Lacrimal gland abscess in a child as a rare manifestation of IgG4-related disease.

Dacryoadenitis is unusual in children, and noninfectious causes can be manifestations of serious undiagnosed systemic conditions. This report brings further attention to this rarely-encountered condition and emphasizes its association with IgG4-related disease, a group of inflammatory disorders of high current interest whose spectrum of manifestations continues to evolve. The pediatric ophthalmologist could be in the position of identifying a patient's serious and previously unappreciated illness.

A chronicle of surgical thinking and doing for exotropia: innovations and rediscoveries.

PURPOSE: To review the evolution of theories and practices concerning surgery for exotropia over the last approximately 200 years. METHODS: Major ophthalmology texts and relevant references were reviewed to discover experience and thinking concerning the causes of comitant intermittent and constant exotropia and corrective surgical approaches. RESULTS: The concept that excessive divergence is the cause of comitant exotropia has given way to one recognizing that this disorder is a position of rest modified by convergence. Some operations discarded as unreliable or dangerous remain so today. Others continue to be well accepted, whether or not relating to advances in understanding of this condition. Several procedures practiced at former times have regained popularity. CONCLUSIONS: Concern for the characteristics of extraocular muscle structure and function has led to surgical thinking that goes beyond consideration only of direction and magnitude of deviation. Sophisticated devices now provide heretofore unavailable information consistent with this new approach. The history of progress in surgery for exotropia is mixed. Although some procedures now employed are new, others currently in favor had been well known and formerly utilized by ophthalmologists for many decades. These should be regarded as rediscoveries or revivals rather than as novel. This review also suggests a need to address how to better report retrospective studies.

Accommodative ET-High AC/A Ratio Esotropia: The Case for Glasses.

BACKGROUND AND PURPOSE: There is a continuing debate as to whether the patient optically correctable at distance to within 8 prism diopters of perfect alignment requires treatment for persisting overconvergence at near, and if treatment is indicated, what it should be. PATIENTS AND METHODS: For the patient whose misalignment at distance is reduced to 8 or fewer prism diopters, my preference is for the full cycloplegic correction plus a bifocal in the first prescription, to discourage virtually all accommodation initially, with pull back later. RESULTS: Review of several reports indicates a continued lack of consensus on whether this causes disuse weakening of accommodation and premature presbyopia. Recent studies found that prolonged convergence tone at near can result in anatomic and physiologic alterations in the medial rectus muscles that threaten a satisfactory distance alignment as well, despite relief of the accommodative demand. Hypoaccommodative esotropia resembles the high AC/A variety. CONCLUSION: Spontaneously improving over-convergence at near is not likely to occur in the hypoaccommodating patient either with observation alone or with surgery. I reserve surgery for the over-convergence at near for the unusual case of an extremely high distance-near disparity, and for the teenager or adult not showing likelihood that the condition will resolve.

DVD--a conceptual, clinical, and surgical overview.

Dissociated vertical deviation (DVD) is a slow, disconjugate hypertropic deviation of a nonfixating eye. It is usually bilateral, asymmetrical, and often associated with congenital esotropia. The deviating eye elevates, abducts, and excyclotorts. This type of strabismus is often variable, making measurement and clinical quantification difficult. Specific knowledge of the mechanisms and characteristics of the dissociated deviation are required for proper assessment and effective treatment. There is currently no consensus on the mechanisms and pathophysiology of DVD. In this workshop, participants discuss the characteristics and most current methods for assessing and quantifying the deviation and explore the potential etiologies, clinical characteristics, and indications for surgical intervention and nonsurgical management of DVD.

Importance of birth weight as a risk factor for severe retinopathy of prematurity when gestational age is 30 or more weeks.

PURPOSE: To determine whether birth weight less than 1500 g is a relevant guideline indicating the need for examination for retinopathy of prematurity (ROP) when gestational age at birth is 30 or more completed weeks. DESIGN: A retrospective observational cohort study. METHODS: A total of 266 infants in a single institutional neonatal intensive care unit (NICU), whose gestational age at birth was 30 or more weeks but whose birth weight was less than 1500 g, were examined according to published guidelines. Infants with lethal congenital anomalies or major ocular abnormalities were excluded. Outcomes were vascularization in retinal zone III without a prior need for treatment, or ROP warranting treatment. RESULTS: A study outcome was reached by 212 infants. Two hundred and eleven (99.5%) became vascularized through zone III without needing treatment. Only 1 (0.5%) required treatment for ROP. The 95% confidence interval for the occurrence rate of ROP requiring treatment in this cohort was 0.01%-2.60%. CONCLUSION: Our results suggest that the occurrence rates of ROP requiring treatment in infants with gestational age 30 or more weeks and birth weight less than 1500 g is very low, and could indicate the need to revise examination guidelines for this subgroup of infants.

Rectus muscle flap tear as an independent cause of restricted motility.

Most published cases of rectus muscle flap tear have been associated with orbital trauma of various degrees of severity. When they accompany an orbital fracture, however, it is difficult to determine whether the flap tear is merely an incidental additional finding or a major contributing cause of the resulting restriction. How to treat the flap itself remains an open question. We report a 24-year-old man with an inferior rectus muscle flap tear caused by direct laceration of the muscle. The major finding was a "reverse leash" vertical restriction. Discarding the flap instead of reattaching it did not prevent a successful result. Our case supports the proposition that rectus muscle flap tear can be a restriction-producing entity.

Questions revisited: is experience still the best teacher?

INTRODUCTION AND PURPOSE: To illustrate the value of experience in developing a simplified binocular sensory evaluation when required by necessity, and to describe the experience gained in repeating and extending a prior study. PATIENTS AND METHOD: Prioritizing the information needed and the tests that provide it, and retrospectively reviewing a new population with similar inclusion and exclusion requirements, and dealing with the problem of uneven follow-up. CONCLUSION: It is possible to derive a limited evaluation that is still sufficient for patient management. The prior results were confirmed and led to better understanding of the possibilities and limitations of retrospective studies.

The parameters of informed consent.

PURPOSE: To describe the components of a proper informed consent; which risks must be disclosed and which need not; additional safeguards for incapacitated persons, minors, and research subjects; and where the law will imply consent that is not otherwise obtained. METHODS: Summarization of current law obtained from legal treatises, reports of recent cases, and personal experience as a reviewer and expert. RESULTS: Lack of informed consent can reinforce a claim of medical malpractice or serve as an alternative point of attack when the case is otherwise weak. Special requirements must be met when patients are the subjects of clinical research. CONCLUSION: Demonstration of a well-conducted process, not merely of a paper, not only protects the physician from exposure to liability, but increases the patient's autonomy in decisions concerning health and encourages compliance with treatment.