucoma. [J Pediatr Ophthalmol Strabismus 2014;51(2):120-127.].

The association of neonatal dacryocystoceles and infantile dacryocystitis with nasolacrimal duct cysts (an American Ophthalmological Society thesis)

PURPOSE

To investigate whether neonatal dacryocystoceles and dacryocystitis are associated with nasolacrimal duct cysts, and to report the outcomes of treatment of these disorders.

METHODS

This was a retrospective medical record review of two groups of infants with nasolacrimal duct (NLD) obstruction. The first group had dacryocystoceles with or without dacryocystitis. The second group had NLD obstruction with symptoms severe enough to require early NLD probing. All of the patients underwent NLD probing and nasal endoscopy. When present, NLD cysts were removed.

RESULTS

In the first group, 33 infants had dacryocystoceles. Acute dacryocystitis was present in 16 patients, 12 had noninfected dacryocystoceles that did not resolve, and 5 had dacryocystoceles that resolved but severe symptoms persisted. All of the patients had NLD cysts that were surgically removed. The symptoms resolved after surgery in 31 patients (94%). In the second group, 27 infants less than 6 months old without dacryocystoceles underwent early NLD probing and endoscopy due to severity of symptoms. Twelve (44%) of these patients had NLD cysts. The symptoms resolved in 11 (92%) of 12 patients following NLD probing and cyst removal.

CONCLUSIONS

Neonatal dacryocystoceles are almost always associated with NLD cysts. The success rate of NLD probing and endoscopic cyst removal in these patients is excellent. Nasolacrimal duct cysts also are present in many young infants with severe symptoms of NLD obstruction. Nasal endoscopy is an important adjunct to the management of these infants.

Delayed visual maturation in otherwise normal infants

BACKGROUND

Children may present in early infancy for evaluation of decreased visual responsiveness. Most such infants have systemic or ocular abnormalities that explain their poor fixation and tracking. Some infants, however, have no other medical or ocular problems. This study evaluated prognostic factors in this latter group of otherwise normal infants with decreased visual responsiveness.

METHODS

This was a retrospective cohort study in which medical records of infants evaluated for decreased visual responsiveness were reviewed to identify children who had no history of premature birth or systemic problems associated with developmental delay. Examination findings that were predicted to indicate a good prognosis included: the presence of some reaction to light, normal pupil responses, no nystagmus, and no structural ocular abnormalities. Follow-up information was obtained from office visits and telephone interviews. Main outcome measures were visual acuity and developmental status.

RESULTS

Thirty-two children met the criteria noted above. Six were excluded due to lack of follow-up. Four were normal by the time of their initial examination. Follow-up for the remaining patients ranged from 3 months to 11 years (mean 2.94 years). One patient developed strabismus and required surgery. The remaining patients all had normal vision and development.

CONCLUSIONS

Otherwise normal infants who present for evaluation of decreased visual responsiveness have a good prognosis if they have some reaction to light, normal pupil responses, absence of nystagmus, and no structural ocular abnormalities. The developmental prognosis for these infants appears to be good. Additional testing at the time of initial evaluation is not indicated.

Oblique muscle surgery for treatment of nystagmus with head tilt

BACKGROUND

Patients with nystagmus may adopt an abnormal head posture if they have a null zone in eccentric gaze. These patients uncommonly present with torticollis due to a null zone when the head is tilted. We describe the results of surgery on the oblique muscles to improve the abnormal head posture in this condition.

METHODS

This was a retrospective review of patients who had head tilts due to null zones of nystagmus. Surgery consisted of an anterior 50% tenectomy of the superior oblique tendon on one side and recession of the inferior oblique muscle to a position 6 mm posterior to the insertion of the inferior rectus muscle on the contralateral side. The patients' clinical histories and outcomes were reviewed.

RESULTS

Six patients underwent the procedure. Of these, four had infantile nystagmus syndrome and two were born prematurely and had histories of intraventricular hemorrhages. Five of the patients had previous Kestenbaum surgery that corrected the horizontal component of their abnormal head postures. Age at time of surgery for the head tilt ranged from 3 to 13 years. Postoperative follow-up ranged from 1.5 to 3 years. The preoperative head tilts ranged from 25° to 45° (mean, 39°). The postoperative improvement ranged from 20° to 40° (mean, 28°). One of the patients with a history of intraventricular hemorrhage required additional surgery for strabismus unrelated to nystagmus.

CONCLUSIONS

Anterior tenectomy of the superior oblique tendon combined with contralateral recession of the inferior oblique muscle improved head tilts related to a null zone of nystagmus.

Common features of periocular tinea

OBJECTIVE

To present the common features of periocular tinea to aid physicians in future diagnosis and therapy of this condition, because superficial fungal infections on the face are often misdiagnosed owing to the diverse morphologies that they manifest. This is especially true of dermatophytoses involving the periocular region.

METHODS

A retrospective review was performed of patients with a diagnosis of periocular tinea who were seen between January 2003 and September 2009 in the pediatric dermatology clinic at St. Louis Children's Hospital.

RESULTS

Ten cases of periocular tinea were identified (6 male patients and 4 female patients). Common features included prolonged misdiagnosis (all 10 cases), a normal ophthalmologic examination (all 10 cases), and inappropriate corticosteroid application (7 cases). Loss of the eyelashes occurred in all 10 patients. No cases had evidence of other tinea infections on examination. Only 2 cases had the central clearing classically associated with tinea corporis. Seven patients had a potassium hydroxide preparation and/or culture positive for fungal elements. Lesions improved with topical and oral antifungal treatment in all cases, and patients were able to regrow their eyelashes.

CONCLUSION

Periocular tinea should be considered in the differential diagnosis for periocular inflammation, especially in those patients refractory to therapy for more common conditions. Loss of the eyelashes is characteristic of these fungal infections, similar to the hair loss that occurs in kerions associated with tinea capitis.

Oral propranolol for treatment of periocular infantile hemangiomas

OBJECTIVE

To evaluate the efficacy and adverse effects of oral propranolol for treatment of periocular infantile hemangioma.

METHODS

Participants were treated with oral propranolol 3 times daily, with outpatient monitoring of adverse effects. The starting dosage was 0.5 mg/kg/d for 1 week, then 1 mg/kg/d for the following week, then 2 mg/kg/d for the remaining duration of treatment. Serial examinations and external photography documented the size of the hemangiomas. Complete ophthalmic examinations included assessing for amblyopia with cycloplegic refraction and visual diagnostic testing. Amblyopia was treated with part-time occlusion therapy.

RESULTS

Nineteen periocular hemangiomas from 17 children (71% girls) were studied. The median age at the start of treatment was 4.5 months (interquartile range, 2.2-5.6 months). The median treatment duration was 6.8 months (interquartile range, 4.1-7.2 months). Treatment with oral propranolol reduced the size of all hemangiomas. Median change in the surface area was 61% (interquartile range, 32%-64%) of the original size. Mild rebound growth that did not necessitate retreatment was found in 2 patients (12%). One patient (6%) experienced a benign episode of bradycardia. Seven patients (41%) had amblyopia.

CONCLUSIONS

Oral propranolol for treatment of infantile hemangiomas was effective in all patients, with 33% reduction in astigmatism and 39% reduction in surface area. Vision equalized in all but 1 child, who receives ongoing amblyopia therapy. Our results suggest that early treatment with propranolol is remarkably effective in treating and preventing loss of visual acuity associated with periocular infantile hemangiomas.

Persistently recurrent infantile esotropia

INTRODUCTION

Children with infantile esotropia often require more than one surgery to align the eyes horizontally, for either recurrent esotropia or consecutive exotropia. We report an unusual subset of patients who had persistently recurrent esotropia despite multiple surgeries.

METHODS

The records of 11 patients who presented before age one year with infantile esotropia and who had three or more surgeries for recurrent esotropia were reviewed. The number of surgeries, outcomes, and associated systemic conditions were recorded.

RESULTS

These 11 patients represented 4% of children who were operated upon for infantile esotropia during the time of the study. The number of surgeries per patient ranged from 3-9 (mean 5). All of the horizontal surgeries in eight patients were for esotropia, while three patients developed exotropia after three or more surgeries for esotropia. Three children were otherwise normal, three had mild nonspecific developmental delay, one was premature, one had Trisomy 21, and one had spina bifida and high myopia. Following their most recent surgery, eight children had deviations of 8delta or less, and three had deviations between 8delta and 16delta. Seven patients demonstrated fusion. Age at last follow-up ranged from 2-13 years (mean 6.7 years).

CONCLUSION

Persistently recurrent esotropia is an unusual occurrence in children with infantile esotropia. Developmental delay is common in these patients, although none were markedly delayed. Satisfactory ocular alignment can be achieved in most patients, but several surgeries may be necessary to achieve this.

Periocular granuloma annulare in four children

Subcutaneous granuloma annulare is a skin condition that occurs on the lower extremities, hands, and scalp of healthy children. It rarely occurs in the periocular area, and when it does, the annular pattern is often absent. Histopathology is diagnostic and shows palisading histiocytes around areas of necrobiosis. Although benign in nature, the lesions tend to multiply, grow in size, and often recur. They usually resolve spontaneously and do not require treatment. Four cases of periocular subcutaneous granuloma annulare, from four different geographical areas, were identified through on-line postings on the worldwide mailing list of the Organization for Pediatric Ophthalmology and Strabismus (http://lists.ucsd.edu/mailman/listinfo/ped-ophth-1). These 4 patients are reported here, and a brief review of the literature is presented.

Ophthalmology education in pediatric residency training programs

PURPOSE

To evaluate the status of ophthalmology education in pediatric residency programs in the United States.

METHODS

A mail survey was sent to 187 directors of pediatric residency programs in the United States, which included questions about current ophthalmology education, desire for additional programs, reasons for dissatisfaction, and types of education desired.

RESULTS

Of a total of 187 surveys mailed, 137 (73%) were returned. Pediatric ophthalmology is part of the curriculum at 72% of pediatric residency programs and not included at 28%. Program directors were satisfied with pediatric ophthalmology education at 76% of the residency programs and not satisfied at 24%. A formal program in ophthalmology was desired by 88% of directors. Reasons for dissatisfaction with ophthalmic education included lack of time during the pediatric residency and lack of ophthalmologists available for teaching. Desired educational programs included didactic lectures by pediatric ophthalmologists, a CD-ROM or web-based program, and rotations through pediatric ophthalmology clinics.

CONCLUSIONS

Most pediatric residency program directors want pediatric ophthalmology as part of their formal curricula, but one-fourth of programs are currently either lacking formal ophthalmic education or their directors are dissatisfied with their ophthalmic curricula. Pediatric ophthalmology training programs should be developed to assist those residency programs that are not satisfied with their ophthalmic education. Ophthalmologists are encouraged to participate in these efforts.

Effect of preoperative stability of alignment on outcome of strabismus surgery for infantile esotropia

INTRODUCTION

Some strabismus surgeons wait until the angle of deviation stabilizes prior to operating on patients with infantile esotropia. This study evaluated whether a preoperative increase in the angle of deviation affected surgical outcomes.

METHODS

This was a retrospective comparative case series in which records of patients with infantile esotropia, who had surgery performed before age 2 years and who were followed for at least 2 years postoperatively, were reviewed to identify two groups for comparison: the first had </=5(Delta) change in the angle of deviation between the first office visit and time of surgery; the second had a >/=10(Delta) increase in the angle of deviation prior to surgery. In the latter group, surgery was performed for the angle present at the time of surgery. Outcomes were considered successful if the patients had microtropias.

RESULTS

Fifteen patients were identified in each group. The interval between the first office visit and time of surgery was the same in both groups (mean, 2 months). Outcomes were successful in 11 of 15 (73%) in each group (no significant difference, p = 0.659).

CONCLUSIONS

There was no difference in outcome between children whose angles of deviation were stable and those whose angles increased prior to surgery. This indicates that strabismus surgery does not need to be delayed while waiting for the angle of deviation to stabilize. Surgical correction may therefore be achieved at an earlier age, which may have a beneficial effect on outcome.

Pseudotumor cerebri following tapered corticosteroid treatment in an 8-month-old infant

The authors report on an 8-month-old infant with an orbital capillary hemangioma. The patient had been treated with high-dose corticosteroid therapy and had had a recent decrease in dose. The patient presented to the emergency department with increased irritability and bulging fontanelles. On lumbar puncture the opening pressure was > 55 cm H(2)O. Ophthalmological examination revealed interval development of papilledema. The child was treated with high-volume lumbar puncture, subsequent drainage of 10 ml of cerebrospinal fluid, resumption of the previous steroid dose, and acetazolomide therapy. The patient's symptoms resolved and follow-up ophthalmological examination revealed interval resolution of papilledema. The authors present the youngest reported case of pseudotumor development after corticosteroid tapering.

Outcomes in children with nasolacrimal duct obstruction: Significance of persistent symptoms while stents are in place

To evaluate the correlation between persistent symptoms while stents are in place and final outcome in children with nasolacrimal duct obstruction (NLDO). A retrospective observational case series, with medical record review that included indications for surgery, surgical procedure, presence of symptoms while stents were in place, and final outcome after stent removal. Twenty-eight children with NLDO had nasolacrimal duct stents placed in 42 eyes. Twenty-one of the 42 eyes (50%) had minimal or no signs or symptoms of NLDO while stents were in place, and 18 of 21 (86%) were symptom-free after stent removal. Twenty-one of the 42 eyes (50%) remained symptomatic while stents were in place. Eleven of these 21 eyes (52%) had good outcomes after stent removal. Ten (48%) of these patients had persistent symptoms after stent removal requiring further treatment. The prognosis for a good outcome is excellent if symptoms of NLDO resolve while stents are in place. The prognosis is poorer if symptoms of NLDO persist, but more than half of such patients still have good outcomes. Careful counseling of parents regarding these outcomes should be performed before considering additional interventions.

Strabismus surgery for elimination of bifocals in accommodative esotropia

PURPOSE

This study reports the outcomes of strabismus surgery to eliminate bifocals in patients with accommodative esotropia with a high accommodative convergence to accommodation (AC:A) ratio.

DESIGN

Retrospective interventional case series.

METHODS

Sixteen patients who wore bifocals for treatment of accommodative esotropia with a high AC:A ratio underwent strabismus surgery following prism adaptation testing (PAT) for the near angle of esotropia without bifocals. Outcomes were considered successful if patients had microtropias and maintained fusion without bifocals.

RESULTS

All patients had successful outcomes after one or two surgeries. Three of 13 (23%) patients with positive PATs required two surgeries. Two of three (67%) patients with negative PATs required two surgeries. Binocularity remained the same in 13 patients and improved in three patients. Glasses were eliminated entirely in eight of 16 (50%) patients.

CONCLUSIONS

Strabismus surgery may eliminate the need for bifocal glasses in patients with accommodative esotropia with a high AC:A ratio, with many patients able to discontinue glasses entirely. Preoperative PAT may help predict the risk of requiring more than one surgery.

Clinical ocular abnormalities in infants with trisomy 13

PURPOSE

Previous reports of ocular abnormalities associated with trisomy 13 have described pathologic abnormalities, with minimal descriptions of clinical findings. This report describes the clinical findings in four infants with trisomy 13.

DESIGN

Retrospective noncomparative case series.

METHODS

Review of medical records of four infants with trisomy 13. One patient underwent cataract surgery and treatment of Coats disease.

RESULTS

All four infants had inferonasal iris colobomas with unilateral inferonasal cataracts, primarily involving the posterior lens surface. Two patients had pigmented tissue associated with the cataracts. Cataract surgery was performed in one of the patients with good results. This patient also developed a unilateral exudative retinal detachment with peripheral telangiectatic vessels. This resolved after treatment with cryotherapy.

CONCLUSIONS

The cataracts in these infants with trisomy 13 had similar clinical features, which were different than those seen in other types of cataracts in infants. In addition, one patient had Coats disease, which has not been previously described in association with trisomy 13. The presence of inferonasal iris colobomas and adjacent sectoral cataracts in patients with other dysmorphic findings should prompt chromosomal analysis for trisomy 13.

Risk of retinopathy in children with type 1 diabetes mellitus before 2 years of age

PURPOSE

To assess the risk of diabetic retinopathy (DR) in children with type 1 diabetes mellitus (T1DM) diagnosed at a very early age.

DESIGN

Observational case series.

METHODS

The records of 51 patients were identified through the diabetes database of the Division of Pediatric Endocrinology and Metabolism at Washington University School of Medicine. The patients were diagnosed with T1DM before 2 years of age and were monitored for at least 5 years after diagnosis. The results of ophthalmic screening examinations were reviewed.

RESULTS

Fifty-one patients were identified, 33 of whom were monitored for >8 years. None of the patients developed DR.

CONCLUSIONS

Children have a negligible risk of developing DR during the first 10 years of life, even if they are diagnosed before age 2. These results indicate that screening for DR is not necessary before age 10.

The effect of initial recognition of abnormalities by physicians on outcome of retinoblastoma

PURPOSE

The purpose of this study was to assess the effect of early diagnosis by physicians on outcome of retinoblastoma.

METHODS

This was an observational case series in which the records of 36 patients with retinoblastoma were reviewed. The age at onset of first symptoms and diagnosis, identity of the individual who first recognized an abnormality, treatment, and outcome were analyzed.

RESULTS

Twenty-two patients had unilateral retinoblastoma. Both eyes were preserved in only 2 of these patients, both of whom had abnormalities first noted by their pediatricians. Fourteen patients had bilateral retinoblastoma. Both eyes were preserved in the 5 bilateral patients who were monitored from birth with serial examinations under anesthesia because of family histories of retinoblastoma. Enucleation of at least 1 eye was required in 8 of the 9 bilateral patients whose families first noted abnormalities. Enucleation of at least 1 eye was required in 27 of 28 patients (96%) in whom abnormalities were first noted by parents.

CONCLUSION

In this series, the only patients with unilateral retinoblastoma who did not require enucleation were those in whom pediatricians, rather than family members, first noted ocular abnormalities. Both eyes were preserved in all patients with bilateral retinoblastoma who underwent serial examinations under anesthesia because of family histories of retinoblastoma. The prognosis for retinoblastoma appears to be greatly improved when physicians initially detect abnormalities. Educational efforts directed at early detection of retinoblastoma by pediatricians and other primary care providers should be encouraged.

Screening for retinopathy in the pediatric patient with type 1 diabetes mellitus

Diabetic retinopathy (DR) is the leading cause of blindness in young adults in the United States. Early identification and treatment of DR can decrease the risk of vision loss in affected patients. This clinical report reviews the risk factors for the development of DR and screening guidance for pediatric patients with type 1 diabetes mellitus.

Conjunctival Pyogenic Granulomas after Strabismus Surgery

PURPOSE

To measure the incidence and evaluate treatment of pyogenic granulomas after strabismus surgery.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Four hundred seventy-nine strabismus surgical patients.

METHODS

Incidence was determined by review of 472 consecutive patients who underwent strabismus surgery from January 6, 1999 to December 29, 2000. Outcomes were evaluated in 7 additional patients who underwent surgical excision of pyogenic granulomas over a 6-year period from July 5, 1995 to September 19, 2001 (exclusive of the years 1999-2000).

MAIN OUTCOME MEASURE

Development and resolution of pyogenic granulomas.

RESULTS

Pyogenic granulomas developed in 10 of 472 patients (2.1%). None of these patients had more than 1 pyogenic granuloma, despite having had surgery before or after the event. Treatment of pyogenic granulomas with topical corticosteroids was successful in 90% of patients. Surgical excision was successful in the group of 7 additional patients who did not respond to corticosteroids.

CONCLUSIONS

Conjunctival pyogenic granulomas are a potential complication of strabismus surgery. Treatment with topical steroids is an effective initial treatment for most patients with pyogenic granulomas. Surgical excision is effective in patients who do not improve with topical medication. Patients with multiple surgeries do not seem to be at increased risk for pyogenic granulomas, and the occurrence of a pyogenic granuloma does not seem to increase the risk of developing pyogenic granulomas in future surgeries.

Severe subacute GM2 gangliosidosis caused by an apparently silent HEXA mutation (V324V) that results in aberrant splicing and reduced HEXA mRNA

We have characterized the molecular basis of beta-hexosaminidase A (HEX A) deficiency in a patient ascertained through an ophthalmologic examination that revealed cherry red spots on his retina. The absence of neurological deficit in this child until 3 3/4 years of age indicated residual HEX A must be present. Three HEXA mutations, 10T > C (S4P) and 972T > A (V324V) on the maternal allele, and 1A > T (M1L) on the paternal allele were identified. The effects of the amino acid substitutions on HEX A expressed in COS-7 cells were analyzed; as expected, no HEX A activity was associated with the M1L mutation but surprisingly, the S4P mutation resulted in 59% of the HEX A activity expressed by the wild type cDNA. The effect of the S4P change was much less than that of another HEXA mutation, G269S, associated with an adult onset form of G(M2) gangliosidosis. This indicated that the S4P change was not the cause of disease and suggested that one of the mutations on the maternal allele, 10T > C or 972T > A, had its effect at the mRNA level. This was confirmed by Northern blot analysis that showed only 7% of the normal level of HEXA mRNA in proband fibroblasts. Analysis of the residual mRNA by RT/PCR and sequencing revealed normal transcripts from both the maternal and paternal allele, as well as a low abundance aberrant transcript from the maternal allele. Sequencing of this aberrant transcript revealed a new exon 8 donor site created by the 972T > A mutation that resulted in a 17 bp deletion and destabilization of the resulting abnormal transcript. The remaining normal mRNA produced from the 972T > A allele must account for the delayed onset of clinical symptoms in this child.

Pediatric transscleral sutured intraocular lenses: efficacy and safety in 43 eyes followed an average of 3 years

PURPOSE

To report longer term results of transscleral sutured intraocular lens (TSSIOL) implantation in a sizable cohort of aphakic children, who were not suitable for contact lens wear and lacked adequate capsular support for sulcus fixation of an intraocular lens.

METHODS

Clinical outcome data were collated by retrospective review after surgery on 43 consecutive eyes in 32 aphakic children (mean age at implantation = 10 years; 33% < or = age 7 years). Outcome measures included visual acuity, postoperative refractive error, postoperative complications, and rate of reoperation. Follow-up averaged 37 months.

RESULTS

Visual acuity improved after surgery in 70% (30) of operated eyes (in 69% or 22/32 children). Fifty-one percent (22/43 eyes) improved by two lines or more. No patient suffered a loss of acuity or exacerbation of preexisting amblyopia. Postoperative refraction was within +/-2.0 D of the predicted refraction in 93% (40/43) of eyes. Complications, with the exception of one eye (2%), were minor/transient and resolved in the first week after surgery. Complications included small hyphemas (7%, 3/43 eyes), vitreous hemorrhage (5%, 2/43 eyes), and ocular hypertension or hypotony (5%). Two eyes (5%) exhibited episodes of iris capture of the IOL optic, one of which (2%, 1/43) eventually necessitated reoperation for IOL exchange. No retinal detachments or other retinal complications were encountered.

CONCLUSION

TSSIOL implantation appears to be a safe and effective method for correcting aphakia in pediatric eyes that lack adequate capsular support. Safety over a follow-up period longer than the average 3 years reported here remains to be determined. The surgery is more difficult to perform than capsular-bag or sulcus implantation and potentially carries greater risks.

Endoscopic treatment of intranasal abnormalities associated with nasolacrimal duct obstruction

PURPOSE

To report the incidence of intranasal abnormalities in children with nasolacrimal duct (NLD) obstruction and the results of treatment, which included nasal endoscopic removal of abnormal tissue.

METHODS

Nasal endoscopy was performed prospectively in 22 infants with mucoceles; in 97 children > or = 18 months at the time of initial NLD probing; and in 59 children with persistent NLD obstruction after previous probing. Endoscopic removal of abnormal tissue was performed in addition to NLD probing or balloon-catheter dilation.

RESULTS

NLD cysts were found in 22 of 22 (100%) infants with mucoceles. Cysts or other abnormalities of the distal duct were found in 6 of 97 (6.2%) children > or = 18 months at the time of initial probing and in 5 of 59 (8.5%) children whose previous NLD probing was unsuccessful. Surgery was successful in 91% of patients.

CONCLUSION

Nasal endoscopy identified intranasal anatomic abnormalities of the distal nasolacrimal duct uniformly in infants with mucoceles and in 6% to 9% of older children with complicated NLD obstruction. Treatment, including endoscopic removal of abnormal tissue, was successful in most patients. The use of nasal endoscopy may improve the treatment of patients with these disorders.

Head tilt-dependent esotropia associated with trisomy 21

OBJECTIVE

To describe a series of patients who used a head tilt to control esotropia.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Seven children with esotropia that decreased with their compensatory abnormal head tilt. Six of the patients had trisomy 21. The patients had no other identifiable etiology for their head tilt, including no oblique muscle dysfunction, nystagmus that changed with head tilt, or uncorrected refractive error.

INTERVENTION

Six patients underwent horizontal extraocular muscle surgery. Preoperative evaluation in 4 patients included assessment of the change in head position with either monocular occlusion or prisms.

MAIN OUTCOME MEASURES

Ocular alignment in primary position and improvement in abnormal head tilt after surgery.

RESULTS

In the 4 patients who underwent preoperative testing, the abnormal head tilt resolved with either monocular occlusion or prisms. The head tilt and esotropia were eliminated or improved in all patients who underwent strabismus surgery.

CONCLUSIONS

Abnormal head tilt may be used as a compensatory maneuver to improve purely horizontal strabismus. This finding appears to be associated with trisomy 21. Horizontal extraocular muscle surgery may improve the head tilt in such patients.

Choroidal neovascular membrane associated with optic nerve coloboma in a patient with CHARGE association

PURPOSE

To report a patient with CHARGE association (coloboma, heart disease, choanal atresia, growth retardation, genital hypoplasia, and ear abnormalities) who developed a choroidal neovascular membrane in association with an optic nerve coloboma.

DESIGN

Interventional/observational case report.

METHOD

A 21-month-old boy with CHARGE association developed a grayish choroidal neovascular membrane associated with lipid exudation, subretinal fluid, and retinal hemorrhage at the temporal edge of his right optic nerve coloboma.

RESULTS

The patient underwent transpupillary diode laser of the choroidal neovascular membrane. Five months later, it and the serous retinal detachment had resolved.

CONCLUSIONS

Patients with CHARGE association may develop choroidal neovascular membrane with serous retinal detachments in association with optic nerve colobomas. These neovascular membranes may be treated successfully with transpupillary diode laser.

Balloon catheter dilation for treatment of older children with nasolacrimal duct obstruction

OBJECTIVES

To describe the outcomes of balloon catheter dilation of the lacrimal duct as the first surgical treatment for older children (>or=18 months) with nasolacrimal duct (NLD) obstruction and to examine the effect of the type of obstruction on outcome.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Seventy-six children 18 months or older with NLD obstruction who had not undergone previous surgery.

INTERVENTION

The patients underwent NLD probing, infracturing of the inferior turbinate, and balloon catheter dilation of the distal NLD. The type of obstruction was noted at surgery.

MAIN OUTCOME MEASURES

Outcomes were considered excellent if the patient had complete resolution of epiphora and dacryocystitis and normal tear drainage on examination, good if the patient had only minimal residual symptoms or a minimally delayed dye disappearance test result, fair if the patient had moderate residual symptoms or delayed tear drainage, and poor if there was no improvement.

RESULTS

Seventy-six children were treated. Overall, results were excellent in 28 (37%) patients, good in 30 (39%), fair in 13 (17%), and poor in 5 (7%). Forty-eight (63%) of the patients had simple membranous obstruction at the Hasner valve. Results were good or excellent in 35 (73%) of these patients. Twenty-eight (37%) patients had stenosis that extended along the length of the distal NLD. Results were good or excellent in 23 (82%) of these patients.

CONCLUSIONS

Balloon catheter dilation is probably more effective than simple probing for older children with NLD obstruction because of stenosis that extends along the distal NLD. The procedure does not provide a significant advantage over simple NLD probing in patients with typical membranous obstruction at the Hasner valve.

The effect of an eyelid speculum on intraocular pressure measurement in children

PURPOSE

To assess the effect of a pediatric eyelid speculum on the measurement of intraocular pressure (IOP) in children.

DESIGN

Observational case series.

METHODS

Intraocular pressure measurements were performed during examination under anesthesia immediately after induction. The measurements were made with and without a pediatric eyelid speculum in place.

RESULTS

Intraocular pressure measurements were made in 77 eyes of 45 consecutive children. The mean IOP without the speculum was 16.33 mm Hg in the right eye and 16.55 mm Hg in the left eye. With the lid speculum in place the mean IOP was 20.26 mm Hg in the right eye and 20.05 mm Hg in the left eye (P <.05).

CONCLUSIONS

The presence of an eyelid speculum raised IOP an average of 4 mm Hg. This effect should be considered when interpreting IOP measurements in children.