Results and complications in 66 cases using a silicone tendon expander on overacting superior obliques with A- pattern anisotropias.

PURPOSE: To supplement limited reports in the literature of the results (outcome)and complications of this procedure with our own recent experience. METHODS: A total of 66 patients with bilateral overaction of the superior oblique and A-pattern strabismus plus 5 patients with a unilateral overacting superior oblique secondary to inferior oblique palsy were treated with a 7 mm silicone expander. RESULTS: The fist group of 66 patients had an average preoperative A-pattern of 39.6 prism diopters with an average correction of the A-pattern from the surgery of 36.3 prism diopters. COMPLICATIONS: Of all 137 operations in these 71 patients, three patients had a sterile orbital cellulitis postoperatively successfully treated with steroids. Also, one patient acquired a Brown's Syndrome-like condition postop'. In these four patients, the sub-Tenon's capsule space had been inadvertently entered during surgery. In addition one unilateral superior oblique palsy occurred postoperatively. CONCLUSION: While this procedure has a very high success rate, special care should be taken with this surgery to avoid entering the sub-Tenon's capsule space.

Ocular plagiocephaly: ocular torticollis with skull and facial asymmetry.

PURPOSE: To observe facial asymmetry in patients with ocular torticollis to better understand its cause. DESIGN: Observational case series. PARTICIPANTS: Forty-four consecutive patients with ocular torticollis in one author's (MFG) private practice were examined for facial asymmetry from January 1998 to August 1998. Some of these, as well as selective others before January 1998 were photographed for a total of 53 photos. METHODS: One author (MFG) examined the frontal, maxillary, and mandibular facial areas of 44 consecutive torticollis patients for appearance of unilateral compression or reduced mass. The laterality of such findings was compared with the side of the head turn or tilt. Photographs of 53 selected ocular torticollis patients were inspected and the direction of nasal tip and columella deviation compared with the direction of head tilt or turn. MAIN OUTCOME MEASURES: Subjective clinical determination of appearance of unilateral facial compression or reduced facial mass. Subjective photographic determination of nasal tip and columella deviation. RESULTS: Forty-three patients with 10 types of ocular torticollis examined were included. Forty-one of 43 showed compression or reduced mass on the same side as the head turn or tilt, including 3 with adult-onset strabismus. Eight nonsuperior oblique palsy patients had nasal deviation to the same side as the torticollis. Six of the eight had head tilts. Seventeen nonsuperior oblique palsy patients had nasal tip deviation to the opposite side of the torticollis. All were pure head turns. Eight superior oblique palsy patients had nasal tip deviation to the same side as the torticollis; nine had deviation opposite. CONCLUSIONS: Patients with multiple types of ocular torticollis, including face turns, show similar appearance of facial compression on the side of the torticollis, suggesting that the tilt or turn itself may cause the asymmetry. This includes face turn strabismus, in which facial asymmetry has not previously been described. Head tilts are frequently associated with nasal tip deviation to the side of the torticollis, head turns with deviation opposite. We refer to such asymmetric facial changes associated with ocular torticollis as "ocular plagiocephaly."

Unusual presentations of accommodative esotropia.

PURPOSE: Most patients with accommodative esotropia are first examined between the ages of 6 months and 2 years. This paper discusses unusual presentations of accommodative esotropia that occur outside of this age-group and/or have a precipitating event that triggered the esotropia. In a series of patients who were from 5 to 11 years of age, trauma was the precipitating event. In some of the patients under 6 months of age, high myopia, as well as a moderate to large amount of hyperopia, was the cause. In 1 teenager, diabetic ketoacidosis precipitated accommodative esotropia. METHODS: We reviewed all of our records for the past 25 years involving patients with a diagnosis of esotropia, and we found 17 patients who had unusual presentations of accommodative esotropia. Of 8 who were under the age of 6 months, 2 had high myopia and 6 had moderate to large amounts of hyperopia. Nine patients were older than age 5. Eight of the 9 had suffered trauma associated with the presentation of accommodative esotropia, and 1 patient's accommodative esotropia was associated with diabetes. The patients with myopia received their full myopic correction. The children under 6 months of age with hyperopia received their full cycloplegic refraction, and the children over age 5 received the most plus that they were able to accept in a noncycloplegic state consistent with good visual acuity (at least 20/30 in each eye). RESULTS: In 17 patients, accommodative esotropia was initially controlled with glasses. In a few of the trauma cases, bifocals were required for control of near deviation. Only 2 of the patients, in whom onset was under 6 months of age, came to surgery. One had hyperopia controlled for 2 years with glasses, and the other had myopia controlled for 3 years with glasses. CONCLUSIONS: Accommodative esotropia can occur prior to 6 months of age. It can also occur in older children (5 to 14 years of age) and can be precipitated by trauma or diabetic ketoacidosis.

Absence of multiple extraocular muscles in craniosynostosis.

The absence of extraocular muscles, particularly the superior rectus1, 2 or superior oblique3, 4 has been recognized to cause strabismus among patients with craniosynostosis. Absence of multiple muscles is less common. In case 1 we note a patient with Pfieffer's syndrome and absent left superior rectus and inferior oblique, with the presence of only a vestigial left superior oblique and an underdeveloped and misinserted left inferior rectus. In case 2 we describe a patient with Apert's syndrome with bilateral absence of the superior rectus and superior oblique muscles. Unsuspected superior rectus absence led to a bilateral elevation deficit after inferior oblique weakening. Also, during the course of treatment, all 3 remaining recti muscles in 1 eye were disinserted. To our knowledge, this is the first report of absent extraocular muscles in Pfieffer's syndrome. Some evidence suggests that collateral anterior segment blood flow exists in cases of absent recti muscles. Further study is needed to determine whether all remaining muscles could be used for strabismus repair. Last, when patients with craniosynostosis require strabismus surgery, we feel that a limited exploration of all extraocular muscles should be carried out.

Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis.

BACKGROUND: Subperiosteal abscess may accompany orbital cellulitis secondary to sinusitis. Common surgical principles include incision and drainage of all abscesses. Previous evidence suggests that some orbital abscesses may be treatable with intravenous antibiotics, especially in young children. Children's hospital records were reviewed to determine which abscesses may be treated medically. PATIENTS AND METHODS: Records of patients admitted for orbital cellulitis from 1993 to 1996 were reviewed. Patients with subperiosteal abscess on CT scan were included. Clinical outcomes for initial surgical versus medical management of medial abscesses were compared. Differences in age, hospital stay, and intracranial involvement were analyzed for medial versus nonmedial abscesses. RESULTS: All patients had abscesses adjacent to infected sinuses. Eighteen young children had medial abscesses. Twelve of 13 were cured by initial medical treatment; 4 of 5 underwent successful initial drainage. Outcomes were not statistically different (P > .490). Seven children with nonmedial abscesses were older (P < .001) and had more complicated courses than those with medial abscess. Three of 6 children with superior orbital abscess also had intracranial abscess. Intracranial complication was more likely with superior versus medial orbital abscess (P < .01). CONCLUSIONS: Medial subperiosteal orbital abscesses secondary to sinusitis in children 6 years of age and younger are highly amenable to treatment with intravenous antibiotics. Older children and children with nonmedial abscesses may have more complicated infections. Children with superior orbital abscesses are at higher risk for intracranial abscess.