Congenital ocular aberrant innervation--new concepts.

BACKGROUND: We have the impression that congenital aberrant innervations are more common than previously reported. Many varieties exist and typically involve the sixth nerve. The most common ocular miswirings are Duane's syndrome and Marcus Gunn jaw-winking ptosis. The second most common miswiring involves lateral rectus activation in upgaze causing a "Y" pattern exotropia (pseudo inferior oblique overaction). This commonly is confused with inferior oblique overaction but surgery on the obliques does not cure the condition. Lateral rectus recession and elevation are required. METHODS: We selected demonstrative cases from our practices to illustrate a variety of congenital aberrant innervations. A literature search for previous reported cases of aberrant innervations was performed. This report is an eclectic collection of observations of individual selected cases. RESULTS: We found aberrant innervations of unusual varieties. These miswirings involve simultaneous firing of the lateral rectus with other muscles, including: the ipsilateral superior rectus, causing "pseudo inferior oblique overaction"; the contralateral lateral rectus, causing synergistic divergence; the ipsilateral superior rectus, in upward saccades only; and the masticatory muscles, causing exotropia with sucking. The third nerve by itself rarely is involved in congenital miswirings, but commonly shows aberrant regeneration after traumatic injuries. We know of no cases of aberrant innervation involving the fourth nerve. SUMMARY: We present cases describing these congenital aberrant innervations and discuss a unifying hypothesis as to their typical involvement of the sixth nerve.

Polaroid photoscreening for amblyogenic factors. An improved methodology.

BACKGROUND: The authors describe a new photoscreening camera designed to detect amblyogenic factors, including strabismus, asymmetric and abnormal refractive errors, and media opacities. The photoscreener uses eccentric photorefraction principles and provides two meridian photographs of the retinal reflex. METHODS: Pass/fail screening data from the photographs of 202 nondilated children as determined by two masked observers were compared with data from complete ophthalmologic examinations. RESULTS: The photoscreener had a sensitivity rate of 87%, a specificity rate of 89%, a positive predictive value of 93%, a negative predictive value of 80%, and an overall agreement rate of 88%. The prescreening probability for amblyogenic factors was 63%. Constant strabismus was detected in all cases. Five intermittent strabismus cases were missed. Two patients with myopia, three patients with hyperopia, and five patients with astigmatism were missed. All media opacities were detected. CONCLUSION: This new two-flash photoscreening camera, which uses high-speed Polaroid film, is an accurate, reliable method of detecting amblyogenic factors in undilated children. The camera offers promise as a useful mass screening tool.

Preservation of anterior ciliary vessels during strabismus surgery: a nonmicroscopic technique.

Preservation of anterior ciliary vessels (ACVs) during strabismus surgery using microscopic dissection techniques and the operating microscope has been previously described. We describe a technique using standard loupe magnification for vessel preservation, in 77 patients, ages 7 months to 69 years, who had surgery between January 1989 and September 1990. ACVs, with a small sheath of connective tissue, were dissected off the surface of the muscles and tendons using blunt and sharp dissection with Knapp iris hooks and Vannas scissors. Key elements of the dissection were sufficient separation of the vessel complex from the anterior tendon insertion and the use of blunt rather than sharp dissection. We successfully preserved 125 ACVs in 97 muscles. Ninety-five vessels were saved with 71 recessions, 14 with 13 resections, and 16 with adjustable sutures. The success rate of surgery was 85% in surgeries done either with or without anterior ciliary preservation. Vessel dissection time averaged 5 to 10 minutes per muscle. ACV preservation can be easily and successfully performed in routine strabismus cases. The procedure does not require the operating microscope and can be done under standard loupe (1.5 to 3.0 x) magnification. This procedure theoretically reduces the risk of anterior segment ischemia in situations where the patient is thought to be at significant risk for this complication.

Heat retention in varieties of warm compresses: a comparison between warm soaks, hard-boiled eggs and the re-heater.

Warm compresses are the most common form of treatment for chalazia and other inflammatory conditions of the eyelids. We compared the heat retention characteristics of warm washcloths, hard-boiled eggs, and a heat-generating product called the Re-Heater when used for delivering heat to the eyelids. Skin temperature was measured during 20-minute applications of each "device." The Re-Heater had the best total heat delivery, followed closely by the hard-boiled egg. Both of these methods are reusable, easy, and cause no discomfort. We recommend that physicians instruct their patients in the use of either of these techniques when heat application to the eyelids is desired.

Vertebral osteomyelitis caused by fusobacterium nucleatum: a case report.

A 58-year-old man with a history of chronic alcohol abuse presented with vertebral osteomyelitis caused by Fusobacterium nucleatum. This case demonstrated the foul smelling abscess characteristic of anaerobic infection. Deep anaerobic infections are well known to be resistant to closed treatment, and the computerized tomographic scan confirmed the diagnosis of a paravertebral abscess in this case. An increased awareness among clinicians that anaerobic bacilli can cause oteomyelitis, together with more sophisticated culture techniques, will greatly aid the management of this virulent form of osteomyelitis.

Cytomegalovirus in juvenile iridocyclitis.

We cultured cytomegalovirus from lens material aspirated from the eye of a 4-year-old boy who had a severe bilateral iridocyclitis and secondary cataracts. There were neither systemic manifestations of congenital disease nor chorioretinitis.