Pediatric Ophthalmology Scope of Practice.

PURPOSE: To determine practice patterns of pediatric ophthalmologists with respect to types of medical conditions cared for and age of patients treated due to limited data regarding pediatric ophthalmologists' scope of practice. METHODS: A survey was sent to 1408 international and United States members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) membership through the group's internet listserv. Responses were collated and analyzed. RESULTS: Ninety members (6.4%) responded. 89% of respondents confine their practices to pediatric ophthalmology and adult strabismus. The percentages of respondents who provide primary surgical and medical treatment of the following conditions include 68% for ptosis and anterior orbital lesions, 49% for cataracts, 38% for uveitis, 25% for retinopathy of prematurity, 19% for glaucoma, and 7% for retinoblastoma. For conditions other than strabismus, 59% restrict their practice to patients less than 21 years of age. CONCLUSION: Pediatric ophthalmologists provide primary medical and surgical care for children with a wide variety of ocular conditions, including complex disorders. Awareness of this variety of practice might prove beneficial in encouraging residents to consider careers in pediatric ophthalmology. Consequently, fellowship education in pediatric ophthalmology should include exposure to these areas.

Long-term outcomes of strabismus surgery in Mobius sequence.

Purpose: Mobius sequence is a rare disorder that results from underdevelopment of the sixth and seventh cranial nerves, with subsequent facial weakness and impairment of ocular abduction. Approximately half of the affected patients have esotropia with limitation of extraocular movements. This study retrospectively reviews the long-term outcome of strabismus surgery for such patients. Methods: The long-term follow-up results in five children with Mobius sequence, who were observed after strabismus surgery for congenital esotropia, were analyzed. Results: All patients had a limitation of abduction in both eyes. Preoperative esotropia ranged from 20 to 30 prism diopters (PD) (mean 27 PD). Patient age at surgery ranged from 4.5 to 14 months. Bilateral medial rectus muscle recession was performed in all cases, ranging from 4.0 to 6.5 mm. Inferior transposition of the medial rectus muscles was performed in two patients for treatment of V-pattern, and two patients also had surgery for vertical strabismus. Follow-up ranged from 4 to 19.5 years (mean 11.7 years). The final horizontal alignment was <8 PD in all patients, and all demonstrated some binocularity. Conclusion: Bilateral medial rectus muscle recession is an effective treatment for esotropia associated with Mobius sequence, with good long-term stability.

Infantile Exotropia and Developmental Delay.

PURPOSE: To evaluate a group of infants with this disorder to determine the long-term outcome of surgery and to assess the need for neurologic evaluations. METHODS: This interventional case series reviewed the records of infants who underwent surgery for the treatment of exotropia with onset during the first year of life. The preoperative ophthalmic and systemic findings, treatment, and developmental and ophthalmic outcomes were reviewed. Surgery was considered successful if the horizontal deviation was less than 10 prism diopters (PD). Developmental assessments were obtained at each visit. RESULTS: Twenty-six patients presented between age 2 and 10 months with exotropia ranging from 20 to 95 PD. Ten (38%) patients had a developmental delay that was recognized at the first visit, 9 of whom had a systemic diagnosis at that time; the other patients remained developmentally normal during a mean follow-up of 7 years. Age at surgery ranged from 4 to 18 months. Surgery was successful in 10 (38%) of 26 patients after 1 surgery and in an additional 13 (50%) of 26 patients after a second surgery. CONCLUSIONS: In this study, the need for more than 1 surgery was higher in infantile exotropia when compared to other forms of childhood strabismus, but most children achieved good alignment with one or two surgeries. Developmental delay is common in patients with infantile exotropia, but this was usually recognized at the time of the initial evaluation. In the current patients, routine neurologic screening or imaging of these otherwise developmentally normal infants was not required. [J Pediatr Ophthalmol Strabismus. 2018;55(4):225-228.].

Comparison of lateral rectus muscle re-recession and medial rectus muscle resection for treatment of postoperative exotropia.

PURPOSE: To compare the outcomes of unilateral lateral rectus muscle re-recession and medial rectus muscle resection for treatment of recurrent or persistent exotropia. DESIGN: Retrospective nonrandomized clinical trial. METHODS: setting: Hospital-based clinical practice. PATIENT POPULATION: Forty patients with recurrent or persistent exotropia following bilateral lateral rectus muscle recessions. INTERVENTION: Fourteen patients were treated with unilateral medial rectus muscle resection and 26 with unilateral lateral rectus muscle re-recession. MAIN OUTCOME MEASURES: Outcomes were considered successful if the patients had deviations less than 10 prism diopters (PD) at last follow-up. All patients were followed for at least 1 year postoperatively. RESULTS: The mean preoperative deviations were 17.4 PD in the medial rectus muscle resection group and 18.1 PD in the lateral rectus muscle re-recession group. Successful outcomes were achieved in 9 of 14 patients (64%) treated with medial rectus muscle resection and 19 of 26 patients (73%) treated with lateral rectus muscle re-recession. There was no statistically significant difference between these outcomes. Mean follow-up was 4.5 years in the medial rectus muscle resection group and 2.9 years in the lateral rectus muscle re-recession group. CONCLUSIONS: Surgery on a single muscle can be used to treat moderate-angle recurrent or persistent exotropia. Unilateral re-recession of the lateral rectus muscle and medial rectus muscle resection have equivalent success rates.

Diplopia following cosmetic surgery.

Cosmetic blepharoplasty is the most often performed procedure in plastic surgery and ophthalmic plastic surgery. Many complications have been reported including ectropion, exposure keratitis, hemorrhage, epiphora, infection, vision loss, and, very rarely, diplopia. Although uncommon, there have been several case reports and case series published evaluating possible causes of this problem, including aggressive excision of fat, wound-related inflammation, conjunctival edema, and temporary muscle disturbances. Although the inferior oblique muscle is most susceptible to injury, the inferior rectus and superior oblique muscles are also subject to trauma. When performing cosmetic blepharoplasties, surgeons should be cautious when dissecting fat pads and should do so under direct visualization. Meticulous cautery is also important to avoiding injury to the extraocular muscles. Fresnel prisms and Bangerter filters can be used to help alleviate diplopia in patients with small-angle strabismus. Surgical exploration and extraocular muscle surgery may be indicated in patients with diplopia that cannot be resolved with nonsurgical treatment.

Oblique muscle surgery for treatment of nystagmus with head tilt.

BACKGROUND: Patients with nystagmus may adopt an abnormal head posture if they have a null zone in eccentric gaze. These patients uncommonly present with torticollis due to a null zone when the head is tilted. We describe the results of surgery on the oblique muscles to improve the abnormal head posture in this condition. METHODS: This was a retrospective review of patients who had head tilts due to null zones of nystagmus. Surgery consisted of an anterior 50% tenectomy of the superior oblique tendon on one side and recession of the inferior oblique muscle to a position 6 mm posterior to the insertion of the inferior rectus muscle on the contralateral side. The patients' clinical histories and outcomes were reviewed. RESULTS: Six patients underwent the procedure. Of these, four had infantile nystagmus syndrome and two were born prematurely and had histories of intraventricular hemorrhages. Five of the patients had previous Kestenbaum surgery that corrected the horizontal component of their abnormal head postures. Age at time of surgery for the head tilt ranged from 3 to 13 years. Postoperative follow-up ranged from 1.5 to 3 years. The preoperative head tilts ranged from 25° to 45° (mean, 39°). The postoperative improvement ranged from 20° to 40° (mean, 28°). One of the patients with a history of intraventricular hemorrhage required additional surgery for strabismus unrelated to nystagmus. CONCLUSIONS: Anterior tenectomy of the superior oblique tendon combined with contralateral recession of the inferior oblique muscle improved head tilts related to a null zone of nystagmus.

Long-term results of botulinum toxin-augmented medial rectus recessions for large-angle infantile esotropia.

PURPOSE: To evaluate the long-term results of medial rectus recessions augmented by botulinum toxin injection for treating infants with large-angle (> 60 prism diopters [PD]) infantile esotropia. DESIGN: Interventional case series. SETTINGS: Hospital-based clinical practice. PATIENT POPULATION: Twenty-three patients with large-angle infantile esotropia who were followed for at least 2 years postoperatively. INTERVENTION: Surgical treatment with botulinum toxin in addition to bilateral medial rectus muscle recessions. The preoperative findings, treatment, and outcomes were reviewed. MAIN OUTCOME MEASURES: Surgery was considered successful if the patients did not require additional horizontal strabismus surgery and had less than 10 PD of horizontal deviation. RESULTS: The age at surgery ranged from 4 to 36 months (mean 14.5 months) and the angle of esotropia ranged from 65 to 100 PD (mean 72 PD). Treatment was successful in 17 of 23 patients (74%), with follow-up of 2 to 13 years (mean 6.6 years). CONCLUSION: Botulinum toxin-augmented medial rectus recession is an effective treatment for large-angle infantile esotropia, with stable results over time.

Persistently recurrent infantile esotropia.

INTRODUCTION: Children with infantile esotropia often require more than one surgery to align the eyes horizontally, for either recurrent esotropia or consecutive exotropia. We report an unusual subset of patients who had persistently recurrent esotropia despite multiple surgeries. METHODS: The records of 11 patients who presented before age one year with infantile esotropia and who had three or more surgeries for recurrent esotropia were reviewed. The number of surgeries, outcomes, and associated systemic conditions were recorded. RESULTS: These 11 patients represented 4% of children who were operated upon for infantile esotropia during the time of the study. The number of surgeries per patient ranged from 3-9 (mean 5). All of the horizontal surgeries in eight patients were for esotropia, while three patients developed exotropia after three or more surgeries for esotropia. Three children were otherwise normal, three had mild nonspecific developmental delay, one was premature, one had Trisomy 21, and one had spina bifida and high myopia. Following their most recent surgery, eight children had deviations of 8delta or less, and three had deviations between 8delta and 16delta. Seven patients demonstrated fusion. Age at last follow-up ranged from 2-13 years (mean 6.7 years). CONCLUSION: Persistently recurrent esotropia is an unusual occurrence in children with infantile esotropia. Developmental delay is common in these patients, although none were markedly delayed. Satisfactory ocular alignment can be achieved in most patients, but several surgeries may be necessary to achieve this.

Effect of preoperative stability of alignment on outcome of strabismus surgery for infantile esotropia.

INTRODUCTION: Some strabismus surgeons wait until the angle of deviation stabilizes prior to operating on patients with infantile esotropia. This study evaluated whether a preoperative increase in the angle of deviation affected surgical outcomes. METHODS: This was a retrospective comparative case series in which records of patients with infantile esotropia, who had surgery performed before age 2 years and who were followed for at least 2 years postoperatively, were reviewed to identify two groups for comparison: the first had /=10(Delta) increase in the angle of deviation prior to surgery. In the latter group, surgery was performed for the angle present at the time of surgery. Outcomes were considered successful if the patients had microtropias. RESULTS: Fifteen patients were identified in each group. The interval between the first office visit and time of surgery was the same in both groups (mean, 2 months). Outcomes were successful in 11 of 15 (73%) in each group (no significant difference, p = 0.659). CONCLUSIONS: There was no difference in outcome between children whose angles of deviation were stable and those whose angles increased prior to surgery. This indicates that strabismus surgery does not need to be delayed while waiting for the angle of deviation to stabilize. Surgical correction may therefore be achieved at an earlier age, which may have a beneficial effect on outcome.

Cerebral Palsy for the Pediatric Eye Care Team Part II: Diagnosis and Treatment of Ocular Motor Deficits.

INTRODUCTION: Cerebral palsy is a term used to describe a spectrum of neurological deficits resulting from damage to the developing nervous system. This paper, the second in a series of three articles, will present frequency, diagnosis, and management of the ocular motor deficits associated with CP. Topics for discussion will include the prevalence and type of strabismus, the effect of CP on eye movement systems, the efficacy of vision therapy for eye movement deficits, and strabismus surgery. METHODS: In 2002, a retrospective chart review of all cases of cerebral palsy referred to the St. Louis Children's Hospital Eye Center was done. Detailed data on the sensory and motor deficits documented in these children was collected. Also recorded was the management strategy and response to treatment. RESULTS: Of the 131 cases reviewed (mean age 5.2 years at presentation), 84 (64%) had strabismus: 55% esotropia and 27% exotropia. Of those patients tested for eye movement disorders 67 (61%) had evidence of instability of fixation; 85% of the patients had a pursuit deficit; and 80% had some type of deficit in performing saccades. Vergence was affected in 45% of our patients. Of the patients who underwent strabismus surgery, 67% achieved success after a mean number of 2.1 surgeries. Surgical success was associated with mild or moderate CP (P <.0005), and a stable preoperative angle. Six percent of our patients underwent vision therapy for strabismus or eye movement anomalies under the direction of an outside optometrist. CONCLUSION: Infantile strabismus is significantly more common in children with CP than in the general pediatric population. Disorders of eye movements are also very common. Based on our experience and review of the literature there is no convincing evidence that vision therapy significantly improves eye movements or visual functioning. Approximately 2 of every 3 cases of nonaccommodative strabismus associated with CP can be successfully managed with conventional strabismus surgery, though most children will require at least two surgeries to achieve alignment.