Delayed adjustable sutures: a multicentred clinical review.

PURPOSE: To characterise the results of the largest patient series to date undergoing closed conjunctival delayed adjustable suture techniques. METHODS: A multicentre retrospective review of 440 operations (patients aged 10-91 years) by five surgeons at four centres were evaluated for surgical outcomes associated with the delayed adjustable suture technique. RESULTS: 26% (116 of 440) of all patients required postoperative manipulation, with individual surgeon rates ranging from 13% to 56%. The majority of these patients did not complain of diplopia in target gaze and/or had satisfactory cosmetic improvement as evaluated at the 1-3 months follow-up visit (84%). Transient complications included dellen, poor conjunctival appearance, filamentary keratitis, infection, granuloma, exposed suture and corneal abrasion. Serious complications were rare. CONCLUSIONS: This large multicentred series characterises the closed conjunctival delayed adjustable suture technique for the correction of strabismus. It may present some significant advantages to more traditional adjustable suture techniques.

Early reoperation after vertical rectus muscle surgery.

PURPOSE: Adjustable suture strabismus surgery has a success rate between 90% and 94%. In some patients, undesirable deviations are noted in the first week after surgery. In this article, we describe a method of reoperation in the first week of the initial repair in an outpatient clinical setting. METHODS: A retrospective review of clinical records from 1990 to 1998 identified 7 patients who underwent reoperation of the original surgical procedure in a clinic setting. All patients had vertical deviations that were overcorrected and had a reversal of their diplopia. RESULTS: Follow-up ranged from 3 months to 59 months. All patients were free of diplopia and were either orthophoric or had small phoric deviations. CONCLUSIONS: Proper identification of patients with strabismus as a result of overcorrected adjustable sutures and prompt reoperation in the first week after surgery are possible and prevent the need for repeat anesthesia in the operating suite.

Effect of bipolar cautery on tensile strength of 6-0 polyglactin 910 suture.

PURPOSE: To determine the effect of bipolar cautery on 6-0 polyglactin 910 suture. METHODS: Three groups of sutures were tested for maximum tensile strength. The first group (direct cautery) had bipolar cautery applied directly to the suture. The second group (scleral cautery) had bipolar cautery applied directly on top of the sclera, through which the suture was passed one-half scleral thickness. The third group (control) had no application of cautery to the suture. RESULTS: The mean tensile strength for the direct cautery sutures (n=8) was 553 g; for the scleral cautery sutures (n=7), 577 g; and for the control sutures (n=5), 553 g. There was no statistically significant difference in tensile strength between the three groups, with the analysis of variance yielding P=.56. CONCLUSION: Bipolar cautery causes little to no risk of reducing the tensile strength of 6-0 polyglactin 910 suture in the setting of strabismus surgery.

Monovision for treatment of accommodative esotropia with a high AC/A ratio.

PURPOSE: The purpose of this study was to determine whether monovision will successfully reduce the near esodeviation in patients with high AC/A ratio accommodative esotropia. METHODS: The records of all patients who wore monovision contact lenses for at least 3 months were retrospectively reviewed to determine baseline patient characteristics, long-term motor alignment, sensory status, and patient convenience. RESULTS: TEN patients 10 to 28 years of age wore monovision contact lenses for a mean of 28.7 months to date. All patients maintained an esodeviation of < or = 10 prism diopters at distance and near, except 1 patient whose near esodeviation increased over time. Of the 5 patients for whom data were available, 1 experienced a significant decrease in stereoacuity. No patients discontinued monovision because of visual symptoms; however, 1 did so because of the inconvenience of contact lens care. No serious ocular side effects from contact lens wear were noted in the study. CONCLUSION: Use of monovision contact lenses is a safe and effective method of reducing near-angle esodeviation associated with nonrefractive high AC/A ratio accommodative esotropia. Many patients are willing to accept the visual compromises inherent in monovision to eliminate wearing bifocal spectacles.

MR imaging and CT of orbital infections and complications in acute rhinosinusitis.

The acute onset of orbital and periorbital inflammation presents the clinician with a diagnostic and therapeutic dilemma, the consequence of which may be very serious. The progression from the initial stage of cellulitis to orbital abscess, cavernous sinus thrombosis, brain abscess, meningitis, or visual loss may be quite rapid at times. CT, ultrasonography, and MR imaging play an important role in clinical management of these patients. Indeed, it is the information obtained through orbital imaging that directs the clinician to use the correct therapeutic modality.

Treatment for amblyopia: results using occlusive contact lens.

PURPOSE: Amblyopia treatment occasionally is complicated by patch intolerance, resulting in a poor outcome. Therefore, a prospective study was designed to examine the efficacy and safety of using occlusive contact lenses in the treatment of amblyopia. METHODS: Twenty-five patients, aged 2.5 to 9.5 years, who were using an opaque hydrogel contact lens for the treatment of amblyopia, were followed prospectively. RESULTS: Overall, 92% of patients improved at least one line of visual acuity. Eight patients improved > or = 2 octaves and 12 other patients improved > or = 1 octave. In three patients, the change in visual acuity was < 1 octave. Complications were seen in nine patients: contact lens irritation in five; poor contact fit in three; and peeking around the lens in one. The recurrence rate was high. In 11 of 25 patients, amblyopia rapidly returned to a reduced level when the contact lens was discontinued. CONCLUSIONS: Occlusive contact lenses can be used in treating amblyopia in children. This treatment is ideal in patients who were patch-intolerant and failed with conventional treatment. Patients should have close follow up, however, to monitor any anterior segment complications from contact lens use and to identify the patients in whom amblyopia recurs.

Inferior oblique overaction in infantile esotropia: fundus extorsion as a predictive sign.

BACKGROUND: Inferior oblique overaction develops in 72% of patients with infantile esotropia but generally is not recognized until the patient is between 2 and 4 years of age. METHODS: While undergoing bilateral medial rectus recessions, photographs were taken of the posterior pole of 27 eyes in 14 patients with infantile esotropia and graded for the presence or absence of torsion by a masked observer. Follow up ranged from 10 months to 6 years. RESULTS: Oblique muscle overaction developed in 15 of the 27 eyes. Of these 15, six demonstrated fundus torsion in infancy, before the oblique dysfunction was recognized clinically. CONCLUSION: The presence of abnormal fundus torsion can serve as a marker for patients with infantile esotropia who ultimately will develop overt oblique muscle dysfunction.

Peroxisomal bifunctional enzyme complex deficiency with associated retinal findings.

Peroxisomal bifunctional enzyme complex deficiency is a recently recognized abnormality of fatty acid metabolism. We herein present the association of a flecked retina with peroxisomal bifunctional enzyme deficiency, a clinical association not previously reported. We suggest the finding of a flecked retina in an infant presenting with hypotonia, seizures, and failure to thrive is highly suggestive of this diagnosis.

Morning glory syndrome in children. Association with endocrine and central nervous system anomalies.

OBJECTIVE: To identify morning glory syndrome, an uncommon optic disc anomaly. Generally, it is an isolated ocular abnormality; however, some cranial facial and neurologic associations have been reported. PATIENTS: We herein report two patients with morning glory syndrome and associated pituitary dwarfism. In one patient, the pituitary insufficiency was secondary to compression of the pituitary gland by a basal encephalocele; in the second patient, causative factors were not identified. CONCLUSIONS: Patients with morning glory syndrome should have a complete general physical examination and growth evaluation so that early recognition and treatment of the patient with pituitary dwarfism can occur.

Cyclotorsion in unilateral and bilateral superior oblique paresis.

We studied excyclotorsion prospectively in 12 non-strabismic normal patients, 24 patients with unilateral superior oblique paresis (SOP), and 14 patients with bilateral SOP to determine which test and position, and what amount of torsion best discriminates between bilateral and unilateral SOP. For each patient, we measured torsion at near in primary position and in 20 degrees downgaze, using both the double Maddox rod (DMR) and Bagolini lens (BL) tests. We calculated the average of three measurements for each test in each position and the differences in mean excyclotorsion between downgaze and primary position for each patient for each test. To discriminate between unilateral SOP and normal, and bilateral and unilateral SOP patients, the best test and position combination was the DMR in downgaze (P = .0001). The probability of a torsion measurement indicating a unilateral SOP rather than a normal value was 95% at 6 degrees of excyclotorsion; of bilateral rather than unilateral SOP, 90% at 20 degrees. The range in the three torsion readings within patients with either DMR or BL in either position varied up to 7 degrees.

Vagal responses to adjustable sutures in strabismus correction.

The oculocardiac reflex is a recognized complication of ocular stimulation, precipitated most commonly by traction on the extraocular muscles. To determine the true incidence of occurrence of the oculocardiac reflex during suture adjustments, 20 patients undergoing suture adjustment were monitored for blood pressure, heart rate, and rhythm abnormalities during the suture adjustment. A control group of ten patients with strabismus were studied postoperatively for comparison. Thirteen study patients and two control patients were noted to have a vagal response (P less than .001). The most common response noted was a decrease in heart rate in 15 patients. Only two patients were symptomatic during vagal response (one patient became light-headed and another had an episode of nausea and vomiting). Suture adjustment was found to be the most common triggering event in precipitating vagal responses. Surgeons performing suture adjustment in strabismus correction should be cognizant of vagal responses so that they may properly inform patients of this possibility and take steps to minimize its occurrence.

Pseudostrabismus secondary to use of cosmetic contact lenses.

The DuraSoft 3 Colors cosmetic contact lens is manufactured with a pattern of opaque dots applied to its front surface in order to produce a change in apparent iris color. We fit ten subjects with the DuraSoft 3 Colors contact lens, and all were found to have pseudoexotropia. The deviation ranged from 10 to 22 delta (prism diopters) (average: 16 delta). The cause of the pseudoexotropia was creation of a pseudopositive angle kappa from lateral displacement of the contact lens. Physicians fitting the DuraSoft 3 Colors contact lens should pay special attention to centration characteristics during the fitting session in order to avoid creation of pseudostrabismus.

Microspherophakia in association with the rhizomelic form of chondrodysplasia punctata.

Chondrodysplasia punctata is a multisystem disorder, primarily involving the musculoskeletal system, skin, and eyes. Children with the rhizomelic form of this syndrome have characteristic facies with a saddle-nose deformity, hypertelorism, and frontal bossing. The musculoskeletal changes include proximal limb shortening, flexion contractures, congenital hip dislocations, and the characteristic radiographic finding of epiphyseal stippling of the axial skeleton and long bones. The most common ocular findings are cataracts and optic atrophy. We describe herein the first reported case of microspherophakia in association with the rhizomelic form of chondrodysplasia punctata.

Phakomatous choristoma: clinical, histopathologic, and ultrastructural findings in a 4-month-old boy.

A case of phakomatous choristoma of the lower eyelid is described. A survey of previously reported cases reveals a characteristic and consistent clinical and morphologic picture. Universally the patient presents in infancy with a rather small, firm, rubbery nodule attached to the lower edge of the inferior tarsal plate. Always present in the nasal aspect of the lower lid, the tumor is easily palpable. Recognition of this clinical picture may allow the ophthalmologist to suspect the appropriate diagnosis, but the final diagnosis should be based on the recognition of characteristic histopathology.

Pupillary block glaucoma following pediatric cataract extraction.

We present a case of pupillary block glaucoma that developed after cataract extraction in a pediatric patient. To prevent pupillary block and secondary glaucoma after cataract surgery we recommend that all pediatric cataract patients be given a prophylactic peripheral iridectomy.

Brown's syndrome.

Brown's syndrome is a well-recognized clinical disorder of ocular motility manifesting most notably a restriction of active and passive elevation in adduction. The original name, "superior oblique tendon sheath syndrome," is no longer appropriate, since it has been shown that the tissue surrounding the anterior superior oblique tendon is blameless as a restrictive force. "True" and "simulated" as descriptive modifiers should also be discarded, as they relate to the disproven sheath concept. Brown's syndrome occurs as a congenital or acquired, constant or intermittent condition; the common link is restriction of free movement through the trochlea pulley mechanism. The various etiologic theories are reviewed and the spectrum of medical and surgical treatments are described and evaluated. Evidence suggests that subtypes of Brown's syndrome lie on a single continuum and that spontaneous resolution occurs in each group, probably more often than previously recognized. A simplified classification scheme is encouraged and possible future directions in Brown's syndrome research are introduced.

Acquired monofixation syndrome.

Monofixation syndrome is a well documented sensory abnormality occurring in patients with childhood-onset strabismus. We report the development of monofixation syndrome in six adults with strabismus. It is proposed that constant strabismus, which precludes and prevents bifixation, can result in the development of monofixation syndrome if the strabismic deviation is not corrected promptly.

Simultaneous superior oblique tenotomy and inferior oblique recession in Brown's syndrome.

The technique and results of simultaneous superior oblique tenotomy and 14-mm inferior oblique recession for true Brown's syndrome are presented for 16 eyes of 13 patients. A good or excellent result was achieved in 15 of 16 eyes (94%). Reoperation for overcorrection was not necessary; however, repeat tenotomy was required in two cases. Inferior oblique underaction was present in 12 of 16 eyes (75%) in the early postoperative period; however, elevation in adduction improved over time. At most recent examination, 92% of eyes demonstrated greater than 25 degrees elevation in adduction. Underaction of the superior oblique occurred in 3 of 16 eyes (19%). A simultaneous superior oblique tenotomy and inferior oblique recession is recommended in all patients selected to undergo surgery for true Brown's syndrome to prevent reoperation for iatrogenic superior oblique palsy.