Vision loss associated with a stiff neck complicating strabismus surgery.

An exotropic 60 year old suffered a scleral-choroidal penetration and vitreous hemorrhage during and after strabismus surgery on a highly myopic eye when her anesthetic airway management was complicated by her previously asymptomatic and unrecognized rigid cervical spine which placed both the surgeon and the anesthetist in disadvantaged positions both physically and medically. Restoration of vision and binocularity ultimately required vitrectomy and intraocular lens implantation.

The Alaska Blind Child Discovery project: rationale, methods and results of 4000 screenings.

BACKGROUND: Photoscreening allows lay persons to adapt the Enhanced Brückner Test to preschoolers in an attempt to identify refractive amblyopia. The Alaska Blind Child Discovery (ABCD) project is charitably funded and administered. METHODS: MTI photoscreening was offered to children in rural and urban communities in southern Alaska from 1996 through June 1999. Parents answered questions concerning the child's health, family ocular history and whether the child had any eye "Warning Signs." The MTI images were interpreted by two eye doctors using a modification in MTI published guidelines. RESULTS: Out of 4000 screenings performed on 3930 children, there was an overall "not normal" interpretation of 9% and an inconclusive rate of 1%. The mean S.D. age was 3.9 2 years. Only 6% had had a prior eye exam. The average number of Polaroid pictures per screening was 1.16. Follow-up data on "not normal" results was obtained on just over 50%. The positive predictive value during the first two years was 77% but improved to 92% from 1998-1999. Affirmative answers to the questions concerning previous eye exam, child's health, siblings eye health and positive "Warning Signs" were significantly associated with "not normal" interpretations but affirmative answers about eye health of mother, father and relatives were not. Community penetrance of photoscreening to the target age-group ranged from only 5% for Anchorage to almost 100% for the Bristol Bay public health nurses. Five percent of parents of "positive" results surveyed would not have recommended screening for their friends. Equipment functioned dependably even in remote Alaska. CONCLUSION: Charitable volunteer Polaroid photoscreening detected amblyopia and significant pediatric eye disease in over 300 children during the first 3.5 years of ABCD.

The detection of congenital glaucoma by photoscreen interpretation.

Photoscreening is designed to detect abnormalities in children's eye, particularly abnormal refractive errors, which can lead to amblyopia. An Alaska Bind Child Discovery MTI Polaroid photoscreen in one girl resulted in diagnosis and treatment of congenital glaucoma. Patients with known pediatric eye disease underwent photoscreening. Subtle non-refractive changes in photoscreen images may reveal eye disease even more serious than amblyopia. We suggest that human or computer interpretation of photoscreening images, particularly when retained, be done conscientiously with respect to the refractive state and alignment of the eyes, but also regarding other potentially serious ocular pathology.

Iris color alone does not predict susceptibility to the oculocardiac reflex in strabismus surgery.

PURPOSE: To test prior published observations that patients with brown irides were more susceptible to the oculocardiac reflex. SUBJECTS AND METHODS: 466 adults and children underwent surgery on an extraocular muscle under general anesthesia without anticholinergic blockade. The first rectus muscle isolated was given a predetermined specific force pull during electrocardiograph monitoring. Iris color was retrieved from the deliberate clinical charting. RESULTS: The occurrence of the oculocardiac reflex did not correlate with age, but did profoundly for the inferior rectus and least for the lateral rectus. Iris color did not influence the incidence of occurrence of moderate or severe oculocardiac reflex. CONCLUSION: The prediction of oculocardiac reflex propensity remains elusive.

Palinopsia with bacterial brain abscess and Noonan syndrome.

Though positive visual symptoms can be psychological in nature, or can result from a perceptive or anxious patients recognizing optical principals in the eye itself, this case illustrates how a thorough history is required to delineate those rarer signs which accompany serious macular or neuro-ophthalmic pathology.

Hypobaric ocular trauma from a Popper.

We have observed 3 cases of ocular trauma in children that were caused by an atypical, hypobaric mechanism induced by a toy called a Popper. When we initially notified the United States Consumer Product Safety Commission in 1990, Poppers disappeared from store shelves. We are concerned that this potentially harmful toy is making a comeback in 1998 (Smilemakers Inc, Spartanburg, SC; June-July 1998 catalog, p. 57). In 1990, packaged poppers cautioned against applying to face or skin; we are not sure that such warnings accompany current Poppers.

The human heart rate response profiles to five vagal maneuvers.

Healthy teens and adults performed four vagotonic maneuvers. A large series of strabismus surgery patients had deliberately quantified tension on extraocular rectus muscles during general anesthesia. The mean bradycardia was greatest for diving response (apneic facial exposure to cold) and Valsalva maneuver and least for pressure on the globe and carotid sinus massage. Bradycardia occurred for every subject for the non-surgical maneuvers, however, extraocular muscle tension frequently caused no change in heart rate or even tachycardia. The inter-subject variance in percent heart rate change was greatest for surgical oculocardiac reflex. Of the rectus muscles, the inferior caused the most bradycardia while the lateral caused the least. The percent oculocardiac reflex was not age dependent. Occasional patients demonstrated profound bradycardia with strabismus surgery. Of these maneuvers, diving response has theoretical advantage in treating paroxysmal atrial tachycardia. The human cardiac vagal efferent was stimulated by several carefully controlled maneuvers resulting in wide inter-maneuver differences in bradycardia magnitude. The greatest intra-maneuver variability occurred with surgical oculocardiac reflex.

Neonatal respiratory distress caused by cryptic dacryoceles.

Two cases of neonatal respiratory distress responded with treatment of bilateral dacryocele. In one case, no visible or palpable external evidence of dacryocele was present until mucopurulent discharge commenced more than a week after birth. While the incidence of typical congenital nasolacrimal duct obstruction is about 6%, dacryocele is 200 times less common.

Bilateral monocanalicular silicone loop: predictable home removal of nasolacrimal stents.

Premature dislocation, a potential disadvantage of conventional, unilateral silicone intubation for lacrimal disease, can be alleviated with a firmly-tied, bilateral, superior canaliculus intubation. Since the looped silicone stent can be removed easily at home by parents, this technique is particularly beneficial for remote patients for whom postoperative, clinic removal is a financial burden.

Lack of global vagal propensity in patients with oculocardiac reflex.

BACKGROUND: Profound bradycardia during ophthalmic surgery is a rare but potentially serious event. Little is known about the predictability of the oculocardiac reflex. METHODS: Four vagotonic maneuvers were performed on six patients who had profound oculocardiac reflex (3- to 10-second asystole) during eye surgery, the results of which were compared with 30 previously studied control subjects. Electrocardiographs were monitored during the following vagotonic maneuvers: diving response (apneic facial immersion), Valsalva maneuver, ocular compression, and carotid sinus massage. RESULTS: The degree of heart rate slowing as a result of diving response, Valsalva maneuver, and, notably, ocular compression did not differ when these patients were compared with the 30 previously studied control subjects. Carotid sinus massage produced significantly (P = 0.01) more bradycardia in the six patients (mean +/- standard deviation, -24% +/- 6%) than in the 30 control subjects (-12% +/- 7%). The heart rate response to pressure on the eyes did not correlate with prior intraoperative oculocardiac reflex. CONCLUSION: The discrepancy in heart rate sensitivity between surgical extraocular muscle tension and ocular compression may be due to different sensory receptors and brain stem processing for the trigeminally mediated oculocardiac reflex. Carotid sinus massage may help predict low heart rates during eye surgery.

Susceptibility to retinopathy of prematurity in Alaskan Natives.

Threshold retinopathy of prematurity occurred in 11 of 34 Alaskan natives compared with 10 of 93 non-natives. Natives constitute 16% of the state population. This significant Alaskan native preponderance was not explained by differences in prenatal or intensive care unit morbidity except that the intervals from birth to extubation and birth to cryotherapy were shorter for natives.