Development of vision in infants and young children.

Behavioral improvement in the quality of infant vision parallels neuroanatomic and neurophysiologic brain development. Progressive refinement of acuity can be tracked by means of tests that employ fixation and following, optokinetic nystagmus, preferential viewing, and pattern-evoked visual responses. These methods of evaluating vision in the preverbal child differ from each other in several respects; their relative advantages and disadvantages are discussed.

Effect of severing the check ligaments and intermuscular membranes on medial rectus recessions in infantile esotropia.

BACKGROUND: The effect of severing the check ligaments and intermuscular membranes on the dose-response curve for medial rectus recessions in patients with infantile esotropia has not been previously studied by randomized assignment techniques using contemporary control and experimental groups and masked precautions. METHODS: A prospective study of 101 patients was performed over an 8-year period. Patients were randomly assigned to either augmented or nonaugmented groups. In the former group, the medial check ligaments and intermuscular membranes were severed; in the latter group, no surgery was performed on the medial check ligaments or intermuscular membranes. Patients were postoperatively evaluated by an observer masked to group assignment. RESULTS: No difference in response to surgery was observed between the two groups at the time of evaluation, which took place, on average, 6 to 7 months after surgery. CONCLUSION: Severing the check ligaments and intermuscular membranes on patients with infantile esotropia undergoing medial rectus recessions does not appear to affect the dose-response curve.

Results of combined surgery on the superior oblique and horizontal rectus muscles for A-pattern horizontal strabismus.

Results obtained in 32 patients with A-pattern horizontal strabismus and overacting superior oblique muscles treated with combined bilateral superior oblique tenotomies and bilateral symmetric surgery on the horizontal rectus muscles were analyzed retrospectively. The magnitude of reduction of the A-pattern correlated positively (r = 0.69) with the size of the preoperative A-pattern. Overall, 27 of the 32 patients (84%) had a satisfactory reduction in their A-pattern. Esodeviated patients received less correction in the primary position than exodeviated patients. Postoperative complications were minimal if the superior oblique tendon was hooked under direct visualization, and minimal dissection was performed on the surrounding tissue prior to transecting it near the nasal side of the superior rectus muscle.

A comparative study of grating and recognition visual acuity testing in children with anisometropic amblyopia without strabismus.

Bailey-Lovie-Ferris visual acuity charts and Teller visual acuity cards were used to compare recognition and grating visual acuity at near testing distances in 32 children with anisometropic amblyopia without strabismus. Appropriate optical corrections were worn. Test-retest intraobserver reliability was higher for letters (r =.95) than for gratings (r = .68). Using 20/30 visual acuity or better as the criterion for normal visual acuity, eight eyes with letter visual acuities ranging from 20/42 to 20/138 would have been inaccurately found to be normal by using the Teller visual acuity cards alone. Grating visual acuity measurements tended to be better than letter visual acuity; and, in general, they did not worsen proportionately with poorer letter visual acuity.

A Polaroid SX-70 camera system for external ocular photography.

An inexpensive Polaroid SX-70 camera system for external eye photography can be assembled from easily obtainable parts. The advantages of this system include a "what-you-see-is-what-you-get" capability, instantly available prints (which permit repeat photography while the patient is still present), and convenient storage of acceptable prints.

Patient data storage and retrieval using dBASE III in a pediatric ophthalmology department.

Ashton Tate's dBASE III has been adapted to store patient data for both medical and administrative purposes by the Department of Ophthalmology of Children's Hospital National Medical Center. The program is run on an IBM-PC microcomputer and stored on twin Iomega 10 megabyte cartridge disks. The advantages of this system include ready availability of both software and hardware, relative ease of customization, simplicity of use, and modest cost.

Amblyopia: definition, classification, diagnosis, and management considerations for pediatricians, family physicians, and general practitioners.

Amblyopia is a reduction in the quality of central, corrected vision resulting from a disturbance in retinal image formation during the first decade of human life. Although the neurophysiology and neuropathology of amblyopia are now better understood than in the past, treatment has not changed significantly in more than 200 years. The earlier amblyopia is detected, the shorter the duration of treatment required to reduce its severity. The mainstay of treatment still consists of forcing the use of the amblyopic eye, most often by occlusion of the sound eye. Complications of treatment include occlusion amblyopia and induction of strabismus in straight-eyed patients.

Pattern-reversal visual-evoked potentials in the diagnosis of amblyopia in children.

We assessed the potential clinical usefulness of pattern-reversal visual-evoked potentials in the diagnosis of amblyopia. Twenty-seven children with anisometropic amblyopia and four children without amblyopia participated. Estimates of visual acuity for each eye (Snellen visual acuity) were obtained by conventional psychometric methods. Visual-evoked potentials to reversing checks subtending 15 minutes of visual arc were also obtained. Visual-evoked potential testing and interpretation were done in a masked fashion. Ten of the 31 children were retested seven to 21 days after the first test to estimate reliability of the procedures. Of the 27 amblyopic children, 22 were correctly identified by the visual-evoked potential test alone. In four patients initial visual-evoked potential tests failed to identify the disparity in visual acuity between the eyes and retests in two of the four again had false-negative results. In one child initial visual-evoked potential testing incorrectly identified the amblyopic eye but repeat testing did identify it. Of the four children with symmetrically good vision, three were correctly identified as normal by the initial visual-evoked potential test. The other normal child was incorrectly identified by the visual-evoked potential test as having amblyopia.

Traumatic retinoschisis in battered babies.

Five infants who were victims of physical abuse had extensive bilateral retinal hemorrhages on initial evaluation and subsequently developed signs of permanent retinal damage. None showed external evidence of trauma to the eyes. Vitreous hemorrhage developed after a delay of several days or more in three cases that were followed closely from the time of the traumatic incident. In several eyes, apparent intraretinal blood-filled cavities were seen acutely in the macular region and elsewhere. Late scarring of the macula typically had a cystic or crater-like configuration. Electroretinography showed loss or reduction of the positive B-wave with preservation of the negative A-wave in every case. We propose that splitting of the retina resulting from the direct mechanical effects of violent shaking was responsible for all of these findings.

Practical management of amblyopia.

One hundred sixteen strabismus patients with amblyopia treated with initial full-time or part-time conventional occlusion of the preferred eye followed when necessary with maintenance occlusion up to a maximum of nine years were studied. Based on the need for maintenance occlusion, patients were divided into a primary occlusion group, composed of patients who did not require maintenance occlusion and a maintenance group occlusion group, composed of patients who did require maintenance occlusion. The main difference between the two groups of patients was the degree of amblyopia at the onset of occlusion therapy, being significantly greater in the maintenance occlusion group. The maintenance occlusion group showed a significantly higher incidence of visual acuity regression when evaluated at ages 12 and 13 years. Occlusion therapy administered to strabismus patients in the manner described in this study resulted in significant visual improvement with a regression in visual acuity of no more than an average of one line on the Snellen chart.

Effect of bright light in the hospital nursery on the incidence of retinopathy of prematurity.

The preterm infant is subjected to prolonged exposure to ambient nursery illumination at levels that have been found to produce retinal damage in animals. We prospectively investigated the effect of exposure to light in two intensive care nurseries by comparing the incidence of retinopathy of prematurity among 74 infants from the standard bright nursery environment (median light level, 60 foot-candles [ftc]) with the incidence among 154 infants of similar birth weight for whom the light levels were reduced (median, 25 ftc). There was a higher incidence of retinopathy of prematurity in the group of infants who had been exposed to the brighter nursery lights, particularly in those with birth weights below 1000 g (86 percent vs. 54 per cent, P less than 0.01 by chi-square test). We conclude that the high level of ambient illumination commonly found in the hospital nursery may be one factor contributing to retinopathy of prematurity and that safety standards with regard to current lighting practices should be reassessed.

Wegener's granulomatosis presenting as orbital pseudotumor in children.

The case of a nine-year-old white female who presented initially with idiopathic inflammatory pseudotumor and was ultimately diagnosed (22 months later) as having Wegener's granulomatosis is presented. A review of the literature reveals that, to date, there are 21 well-documented cases of Wegener's granulomatosis occurring in children under the age of 16. Of these 21 cases, eight patients (39%) manifested ocular or orbital signs during the course of the disease. Four of these cases (50%) presented initially with idiopathic inflammatory pseudotumor. The diagnosis of Wegener's granulomatosis should be considered in children with orbital pseudotumor. Long-term follow-up may be necessary to exclude this possibility.

An automated visual acuity testing computer program using the Apple II system.

We developed an automated visual acuity testing program that uses an E optotype with surrounding confusion bars. The computer software program runs on Apple II equipment and a black-and-white monitor with a five-inch screen. The program is available in response box and joystick versions. The test is suitable for children older than 31/2 to 4 years of age and for adults. A t-test on the same floppy disk as the visual acuity programs is used to test the probability that the differences in test results are greater than chance. Visual acuities of 20 normal subjects were reduced by means of plus lenses. Test-retest acuity correlation coefficients were similar for letter charts and computer-generated E optotypes, suggesting approximately equal reliability under the test conditions employed. Visual acuities of 12 amblyopic eyes were obtained by a Ferris-type letter chart and computer-generated E optotypes. The correlation coefficient was +0.93, suggesting similar test results by these two methods.

Management of infantile esotropia.

The population of patients with infantile esotropia is etiologically and neuroanatomically heterogeneous, and major advances in management will probably require more accurate subgroup delineation. Amblyopia is relatively common in patients with infantile esotropia. It should always be suspected and, when found, should be vigorously treated. Present methods of amblyopia detection and evaluation in young children are still imperfect. Most clinical evidence suggests rather strongly that sensory and motor functions are more nearly normal if alignment (within 10 prism diopters of orthotropia) is attained within the first 2 years of life. Whether alignment obtained within the first year of life provides higher grades of binocular vision is less certain. Virtually all patients with infantile esotropia fail to develop normal binocular vision. Central scotomas are almost always identifiable, even in patients with optimal motor alignment and with the highest levels of binocular vision. Past surgical protocols have tended to produce an excess of under-corrections. More recent surgical protocols are more generous in terms of millimeters of surgery per prism diopter of deviation. Higher cure rates are now being reported. Patients who are successfully aligned early in life still need careful postoperative monitoring for amblyopia, nystagmus, inferior oblique overactions, dissociated vertical divergence, and accommodative esotropia. These patients require frequent follow-up visits until they reach the age of approximately 9 years.

Ophthalmia neonatorum.

Although many types of conjunctival infections in neonates are relatively inconsequential, chlamydial, gonococcal, and herpes simplex infections can cause permanent ocular damage and serious systemic complications. These specific causes are discussed along with silver nitrate conjunctivitis, staphylococcal infections, and nasolacrimal duct obstructions.