Late Recurrence of Anisometropic Amblyopia.

A 15-year-old boy whose anisometropic amblyopia was effectively treated with glasses was examined. Despite years of stability, his visual acuity decreased from 20/20 to 20/60 with poor glasses compliance. Although amblyopia recurrence is well recognized, this case emphasizes potential late recurrence after prolonged success. Fortunately, he improved to 20/20 after improved compliance. [J Pediatr Ophthalmol Strabismus. 2024;61(1):e11-e12.].

One-Month Postoperative Horizontal Strabismus Surgery Outcomes Using Adjustable and Nonadjustable Sutures.

INTRODUCTION: Previous series suggest adjustable sutures (AS) in adult strabismus surgery yield improved ocular alignment and better success rates compared to nonadjustable sutures (NAS). We questioned whether these differences are clinically significant and whether they justify the added time and discomfort required for AS. METHODS: We reviewed all available records of adults undergoing horizontal strabismus surgery by the last two authors between 2000 and 2014. Independently, the two surgeons developed a preference for NAS midway through the study period, permitting comparisons between two treatment groups. Results were assessed at one to two months postoperatively. The primary outcome was alignment in primary position at one to two months postoperatively. The secondary outcome was success rate, defined as <10PD residual or consecutive deviation. RESULTS: We included 184 patients, 68 with AS and 116 with NAS. No significant difference in primary position alignment at 1-2 months was noted between AS and NAS for esotropia (P = .26) or for exotropia (P = .10). Success rates were similar (P = .58 for esotropia and P = .34 for exotropia). DISCUSSION: Although we acknowledge limitations in this retrospective study, our results suggest that AS overall was not associated with improved alignment or success rates, compared to NAS, at 1- to 2- months postoperatively. CONCLUSIONS: Although adjustable sutures represent a valuable surgical option at the discretion of individual surgeons and their patients, we no longer routinely use AS in all adult cases. A prospective study to evaluate long-term outcomes would be helpful.

Surgical Confusions in Ophthalmology: Description, Analysis, and Prevention of Errors from 2006 through 2017.

PURPOSE: To characterize surgical confusions in ophthalmology to determine their incidence, root causes, and impact on patients and physicians. DESIGN: Retrospective cohort study of errors in ophthalmic surgical procedures between January 1, 2006, and December 31, 2017. PARTICIPANTS: One hundred forty-three cases involving surgical confusions. METHODS: Cases were identified by the Ophthalmic Mutual Insurance Company from closed case files and by the New York State Health Department from the New York Patient Occurrence Reporting and Tracking program that identified the surgical confusions. MAIN OUTCOME MEASURES: Incidence and impact by intended surgery, error type, and root cause as well as preventability by the Universal Protocol. RESULTS: Of the 143 cases of surgical confusions identified, 92 cases (64.3%) were deemed preventable by the Universal Protocol. Approximately two thirds, 95 cases (66.4%), were cases of incorrect implants being used during cataract surgery (cataract extraction and intraocular lens implantation), of which 33 cases (34.7%) were not preventable by the Universal Protocol. Wrong eye blocks or anesthesia accounted for 20 cases (14.0%), incorrect eye procedures accounted for 10 cases (7.00%), incorrect refractive surgery measurements accounted for 6 cases (4.20%), incorrect patient or procedure accounted for 5 cases (3.50%), incorrect intraocular gas concentration accounted for 4 cases (2.80%), and incorrect medication in surgery accounted for 3 cases (2.10%). The most common root cause of confusion was an inadequately performed time out, which was responsible for nearly one third of all surgical confusions, 46 cases (32.2%). Incorrect lens orders or calculations before surgery (so-called upstream errors) were the second most common cause of surgical confusion, involving 31 cases (21.7%). The average legal indemnity for incorrect implant during cataract surgery was $57 514 (United States dollars). The average indemnity for incorrect refractive surgery measurement was $123 125, that for incorrect eye procedure was $50 000, and that for incorrect gas concentration was $220 844. CONCLUSIONS: Most surgical confusions could have been prevented by following the Universal Protocol properly. However, upstream errors, originating in the clinic or office before surgery, and ineffective communication during time outs suggest a need for modification of the Universal Protocol.

Acquired, Comitant, Non-Accommodative Esotropia (ANAET): Evaluation, Treatment, and Prognosis.

Children presenting in later childhood with isolated, acquired, comitant non-accommodative esotropia (ANAET) form an unusual clinical group whose evaluation, treatment, and prognosis are unclear. We identified 9 such patients with no evidence of intracranial pathology whose outcomes following standard bilateral medial rectus recessions were excellent.

Long-Term Follow-up of Spasmus Nutans.

PURPOSE: Spasmus nutans is an acquired form of nystagmus that is classically associated with torticollis and titubations of the head, often presenting in the first year of life and spontaneously resolving within the next 2 years. The purpose of our study was to record and characterize the long-term prognosis of children diagnosed with spasmus nutans. METHODS: All patients under the age of 21 years with a diagnosis of spasmus nutans were included. Parameters of age, nystagmus symmetry and quality, presence of titubations, torticollis, and strabismus, and findings on CT or MRI were recorded. RESULTS: Our 22 patients had an average age of onset of 9.8 and a follow-up of 62.6 months. Nystagmus was unilateral in 5 children, asymmetric in 5, symmetric in 10, and inapparent in 2. Titubations were identified in 10 and torticollis in 7. Nystagmus persisted in 16 of 20 children, titubations in 3, and torticollis in 6. Neuroimaging, performed on 17 of the 22 children, was negative for any space-occupying lesions. CONCLUSION: In conclusion, we are reluctant to assure parents of children who have even the most typical spasmus nutans that their child will be normal after a predictable interval. Instead, we advise them that many children do well, assuming normal imaging, but that nystagmus, torticollis, and even titubations may persist. Follow-up, especially for strabismus and amblyopia, should be continued throughout childhood.

Conservative Management of Lower Eyelid Epiblepharon in Children.

PURPOSE: Although much literature has focused on various techniques to repair epiblepharon, no study has addressed how frequently surgical intervention is required. METHODS: The authors tabulated data from all patients with epiblepharon seen over the past 15 years. RESULTS: Eighty-nine patients were included, 61 (69%) with tearing, discharge, conjunctival injection, or eye rubbing. Trichiasis was present in 15 cases (17%), 6 (7%) with corneal staining. In all cases, the initial treatment was conservative: antibiotic ointment or tear substitutes in 73 cases with trichiasis, symptoms of irritation, or corneal changes and observation in the remaining 16 cases. Three children (3%) were referred for eyelid surgery because of persistent symptoms. No patient had corneal scarring or long-term complications. CONCLUSIONS: Although vision-threatening complications can result, a trial of topical antibiotic ointment and/or ocular lubricants was effective in nearly all patients. Most resolved with minimal symptoms. The few eventually requiring eyelid surgery suffered no long-term complications. The authors recommend a trial of conservative treatment before eyelid surgery is undertaken. [J Pediatr Ophthalmol Strabismus. 2017;54(1):15-16.].

Episodic Excessive Blinking in Children.

PURPOSE: Many children present with excessive blinking. Categorization, associated conditions, and prognosis are controversial. METHODS: All children with excessive blinking were reviewed, excluding those with known uveitis, glaucoma, or obvious eyelid abnormalities. Parents were telephoned for follow-up. RESULTS: No ocular pathology was identified in 31 of 34 children with excessive blinking (91%). Parents were able to report a specific cause of blinking in 7 (21%). In 24 of 34 (71%), parents reported complete resolution of excessive blinking. No new ophthalmologic diagnoses were uncovered on follow-up. CONCLUSIONS: Episodes of excessive blinking rarely indicate neurologic disorders and frequently resolve spontaneously.

Optic nerve morphology in normal children.

PURPOSE: To expand the normative database of pediatric eyes analyzed with the Optovue optical coherence tomography (OCT). METHODS: In a community-based, cross-sectional analysis, 77 healthy 5-year-old children were recruited from pediatric practices. No subject had any known ocular disorder. Their optic nerves were assessed using Optovue optical coherence tomography (OCT). Data were compared to the normative database obtained by Optovue for adults, ages 18-25, 40-45, and 55-60. Comparisons included thickness of retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC), and optic nerve head disk area, vertical (VCD) and horizontal (HCD) cup:disk ratios, and cup area. RESULTS: In comparison to all adult age groups, the children's optic nerve heads were statistically less cupped (cup area, VCD, HCD), all with P values of <0.0003. No statistical difference was identified between the children and adults aged 18-25 and 40-45 with respect to RNFL or GCC. Both RNFL and GCC were thicker in the children compared to adults aged 55-60 (P < 0.003). Children's disk area's were marginally smaller than those of adults, the difference not reaching statistical significance. CONCLUSIONS: Our OCT results demonstrate that young children's optic nerves are statistically less cupped than those of all normal adults. The children's RNFL and GCC are statistically thicker than those of adults aged 55-60.

Long-term Cosmetic Alignment Following Surgery for Esotropia Versus Exotropia in Childhood: A Comparison Using Survival Curves.

PURPOSE: Although long-term results following repair of esotropia and exotropia in childhood have been reported, the two entities have never been directly compared. METHODS: Records of all children younger than 18 years who underwent horizontal strabismus surgery from 2000 through 2012 were reviewed. Children with structural eye pathology, severe vision loss, neurologic disorders, and incomitant or combined horizontal and vertical deviations were excluded. Failure was defined by a second horizontal surgery or a primary position deviation greater than 20 prism diopters (PD) at any time during follow-up (as long as 10 years). A threshold of 20 PD was chosen because families often consider deviations important enough to warrant a first or second surgery if it is larger but not if it is smaller. RESULTS: Of 317 children, 235 with esotropia had surgery at a mean age of 42 months and 82 with exotropia had surgery at a mean age of 60 months. Overall, surgery was successful in 78% of those with esotropia and 65% of those with exotropia. A second surgery was performed in 29 (12%) of those with esotropia and 15 (18%) of those with exotropia. The mean deviation at last follow-up, using absolute values, was 9 PD for esotropia and 10 PD for exotropia. Survival curve success was better for esotropia (P = .008). CONCLUSION: By survival curve analysis, success was more likely among children with esotropia. Many "failures" slipped beyond the 20 PD threshold only transiently and had deviations that were not noticeable to family or friends. Overall, children did reasonably well long-term following surgery for both esotropia and exotropia. Only 14% of the entire group required a second surgery during an average of 41 months of follow-up.

Treatment of consecutive exotropia: unilateral lateral rectus recession combined with medial rectus advancement or resection.

PURPOSE: Consecutive exotropia presents a difficult clinical problem, especially when previously recessed medial recti are to be strengthened. Surgical options include advancement, typically with a small resection, and resection alone. METHODS: The authors retrospectively reviewed records of all patients who underwent a second two-muscle surgery on a single eye for consecutive exotropia. Patients with paralytic strabismus and those with less than 1 month of postoperative follow-up were excluded. In 2003, one of the authors began medial rectus resections without advancements in most cases, whereas a second author continued to perform advancements. Two treatment groups were thus reviewed. RESULTS: Forty-two patients qualified for inclusion, including 23 for the resection group and 19 for the advancement group. Preoperative deviations were similar (P = .35, 95% confidence interval: -2.64 to 9.82). Postoperative deviations averaged 11.4 prism diopters (PD) in the resection group and 11.5 PD in the advancement group (P = .98, 95% confidence interval: -12.2 to 12.3). Forty-eight percent of the resection group and 63% of the advancement group achieved alignment within 10 PD of orthophoria (P = .33, 95% confidence interval: -9.0% to 39%). CONCLUSIONS: Surgical results were favorable following both techniques. Although both techniques appear to be adequate, resection of previously recessed medial recti may be preferable because they allow use of standard surgical tables and avoid advancement of inflamed tissue into the palpebral fissure.

The effectiveness of policy changes designed to increase the attendance rate for outpatient retinopathy of prematurity (ROP) screening examinations.

PURPOSE: To determine the effectiveness of a series of policy changes designed to increase the attendance rate for outpatient retinopathy of prematurity (ROP) screening examinations. METHODS: We retrospectively reviewed the records of consecutive neonatal intensive care unit patients before and after the implementation of policy changes. Policy changes included parent education forms, streamlined scheduling, and creation of a log for all patients seen. The primary outcome measure was attendance rates for the first outpatient appointment after discharge. The Fisher exact test was used to compare rates between the two groups. RESULTS: Before the policy was implemented, 22 of 52 (42%) neonates and their caregivers attended their first outpatient ROP screening examination on the recommended date. This rate improved significantly after policy implementation, when 46 of 57 (81%) neonates and their caregivers were seen on the recommended date (P < 0.01). The number of patients who ultimately met the criteria for conclusion of acute retinal screening examinations also significantly improved, from 47 of 52 (90%) of neonates in the pre-implementation group to 57 of 57 (100%) in the post-implementation group (P = 0.02). CONCLUSIONS: The attendance rates for initial outpatient ROP examinations and the number of patients who ultimately met criteria for conclusion of acute retinal screening examinations significantly improved after the implementation of new policies.

Combined optical and atropine treatment of children with residual amblyopia after atropine penalization.

The authors studied 5 cases in which combined optical and atropine treatment (COAT) was instituted in children with residual amblyopia after atropine penalization. All 5 amblyopic eyes improved without lasting decrease in the visual acuity of the dominant eyes. Appropriately administered, COAT may rescue atropine failures.

Left-Sided Predominance in Pseudo-esotropia.

Pseudo-strabismus, or more precisely, pseudo-esotropia, is commonly encountered in pediatric ophthalmology. In our practice, the left eye was reported by parents as being deviated more frequently than the right eye. We attribute this laterality to the fact that most parents are right handed. They therefore tend to hold their children with their left arm, and to feed them with their right hands, in both cases viewing the left eye of the child in the adducted position.

The association of refractive error, strabismus, and amblyopia with congenital ptosis.

PURPOSE: To determine the frequency of amblyopia and its associations among children with congenital ptosis. METHODS: A retrospective chart review of 92 active patients with congenital ptosis in the practices of 2 of the authors. The main outcome measures were relative eyelid ptosis severity, presence and type of strabismus, refractive error, and amblyopia. RESULTS: Amblyopia was identified in 22 of 92 patients (23.9%), in almost every case occurring in the context of coexisting anisometropia or strabismus and affecting the eye with the more severe ptosis (P = 0.0001). Amblyopia was more likely to occur in cases with greater relative eyelid asymmetry and did not develop in children with symmetric ptosis. In several cases, anisometropia and amblyopia were not initially apparent but progressively developed during follow-up. CONCLUSIONS: Children with congenital ptosis are at risk of anisometropic and strabismic amblyopia, which may progress during early development. Patients should be examined at regular intervals to evaluate and treat these potential complications.

Varying difficulty of Snellen letters and common errors in amblyopic and fellow eyes.

OBJECTIVE: To investigate the varying difficulty of Snellen letters in children with amblyopia. METHODS: We tabulated the letter-by-letter responses of amblyopic and nonamblyopic fellow eyes on random, computer-generated Snellen lines. Participants were 60 children, aged 5 to 13 years, with a history of amblyopia. Main outcome measures were relative difficulties of Snellen letters and common misidentifications. RESULTS: Errors were 7.5 times more common with certain letters (B, C, F, S) than with others (A, L, Z, T), this difference increasing to 17.6-fold at threshold. Similar relative letter difficulty was demonstrated at lines above and at visual acuity thresholds, and both difficult and easy letters were the same for amblyopic and nonamblyopic fellow eyes. Specific misidentification errors were often repeated and were often reciprocal (eg, B for E and E for B). CONCLUSION: Since therapeutic decisions in amblyopia management are often based on small differences in visual acuities, the relative difficulties of letters used in their measurement should be considered. The Early Treatment Diabetic Retinopathy Study system should be considered for use in this clinical setting.

Eye pain in preschool children: diagnostic and prognostic significance.

BACKGROUND: Preschool children often present for ophthalmologic examination because of eye pain. Although the differential diagnosis includes serious conditions, the diagnostic and prognostic importance of apparently isolated eye pain are unknown. METHODS: We reviewed records of 80 consecutive patients presenting between 2 and 6 years of age with eye pain but without a red eye or a history of an obvious cause of pain. Families of children seen in the office only once were contacted by phone to obtain follow-up information. RESULTS: Functional eye pain was diagnosed in 73 of 80 patients (91%). Of the 64 patients with follow-up between 1 week to 4 years (mean, 21 months), 56 (88%) had no other cause of eye pain. Dry eyes, allergic conjunctivitis, blepharitis, corneal foreign body, sinusitis, and trichiasis were diagnosed in 7 patients. Other children were found to have refractive error, amblyopia, blepharospasm, and nystagmus--all considered unlikely to cause eye pain. CONCLUSIONS: Absent a preexisting or obvious cause of eye pain, the symptom is usually functional in preschool children who may have difficulty communicating vague visual symptoms to caregivers. However, such children deserve examination, not only so that unapparent causes can be excluded but also because unrelated conditions may require further evaluation and treatment. Parents can be reassured that if no abnormality is found on initial ophthalmologic examination, children with eye pain are unlikely to have subsequent diagnoses.

Anisometropic amblyopia: axial length versus corneal curvature in children with severe refractive imbalance.

PURPOSE: To define the ocular parameters associated with anisometropic ambylopia in children with severe hyperopia, myopia, or astigmatism in 1 eye. METHODS: Anisometropic and fellow eyes of 13 children, ages 7-8, with anisometropia >3.0 D and amblyopia without strabismus or other visually significant ocular pathology were studied. Axial length, corneal curvature, anterior chamber depth, and corneal diameter measurements of amblyopic and fellow eyes were obtained using the IOL Master (Carl Zeiss Meditec, Dublin, CA). RESULTS: Comparing amblyopic eyes with unaffected fellow eyes as reference, patients with anisohyperopia had shorter axial lengths by an average of 1.49 mm (p = 0.001), and patients with anisomyopia had longer axial lengths by an average of 2.26 mm. Corneal astigmatism was the source of amblyogenic refractive error in 1 child. CONCLUSIONS: In children with anisometropic amblyopia, interocular differences in spherical refractive error was attributed to axial length with no differences in corneal curvature, whereas the anisoastigmatism observed in 1 case was attributed to asymmetric corneal curvature.

Ptosis and ophthalmoplegia associated with epidermolysis bullosa simplex-muscular dystrophy.

The association of epidermolysis bullosa simplex and muscular dystrophy (EBS-MD) has rarely been discussed in ophthalmology literature. This case report offers a brief summary of epidermolysis bullosa and describes what is known about EBS-MD. The case involves a patient with EBS-MD who presented with ptosis and ophthalmoplegia, suggesting that these may be complications of EBS-MD.

Complications of strabismus surgery.

PURPOSE OF REVIEW: To examine the common and serious complications of strabismus surgery, emphasizing prevention, identification, and treatment. RECENT FINDINGS: Confusions involving incorrect procedures and patients can occur despite the Universal Protocol, but should be preventable and treatable. Damage to structures adjacent to muscles and scleral perforations should be prevented by careful surgical technique and effective magnification. Orbital inflammations and anterior segment ischemia can usually be treated effectively. Slippage of muscles can be prevented by effective suturing and 'lost' muscles can usually be recovered. Conjunctival cysts and wound irregularities can be prevented using meticulous technique, though repeat surgery may be required in some cases. Postoperative alignment may be compromised by variability in preoperative measurements and by long-term drift, especially toward exotropia; outcomes in specific situations, for example, Duane syndrome, Graves' ophthalmopathy, may be particularly problematic. Nausea and vomiting have become much less common, and serious anesthesia complications extraordinarily rare, though asystole may occur as part of the oculocardiac reflex. SUMMARY: The many possible complications are rare, preventable, and treatable. Generally, surgery almost always improves, if not permanently curing, strabismic deviations.