A Comparison of Chemodnervation to Incisional Surgery for Acute, Acquired, Comitant Esotropia: An International Study.

PURPOSE: To compare the efficacy of botulinum toxin injections to strabismus surgery in children with acute, acquired, comitant esotropia (ACE), and to investigate factors predicting success. DESIGN: International, multi-center nonrandomized comparative study METHODS: Setting: Cloud-based survey. STUDY POPULATION: Children aged 2 to 17 years who underwent a single surgical intervention for ACE. INTERVENTIONS: Botulinum toxin injection ("chemodenervation" group) or strabismus surgery ("surgery" group). MAIN OUTCOME MEASURES: Primary measure: success rate at 6 months in propensity-matched cohort, defined as total horizontal deviation of 10 prism diopters or less with evidence of binocular single vision. Secondary measure: Risk factors for poor outcomes in the full cohort. RESULTS: Surgeons from 19 centers contributed. There were 74 patients in the chemodenervation group and 97 patients in the surgery group. In the propensity-matched data (n = 98), success rate was not significantly different at 6 months (70.2% vs 79.6%; P = .2) and 12 months (62.9% vs 77.8%; P = .2), but was significantly lower in the chemodenervation group at 24 months (52% vs 86.4%; P = .015). Irrespective of treatment modality, treatment delay was associated with lower success rates at 6 months, with median time from onset to intervention 4.5 months (interquartile range (IQR): 2.1, 6.7) in the success group and 7.7 months (IQR: 5.6, 10.1) in the failure group (P < .001). CONCLUSIONS: In children with ACE, success rate after chemodenervation was similar to that of surgery for up to 12 months but lower at 24 months. Those with prompt intervention and no amblyopia had the most favorable outcomes, regardless of treatment modality.

Prenatal diagnosis of intraconal lymphatic malformation on fetal magnetic resonance imaging.

Lymphatic malformations are benign hamartomatous tumors present at birth but usually diagnosed in early childhood. We report a case of prenatal diagnosis of an isolated unilateral retrobulbar lymphatic malformation with fetal magnetic resonance imaging (MRI). This was first detected at 27 weeks' gestational age. Postnatal ocular examinations at 4 days and 5 weeks of age showed no signs of optic nerve compromise. Postnatal MRI at 18 days of age showed slight increase in size of the lesion, and no intracranial vascular malformations were detected.

A national survey of Canadian ophthalmologists to determine awareness of published guidelines for the management of uveitis.

BACKGROUND: The objectives of this study are to assess Canadian ophthalmologists' awareness of established uveitis treatment guidelines and clinical management of uveitis and to assess the frequency of government applications for immunomodulatory therapy (IMT) and identify primary prescribers. A 25-item questionnaire was sent to 759 practicing Canadian ophthalmologists. Six questions assessed demographics including the year of residency completion, training by uveitis specialists during residency, and fellowship training. Five questions assessed application of guidelines to clinical scenarios, and 12 questions assessed referral patterns and success of obtaining coverage for IMT. RESULTS: Of 144 respondents, 12 (8.3 %) were uveitis specialists; 45.1 % of respondents had uveitis training during residency by a uveitis specialist. Sixty-one percent reported awareness of management guidelines. Recent graduates (2001-2012) referred patients to uveitis specialists (55.3 %) less frequently than earlier graduates. Recent graduates also managed uveitis patients more frequently with corticosteroid injections (15.6 %) than those who graduated before 1980 (9.75 %). The majority (93.6 %) of respondents submitted less than six IMT funding applications for provincial drug coverage yearly, and 5.5 % reported prescribing IMT themselves, rather than referring to other specialists. CONCLUSIONS: Although greater than half of respondents reported awareness of uveitis treatment guidelines, Canadian ophthalmologists' awareness of uveitis treatment guidelines and application of the guidelines to patient care could be improved. Few applications are made for IMT, and the majority of applications are sent by non-ophthalmologists. This suggests the need for further education of ophthalmologist about uveitis treatment guidelines and for more ophthalmologists trained to manage uveitis with IMT.

Successful Treatment of Acute Ocular-Involving Toxic Epidermal Necrolysis Using Amniotic Membrane Suture Fixated to Custom Designed Symblepharon Rings.

PURPOSE: The purpose of this study is to describe a novel technique using amniotic membrane suture-fixated onto custom-designed symblepharon rings in a patient with acute toxic epidermal necrolysis (TEN). METHODS: A 61-year-old man developed bilateral symblephara and severe ocular surface inflammation from Stevens-Johnson syndrome/TEN secondary to allopurinol. Eight days after admission, he was treated with placement of custom-designed symblepharon rings, designed by one of the authors (A.A.), covered with amniotic membrane. This method was used to allow for efficient placement of the membrane and to minimize operative time and perioperative risks due to his worsening systemic condition. RESULTS: On postoperative day 49, his visual acuity was 20/20 in the right eye and 20/25 in the left eye. Both eyes were quiet with only small symblephara noted temporally. CONCLUSIONS: The use of amniotic membrane suture-fixated to custom-designed symblepharon rings provides sufficient coverage of the ocular surface, leading to excellent visual and clinical outcomes by reducing inflammation and protecting the ocular surface from the cicatrizing sequelae associated with ocular-involving TEN. This novel technique is less invasive, more time efficient, and likely safe for even the most critically ill patients with significant risk for mortality, thus allowing any treating ophthalmologist to comfortably perform this important sight-saving procedure.

Incidence of endophthalmitis and use of antibiotic prophylaxis after intravitreal injections.

PURPOSE: To report the incidence of endophthalmitis in association with different antibiotic prophylaxis strategies after intravitreal injections of anti-vascular endothelial growth factors and triamcinolone acetonide. DESIGN: Retrospective, comparative case series. PARTICIPANTS: Fifteen thousand eight hundred ninety-five intravitreal injections (9453 ranibizumab, 5386 bevacizumab, 935 triamcinolone acetonide, 121 pegaptanib sodium) were reviewed for 2465 patients between January 5, 2005, and August 31, 2010. The number of injections was determined from billing code and patient records. METHODS: The indications for injection included age-related macular degeneration, diabetic macular edema, central and branch retinal vein occlusion, and miscellaneous causes. Three strategies of topical antibiotic prophylaxis were used by the respective surgeons: (1) antibiotics given for 5 days after each injection, (2) antibiotics given immediately after each injection, and (3) no antibiotics given. MAIN OUTCOME MEASURES: The primary outcome measures were the incidence of culture-positive endophthalmitis and culture-negative cases of suspected endophthalmitis. RESULTS: Nine eyes of 9 patients with suspected endophthalmitis after injection were identified. Three of the 9 cases had culture-positive results. The overall incidence of endophthalmitis was 9 in 15 895. The incidence of culture-negative cases of suspected endophthalmitis and culture-proven endophthalmitis after injection was 6 in 15 895 and 3 in 15 895, respectively. Taking into account both culture-positive endophthalmitis and culture-negative cases of suspected endophthalmitis, the incidence per injection was 5 in 8259 for patients who were given antibiotics for 5 days after injection, 2 in 2370 for those who received antibiotics immediately after each injection, and 2 in 5266 who received no antibiotics. However, if considering culture-proven endophthalmitis alone, the use of topical antibiotics, given immediately or for 5 days after injection, showed lower rates of endophthalmitis compared with those without postinjection antibiotics. The risk of endophthalmitis after intravitreal injection varied among agents that were used. Among the 9 cases of clinically suspected endophthalmitis, regardless of prophylactic strategies used, the incidence of endophthalmitis per injection was 2 in 935 for triamcinolone acetonide, 3 in 9453 for ranibizumab, and 4 in 5386 for bevacizumab. CONCLUSIONS: The overall rate of intravitreal injection-related endophthalmitis is greater with the use of topical antibiotics, given immediately or for 5 days after the injection, compared with no antibiotics.

Computer-assisted image analysis of temporal retinal vessel width and tortuosity in retinopathy of prematurity for the assessment of disease severity and treatment outcome.

PURPOSE: To quantify the severity of retinopathy of prematurity (ROP) through temporal retinal vessel diameter and tortuosity by the use semiautomated analysis and to evaluate the effects of laser treatment on retinal vessel measurements. METHODS: A total of 176 RetCam digital fundus images from 63 infants diagnosed with ROP between January 2005 and December 2008 were retrospectively analyzed with Retinal Vessel Measurement V5.8 software. Patients were classified into 1 of 3 groups: stage 1 and 2 (Group 1), stage 3 not requiring treatment (Group 2), and stage 3 requiring treatment (Group 3). Diameter and tortuosity of the 4 major temporal retinal arteries and veins close to the optic disk were quantified. Tortuosity was measured as central (within 2 disk diameters from the center of the optic disk) and paracentral (from 2 to 4 disk diameters). For Group 3, measurements of vessels immediately before treatment and all follow-up post-treatment measurements of vessels were analyzed. RESULTS: Differences in central and paracentral arteriolar tortuosity were pronounced. The average central arteriolar tortuosities were 1.12 ± 0.018 for Group 1, 1.13 ± 0.018 for Group 2, and 1.32 ± for Group 3; the paracentral arteriolar tortuosities were 1.11 ± 0.019 for Group 1, 1.12 ± 0.019 for Group 2, and 1.31 ± 0.02 for Group 3. In the post-treatment analysis of Group 3 patients, significant reductions in all vascular measurements were observed compared to pre-treatment, except for central and paracentral vein tortuosity. CONCLUSIONS: Computerized systems can be used to objectively assess differences in vascular parameters between ROP stages.