Poverty predicts amblyopia treatment failure.

OBJECTIVE: Clinical impressions suggested a hypothesis that poverty is associated with poorer results in amblyopia therapy. To test this hypothesis, we compared patients with amblyopia who had Medicaid assistance with those who did not. METHODS: Of 1272 patients recorded to have amblyopia in the eye center computer, 280 met inclusion criteria of first visit under age 10 years and had treatment instituted and visual acuities recorded then and at follow-up visits. Seventy-one had Medicaid assistance, and 209 did not. Age at first visit, age at final visit, severity of amblyopia as measured by visual acuity at the first visit, and number of visits were all statistically indistinguishable. A large difference in final visual acuity, number of missed visits, and the parent's estimate of compliance was found. RESULTS: The likelihood of good final visual acuity of 20/30 or better was 26.8% in the Medicaid group and 58% in the non-Medicaid group. The likelihood of a poor final visual acuity of 20/70 or worse was 33.8% in the Medicaid group versus 11.5% in the non-Medicaid group. CONCLUSION: These results established socioeconomic status, measured by qualification for Medicaid assistance, to be an important predictor for success for amblyopia therapy. Work is in progress to better understand more specific factors and to meet the therapeutic challenge of amblyopia therapy for children.

Botulinum treatment of childhood strabismus.

Four hundred thirteen children ranging in age from 2 months to 12 years were treated for strabismus by botulinum injection of extraocular muscles. An average of 1.7 injections per patient was given. Follow-up at an average of 26 months after the last injection (minimum, 6 months) was available on 362 children (88%). The frequency of correction of 10 prism diopters (PD) or less in various groups of strabismus cases was: all 362 cases, 61%; all esotropia, 66%; infantile esotropia, 65%; and exotropia, 45%. Smaller deviations (10-20 PD) were more frequently corrected (73%) than were larger deviations (20-110 PD, 54%). The frequency of correction to 10 PD or less of previously operated cases was not different from that of unoperated cases. There was no globe perforation, amblyopia, or visual loss produced by the injection treatment in this series.

The role of the office assistant or operating room nurse in botulinum injection as an alternative to strabismus surgery.

Botulinum injection of eye muscles as an alternative to strabismus surgery can be performed in young children with low dose ketamine sedation, or reassurance without sedation for older children. The OR nurse or office assistant should provide a calm, restful environment rapport with the patient prior to surgery, a connection with her voice through the procedure and rapid reunion of the child and parent in a restful environment. If a child over 6 years is unable to cooperate with the office procedure, it quickly abandoned and it is done in the operating room under sedation.

Side effects of the use of botulinum toxin for treatment of benign essential blepharospasm and hemifacial spasm.

From April 1983 to April 1988, 381 botulinum toxin injections for lid spasms were administered to 106 patients. Sixty-nine had bilateral blepharospasm and 37 had hemifacial spasm. Of the 381 injections, 308 had been given to patients who returned for follow-up examinations. No systemic effects were noted at any of these visits; all side effects were temporary; there were no serious complications. Ptosis, the most frequently encountered problem, occurred after 26 (8.4%) of the injections. Other complications included: corneal exposure (after eight injections, 2.59%); face droop (after 11 injections, 3.57%); diplopia (after five injections, 1.62%); and subtle visual blurring (after eight injections, 2.59%). One patient noted jaw tenseness, another mentioned tearing, one reported brow droop, and another complained of crossed eyes. Ten injections had minimal effect; in these cases a repeat injection usually was effective. Only four patients chose surgery after beginning injections. We conclude that botulinum toxin injections are a safe, effective means of treating lid spasms.

Chemodenervation of strabismic children. A 2- to 5-year follow-up study compared with shorter follow-up.

To determine longer-term efficacy of botulinum treatment, the author examined 85 children younger than 14 years of age who had been treated from November 1982 to February 1984, comparing shorter follow-up (range, 6-24 months) with longer follow-up (range, 2-5.5 years) as of last examination before March 1988. Fifty esotropes meeting the 2-year criteria for follow-up had an average of 35 prism diopters (PD) before and 5 PD after treatment. Twelve exotropes averaged 30 and 5 PD. No long-term complications were discovered. The results are similar to the shorter follow-up and suggest that botulinum is effective in creating a 2- to 5-year stable improvement for strabismic children.

Botulinum toxin chemodenervation in infants and children: an alternative to incisional strabismus surgery.

Eighty-two children aged 13 years or younger were given injections of botulinum toxin for horizontal strabismus. Improvement was achieved in all but one patient. Children younger than 1 year or older than 6 years of age received only topical drop anesthesia and no sedation. Young children generally required low-dose ketamine sedation. The technique typically undercorrects, so reinjection was necessary in 85% of the patients. There were no systemic complications. Side effects, lasting up to a few weeks, included transient ptosis and hypertropia caused by involvement of other extraocular muscles.

Botulinum toxin chemo-denervation for strabismus in infants and children.

Fifteen children and five infants with short follow-up show chemo-denervation with botulinum toxin to be a safe and effective alternative to surgery.

Recurrent isolated sixth nerve palsy in children.

Six children had recurrent sixth nerve palsy the average duration of which was six weeks. One youngster, after several episodes of sixth nerve palsy, had residual esotropia and underwent strabismus surgery. The average interval between recurrences was 1.3 years. Ipsilateral recurrences were a prominent feature. Thus far the recurrences of palsy in this group of patients has not been associated with any identifiable intracranial process. Multiple recurrences in the absence of any recognizable febrile illness clearly suggests that not all "benign" sixth nerve palsies in children are due to postinfectious processes. The etiology of isolated benign sixth nerve palsy remains uncertain. Benign sixth nerve palsy with recurrence may account for a larger percentage of truly "isolated" palsies in otherwise healthy youngsters than has been generally appreciated since several widely quoted papers on this subject have included individuals with multiple neurologic deficits at the time of initial presentation. This report of recurrent palsies for which etiologies were not established should not diminish the concern that there might be an identifiable, serious, cause for sudden onset of sixth nerve palsy in a youngster. The diagnosis of "benign" sixth nerve palsy is one of exclusion that is made retrospectively and only after an adequate period of close observation.

Clinical and subclinical oculomotor findings in the Eaton-Lambert syndrome.

Five patients with the Eaton-Lambert syndrome were examined neuro-ophthalmologically. Three were studied using electro-oculographic saccadic velocity recordings. Four complained of blurred vision and all complained of ptosis during the course of their disease. Clinical examination revealed mild ptosis in three of the five patients. Saccadic velocities before exercise were normal. After saccadic exercise, an increase in velocity of up to 40% was noted in two of the three patients studied.

Diagnostic injection of Xylocaine into extraocular muscles.

In situations where it is unclear which extraocular muscle is causing anomalous eye movement or to what extent one of two muscles is responsible, temporary paralysis of the muscle with Xylocaine may provide the answer. The procedure is to inject 0.2 to 0.5 cc 2% Xylocaine directly into the muscle using electromyography (EMG) for precise localization, a technique similar to that of therapeutic injections of botulinum toxin (Oculinum). The procedure is especially useful for Duane's syndrome, superior oblique palsy, and other situations where abnormal muscle insertions or innervations make diagnosis of the muscle responsible for an eye movement anomaly difficult and surgery unpredictable.

Dissociated vertical deviation: an asymmetric condition treated with large bilateral superior rectus recession.

Bilateral superior rectus recessions were performed on 25 patients for dissociated vertical deviation (DVD). Large recessions (at least 10 mm from the original insertion) have proved effective and safe, although all patients were slightly undercorrected. There were no complications of ptosis, upper lid retraction, alterations of palpebral fissure width, failure of upgaze, oblique dysfunction or overcorrection. The DVD was always asymmetric, with the greater deviation in the non-dominant eye. Forty percent of the patients had a decompensated asymmetry manifested by unilateral hypertropia of at least 10 prism diopters in addition to the DVD. These patients require an asymmetrical amount of surgery. Two such patients required reoperation, not because of residual DVD, but because of failure to correct this hypertropia. Currently we do bilateral superior rectus recessions of greater than 10 mm OU for DVD, reserving unilateral surgery for the patient with such deep amblyopia that he will never fix with the operated eye. An eye with manifest hypertropia in addition to DVD requires at least five more millimeters (greater than 15 mm) than the fixating eye. Maximum amounts of recession have not yet been determined.

Development of myelin in human optic nerve and tract. A light and electron microscopic study.

The early development of myelin in human optic nerve and tract was studied in plastic-embedded material from post-mortem examinations of 18 infants and children. Specimens were examined by light and electron microscopy, and a good correlation was found between the data obtained by the two techniques. The characteristic lamellae of myelin were first seen around a few fibers of tract and intracranial optic nerve at 32 weeks of gestation. By term, these myelin sheaths had become thicker, and a majority of the nerve fibers had become myelinated. In the optic nerve near the globe, myelin was first seen at term and virtually all fibers were myelinated by 7 months of age. Significant increases in sheath thickness were seen in the first two years, and modest increases were found thereafter. These results are in agreement with earlier observations that, in the optic nerve, myelination proceeds from the brain toward the eye. The present data suggest that a significant amount of myelination in the human optic nerve occurs after a full-term (40-week) gestation, during a period of rapid postnatal visual development.

Construcción de secciones de concreto para la pavimentación de fosos o zanjas de desague

También publicado en la OSP.Publicación No. 116. Octubre,1936