Fibrovascular ingrowth as a cause of Ahmed glaucoma valve failure in children.

PURPOSE: The purpose of this study is to document the presence of fibrovascular ingrowth into the Ahmed glaucoma valve (AGV) as a cause of AGV failure in the pediatric population. DESIGN: Retrospective case series. METHODS: Retrospective study of six children with histologically documented fibrovascular ingrowth of their AGV, with review of relevant demographic, clinical, and surgical factors. RESULTS: Six patients, two males and four females, with a mean age at AGV placement of 27.5 months (range 1 to 122) were identified with AGV failure, AGV removal, and subsequent histology documenting fibrovascular ingrowth into the valve chamber. Etiology of glaucoma included: trauma, aphakia, angle-closure, aniridia, and infantile. Mean time from AGV implantation to explantation was 23 months (range 6 to 65). Mean intraocular pressure at AGV explantation was 35 mm Hg (range 27 to 48). CONCLUSIONS: Fibrovascular ingrowth of both the pediatric and adult size AGV occurs in children and should be considered in the presence of AGV failure.

Case series of angle-closure glaucoma after laser treatment for retinopathy of prematurity.

PURPOSE: Laser photocoagulation is the current treatment standard for severe retinopathy of prematurity (ROP). Uncommon, but well recognized complications include cataract, and vitreous and retinal hemorrhage. Angle-closure glaucoma after laser photocoagulation for ROP is rare. The purpose of this study was to identify additional cases of angle-closure glaucoma following laser treatment for ROP. METHODS: Five eyes of four patients with angle-closure glaucoma following laser treatment for ROP were identified by three ophthalmologists at separate institutions between 1997 and 2001. Demographic and clinical data were obtained from medical records. Clinical and surgical findings associated with the diagnosis and management of angle-closure glaucoma following ROP laser were evaluated. RESULTS: The following data were collected (mean (range)): gestational age, 26.8 (24 to 29) weeks; birth weight, 833 (570 to 1062) g; age at laser treatment for ROP, 35 (33 to 37) weeks; number of laser burns, 1598 (930 to 2400); and time to diagnosis of angle-closure glaucoma, 3.6 (2 to 5) weeks. Three of five eyes had objective data for intraocular pressure (IOP) and corneal diameter with mean IOP 41 mm Hg (35 to 44) and mean corneal diameter 11.1 mm (10.25 to 11.5). Initial treatment included topical and systemic medications. Three eyes required surgical intervention. Angle-closure resolved in all cases with normalization of IOP. Follow-up (5 months to 3.6 years) showed that affected eyes tended to be more myopic than unaffected fellow eyes (mean spherical equivalent -6.5 vs -4.7 diopters). CONCLUSIONS: Angle-closure glaucoma can develop following laser treatment for severe ROP. Medical, and frequently surgical, intervention provides effective management.

Retinopathy in patients with diabetic ophthalmoplegia.

PURPOSE: To review the clinical characteristics, prevalence, and severity of retinopathy in diabetics with cranial nerve (CN) 3, 4, and/or 6 palsies, and to determine the relationship between type and duration of diabetes mellitus (DM), presence of retinopathy, and occurrence of CN palsy. DESIGN: Retrospective, comparative cohort study. PARTICIPANTS: Chart reviews of 2229 patients with CN 3, 4, and/or 6 palsies were performed at the Bascom Palmer Eye Institute (BPEI) from January 1991 through December 1997 and at the Dean A. McGee Eye Institute (DMEI) from January 1994 through July 2001. A total of 306 patients qualified for the study group. The Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) was used as a control. METHODS: Demographic and clinical data were extracted to determine characteristics of patients with diabetic ophthalmoplegia. The subsets of data regarding type of DM and level of diabetic retinopathy in the study population were compared with the WESDR control data for statistical analysis. MAIN OUTCOME MEASURES: The prevalence of diabetic retinopathy in patients with diabetic ophthalmoplegia. RESULTS: Of 2229 patients at both institutions with ocular motor CN palsy, 306 (13.7%) were associated with DM. The frequency of CN involvement was 6 (50.0%), 3 (43.3%), and 4 (6.7%). There was a total of 12 patients (3.9%) with consecutive palsies and 8 patients (2.6%) with simultaneous palsies (5 unilateral and 3 bilateral). At both institutions, the prevalence of retinopathy controlling for duration of DM was lower in both insulin-dependent DM (IDDM) and non-IDDM (NIDDM) type II diabetics as compared with controls (BPEI, P = 0.009 and P = 0.005; DMEI, P = 0.004 and P = 0.29). When data from both locations were combined, the difference was even more significant (IDDM, P = 0.001 and NIDDM, P = 0.006). There were no significant differences between the two institutions in gender, type or duration of DM, age at presentation, or frequency of CN involvement. CONCLUSIONS: Diabetic ophthalmoplegia most commonly involves CN 3 and 6, with relative sparing of CN 4. Multiple cranial nerves are affected simultaneously in 2.6% of cases, and consecutive palsies occurred in 3.9% of cases. Type II diabetics with ocular motor CN palsy have significantly less diabetic retinopathy than do controls. This may imply a different pathophysiologic mechanism for these two microvascular complications of DM.

Factors associated with horizontal reoperation in infantile esotropia.

PURPOSE: Risk factors for requiring multiple surgeries in infantile esotropia remain unclear. We identified clinical and demographic factors associated with horizontal reoperation in this disease. METHODS: A retrospective chart review of patients who underwent surgery from 1994-1997 was performed. Subjects were divided into 2 groups: those requiring only one operation and those requiring 2 or more operations to achieve orthotropia +/-10 PD. RESULTS: In 149 patients, the overall horizontal reoperation rate was 34%. There were no statistically significant differences between the 2 groups with respect to mean age at first surgery, mean preoperative deviation, gender, prematurity, Medicaid coverage, parental age, family history of strabismus, or refractive error. The presence of nystagmus, oblique muscle dysfunction, dissociated vertical deviation (DVD), or a variable angle of esotropia was not associated with increased horizontal reoperation rate. There was a greater frequency of horizontal reoperation in patients with amblyopia, although not significant. Premature infants and infants with neurologic dysfunction had a lower incidence of horizontal reoperation, but also not significant. Deviations of less than 30 PD were associated with fewer horizontal reoperations (16% vs 31%, P =.047). Significantly more patients underwent horizontal reoperation when initial surgery was performed at less than or equal to 15 months of age (67% vs. 47%, P =.022). CONCLUSIONS: Several factors thought to predispose to poor sensorimotor outcome (dissociated vertical deviation, oblique muscle dysfunction, and nystagmus) were not associated with an increased incidence of horizontal reoperation. Horizontal reoperation was less frequent in patients with angles less than 30 PD. Although some studies suggest that early surgical intervention in patients with infantile esotropia affords better sensory outcome, it may be associated with a higher horizontal reoperation rate.