Essential Infantile Esotropia: Postoperative Sensory Outcomes of Strabismus Surgery.

BACKGROUND: The optimum age for Essential Infantile Esotropia surgery is a controversial subject. Sensory status was evaluated in patients who underwent surgery at different ages in a retrospective study. The setting of the study is the ophthalmology department of a teaching hospital. METHODS: Different clinical characters were analyzed pre- and postoperatively; nine different surgeries were performed. A total of 188 patients presented valid postoperative sensorial data, divided in two groups: surgery at ≤2 years (n=69) or >2 years (n=119). Sensory status was dichotomized in binocular single vision (BSV) and exclusion. Univariate differences were assessed with the chi-square test (or Fisher exact test). To identify the independent role of factors associated with the sensory status, all variables showing in univariate analyses a significant association (p<0.05) with the outcome variable were entered into a multivariate logistic regression model. All statistical tests were two-sided. RESULTS: Multivariate analysis confirmed that children operated >2 years were 0.4 times less likely to obtain BSV compared with children operated at ≤2 years (AOR. 0.38, 95% C.I. 0.17-0.89, p=0.025). Patients operated on by OO MR rec.+ OO LR res. + OO IO rec.-ap. (intervention type 6) were about 11 times more likely to have BSV than those by OO rec.MR + unilateral res. LR (operation type 2); AOR.: 10.67, 95% C.I.: 1.34 - 85.29, p=0.026). Twenty-nine patients (12.1%) operated at ≤2 years of age underwent a reoperation, compared to 33 (8.6%) who underwent surgery after two years (p>0.05). CONCLUSIONS: Our findings suggest to perform EIE surgery between age 1 and 2 and, when indicated, to prefer a six-muscle approach in order to achieve a better sensory function.

Congenital and Developmental Cataracts: Focus on Strabismus Outcomes at Long-Term Follow-Up.

PURPOSE: To evaluate the incidence of strabismus in congenital and developmental cataract surgery in patients with a follow-up longer than five years. METHODS: All patients with congenital and developmental cataracts observed from 1996 to 2013 with a follow-up longer than five years were retrospectively included. RESULTS: We included 117 patients (58 females and 59 males, mean age 0.62±0.3 years, 160 eyes) with congenital cataracts and 73 patients (32 females and 41 males, mean age 6.63±0.7 years, 121 eyes) with developmental cataracts. Before cataract surgery, strabismus was present in 88 patients with congenital cataracts (75.2%) and in 30 patients with developmental cataracts (41.1%) (p=0.01). After a follow-up of 9.26±1.3 years (range, 5-14 years), a significantly greater incidence of strabismus was observed after surgery only in patients with unilateral congenital cataracts who underwent cataract removal and primary IOL implantation (p=0.02). Distance BCVA and near BCVA were better after surgery for developmental cataracts (p<0.05). Presence of binocular vision was more frequent after surgery for developmental cataracts (p=0.001). CONCLUSION: Incidence of strabismus and postsurgical onset of strabismus at long-term follow-up was greater in patients with congenital cataracts.

Essential infantile esotropia with inferior oblique hyperfunction: long term follow-up of 6 muscles approach.

AIM: To evaluate long term follow-up (10y) of 6 muscle surgical approach in essential infantile esotropia (EIE). METHODS: A 6 muscle approach to EIE was retrospectively evaluated in patients with inferior oblique (IO) hyperfunction and lateral rectus (LR) pseudoparalysis, who underwent surgery at different ages. Different clinical characters were analyzed pre- and postoperatively, in patients who underwent a 6 muscles approach ≤4 years of age. All patients underwent a multiple muscles approach: bilateral medial recti (MR) recession (4-5 mm), bilateral LR resection (lower than 7 mm) and bilateral IO recession and anteroposition. Of 108 children with preoperative angle ≥+30 prism diopters (PD) and IO hyperfunction were selected from larger cohort of patients (n=213, 103 females and 110 males) after excluding patients with: angle variability, who underwent reoperation and with incomplete follow up. Preoperative assessment and complete orthoptic examination were performed. Follow-up was performed 3mo, 2, 5 and 10y after surgery. Statistical analysis was performes using SAS statistical software package (version 9.1, SAS Institute Inc., Cary, NC, USA). RESULTS: Ten years follow up data analysis showed the following percentage of orthotropic patients: (0 PD): 3mo, 22.2%; 2y, 16.7%; 5y, 25.0% and 10y, 27.8%. A slight, significant (P<0.01), increase of 2y follow up residual deviation was found when compared to 3mo one. Stationary surgical results is reported during time, with a trend of mean residual deviation reduction (P=0.04). CONCLUSION: Our results confirm the reliability of multiple muscles surgical approach in the treatment of patients affected by EIE with OI hyperfunction.

Infantile esotropia: risk factors associated with reoperation.

The aim of this study was to identify clinical and demographic factors associated with misalignment after first surgery performed on children affected by infantile esotropia to evaluate the reoperation rate. A retrospective study was carried out, analyzing data from 525 children who underwent bilateral medial recti recession, bilateral lateral recti resection, and inferior oblique recession and anteroposition by the same surgeon (AM). Postoperative evaluation included assessment of motor alignment at approximately 3 months, 6 months, 1 year, and 5 years. Statistical analysis was performed with a logistical regression model in which the dependent variable was the presence/absence of reoperation. We found that late surgery (after 3 years of age) and a family history of strabismus are associated with a higher risk of reoperation, while some clinical factors, including some classically associated with worst motor outcome as preoperative angle, dissociated vertical deviation, and amblyopia, did not influence the incidence of reoperation in infantile esotropia. Male patients and patients with hyperopia in preoperative examinations have a significantly decreased reoperation rate.

Pediatric keratoconus and iontophoretic corneal crosslinking: refractive and topographic evidence in patients underwent general and topical anesthesia, 18 months of follow-up.

To evaluate the efficiency and safety of iontophoretic transepithelial corneal crosslinking in pediatric patients with progressive keratoconus underwent general or topical anesthesia in 18 months follow-up. 13 patients (13 eyes) diagnosed with progressive keratoconus underwent corneal CXL with iontophoresis (I-CXL). Riboflavin solution was administered by iontophoresis for 5 min, and then UV-A irradiation (10 mW/cm) was performed for 9 min. Preoperative and post-operative visits at 1, 6, 12, and 18 months assessed the following parameters: uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, corneal topography, optical tomography, and pachymetry with Pentacam (Oculus Optikgeräte GmbH, Wetzlar, Germany), endothelial biomicroscopy (Konan Specular Microscope; Konan Medical, Inc., Hyogo, Japan). The paired Student t test was used to compare data during the follow-up. 10 males and 3 females with a mean age of 15.4 ± 1.7 years (range 11-18 years) were included. The results showed a stabilization of the refractive UCVA and BCVA as early as the first post-operative month, with a slight improvement over time. The Kmax remained stable throughout follow-up (p = 0.04). Transepithelial collagen crosslinking by iontophoresis, unlike other transepithelial techniques seems to halt pediatric keratoconus progression over 18 months. This is the second study evaluating CXL with iontophoresis in pediatric patients with progressive keratoconus with 18 months of follow-up using two different ways of anesthesia.

Long-Term Follow-Up after Surgery for Congenital and Developmental Cataracts.

PURPOSE: To evaluate long-term functional outcomes after surgery for congenital and developmental cataracts. METHODS: In this retrospective interventional study, patients with congenital and developmental cataracts observed from 1996 to 2013 were included. Traumatic cataracts and cataracts secondary to other pathologies were excluded from the study. Minimum follow-up for inclusion was five years. RESULTS: We included 117 patients operated on for congenital cataracts (58 females and 59 males, mean age 0.59 ± 0.2 years, 160 eyes) and 73 patients operated on for developmental cataracts (32 females and 41 males, mean age 6.63 ± 0.7 years, 121 eyes). Mean postsurgical follow-up was 9.26 ± 1.3 years (range, 5-14 years). After surgery for developmental cataracts, both distance and near BCVA were greater (p = 0.001), as was the presence of binocular vision (p = 0.001), while incidence of strabismus and myopic shift was lower (p = 0.001 and p = 0.02, respectively). CONCLUSION: Postsurgical data showed better functional outcomes in developmental cataracts when compared to congenital cataracts.

Long-Term Outcomes of Primary Intraocular Lens Implantation for Unilateral Congenital Cataract.

PURPOSE: In congenital cataracts, the need for early intervention is well established to prevent visual deprivation and amblyopia. We evaluated patients with unilateral amblyogenic congenital who had undergone simultaneous cataract removal and intraocular lens implantation. METHODS: We retrospectively reviewed all patients operated on between 1990 and 2010 at the Pediatric Eye Department of the University Federico II of Naples (Italy). Minimum follow-up for inclusion was 48 months. RESULTS: 52 patients (28 females, 24 males, mean age at surgery 9.0 ± 4.5 months, range 2-21 months) were included in this retrospective review. Mean follow-up was 100.7 ± 57.0 months (range, 48-270 months). At last visit, mean BCVA in the operated eyes was 0.65 ± 0.4 (range, 0.04-1.3) LogMAR and 40 patients (76.9%) had strabismus. In patients undergoing surgery at an age >12 months, BCVA was significantly lower (0.92 ± 0.4 LogMAR versus 0.60 ± 0.4 LogMAR, p = 0.01), although development of myopic shift was less frequent (61.5% versus 43.5%, p = 0.03). BCVA at last visit was higher in patients with a first stable pseudophakic SE between +1D and +3D (p = 0.02). CONCLUSIONS: Worse final BCVA, despite less frequent development of myopic shift, was observed when surgery was performed after 12 months of age. A hyperopic correction in first stable pseudophakic SE seems advisable.

Long-term longitudinal assessment of postoperative outcomes after congenital cataract surgery in children with congenital rubella syndrome.

PURPOSE: To assess the intraoperative and long-term longitudinal postoperative outcomes of cataract surgery in children with congenital rubella syndrome. SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. DESIGN: Prospective observational clinical study. METHODS: Children with congenital rubella syndrome who had cataract surgery were enrolled. All microphthalmic eyes were left aphakic. A 1-piece hydrophobic acrylic intraocular lens was implanted in the capsular bag in eyes without microphthalmos. The postoperative observations included complications and visual assessments up to 5 years. RESULTS: The mean age of the 21 children (37 eyes) was 3.97 months ± 2.1 (SD). Intraocular lens implantation was performed in 12 eyes (32.4%), while 25 eyes (67.6%) were left aphakic. Postoperatively, the median follow-up was 60.79 months. Posterior synechiae were observed in 22 eyes (59.5%) and visual axis opacification in 9 eyes (24.3%). Secondary glaucoma was observed in 16 eyes (43.2%), of which 14 were aphakic and 1 was pseudophakic. Nine eyes required trabeculectomy. Age at surgery and ocular comorbidities were statistically significantly associated with secondary glaucoma (P<.05, χ(2) test and Kendall τB criteria P<.05). The mean corrected distance visual acuity at the final follow-up was 0.72 ± 0.56 logMAR. CONCLUSIONS: The long-term results suggest good visual outcomes can be obtained with congenital cataract associated with congenital rubella syndrome after early surgical intervention. The rate of serious postoperative complications was acceptable.

Refractive surgery for accommodative esotropia: 5-year follow-up.

PURPOSE: To assess the long-term effectiveness and safety of refractive surgery with LASIK or photorefractive keratectomy (PRK) for treating accommodative esotropia in adults. METHODS: All patients with accommodative esotropia treated with LASIK or PRK until December 2007 and with a minimum follow-up of 5 years were retrospectively included. RESULTS: LASIK was performed on 44 eyes of 22 patients (12 women, 10 men; mean age: 22.7 ± 2.9 years). Mean postoperative follow-up was 62.1 ± 3.2 months. PRK was performed on 16 eyes of 8 patients (4 women, 4 men; mean age: 23.7 ± 1.7 years). Mean postoperative follow-up was 61.3 ± 2.8 months. At the 5-year follow-up, the mean cycloplegic refraction was more hyperopic in the PRK group (0.3 ± 0.8 vs 0.06 ± 0.3 diopters, P = .01). Correction of esotropia to esophoria or orthotropia was present in 21 patients (95.4%) treated with LASIK and in all patients treated with PRK. CONCLUSIONS: Both LASIK and PRK were effective in the long-term reduction of accommodative esotropia.

Essential infantile esotropia: postoperative motor outcomes and inferential analysis of strabismus surgery.

BACKGROUND: The aim of this retrospective study is a long-term evaluation of postoperative motor outcomes and the inferential analysis of strabismus surgery in infant eyes with essential infantile esotropia. METHODS: 576 patients were compatible with the criteria: confirmed EIE diagnosis, angle ≥ 30 pD, absence of associated ocular anomalies, onset by 6 months of age, absence of hyperopia > 3 Diopters, operation before age 4. Preoperative deviation classes (30-40 pD, 41-59 pD, ≥ 60 pD) were established, different types of surgery were performed. Follow-up was conducted for 5 years after surgery. Longitudinal data were analyzed using general linear mixed models stratified according to the class of pre-operative deviation. A random intercept and a random slope with time (in months) was assumed with an unstructured within subject correlation structure for repeated measurements. RESULTS: In patients with preoperative angle ≤ 40 pD, a significant interaction effect for intervention by time (F5,155.9 = 3.56, p = 0.004) and a significant intervention effect (F5,226.1 = 6.41, p < 0.001) on residual deviation were observed; only the intervention 5 showed a residual deviation inside the limits of a partial success. In Class 41-59, a significant interaction effect for intervention by time (F4,166.7 = 5.16, p = 0.001), intervention (F4,178.1 = 2.48, p = 0.046) and time (F1,174.6 = 9.99, p = 0.002) on residual deviation were observed; intervention 7 had the highest degree of stability showing an outcome within the range of a partial success. In Class ≥ 60 pD no significant effect for intervention (F4,213.9 = 0.74, p = 0.567), time (F1,169.5 = 0.33, p = 0.569) or intervention by time (F4,160.9 = 1.08, p = 0.368) on residual deviation was observed; intervention 3,6 and 7 resulted in a residual deviation within the range of a partial success. CONCLUSIONS: We suggest, where possible, a two-horizontal muscles approach in small angle EIE, while a multiple muscles surgery in large angle EIE.

Bilateral methicillin-resistant Staphylococcus aureus keratitis following hyperopic photorefractive surgery.

To report clinical manifestations of a female patient with bilateral bacterial keratitis following photorefractive keratectomy (PRK). Bilateral PRK was performed for moderate hyperopia. Bandage contact lenses were fitted at the conclusion of the surgery. Bilateral infectious keratitis with hypopion was diagnosed within 4 days after surgery. Smear and culture were obtained and showed the presence of methicillin-resistant Staphylococcus aureus (MRSA). The patient was treated with systemic prednisone and topical antibiotics (vancomycin, tobramycin and netylmicin) and betamethasone. After 1 month corneal leukoma was still present and remained unchanged during the following 7 months. Infectious keratitis is a rare complication of PRK that appears early in the postoperative period. MRSA keratitis may determine long-term visual impairment despite prompt therapeutic intervention.

Ocular complications of eyebrow piercing.

Piercing, a type of body art, is increasing in popularity among young people. Two patients presented with complications a few days after having an eyebrow piercing. The first had posterior cellulitis and the second had anterior cellulitis. In both cases, symptoms decreased after 1 week of therapy with antibiotics and cortisone.