Cluster of diplopia cases after periocular anesthesia without hyaluronidase.

PURPOSE: To describe a cluster of cases of iatrogenic diplopia after cataract surgery that occurred in 1998, when hyaluronidase was unavailable for use in periocular anesthetic regimens. SETTING: The clinical practices of the authors. METHODS: This study comprised a retrospective chart review. RESULTS: Twenty-five cases of transient or permanent diplopia were reported. Of these, 13 eyes had retrobulbar and 10 had peribulbar injections; in 2 cases the injection technique was unknown. The inferior rectus was affected in 19 eyes; of these, 1 had a temporary palsy and 18 had permanent restriction. Temporary paresis developed in the lateral rectus in 5 cases and the superior rectus in 2. Eleven cases were submitted by 4 anterior segment surgeons, who collectively had a zero incidence of iatrogenic postoperative diplopia in the preceding 4 to 11 years of practice (approximately 6900 cases). CONCLUSION: Hyaluronidase may be more important than previously suspected in preventing anesthetic-related damage to the extraocular muscles. The inferior rectus muscle is particularly vulnerable, presumably because of the injection technique.

The correction of unilateral aphakia in children treated for orbital rhabdomyosarcoma.

The survival rate of children with localized orbital rhabdomyosarcoma is now greater than 90% 3 years after diagnosis as a result of advances in radiation and chemotherapy. Ninety percent of these children develop cataracts within 1 to 4 years after the completion of radiotherapy. The correction of aphakia in these children is complicated by the concurrent keratoconjunctivitis and dryness associated with radiotherapy. Three patients with a diagnosis of orbital rhabdomyosarcoma underwent treatment for uniocular cataract. Two of the patients were unable to use extended wear contact lenses. Both underwent epikeratophakia with poor results. One patient who had clinically significant ocular drying prior to cataract extraction underwent successful implantation of an intraocular lens as a primary procedure, with excellent visual results. Clinicians should be aware of the difficulties associated with contact lens wear and epikeratophakia tissue lenses in children who have had high doses of radiation for orbital rhabdomyosarcoma. Such patients are probably best served by primary intraocular lens implantation or by preservation of the posterior capsule at the time of cataract extraction to allow secondary lens implantation if contact lens wear is unsuccessful.

A case report and review of band keratopathy.

A five-year-old male presented with band keratopathy as the first sign of proximal renal tubular acidosis. The band keratopathy was progressive with decreasing visual acuity. Treatment with EDTA was repeated in each eye with only minimal improvement. The pediatric renal service found the serum calcium to be no higher than 10.5 mg% and phosphorus no higher than 6.8 mg%. The calcium-phosphorus product was in the range of 60-65. Band keratopathy can be visually incapacitating and has multiple etiologies. Factors other than elevated calcium concentrations must predispose to development of this disorder. Certain of these factors and a review of band keratopathy are presented in the following article.

Curved ruler for measurement along the surface of the globe.

A curved ruler for measurement along the surface of the globe has been designed to measure the arc instead of the cord measurement. The ruler is especially helpful when one is doing large recessions and posterior fixation of the recti muscles (Faden operation).

Unusual case of acute orbital cellulitis.

A three and one-half year-old female who presented with orbital cellulitis and leukocoria is described. Enucleation was performed as the eye was microophthalmic, blind, and painful. Histopathologic study revealed uveitis with total retinal detachment. The etiology of the retinal detachment was indeterminable. The differential diagnosis of orbital cellulitis in children is reviewed.

Surgical correction of dissociated vertical deviations.

The surgical treatment and results of 17 patients with DVD is presented. Supermaximum recessions of the superior rectus muscle were performed on the deviating eye. No lid changes or any limitation of elevation were noted following the surgery. The manifest deviation was converted to less than ten prism diopters in all except one case. Four over-corrections of two to six prism diopters of hypotropia resulted. There was no change in eye preference to the operated eye. Saccadic velocities showed no change in the acceleration or velocity of the operated superior rectus. Discussion of this technique compared to other modalities is made.