The effect of masking manuscripts for the peer-review process of an ophthalmic journal.

BACKGROUND/AIM: To investigate the effect of masking the author's identity to peer reviewers on reviewer bias in an ophthalmic subspecialty journal. DESIGN: A retrospective study of 531 manuscripts, involving 1182 masked reviews, submitted to Journal of American Association for Pediatric Ophthalmology and Strabismus from 2000 to 2005. METHODS: Data were extracted from recommendation forms completed by each referee during review. Investigated variables consisted of reviewer's knowledge of author identity, recommendation (accept, revise, or reject publishing), eventual manuscript status (published or not), review quality, gender, country, medical practice setting (academic or private) and editorial board status. RESULTS: This study involved the largest number of manuscripts ever used to evaluate the importance of author masking. Reviewer's knowledge of the author's identity had no effect on review quality. However, proportionally fewer manuscripts were published when there was no idea of the author's identity, compared with when it was allegedly known or suspected (p<0.0001). Manuscripts had lower recommendation scores when there was no idea of the author's identity compared with when allegedly known (p = 0.0001) or suspected (p = 0.004). CONCLUSION: Reviewers were more favourable when they allegedly knew or suspected the author's identity. Double-masking may improve the quality of biomedical publishing or at least reduce reviewer bias for effectively masked manuscripts.

Drift of ocular alignment following strabismus surgery. Part 1: using fixed scleral sutures.

AIMS: To evaluate the postoperative alignment drift following traditional strabismus surgery utilizing direct attachment of muscle to sclera. METHODS: The ocular alignment drift (change from the first postoperative week) of 106 patients who underwent scleral fixation strabismus surgery at age 0.5 to 35 years with 5 years' maximal follow-up was analysed. RESULTS: There was a mean undercorrection drift of 4.6 (SD 8.9) prism dioptres (PD) at distance fixation (p = 0.025) and 3.4 (7.6) PD at near (p = 0.053) for all subjects, and 11.3 (8.6) PD distance (p = 0.008) and 10.6 (6.0) PD near (p = 0.016) for exotropic patients. Recession surgery produced an undercorrection drift of 5.3 (8.8) PD (p = 0.021) at distance fixation. Esotropic patients and those undergoing unilateral recession/resection surgery had no significant drift. Patients overcorrected at the 1-week postoperative visit later developed an undercorrection drift at distance (10.3 (7.9) PD, p = 0.002) and near fixation (5.5 (9.2) PD at 36 months, p = 0.041), while undercorrected patients showed no significant drift and largely stayed undercorrected. CONCLUSION: Fixed scleral-suture strabismus surgery generally produces a postoperative undercorrection drift, especially following recession surgery, exotropia or overcorrection at the first postoperative week.

Drift of ocular alignment following strabismus surgery. Part 2: using adjustable sutures.

AIM: To measure the drift of ocular alignment following strabismus surgery utilising adjustable sutures. METHODS: 106 patients, aged 12 to 84 years, underwent adjustable suture strabismus surgery with a follow-up of 0.5-4 years (mean 24.3 months). RESULTS: For all subjects measured on distant fixation, there was a mean undercorrection drift of 8.3 (SD 2.3) prism dioptres (PD) from week 1 to 48 months postoperatively (p = 0.005). Patients with exotropia demonstrated an undercorrection drift on distant fixation from week 1 to 2 years (mean 10.1 (3.5) PD, p = 0.023). Patients who underwent recession surgery developed a mean 9.1 (3.3) PD undercorrection drift from week 1 to 3 years (p = 0.031). Patients who had unilateral recession and resection surgery showed a mean 6.8 (2.9) PD undercorrection drift from week 1 to 18 months (p = 0.049). Patients with constant or intermittent postoperative stereopsis had a statistically significant undercorrection drift (

A double application approach to ophthalmia neonatorum prophylaxis.

AIMS: To investigate if a second drop of 2.5% povidone-iodine ophthalmic solution placed within the first postnatal day would achieve better prophylaxis against ophthalmia neonatorum than a single drop applied at birth. METHODS: A masked, prospective, controlled trial was conducted over a 2 year period in a Kenyan hospital. Randomisation was achieved by alternating weeks of one or two eye drop application to both eyes. All 719 neonates received one drop of the povidone-iodine solution to both eyes at birth, while 317 received a second drop at hospital discharge or 24 (SD 4) hours after delivery, whichever was first. All infants developing conjunctivitis within a month after birth underwent microbiological analysis using Gram and Giemsa stains, direct fluorescent antibody assay for Chlamydia trachomatis, and culture. RESULTS: Of the neonates receiving the one eye drop application, 18.4% returned with a red eye with discharge, 4.0% had organisms found on the initial smear, and 8.2% had a positive culture. The corresponding proportions for the multidrop group were 24.3%, 4.7%, and 10.4%. Of those returning with an inflamed eye, there were no cases of Neisseria gonorrhoeae, 4.2% in the single dose group and 3.9% in the double dose group were positive for C trachomatis, and 5.4% and 6.5% respectively for Staphylococcus aureus. At discharge, the eyelid oedema score of the double dose group was mildly greater than the single dose group (1.4 (0.67) v 1.2 (0.73), p=0.0002). There was no statistically significant difference between the groups in any other category. CONCLUSION: There is no advantage to administering povidone-iodine prophylaxis against ophthalmia neonatorum twice in the first postnatal day over a single application at birth.

Ocular applications of povidone-iodine.

Ocular infections can have devastating consequences and may lead to blindness. Povidone-iodine (PVP-I) has many potential advantages over the currently used drugs, including a broader antibacterial spectrum, it turns the surface of the eye brown for a few minutes, bacterial resistance has not been seen and it is cheaper than other agents. PVP-I has made a significant contribution to pre- and postoperative ocular surgical prophylaxis, ophthalmia neonatorum prophylaxis and treatment of bacterial conjunctivitis. Scientific support for these applications includes studies conducted over the past 17 years, which are reviewed.

Atropine and bifocals can slow the progression of myopia in children.

BACKGROUND: Atropine 1% ophthalmic solution has been used to retard progression of simple childhood myopia. Problems have been identified in previous studies, including possible observer bias. To address this issue, we evaluated our experience including the duration that atropine maintains a child at 20/30 or better in one spectacle correction compared with controls. METHODS: Fifteen myopic children who received daily atropine 1% ophthalmic solution bilaterally for a mean of 29.3 months (range 3-96) were compared to a control group of 15 unrelated similar myopic patients. The progression of myopia, change of glasses, patient demographics, and any side effects or complaints were recorded. RESULTS: The mean annual myopic progression in the atropine group was 0.05 diopters (D) (+/-0.67) and in the control group 0.84 D (+/-0.26)(P=0.00021). The number of months that vision remained 20/30 or better using the same pair of glasses was 25.1 (+/-19.3) for the atropine group and 13.5 (+/-10.3) for the control group (P=0.049). Mean followup time was 29 months for the atropine group and 42.6 months for the control group. There were no statistical differences between the two groups regarding sex, age, or age at first glasses. CONCLUSIONS: Atropine ophthalmic solution nearly halted myopic progression in this investigation. Patients on atropine remained 20/30 or better with a single pair of glasses significantly longer than the control group. While a larger and better controlled study is desirable, atropine appears to be a viable method to retard myopic progression.

Timing of postoperative adjustment in adjustable suture strabismus surgery.

PURPOSE: The use of adjustable sutures in strabismus surgery has increased the rate of surgical success. Little data are available on the optimum timing for postoperative adjustment after strabismus surgery. We wanted to compare 2 common practices of adjustable suture technique after strabismus surgery. METHODS: Two comparable groups of 40 patients each, who had strabismus surgery with adjustable suture technique, were prospectively studied. Group A had early adjustment the same day of the surgery about 6 hours after the operation, and group B had late adjustment the next day about 24 hours after the operation. Subjective scoring tables were used to evaluate the pain felt by the patient before, during, and after the adjustment and any difficulties of the adjustment process. Requirements of postoperative pain medications and final alignment 6 weeks after surgery were also compared. RESULTS: Despite adequate statistical power, no significant differences were found between the groups regarding pain before, during, and after adjustment, difficulties performing the adjustment, and final alignment after 6 weeks (P > .05). Both adjustment schedules were equally associated with mild to moderate pain before, during, and after the adjustment. In the first 24 hours after surgery, no overall difference in the use of pain medications was found. Nausea and vomiting in the first 24 postoperative hours were more common in the early adjustment group (P = .02). CONCLUSION: The surgeon can feel free to choose the timing for postoperative adjustment. However, when performing an early adjustment, the surgeon should be especially prepared to control nausea and vomiting.

Use of the HARK autorefractor in children.

PURPOSE: We investigated the reliability, accuracy, and repeatability of an autorefractor with the capability of over-refracting and measuring visual acuity for use in children in a prospective study. METHODS: Before and after cycloplegia, 68 children (mean +/- SD age, 10 +/- 3 years, range 5-16 years) underwent autorefraction twice with the HARK 599 Autorefractor (Humphrey Instruments Inc., San Leandro, CA), subjective over-refraction through the HARK autorefractor, and subjective refraction using a phoro-optometer. After cycloplegia, retinoscopy was performed. Results are reported for one eye (left) of each child. RESULTS: For 68 eyes of 68 children, before and after cycloplegia, correlation coefficients (R) for autorefraction reproducibility exceeded 0.95 for all comparisons of sphere and cylinder. R for spherical values for autorefraction vs. over-refraction was 0.93 and vs. subjective refraction 0.83 before cycloplegia and 0.94 and 0.97 after cycloplegia. Comparing values before and after cycloplegia, autorefraction, over-refraction, and subjective refraction, the data correlated > 0.81 for sphere and 0.75 to 0.87 for cylinder. Cycloplegic retinoscopy compared with autorefraction, over-refraction, and subjective refraction had R > 0.86 for sphere and cylinder for all comparisons except one. Cycloplegia increased the proportion of spherical equivalent values within 0.625 D of the subjective refraction from 41 of 68 eyes (61%) for auto- and over-refraction to 64 (94%) and 51 (75%) of the 68 eyes, respectively. A visual acuity of 20/30 or better was produced in 50 of 68 (73%) eyes with automated refraction before and after cycloplegia and in 62 (92%) with subjective refraction before cycloplegia and subjective refraction and retinoscopy after cycloplegia. Subjective over-refraction did not significantly improve the visual acuity. CONCLUSIONS: In children, HARK autorefraction improved in accuracy, when compared to subjective refraction, and the level of visual acuity improved after cycloplegia. Over-refraction through the instrument did not improve the results before or after cycloplegia.

Vertical strabismus in monofixation syndrome.

PURPOSE: The manifest angle of the horizontal deviation in monofixation syndrome (MFS) has been reported to reach a maximum of 8 to 10 PD. Review of the literature, however, revealed no studies about the vertical deviation associated with MFS. The purpose of this study is to evaluate the range of the angle of the vertical deviation in MFS. METHODS: Forty patients who had MFS with vertical strabismus in the distance primary position were included in this study. All fulfilled the criteria for monofixation, fusing Worth 4 dots at near but suppressing at distance and/or having stereoacuity between 3000 and 60 seconds of arc by using Titmus stereotest and a horizontal deviation within 8 PD of orthophoria by simultaneous prism and cover test. Patients were divided into 3 groups: patients with hypertropia without any dissociated vertical deviation (DVD) (group I), patients with only DVD (group II), and patients with both hypertropia and DVD (group III). RESULTS: Eighteen patients (45.0%) had hypertropia only (group I), 15 (37.5%) had DVD only (group II), and 7 (17.5%) had both (group III). In groups I and III the angle of hypertropia by simultaneous prism and cover test was 2 to 6 PD (mean, 3.9 PD) and in group II and III the angle of DVD was 4 to 14 PD (mean, 7.5 PD) at distance. CONCLUSIONS: These results suggest that in MFS the angle of hypertropia can range up to a maximum of 6 PD. However, monofixation was observed in patients with a larger absolute angle of DVD (up to 14 PD), possibly due to an intermittent nature of the DVD.

The range of ocular movements decreases with aging.

PURPOSE: To determine whether normal maximum versions change as a function of age. METHODS: One hundred twenty-four healthy subjects without any history of strabismus, ocular or periocular surgery, or major illness were examined to confirm visual acuity better than 20/60 in each eye and the absence of strabismus. Maximum sustained elevation, depression, dextroversion, and levoversion were quantified by using a standardized lateral version light-reflex (LVR) test. RESULTS: Subjects ranged in age from 23 to 84 years. All LVR measurements were converted into degrees of eye rotation assuming standard globe size. For each maximal gaze position, the regression line (whether determined directly or scaled against historical normal values) was formed by plotting the LVR measurements versus age had a negative slope significantly different than zero (P =.0001 for all). Depression had a significantly smaller decrease in LVR measurement with age (-0.5% per year) than elevation (-1% per year, P = .0001), adduction (-0.8% per year, P = .0001), or abduction (-0.7% per year, P = .0017). Elevation had the largest decrease in LVR measurement with age compared with depression and abduction (P = .003). CONCLUSION: As measured by LVR, the maximum versions into extremes of gaze decrease by an average of 0.5% to 1.0% per year of life between the third and ninth decade. The version least affected and most affected by age is depression and elevation, respectively. Age should be considered when assessing versions for evidence of rectus muscle overaction and underaction.

Ocular involvement in patients with posttransplant lymphoproliferative disorder.

OBJECTIVES: To describe ocular disease in 3 patients with posttransplant lymphoproliferative disorder (PTLD) and to identify the frequency of such ocular involvement. METHODS: Medical record reviews. Using Kaplan-Meier analysis, we calculated the frequency of ocular involvement among pediatric patients with systemic PTLD after liver transplantation. RESULTS: Each patient had bilateral anterior chamber cells. Biopsy of an iris nodule from a patient who had undergone cardiac transplantation confirmed the diagnosis of PTLD, but no signs of systemic PTLD were found. The other 2 patients had systemic PTLD after liver transplantation; 1 presented with iris nodules in both eyes and a subretinal mass in the left eye, while the other had bilateral anterior chamber cells only. Ocular signs improved slowly after reduction of immunosuppressive drug therapy. Ophthalmological examinations were performed on 22 of 25 pediatric patients with PTLD after liver transplantation; 2 had ocular disease. Kaplan-Meier analysis indicated a 20% risk of ocular involvement at 3 years after development of PTLD (95% confidence intervals, 0%-50%). CONCLUSIONS: Posttransplant lymphoproliferative disorder should be considered in the differential diagnosis of uveitis after organ transplantation. Anterior chamber cells and iris nodules are the most common ocular signs, but the posterior segment can be involved. Ocular involvement can occur without evidence of systemic disease and can be asymptomatic. Reduction of immunosuppressive drug therapy is an appropriate treatment.

Posterior fixation sutures: a revised mechanical explanation for the fadenoperation based on rectus extraocular muscle pulleys.

PURPOSE: To determine the effect of the rectus extraocular muscle pulleys on the fadenoperation, an operation designed to fixate the posterior muscle belly to the underlying retroequatorial sclera. METHODS: First, duction into the field of action of the operated-on muscle was quantified retrospectively after fadenoperation. Magnetic resonance imaging was then performed prospectively after surgery to verify anatomic changes. Forced duction testing was performed prospectively during surgery before and after faden placement. Finally, computed tomography in a cadaver containing radiographic markers was performed prospectively to determine the effect of fadenoperation on the position of the medial rectus insertion relative to its pulley. RESULTS: Mean maximum adduction after medial rectus fadenoperation was 18 degrees (range, 10 to 25 degrees; 13 eyes). Fadenoperations combined with large medial rectus recessions restricted adduction more than fadenoperations combined with smaller recessions (P = .019), but even fadenoperations without recessions substantially restricted adduction. Mean maximum abduction after lateral rectus fadenoperation was 40 degrees (range, 25 to 45 degrees; four eyes). Axial magnetic resonance imaging in two eyes demonstrated a smaller loss of muscle tangency to the globe during contraction than predicted by geometric models. Forced ductions in nine patients performed immediately after faden placement demonstrated a new mechanical restriction to duction toward the operated-on muscle. Cadaveric computed tomographic scans demonstrated posterior displacement of the medial rectus pulley during adduction after fadenoperation. CONCLUSIONS: Posterior fixation sutures do not significantly decrease muscle torque during contraction. Because posterior fixation sutures posteriorly displace the pulley sleeve during duction toward the operated-on muscle, the mechanical restriction after surgery probably represents the force deforming the pulley. This mechanical restriction may account for the limitation in duction seen after fadenoperation.

A comparison of sutures for adjustable strabismus surgery.

BACKGROUND: The adjustable suture technique after strabismus surgery may be more easily performed if the sutures offered minimal resistance during the procedure as desired by the surgeon. METHODS: In a rabbit model, 3 different types of 6-0 absorbable sutures-Biosorb-C (polyglycolic acid with polycaprolate coating, Alcon Surgical), coated Vicryl (polyglactin 910 coated with polyglactin 370 and calcium stearate, Ethicon), and Dexon-"S" (polyglycolic acid, Davis and Geck)-were advanced through scleral tunnels when attached and not attached to extraocular muscles. Resistance was measured with a precise strain gauge accurate to 0.1 g with an intrinsic microprocessor. RESULTS: For unattached advancements, Biosorb-C offered significantly less resistance than Vicryl at 6 and 24 hours after operation (P < .02), whereas Dexon-"S" offered less resistance than Vicryl only at 24 hours (P = .001). At 6 hours, Biosorb-C sutures were marginally more slipperythan Dexon-"S" (P= .07). For sutures attached to extraocular muscles at 6 hours after surgery, the 3 sutures offered similar resistance. By 24 hours after the initial procedure, Vicryl presented significantly more resistance than either Biosorb-C or Dexon-"S" (P< .01 for both). For all comparisons of 6 versus 24 hours after surgery, the only significant increase in resistance were Vicryl sutures attached to muscles (P= .02). CONCLUSIONS: These data support the use of Biosorb-C and Dexon-"S" for the adjustable suture technique whether adjusted at 6 or 24 hours after the initial procedure, although Biosorb-C may be slightly easier to adjust at 6 hours. If Vicryl is used, it would be easier to adjust the muscle 6 hours after surgery rather than after 24 hours.

A randomized clinical trial of the nonsteroidal eyedrop diclofenac after strabismus surgery.

OBJECTIVE: This study aimed to compare the anti-inflammatory and analgesic effects of topical diclofenac sodium 0.1% (Voltaren) with prednisolone sodium phosphate 1% ophthalmic solution after strabismus surgery. DESIGN: A prospective, double-masked, randomized, two-center clinical trial. PARTICIPANTS: Eighty eyes of 52 patients undergoing strabismus surgery were examined. INTERVENTION: For 1 week after surgery, the eye that was operated on received one drop of either diclofenac or prednisolone four times a day. MAIN OUTCOME MEASURES: The diclofenac- and prednisolone-treated eyes were compared on postoperative days 3 and 7 with respect to signs of inflammation (e.g., erythema, edema, discharge), patient comfort, and conjunctival incisional healing. RESULTS: On postoperative day 7, in eyes that received prednisolone, the conjunctival defects were larger (P = 0.004) and more frequent (P = 0.02). For all subjects, despite adequate statistical power, there was no statistically significant difference in inflammatory scores between eyes that received diclofenac or prednisolone. In cases of bilateral surgery, however, there was less postoperative erythema and edema in the diclofenac-treated eyes. CONCLUSIONS: In the first week after strabismus surgery, topical diclofenac proved at least as effective as prednisolone in controlling inflammation and discomfort with less delay in incisional wound healing. Topical diclofenac, a nonsteroidal anti-inflammatory agent, may be considered for use after strabismus surgery in place of corticosteroids.

Development of tearing in preterm and term neonates.

BACKGROUND: Although term and preterm infants have the capacity to secrete tears, the relative contribution of basal and reflex secretion of tears has not been previously assessed together in a prospective study. This information potentially has practical clinical importance. OBJECTIVES: To measure basal and reflex tear secretion in preterm (30-37 weeks after conception) and term (38-42 weeks) newborns and to determine the developmental pattern of tear production. METHODS: Tear secretion was evaluated by applying Schirmer tear test strips to the inferior fornix for 5 minutes before (reflex plus basal secretion) and after (basal secretion) applying a topical anesthetic agent. RESULTS: Seventy infants (36 preterm and 34 term) were tested. Mean (+/- SD) basal tear secretion was 6.2 (+/- 4.5) mm in preterm and 9.2 (+/- 4.3) mm in term infants and increased progressively with increasing weight (P<.001) for all newborns. Mean (+/- SD) reflex tear secretion was 7.4 (+/- 4.8) mm in preterm and 13.2 (+/- 6.5) mm in term infants and also increased with increasing weight (P<.001) for all newborns. CONCLUSIONS: Preterm infants have reduced reflex and basal tear secretion. This may mask the diagnosis of a nasolacrimal duct obstruction, concentrate topically applied medications, and allow corneas to quickly become dry during ophthalmological examination and treatment. By term, tear production in newborns is similar to that in adults.

The paralimbal approach with deferred conjunctival closure for adjustable strabismus surgery.

Interest in the adjustable suture technique was renewed in the mid-1970s. The authors report a new modification of the fornix and limbal conjunctival approaches that combines the advantages of both. A paralimbal conjunctival incision is placed halfway between the limbus and the muscle insertion and directed parallel to the muscle insertion. This approach permits easy access to the rectus muscle. After the adjustable suture is temporarily secured with a bow-tie knot, the conjunctiva is partially closed using a loop suture over the muscle suture. An optional modification is the use of a "sweep suture" to break early adhesions at the time of adjustment. The adjustment procedure is performed at least 6 hours after the surgery. The conjunctiva is retracted as necessary for access to the muscle suture. If a sweep suture is used, this is first withdrawn before attempting any adjustment. After adjustment, the conjunctival loop suture is closed, covering the muscle suture. The sweep suture serves as a safeguard for what may otherwise be a difficult adjustment. This approach increases patient comfort after the surgery.

Efficacy of topical povidone-iodine during the first week after ophthalmic surgery.

PURPOSE: In the first postoperative day, povidone-iodine ophthalmic solution prevents an increase in conjunctival bacterial colony-forming units and decreases the species compared with antibiotic. We sought to determine whether these beneficial effects of povidone-iodine could be sustained during the first postoperative week. METHODS: In 42 eyes of 35 consecutive patients, one or two drops of either a broad-spectrum antibiotic (polymyxin B sulfate-neomycin sulfate-gramicidin) or povidone-iodine 1.25% to 2.5% were placed in the treated eye or eyes at the conclusion of surgery and three times daily during the first postoperative week. Bacterial cultures were taken from both eyes at the end of surgery before instillation of either of the eyedrops and again 1 week later. Twenty-eight untreated eyes served as a control group. RESULTS: During the first postoperative week, the number of colony-forming units and species increased in both treatment groups. Relative to the control group, both medications effectively reduced the mean number of colony-forming units at 1 week (P < .02), but their effects on colony-forming units did not significantly differ from each other (80 +/- 290 for the povidone-iodine-treated eyes and 75 +/- 90 for the antibiotic-treated eyes). At 1 week, the species count increased 281% in the antibiotic group but only 106% in the povidone-iodine group. Compared to the control group, eyes that received povidone-iodine had a significantly lower species count (P = .0097). CONCLUSION: Povidone-iodine ophthalmic solution is an alternative to postoperative topical antibiotics because of its effectiveness in controlling conjunctival bacterial colony-forming units and species, its relatively low cost, and its availability.

Ultrasonographically guided injection of corticosteroids for the treatment of retroseptal capillary hemangiomas in infants.

PURPOSE: Injection of corticosteroids is a well-documented and successful mode of treatment for periorbital capillary hemangiomas. Because of the greater potential risk involved with retrobulbar injections, no prior study has described this treatment for tumors located behind the orbital septum. Although retroseptal intraorbital capillary hemangiomas comprise only 7% of all adnexal capillary hemangiomas, complications such as optic nerve compression or astigmatism may necessitate treatment. METHODS: Three patients with deep orbital hemangiomas that caused vision-threatening complications were treated with intralesional injections of triamcinolone and betamethasone. Orbital injection was performed with use of real-time ultrasonographic guidance of the needle. This technique was valuable in providing continuous, accurate, and safe advancement of the needletip in the orbit to avoid the globe and orbital walls. Ultrasonography also permitted precise placement of the needle tip within the tumor and visualization of the injected material. RESULTS: Significant improvement was demonstrated in all cases on the basis of both ultrasonographic measurements and regression of clinical manifestations such as astigmatism, chemosis, proptosis, and optic nerve pallor. No complications were noted. CONCLUSION: Intralesional injection of corticosteroids to treat retroseptal and retrobulbar capillary hemangiomas was found to be a safe and effective treatment modality in our patients. Positioning of the injecting needle was guided by ultrasonography.