The effect of corneal grafting on vision in bilateral amblyopia

Two children with bilateral congenital corneal opacities (sclerocornea) received unilateral corneal transplants at the ages of 4 1/2 and 16 years, respectively. Both developed reading vision and reduced nystagmus excursions.

[The autologous ipsilateral rotating penetrating keratoplasty: an early surgical procedure to prevent deep irreversible amblyopia in Peters anomaly]

PURPOSE

It is a challenge to prevent irreversible amblyopia in infants suffering from Peters anomaly. In some cases of centrally located corneal opacifications an optical sector iridectomy can not lead to a clear optical axis. The homologous penetrating keratoplasty as early surgical procedure has shown an extremely poor outcome with a high risk of irreversible graft failure. We report on the autologous ipsilateral rotating penetrating keratoplasty in an eight-week-old infant suffering from Peters anomaly.

PATIENTS

An autologous ipsilateral rotating penetrating keratoplasty was performed in an eight-week-old infant suffering from Peters anomaly to prevent irreversible amblyopia.

RESULTS

After a follow-up time of 8 months we saw a clear graft within the optical axis without any complications in wound healing. We removed the single sutures two months after keratoplasty. Postoperative astigmatism could be corrected first by fitting a special nursery contact lens and after reduction of astigmatism because of suture removal we fitted special nursery glasses. The intraocular pressure remained within the normal range during the follow-up period.

CONCLUSION

The autologous ipsilateral rotating penetrating keratoplasty should be considered superior to homologous keratoplasty in infants with Peters anomaly if sector iridectomy is not advisable because of a central corneal opacification. Resulting high refractive errors can be successfully corrected by special contact lens fitting or by nursery glasses.

[The therapeutical approach in the unilateral congenital cataract of the child]

The management of pediatric cataracts is, by far, more complex than the management of cataracts in adults and depends not only on deterioration of visual acuity, but also on the status of the other eye, the general health of the child, the motivation and the financial situation of the parents and last, but not least, on the surgeons' experience and skill, and the technical support. The therapeutically approach involves: the preoperative evaluation to establishes the indication and the timing of surgery the adaptation of the surgical technique for each case the choice of the aphakic correction the visual rehabilitation in the context of amblyopia management.

[Long-term functional results of unilateral congenital cataract treatment with early surgery: 20 case studies]

PURPOSE

Evaluation of the long-term functional results of the treatment of unilateral congenital cataract (UCC) surgery before age 1.

MATERIAL AND METHODS

Retrospective analysis of 20 consecutive cases of UCC operated on before age 1 and followed by the same medical team during the entire treatment period. Lens implantation adopted when surgically possible (15 cases) and medical treatment of amblyopia are described. Functional results are analyzed with a mean follow-up of 6 years (3.5-11 years) and compared with those of 31 similar cases operated on between 1 and 8 years of age.

RESULTS

Four cases had less than 0.1 of final visual acuity, 8 cases remained between 0.1 and 0.4, and 8 cases obtained at least 0.5. Functional results with surgical, refractive, visual, oculomotor, and binocular data of all cases are described. Amblyograms are presented.

DISCUSSION

Age at surgery, postoperative delay, type of cataract, and refractive progression were not found to be decisive in final results. We discuss the factors that seem important in the visual outcome and consequences on the sound eye of this heavy amblyopia treatment. In addition to early treatment, the absence of surgical complications and the continuity of patching, the quality of the initial organization of therapeutic strategy, and the continuity of the follow-up seem to be major factors for the success of long-term treatment. Treatment and follow-up should be centralized around a specialized team that will help the local team during the entire length of the treatment.

[Congenital ptosis: amblyogenic refractive errors, amblyopia, manifest strabismus and stereopsis related to the types of ptosis. Data on 77 patients and review of the literature]

BACKGROUND

Former reports on amblyogenic refractive errors, amblyopia and binocular vision in congenital ptosis usually comprise all forms of ptosis without any differentiation. This study is an analysis of different kinds of ptosis.

PATIENTS AND METHODS

154 eyes (98 ptotic eyes) of 77 patients with congenital ptosis aged > or = 1 year (56 unilateral ptoses: 45 simple, 1 with rectus superior paresis, 7 with Marcus Gunn's syndrome, 2 congenital oculomotor palsies, 1 unilateral fibrosis syndrome; 21 bilateral ptoses: 10 simple, 2 with bilateral double elevator paresis, 7 blepharophimosis syndromes and 2 bilateral fibrosis syndromes) were investigated concerning visual acuity, refractive error (94 % in cycloplegy), strabismus and stereo acuity. As amblyogenic refractive errors were defined: astigmatism > or = ldpt, anisometropia > or = 1 dpt (spherical equivalent) and hyperopia > or = 3 dpt; amblyopia was defined as visual acuity less than 1.0 or a difference between both eyes of at least 0.2.

RESULTS

Altogether were found: Hyperopia > or = 3 dpt in 28.6 % (n = 28); astigmatism > or = 1 dpt in 63.3 % (n = 62), anisometropia in 27.3 % (n = 21), amblyopia in 65.3 % (n = 64), strabismus in 29.9 % (n = 23) and stereopsis in 76.6 % (n = 59). In unilateral simple ptosis, astigmatism of the fellow eye was found in 26.8 % (n = 14). In unilateral ptosis, esotropia was 21.4 % (n = 12), in bilateral ptosis, exotropia 19 % (n = 4), as well as astigmatism > or = 3 dpt 26.2 % (n = 11). As was to be expected, ptosis groups with motility disorders were associated with higher rates of strabismus and amblyopia. The blepharophimosis syndrome could be differentiated by the typical lid anomalies.

CONCLUSION

The subgroups of congenital ptosis differ in frequency of amblyogenic factors. In unilateral ptosis these are also frequent in the fellow eye.

Congenital trigeminal anesthesia in two siblings and their long-term follow-up

PURPOSE

To alert ophthalmologists to congenital trigeminal anesthesia as a cause of corneal scarring and amblyopia and its effective treatment with tarsorrhaphies.

METHODS

Case reports. A 2-month-old infant presented with bilateral corneal erosions and complete corneal anesthesia. Her sister presented at age 3 years with a corneal ulcer and corneal hypoesthesia (sensation markedly decreased). The father and paternal grandmother of the siblings also had corneal hypoesthesia.

RESULTS

Further investigation of the infant revealed bilateral hearing loss, swallowing difficulties, and decreased sensation in the trigeminal nerve distribution. A diagnosis of congenital trigeminal anesthesia was made. The corneal erosions of the patient resolved with bilateral two-thirds width tarsorrhaphies. The girl continues to do well now at 10 years of age with ocular lubrication and superficial corneal scar removal. Her older sister initially required antibiotic ointment for her corneal ulcer but now requires only ocular lubrication for congenital trigeminal anesthesia.

CONCLUSION

This study describes the earliest reported use of tarsorrhaphies in an infant with congenital trigeminal anesthesia. The presence of this condition in her sister and relatives makes it one of the few reports of congenital trigeminal anesthesia in more than two generations. Early recognition of this condition is essential in the preservation of useful vision.

[Photoscreening for early detection of amblyogenic eye changes]

BACKGROUND

Congenital and early acquired ocular changes impairing the optic input induce amblyopia when left untreated. Amblyopia treatment must start early to be efficient. Therefore it seems necessary to employ screening tests in preverbal childhood.

PATIENTS AND METHODS

The reliability of two commercially available photoscreening devices, the "Visiscreen 100" (Vision Research Corp.) and the "MTI-Photoscreener" (Medical Technology Inc.), was tested. 180 children from a kinder-garten and 120 infants from our outpatient clinic were screened. The results were compared to the findings of a full ophthalmologic and orthoptic examination.

RESULTS

The efficacy of the photoscreening depended on the skill of the examiner and on the age of the children tested. The rate of interpretable photographs was 94% in the older group and 63.3% in the infants. The mean sensitivity for detection of amblyogenic factors was 63% in the older and 80% in the infant group. The mean negative predictive value was 90%, and 75%, respectively.

CONCLUSION

Modern photoscreening techniques can help to detect amblyogenic factors in early childhood. However, in addition to the non-interpretable photographs, about 20% of the affected children are missed. Therefore, photoscreening cannot be recommended for countries with a high number of ophthalmologists, such as Germany. Instead, an ophthalmologic and orthoptic investigation in early childhood would be preferable.

[Amblyopia, refractive errors and strabismus in congenital ptosis]

The incidence of amblyopia in the normal population is 2-6%, whereas among patients with congenital ptosis it can be as high as 50%. We reviewed 146 cases of congenital ptosis in patients aged between 5 months and 15 years and compared them to a control group of 34 age- and sex-matched patients. In 78 children (156 eyes) reliable optotype visual acuity could be obtained. Fifty-three eyes (34%) were amblyopic. Ametropia was responsible for 34% and anisometropia for 28.3% of the amblyopia cases. In 25.4% of cases strabismus, and in 11.34% stimulus deprivation, was the reason for the development of amblyopia. Children with congenital ptosis should have retinoscopy done in cycloplegia, and refractive errors should be corrected early. Controlled patching therapy should also be started early. Since stimulus deprivation amblyopia is rare, congenital ptosis need not be corrected early in life.

The use of spectacles in the treatment of congenital esotropia and amblyopia--a financial hazard

Congenital esotropia and amblyopia are treated during the 'sensitive period' of brain-eye development. Not all children require spectacles for treatment of these conditions but when refractive errors are present, correct and properly fitting spectacles play an important part. This prospective survey shows that one-third of the under three-year-old children wearing spectacles require surgery for esotropia, and that one-third of all children under eight years of age wearing spectacles need amblyopia treatment. It is uninterrupted treatment in these age groups that produce results. Approximately 50% of children wearing spectacles in the four-year-old and under group need a second or third pair of spectacles within a 12-month period. If these spectacles become unsuitable because of dense scratches, changed refraction or poor fit because of increasing P D, then the treatment is interrupted and the visual acuity is likely to regress. Many families cannot afford a second or third pair of spectacles within the 12-month period and hospital benefit funds often will not help. The treatment is interrupted. This financial hazard must be overcome.

Ocular and systemic findings in the Aarskog (facial-digital-genital) syndrome

The Aarskog (facial-digital-genital) syndrome is an X-linked disorder in which short stature is accompanied by hypertelorism, digital anomalies, and shawl scrotum. Except for hypertelorism and blepharoptosis, ophthalmic abnormalities have been rarely noted in this condition. We examined four patients who had Aarskog syndrome and unilaterally or bilaterally decreased vision on initial examination. Three family members had V-pattern esotropia, latent nystagmus, inferior oblique overaction, and amblyopia. A fourth patient had bilateral blepharoptosis and severe astigmatism. Other ocular features included hyperopia, anisometropia, deficient ocular elevation, blue sclerae, and posterior embryotoxon. These findings underscore the need for ophthalmic examination in asymptomatic patients with Aarskog syndrome to rule out treatable causes of visual loss.

Amblyopia and congenital esotropia. Visually evoked potential measurements

Amblyopia in patients with congenital esotropia was studied using visually evoked cortical potentials. In only four of 31 patients with esotropia and no abducting nystagmus was amblyopia detected before surgery. Postoperatively, 19 of these patients had amblyopia. In contrast, nine of the 11 patients with esotropia and nystagmus exhibited amblyopia before surgery. We conclude that amblyopia occurs infrequently in patients with congenital esotropia and no nystagmus until surgery reduces the angle of deviation and breaks down the cross-fixation reflex.

Brown's syndrome: fusion status and amblyopia

Many children with Brown's superior oblique tendon sheath syndrome do not have full fusion and stereopsis. Of 28 such patients 8 failed to demonstrate orthophoria in their assumed head position, and many continued to have a head tilt with one or the other eye patched. All eight showed an appropriate vertical deviation, but in addition six showed esotropia and two exotropia. The lack of fusion in their assumed head position led to amblyopia in seven patients.

Unilateral congenital ptosis and amblyopia

Amblyopia was detected in 15 of 55 children with unilateral congenital ptosis. Anisometropia was the main cause of the amblyopia in 10 cases, and strabismus alone was the cause in 2 cases. In three cases amblyopia developed after ptosis surgery.