Correlation between optical coherence tomography and glaucomatous optic nerve head damage in children.

AIM: To compare analysis of macular and nerve fibre layer thickness by optical coherence tomography (OCT) with optic nerve head (ONH) morphology based on stereophotography. DESIGN: Prospective observational case-control series. METHODS: Normal and glaucomatous eyes of children (age 4-17 years) were scanned using Stratus OCT (Carl Zeiss Meditec, Dublin, California, USA). Fast macular and retinal nerve fibre layer (RNFL) thickness map were performed on 372 eyes of 222 children. ONH stereophotographs were taken and evaluated by two masked observers using a grading system of 0 to 5 based on both cupping ratio and morphology. OCT3 analyses were compared across ONH grades for different areas around the macula and the peripapillary RNFL. RESULTS: Analysis included OCT values and ONH grading for 139 eyes of 139 children. There was a negative correlation between ONH grade and both macular thickness and RNFL thickness in all areas measured. There was a difference in the correlation identified for black versus white children. CONCLUSION: OCT measurements of RNFL and macular thickness declined with increasing grade of glaucomatous damage seen on stereophotographs in black and white children. Further study will help quantify the value of OCT in the diagnosis and management of paediatric glaucoma.

Safety and efficacy of brimonidine in children with glaucoma.

PURPOSE: Brimonidine is a relatively selective alpha-agonist, which reduces intraocular pressure (IOP) by decreasing aqueous production and increasing uveoscleral outflow. Brimonidine passes through the blood-brain barrier, potentially causing central nervous system (CNS) toxicity. There have been reports of bradycardia, hypotension, hypothermia, hypotonia, and apnea in infants after topical brimonidine. METHODS: We reviewed the IOP data and side effects of children at the Duke University Eye Center placed on brimonidine from June 1997 to October 2000. Brimonidine 0.2% was used for patients whose glaucoma was uncontrolled on maximal tolerated medical therapy. A monocular trial was performed whenever possible, and brimonidine was not prescribed for infants. Included were 32 eyes of 30 patients with uncontrolled IOP and varied glaucoma diagnoses. RESULTS: The mean patient age was 10.5 years, with a mean follow-up on brimonidine of 10.8 months. Most patients were on other glaucoma medications. In 11 of the 32 eyes the IOP data could be interpreted, and in these eyes the IOP decreased from a mean of 22.5 +/- 4.9 mm Hg to a mean of 20.8 +/- 4.0 mm Hg (a mean decrease of 6.7% +/- 10%, P =.04) on brimonidine after a mean follow-up of 11.0 +/- 6.9 months. Two young children (ages 2.4 and 3.7 years) repeatedly were unarousable soon after the administration of brimonidine. Five other children experienced extreme fatigue after brimonidine administration. All symptoms resolved after brimonidine was discontinued. DISCUSSION/CONCLUSIONS: Brimonidine should be used with caution in young children because of the potential for CNS depression. In selected patients, brimonidine has a substantial ocular hypotensive effect.

Macular translocation with 360-degree peripheral retinectomy impact of technique and surgical experience on visual outcomes.

PURPOSE: To evaluate the impact of technique and surgical experience on complications and outcomes of macular translocation surgery with 360-degree peripheral retinectomy (MTS360). METHODS: Twenty-six consecutive patients underwent MTS360 in a prospective study of macular translocation surgery for subfoveal choroidal neovascularization (CNV) in eyes with age-related macular degeneration (ARMD). Data gathered included intraoperative and postoperative events and pre- and postoperative standardized visual acuity recorded as number of letters read. Because the surgical technique changed particularly during the first 16 cases, patients were grouped into an evolving treatment group of the first 16 patients (Group 1) and a modified treatment group of the final 10 patients (Group 2). RESULTS: As techniques evolved in this series, ease of surgery increased. There were significant decreases in surgery duration and in number of retinotomies required to induce artificial retinal detachment. Number of postoperative retinal detachments decreased from five in Group 1 to none in Group 2. Change in visual acuity was significantly different between the two groups: Group 1 had an average loss of 14 letters (<3 lines) and Group 2 an average gain of 3 letters (<1 line) (P < 0.05). Average postoperative visual acuity was significantly better for Group 2 (68 letters, approximately 20/80) than for Group 1 (47 letters, approximately 20/250) (P < 0.01). CONCLUSION: Surgical experience and a progressively modified surgical technique decreased perioperative complications and improved visual outcomes after MTS360. With modified MTS360, central vision has been salvaged for almost 1 year of follow-up in patients presenting with vision loss from subfoveal CNV and ARMD.

Combined superior oblique muscle recession and inferior oblique muscle advancement and transposition for cyclotorsion associated with macular translocation surgery.

PURPOSE: The purpose of this study was to evaluate the effects of oblique muscle surgery on the large-angle incyclotorsion resulting from macular translocation surgery for severe age-related macular degeneration. METHODS: Patients undergoing macular translocation (superiorly) at our institution from May 1996 until November 1998 were included. In the Staged Group, strabismus surgery for symptomatic incyclotorsion was performed after the macular translocation, and in the Combined Group, it was performed simultaneous with the macular translocation. Cyclotorsion was quantified using Maddox rod testing. Surgery for incyclotorsion included superior oblique muscle recession combined with inferior oblique muscle advancement and transposition in the affected eyes. The minimum follow-up time was 6 weeks. RESULTS: Fifteen patients (15 eyes) were included (ages 66-89 years). Nine eyes (Baseline Group) had macular translocation surgery before any strabismus surgery; the mean postoperative incylotorsional angle was 33.4 +/- 18.3 degrees (range, 20-80 degrees) after a mean follow-up of 6.6 months. Four of these eyes (Staged Group) underwent oblique muscle surgery for symptomatic incyclotorsion, which reduced the mean incyclotorsion from 26.9 +/- 6.9 degrees (range, 20-35 degrees) to 9. 9 +/- 7.9 degrees (range, 2.5-20 degrees)-a mean reduction of 16.9 +/- 1.3 degrees (P =.00012), after a mean follow-up of 4.6 months. Six additional eyes (Combined Group) had simultaneous macular translocation and oblique muscle surgery, with a mean postoperative cyclotorsional angle of 14.0 +/- 6.7 degrees (range, 4-22.5 degrees), after a mean follow-up of 3.75 months. CONCLUSION: Oblique muscle surgery is effective at reducing the large degree of incyclotorsion resulting from macular translocation surgery and may be used either following or simultaneous with retinal surgery.

A comparison of the rate of refractive growth in pediatric aphakic and pseudophakic eyes.

OBJECTIVE: To compare the rate of refractive growth in pseudophakic children's eyes to that of aphakic eyes. DESIGN: Multicenter, retrospective observational case series. PARTICIPANTS: 83 patients with pseudophakic eyes (100 eyes) and 74 patients with aphakic eyes (106 eyes), with an age of surgery between 3 months and 10 years and a minimum follow-up time of 3 years or more, depending on the age at surgery. METHODS: A logarithmic model was used to analyze the rate of refractive growth for each eye. MAIN OUTCOME MEASURES: Age at surgery, intraocular lens power, intraocular lens A-constant, initial postoperative refraction, final refraction, and final age. RESULTS: Overall, pseudophakic eyes showed a lesser rate of refractive growth than aphakic eyes (-4.6 diopter vs. -5.7 diopter, P = 0.03). This trend was also present but less significant when the eyes were grouped into those less than 6 months of age at surgery (-3.3 diopter vs. -4.6 diopter, P = 0.09) and older patients (-5.0 diopter vs. -6.1 diopter, P = 0.07). However, the mean quantity of myopic shift was greater in pseudophakic eyes than in aphakic eyes (-5.26 diopter vs. -4.54 diopter), despite shorter follow-up times in the pseudophakic eyes. This is due to the optical effects of a constant intraocular lens power in a growing eye. CONCLUSIONS: Pediatric pseudophakic eyes have a slightly lesser rate of refractive growth than aphakic eyes. The new rate values should be used for predicting future refractions in these eyes.

Combined resection and recession of a single rectus muscle for the treatment of incomitant strabismus.

BACKGROUND: The treatment of incomitant strabismus is challenging. Traditional approaches include the use of asymmetric bilateral surgery and the fadenoperation (posterior fixation suture). We report our experience with a different approach: combined resection and recession of a single rectus muscle. METHODS: The charts of 12 patients who underwent resection of a single rectus muscle with an equal or greater amount of recession of the same muscle were identified. In 5 patients, the procedure was performed using the adjustable suture technique, and the adjustment was performed later the same day (Group 1). In the remaining 7 patients, permanent sutures were placed at the time of surgery (Group 2). The procedure was performed for horizontal and vertical gaze incomitance, dissociated horizontal deviation, and distance-near disparity. RESULTS: Four of the 5 patients in Group 1 showed stable, long-term correction of their incomitance, both in primary gaze and in gaze in the direction of the muscle operated on. The results for patients in Group 2 showed stable, long-term correction of incomitance in 3 patients; however, these patients also had slight overcorrections in the direction of gaze opposite to the muscle operated on. An additional patient in Group 2 had a shift of her distance-near disparity, shifting from relatively exotropic to relatively esotropic disparity postoperatively. All patients in Group 2 showed at least some decrease in the amount of measured incomitance. We did not encounter complications such as muscle slippage or loss, scleral perforation, or late overcorrection in the field of gaze of the operated muscle. CONCLUSIONS: The technique of combined resection and recession of a single rectus muscle shows promise in the treatment of incomitant strabismus. It offers the advantages of posterior fixation combined with the greater technical ease of a standard hangback recession. The muscle may also be placed on an adjustable suture, allowing for postoperative adjustment in selected patients.

Mitomycin C-augumented trabeculectomy with postoperative wound modulation in pediatric glaucoma.

PURPOSE: The purpose of this study was to evaluate mitomycin C-augmented trabeculectomy combined with postoperative subconjunctival 5-fluorouracil and laser suture lysis in the treatment of refractory pediatric glaucoma. METHODS: Twenty-one consecutive cases (17 patients) with refractory pediatric glaucoma treated with mitomycin C trabeculectomy (0.4 mg/mL for 3 to 5 minutes) and postoperative 5-fluorouracil, laser suture lysis, or both were retrospectively reviewed. Success was defined as intraocular pressure between 4 and 16 mm Hg without further glaucoma surgery or devastating complication. RESULTS: The median age of the study population was 2.6 years (range, 0.05 to 16 years). The overall success rate was 52.4%, with a median follow-up of 23 months for successful cases. Success rates for patients older than 1 year of age versus those younger than 1 year of age at surgery were 73% and 30%, respectively. Success rates for phakic versus aphakic eyes were 64% and 29%, respectively. Age and lens status, taken together, were significant predictors of outcome (P = .013). Reasons for failure in this study were uncontrolled intraocular pressure (8 cases), persistent wound leak (1 case), and endophthalmitis (1 case); the latter 2 cases required bleb excision. Other complications encountered included chorioretinal detachment, shallow anterior chamber, 5-fluorouracil toxicity, and cataract formation. No irreversible visual deficits could be attributed to the trabeculectomy procedure or subsequent complications in any of these cases. CONCLUSIONS: Mitomycin C-augmented trabeculectomy combined with postoperative suture lysis and 5-fluorouracil is a viable option for older phakic children with refractory glaucoma. This procedure has a lower success rate in infants and in aphakic eyes. Both early and late postoperative complications are common, and diligent lifelong long-term follow-up is needed to detect bleb leaks and infection. The addition of postoperative suture lysis and 5-fluorouracil to mitomycin C-augmented trabeculectomy did not provide any convincing improvement in the success of this procedure in pediatric patients with refractory glaucoma and may have increased the complication rate.

The effectiveness of latanoprost for the treatment of pediatric glaucoma.

PURPOSE: Latanoprost is a prostaglandin F2alpha analogue that substantially reduces intraocular pressure (IOP) in adults with open-angle glaucoma or ocular hypertension. The efficacy and safety of latanoprost in children is unknown. We wished to evaluate latanoprost therapy for children with glaucoma. METHODS: This was a prospective study of all patients who were given latanoprost at our institution between September 1996 and January 1998. The baseline IOP was compared with the postlatanoprost IOP for each patient, and side effects and any iris color change were noted at each follow-up examination. Responders were defined as those who had at least a 15% IOP reduction on latanoprost, whereas nonresponders showed less than a 15% IOP reduction on latanoprost. RESULTS: Fifty-seven eyes of 48 pediatric patients with a variety of glaucoma diagnoses and an average age of 7.1 years were included in the study. Of these, 31 eyes of 31 patients had interpretable IOP data; the mean IOP reduction for this group after the addition of latanoprostwas 0.9% (0.2 mm Hg). Six patients (6 eyes) were responders, with an average IOP reduction of 8.5 mm Hg (34%), whereas the majority of patients (25) were nonresponders. In the responders, there was a good correlation (r = 0.9) between baseline IOP and the magnitude of IOP reduction. Responders were significantly more likely to have juvenile open-angle glaucoma and to be older than nonresponders. Systemic and ocular side effects were infrequent and mild, and no patient had noticeable iris color changes. CONCLUSIONS: When used in a group of pediatric patients with a variety of glaucoma diagnoses and on various therapies, latanoprost is effective in only a minority of cases. In selected patients, however, latanoprost shows an impressive ocular hypotensive effect, comparable with that obtained when this drug is used in adults with open-angle glaucoma. This drug appears to be well tolerated in this short-term study of pediatric patients with glaucoma.

The Ahmed valve in refractory pediatric glaucoma.

PURPOSE: To evaluate the efficacy of the Ahmed Glaucoma Valve implant in pediatric patients with refractory glaucoma. METHODS: A retrospective chart review was conducted of 27 eyes from 23 consecutive pediatric patients (younger than 18 years) with refractory glaucoma treated with Ahmed Glaucoma Valve implant placement. The main outcome measure was time after surgery without failure. Success was defined as an intraocular pressure of 21 mm Hg or less without visually devastating complications or additional glaucoma surgery (exclusive of tube revision). Previous cycloablation, which was present in a subset of eyes, was examined as a possible influence on postoperative intraocular pressure control, glaucoma medication dependence, and surgical success. RESULTS: The median patient age was 4.8 years (range, 0.3 to 16.8 years), with a follow-up of 3 to 31 months (mean, 12.6 +/- 8.2 months). Intraocular pressure was reduced from a preoperative mean of 32.8 +/- 7.5 mm Hg to 16.7 +/- 5.4 mm Hg at 18 months postoperatively, with an overall success rate of 85.2% at last follow-up. Cumulative probabilities of success by Kaplan-Meier analysis were 90.6% at 12 months and 58.3% at 24 months. Compared with those that did not undergo previous cycloablation, eyes that had undergone previous cycloablation had a lower mean postoperative intraocular pressure at 3- and 6-month follow-up (P < .001 and P = .057, respectively) and required fewer glaucoma medications at postoperative examination time points up to 18 months (P < or = .01 at each time point). Fifteen eyes (56%) required glaucoma medications after surgery. The most common complication was corneal-tube contact, which occurred in five eyes (18.5%). One eye with a wound leak required anterior chamber reformation. Retinal detachment occurred in one aphakic eye 2 years postoperatively, resulting in loss of vision. One eye with neovascular glaucoma required enucleation after an enlarging (presumably preexisting) medulloepithelioma was discovered. CONCLUSIONS: Ahmed Glaucoma Valve implantation is a useful therapy for the treatment of refractory pediatric glaucoma, and it may be safely used in a subgroup of eyes with uncontrolled intraocular pressure despite previous cycloablation procedures.

Refractive changes after pediatric intraocular lens implantation.

PURPOSE: To report refractive changes after cataract surgery and intraocular lens implantation in infants and children. METHODS: In an ongoing prospective study, the refractive errors of all patients younger than 18 years undergoing intraocular lens implantation were determined at 6 weeks, 3 months, 6 months, and 1 year, and at least yearly thereafter. All patients with greater than 6 months of follow-up were included in the study. RESULTS: Eighty-three eyes of 81 patients were identified. Cataracts were traumatic in 32 eyes (38%) and developmental in 42 eyes (50%). At implantation, the mean (+/-SD) age was 6.3 +/- 4.6 years (range, 9 months to 17 years). The mean follow-up was 26.6 months (range, 6 months to 6.6 years). Patients 0 to 2 years old at the time of implantation demonstrated a mean myopic shift of -3.00 diopters during a mean follow-up period of 2.5 years. Patients 2 to 6 years old at the time of implantation demonstrated a mean myopic shift of -1.50 diopters in a similar follow-up period. Children aged 6 to 8 years experienced a mean myopic shift of -1.80 diopters during a mean follow-up period of 3.0 years, while children older than 8 years at the time of intraocular lens implantation experienced a mean myopic shift of -0.38 diopters during a mean follow-up period of 1.8 years. On average, the operated-on eye showed a greater mean myopic shift than the fellow eye. No statistically significant differences in refractive change were found in comparing amblyopic to nonamblyopic eyes, traumatic to nontraumatic cataracts, or primary to secondary intraocular lenses. CONCLUSIONS: Our data demonstrate a trend toward increasing postoperative myopia in pediatric patients undergoing intraocular lens implantation. This myopic shift is greatest in the younger age groups and persists until at least 8 years of age. There is much variability in the postoperative refractive changes, and predicting exactly when and where the refraction will stabilize for an individual patient is difficult.

Long-term outcome of cyclocryotherapy for refractory pediatric glaucoma.

OBJECTIVE: To evaluate the success rate and long-term outcome of cyclocryotherapy for refractory pediatric glaucoma. DESIGN: Retrospective interventional case series. PARTICIPANTS: A total of 64 eyes of 49 patients from 2 institutions with pediatric glaucomas resistant to conventional medical and surgical therapies treated with cyclocryotherapy from 1975 to 1996 were included in this review. INTERVENTION: Cyclocryotherapy was performed on eyes with pediatric glaucoma resistant to maximal medical and surgical interventions. Each cyclocryotherapy session was evaluated in terms of area treated, temperature, and number of applications placed. MAIN OUTCOME MEASURES: Criteria for success included intraocular pressure (IOP) of 21 mmHg or less without devastating complications or need for further glaucoma surgery. RESULTS: The mean baseline pretreatment IOP of all eyes was 30.0 +/- 8.1 mmHg. Six months after their last treatment, 42 eyes (66%) were successes. Longer term follow-up (mean, 4.8 +/- 3.3 years) yielded a lower final success rate in 28 eyes (44%). For these 28 eyes, mean IOP was reduced from 30.3 +/- 7.8 mmHg pretreatment to 16.8 +/- 4.0 mmHg after their last cyclocryotherapy treatment session (P < 0.001). The average number of cyclocryotherapy sessions for successful eyes was 4.1 +/- 4.0 (range, 1-17). The mean follow-up time for these successful eyes was 4.9 +/- 3.4 years. Devastating complications attributable to cyclocryotherapy included phthisis (5 eyes) and retinal detachment (5 eyes). Devastating complications occurred more frequently among eyes with aniridia than among all other eyes (nonaniridics) (50% vs. 11%, respectively; P < 0.05). CONCLUSION: Cyclocryotherapy is an effective means of lowering IOP and is a reasonable treatment option in selected pediatric patients with refractory glaucoma. Eyes with aniridia experienced a very high rate of phthisis after cyclocryotherapy and may be poor candidates for this treatment.

Use of latanoprost in the treatment of glaucoma associated with Sturge-Weber syndrome.

PURPOSE: To determine if latanoprost reduces intraocular pressure in eyes with glaucoma associated with Sturge-Weber syndrome. METHODS: We conducted a prospective study in which eyes with uncontrolled intraocular pressure associated with Sturge-Weber syndrome were treated with latanoprost 0.005% once daily. All eyes were already receiving at least two other antiglaucoma medications. Intraocular pressure was measured at baseline and after treatment for at least 1 month. All intraocular pressure measurements were taken within 24 hours of drug instillation. RESULTS: Six eyes of six patients received latanoprost. Two (28%) of the six eyes demonstrated an intraocular pressure decrease that averaged 8.8 mm Hg. These two responders had juvenile onset glaucoma, whereas the four nonresponders had congenital onset glaucoma. CONCLUSIONS: Latanoprost may significantly reduce intraocular pressure in selected patients with glaucoma associated with Sturge-Weber syndrome.

Topical versus oral carbonic anhydrase inhibitor therapy for pediatric glaucoma.

PURPOSE: Our purpose was to compare, in a crossover design,the hypotensive effect of oral acetazolamide (Diamox) and topical dorzolamide (Trusopt) in patients with pediatric glaucoma. METHODS: All patients less than 18 years old who were switched from acetazolamide to dorzolamide without other intervention were reviewed. Intraocular pressures were obtained with either a Tono-Pen (Mentor Ophthalmics, Santa Barbara, Calif.) or applanation tonometer. Minimum follow-up times on acetazolamide and on dorzolamide were 1 month (mean 12.2 +/- 19.7 months) and 2 months (mean 8.2 +/- 5.1 months), respectively. The average dose of acetazolamide was 9.9 +/- 1.8 mg/kg/day. RESULTS: Eleven eyes (11 patients) were included. Indications for crossover from oral to topical carbonic anhydrase inhibitor (CAI) therapy were intolerance to acetazolamide (6 eyes) and surgical intervention in the fellow eye (5 eyes). The mean age at the time of crossover was 7.4 +/- 3.0 years. A comparison of intraocular pressure (IOP) before addition of a CAI was made in 8 eyes. The mean IOP off of a CAI was 27.8 +/- 4.9 mm Hg. The mean 10P was reduced to 18.5 +/- 4.3 mm Hg on acetazolamide (mean percent IOP reduction 35.7% +/- 15.6%, p < 0.01) and to 22.2 +/- 5.4 mm Hg on dorzolamide (mean percent IOP reduction 27.4% +/- 17.1%, p < 0.01). All 11 eyes showed an increase in IOP when switched from acetazolamide to dorzolamide, with a mean increase of 3.7 +/- 2.5 mm Hg (20.2% -/+ 13.7%, p < 0.01). Five eyes have remained controlled on dorzolamide and a topical beta-blocker. Five eyes required further intervention for the control of glaucoma. One eye was switched back to acetazolamide for better IOP control. CONCLUSION: Although not as effective as oral acetazolamide, topical dorzolamide causes a significant IOP reduction in this group of pediatric glaucoma patients and appears to be well tolerated.

Significance of isolated neovascular tufts ("popcorn") in retinopathy of prematurity.

BACKGROUND: The significance of isolated neovascular tufts ("popcorn") occurring in association with stage 2 retinopathy of prematurity (ROP) has not been studied. METHODS: We retrospectively reviewed the clinical courses and outcomes of all patients with zone II, stage 2 ROP with popcorn examined over the past 3 years at one institution. Eyes with zone I disease, plus disease, or stage 3 at the initial appearance of popcorn were excluded. The study group was compared with a control group of patients of similar birth weight and gestational age with zone II, stage 2 ROP without popcorn. RESULTS: Popcorn first appeared at a mean age of 36.4 (+/- 2.2) weeks after conception in 26 patients. Of these, 17 patients (65%) progressed to stage 3, 10 (38%) had plus disease, 6 (23%) reached threshold, and 9 (35%) required laser treatment. Of 19 control patients, 4 (21%) progressed to stage 3, 1 (5%) had plus disease, 1 (5%) reached threshold, and 1 (5%) required laser treatment. The popcorn group had a significantly higher incidence of progression to stage 3 (p < 0.005), plus disease (p < 0.025), and laser treatment (p < 0.025). All eyes of both groups had complete regression of disease. CONCLUSIONS: The presence of popcorn significantly increases the risk that an eye with zone II, stage 2 ROP will progress to stage 3, develop plus disease, and require laser treatment. Patients with popcorn and coexistent mild vascular dilation or tortuosity insufficient for plus disease are at particularly high risk for disease progression.

Transscleral diode laser cyclophotocoagulation for refractory pediatric glaucomas.

PURPOSE: To evaluate the success of contact transscleral cyclophotocoagulation (TDC) in patients with refractory pediatric glaucomas. METHODS: Twenty-six eyes of 20 patients with therapy-resistant pediatric glaucomas were included in this retrospective study. Subgroup analysis was performed for patients 10 or younger and patients older than 10 at time of first TDC procedure. Diode laser cyclophotocoagulation was applied using a fiber optic G-probe. Follow up until time of failure or for a minimum of 6 months was obtained for all procedures in all eyes. Failure was defined as intraocular pressure (IOP) greater than 21 mm Hg, repeat of TDC due to clinically inadequate IOP control, progression to another procedure, or serious complication. RESULTS: Baseline mean pretreatment IOP was 34.2 +/- 10.4 mm Hg (range, 15 to 62 mm Hg). Ten of 26 eyes (38%) were successful 6 months after initial TDC. A mean decrease in IOP of 10.3 +/- 14.7 mm Hg was noted after the first procedure (P < 0.05). Eighteen eyes (70%) were retreated at least once. The mean decrease in IOP for all patients after all procedures was 12.9 +/- 13.4 mm Hg (P < 0.001). This represents a mean percent decrease in IOP of 33.2 +/- 6.9%. The overall success rate was 50%, including retreated patients. The younger and older subgroups did not differ with regard to overall success, time to failure, or retreatment rats. One patient suffered a retinal detachment. Visual loss was noted in 4 of 22 eyes with reliable visual acuity measurements. CONCLUSION: TDC is an effective means of decreasing IOP in some patients with refractory pediatric glaucomas. Although the retreatment rate is high, the procedure generally is well tolerated with few complications.

Observer sensitivity to retinal vessel diameter and tortuosity in retinopathy of prematurity: a model system.

BACKGROUND: Abnormally increased diameter and tortuosity of retinal blood vessels in the posterior pole, or "plus disease," is recognized as a powerful predictor of poor outcome in eyes with retinopathy of prematurity (ROP). Although the diagnosis of plus disease depends upon the examiner's ability to examine retinal blood vessels, the ability of the human observer to identify changes in retinal blood vessel diameter and tortuosity accurately has not been studied. METHODS: Using computer-aided analysis of fundus photographs from eyes with a wide range of ROP severity, we generated tracings of posterior pole blood vessels which varied by quintiles of mean vessel diameter and tortuosity. Subjects (23 naive and 12 expert observers) ranked groups of tracings in order of increasing mean vessel diameter and tortuosity. These ranking tests were performed on tracings derived from the same fundus and tracings derived from distinct fundi. In a similar fashion, subjects also compared one designated standard fundus tracing with 25 distinct fundus tracings. RESULTS: Vessel diameter was assessed correctly more often than vessel tortuosity, both among similar (> 99% vs 92% of the time, respectively, P < 0.001), or among distinct (88% vs 78% of the time, respectively, P < 0.001) fundus images. The mean vessel diameter and tortuosity of 25 distinct fundus images were correctly ranked versus a standard image in 89% of attempts. Assessments of increments in vessel diameter and tortuosity were independent. Naive and expert subjects performed indistinguishably on all tests. CONCLUSIONS: Intelligent human observers have considerable ability to discern clinically relevant increments in blood vessel diameter and tortuosity. This ability may facilitate standardization in the diagnosis of plus disease in ROP.

Clinical course and systemic correlates of retinopathy of prematurity in quintuplets.

PURPOSE/METHODS: We studied clinical correlates of retinopathy of prematurity in four surviving quintuplets with similar low birth weights and gestational age of 27 weeks. Prospective serial ophthalmoscopic examinations and retrospective chart analysis were used. RESULTS/CONCLUSIONS: Retinopathy of prematurity varied among the neonates from stage 2 with total regression to threshold progressing to retinal detachment. Severity of eye disease correlated with duration of mechanical ventilation and of parenteral nutrition, as well as frequency of hypoglycemia and of hypercapnia. Poor outcome correlated inversely with weight gain.

A numeric index based on spatial frequency for the tortuosity of retinal vessels and its application to plus disease in retinopathy of prematurity.

BACKGROUND: In retinopathy of prematurity (ROP), tortuosity of vessels near the posterior pole of the fundus is an important clinical sign, yet clinicians have difficulty estimating how tortuous the vessels are. METHODS: The authors have devised an objective, numeric index of retinal blood vessel tortuosity that is especially sensitive to the structural changes in vessels that occur in ROP, but it is not particularly sensitive to non-ROP changes. Computer software is used to calculate the index from fundus images; the quality of these images is typical of photographs or video-cassette frames that the authors record in the premature nursery. RESULTS: The index reliably segregates tortuous vessels from nontortuous ones and separates eyes that reach ROP treatment threshold from eyes that do not. CONCLUSIONS: The index forms an objective measure of the ROP disease state. Its calculation requires only segments of vessels and thus, is potentially adaptable to imaging systems that automatically extract vessel portions from fundus images.