Age of the emergence of negative attitudes toward strabismus.

INTRODUCTION: Strabismus impacts a variety of psychosocial variables in both children and adults. Poor self-esteem, lack of confidence, altered interpersonal relationships, and difficulty with employment procurement have been reported. The purpose of this study was to determine the age at which children perceive strabismus in dolls and to evaluate their reactions. METHODS: Three identical dolls were altered so that one was orthotropic, one esotropic, and one exotropic. Thirty-four naïve children between 3 and 7 years of age were individually placed in a waiting room with the 3 dolls as the only toys with which to play. A one-way mirror allowed a hidden observer to tabulate the number of positive and negative behaviors exhibited toward each doll. After a 10-minute observation period, the children were asked a short series of questions about their preferences and attitudes toward the dolls. Odds ratios were then determined for both the observed behaviors and the expressed responses to the strabismic dolls compared with the orthotropic dolls. RESULTS: Children aged 5(3/4) years and older were 73 times more likely than younger children to express a negative feeling about the strabismic dolls when asked (P =.003). Additionally, when comparing the strabismic dolls with the orthotropic doll, children aged 3 to 4(1/4) years did not notice a difference, children aged 4(1/2) to 5(1/4) years tended to describe the eyes as "different," and children aged 5(3/4) years or older almost uniformly gave a negative description of the strabismic dolls. CONCLUSIONS: A negative attitude toward strabismus appears to emerge at approximately 6 years of age. The biopsychosocial determinants of dislike and hostility toward ocular deviations are apparently acquired, learned responses.

Split rectus muscle modified Foster procedure for paralytic strabismus: a report of 5 cases.

PURPOSE: To describe a new eye muscle surgical technique and its outcome in a small series of patients. METHODS AND STUDY: The Foster augmented rectus muscle transposition procedure, which utilizes posterior "lateral" fixation sutures [retroequatorial scleral myopexy parallel and adjacent to the lateral rectus muscle] to obtain greater effect from the transpositions, is modified, to preserve ciliary vessels, by doing only a partial 75-80% transposition of the rectus muscles, preserving and leaving behind a small portion of the muscle containing a ciliary vessel. RESULTS: In five patients in whom preserving ciliary vessel supply was particularly important, the procedure produced results in improving binocular alignment and motility equal to that of the unmodified Foster augmented transposition. There were no complications or undesirable results. CONCLUSION: The modified ciliary vessel preserving procedure can be applied in most cases and may be especially useful in those where this is a high likelihood of additional eye muscle surgery being necessary in the future.

Detection of red reflex asymmetry by pediatric residents using the Brückner reflex versus the MTI photoscreener.

OBJECTIVE: To compare the ability of pediatric residents to differentiate an asymmetric from a symmetric red reflex in patients with anisometropia and microstrabismus using the Brückner reflex and the Medical Technology Innovations (MTI) photoscreener. METHODS: A prospective, masked, case-control study was performed. Twelve pediatric residents evaluated 10 study patients and 6 control subjects in a masked manner in 2 separate sessions, using the Brückner reflex or the MTI photoscreener, evaluating for asymmetric (abnormal) or symmetric (normal) red reflexes between the 2 eyes. Each study patient had asymmetric red reflexes and the amblyogenic risk factor of anisometropia or microstrabismus. Each control subject had symmetric red reflexes. RESULTS: The pediatric residents had a mean correct score of 82% (69%-100%) using the MTI photoscreener versus a mean correct score of 65% (44%-81%) using the Brückner reflex (McNemar test: alpha < 0.01). The sensitivity of the MTI photoscreener evaluation was 89% in comparison to 61% for the Brückner reflex. The specificities for the MTI photoscreener versus the Brückner reflex were similar at 69% and 71%, respectively. CONCLUSIONS: Pediatric residents were better at detecting asymmetric red reflexes in patients with anisometropia and microstrabismus when evaluating MTI photoscreener photographs than when evaluating the red reflexes by the Brückner reflex. The MTI photoscreener may be a more sensitive method than the Brückner reflex to screen for the common amblyogenic risk factors of anisometropia and microstrabismus by easier detection of red reflex asymmetry.

Excessive blinking in childhood: a prospective evaluation of 99 children.

OBJECTIVE: To determine the characteristics and causes of excess blinking in children and to determine outcomes after treatment. DESIGN: Prospective, noncomparative, consecutive case series. PARTICIPANTS: Ninety-nine consecutive children who presented for evaluation of excessive blinking over a 2 year period. METHODS: Children less than 16 years of age who had excessive blinking as their sole or major chief complaint underwent detailed history and ophthalmologic examination. Treatment was recommended based on clinical examination findings. Follow-up evaluations were performed at least 2 months after initial examination. MAIN OUTCOME MEASURES: Etiology of excess blinking and patient characteristics in each diagnostic group. RESULTS: The majority (89%) of children presented with bilateral excessive blinking. Boys outnumbered girls at a ratio of almost 2:1. The most common etiologies were anterior segment and/or lid abnormalities (37%), habit tics (23%), uncorrected refractive errors (14%), intermittent exotropia (11%), and psycogenic blepharospasm (10%). A history of neurologic disease was present in 22% of the patients but was not causally related to the excessive blinking in most cases. Vision-threatening disease was noted in 6% and was easily detected on standard clinical examination. Life-threatening disease was the cause in 4% of the children, but the presence of life-threatening disease was already known in all such patients. CONCLUSIONS: Excessive blinking in children can occur because of a large number of potential problems. Most cases are caused by benign and/or self-limiting conditions. The cause can usually be determined after careful history and clinical examination and routine neurologic evaluation and neuroimaging is unnecessary.

Ocular injury from the venom of the Southern walkingstick.

PURPOSE: To report a case of severe conjunctival and corneal epithelial defects resulting from exposure to the venom of the Southern walkingstick, Anisomorpha buprestoides. DESIGN: Case report. INTERVENTION: The patient was treated with cyclopentolate 1% and underwent daily examinations until the corneal and conjunctival epithelial defects resolved. MAIN OUTCOME MEASURE: Resolution of corneal and conjunctival epithelial defects. RESULTS: The corneal and conjunctival epithelial defects slowly resolved over 6 days. Visual acuity improved to 20/20 in the affected eye. No residual corneal scarring was evident. CONCLUSIONS: Slowly resolving corneal and conjunctival epithelial defects can occur from direct contact with the venom from the Southern walkingstick, A. buprestoides; therefore, this insect should be approached with caution.

Surgical management of V-pattern strabismus and oblique dysfunction in craniofacial dysostosis.

INTRODUCTION: Strabismus affects as many as 60% to 70% of patients with craniofacial dysostosis. V-pattern strabismus with severe oblique muscle dysfunction is the most common ocular motility problem seen and can be difficult to manage. Few studies have reported on the results of strabismus surgery in this condition. METHODS: We retrospectively reviewed the surgical management and outcomes of 14 patients with craniofacial dysostosis who underwent 16 operations to determine the optimal surgical procedure and to report on extraocular muscle anomalies noted at the time of surgery. Operations performed included medial rectus muscle infraplacement (n = 2), inferior oblique (IO) recession (n = 3), IO myectomy (n = 3), IO anterior transposition (n = 3), and IO denervation/extirpation (n = 5). RESULTS: All patients had significant residual ocular motility dysfunction postoperatively. No beneficial effect was noted after IO anterior transposition or after medial rectus muscle infraplacement. Modest improvement of the V-pattern and oblique muscle dysfunction was noted after denervation/extirpation and myectomy of the IO muscle. Bilateral absent or anomalous superior oblique tendons were noted in 8 of 9 patients in whom the superior oblique tendon was examined at surgery. CONCLUSIONS: Strabismus in craniofacial dysostosis is complex and difficult to cure with surgery. Denervation/extirpation and myectomy of the IO muscle offered modest benefits, though neither procedure resulted in normalization of ocular motility. Agenesis of the superior oblique tendon may be causally related in a large proportion of affected patients.

Compliance with outpatient follow-up recommendations for infants at risk for retinopathy of prematurity.

OBJECTIVES: We undertook this study to determine how frequently at-risk infants were scheduled for and brought to follow-up appointments for retinopathy of prematurity (ROP) examination after hospital discharge and to identify barriers to follow-up. METHODS: The records of 126 infants with or at risk for ROP at the time of hospital discharge were retrospectively reviewed. Data recorded included the presence or absence of a timely outpatient follow-up appointment, the identity of the person who scheduled the appointment (hospital staff or parents), attendance rate for appointments made, race or ethnicity, and insurance status. RESULTS: Sixty-two of 126 (49%) infants were scheduled for a timely outpatient examination. Sixty-four of 126 (51%) required telephone contact from our office to be scheduled for an appointment. Eight of 21 (38%) African American infants had an appointment scheduled without additional intervention by our office personnel, and 6 of 21 (29%) were brought to an appointment in a timely manner. Twenty-two of 33 (68%) white infants had an appointment scheduled without additional intervention by our office personnel, and 20 of 33 (61%) were brought to an appointment in a timely manner. African American patients were less likely than white patients to be brought to a follow-up appointment (P =.022). Eleven of 15 (73%) patients, whose appointments were scheduled by hospital personnel before discharge, were brought to their follow-up appointment, compared with 39 of 105 (37%) patients, whose parents were requested to schedule their own appointment (P =.008). CONCLUSION: Almost 50% of infants with or at risk for ROP were not scheduled for a timely outpatient follow-up appointment, putting these neonates at risk for ROP-related blindness. Patients whose appointments were scheduled by hospital personnel before discharge were more likely to be brought to a follow-up examination. Extensive utilization of office support staff was required to ascertain the status of infants who did not have appointments scheduled or who were not brought to follow-up appointments.

Disintegration of the inferior rectus muscle during strabismus surgery for restrictive hypotropia.

We describe a case of disintegration of the inferior rectus muscle during routine strabismus surgery for restrictive hypotropia after cataract surgery. We used this surgical approach to repair the complete infraduction deficit incurred from the injury.

Outpatient management of traumatic hyphemas in children.

OBJECTIVE: There are no outcome reports in the literature for outpatient management of traumatic hyphemas in children. Therefore we studied such cases at our institutions. DESIGN: Retrospective chart review. PARTICIPANTS: 25 children less than 16 years of age with grade I traumatic hyphemas. INTERVENTION: Inactivity at home with frequent office visits to monitor progress and complications. Treatment otherwise varied but virtually all patients received protective eye shields and topical steroids. MAIN OUTCOME MEASURES: Rate of rebleeding and final visual acuity. RESULTS: Three patients (12%) suffered a rebleed; one required surgery for clot evacuation. One of the three did not receive topical steroids and if he is excluded, rebleed rate is 2/24 or 8.3%. The hyphema resolved without sequelae in the other 22 patients. All patients had a final visual acuity of 20/40 or better except three patients (12%) who had concurrent vision-limiting ocular injuries and/or disease. Final visual acuity was 20/30 or better in all three patients with rebleeds. CONCLUSIONS: Our rebleed rate was within the broad range of rebleed rates reported in the literature. However, improved efforts to identify children at highest risk for rebleeding, to maximize compliance with treatments, and to consider systemic agents in selected cases, could further reduce the rebleed rate and increase acceptance and safety of outpatient management in pediatric traumatic hyphemas.

Surgical management of strabismus after rupture of the inferior rectus muscle.

BACKGROUND: Rupture of an inferior rectus muscle is an uncommon problem. The resulting absence of infraduction and large hypertropia that result when the muscle cannot be repaired are challenging to manage surgically. METHODS: We treated 2 patients who had traumatic rupture of the inferior rectus muscle. Both patients underwent an inferior transposition of the inferior halves of the medial and lateral rectus muscles without disinsertion (modified Jensen transposition procedure). RESULTS: Both patients had a persistent small overcorrection in the primary gaze position. One patient was treated with a second strabismus surgery consisting of a recession of the contralateral superior rectus muscle; the other was treated with prism glasses. Both achieved restoration of depression to approximately 40 degrees and single binocular vision in the primary position at distance, near, and in the reading position. CONCLUSION: This modified Jensen transposition procedure of the horizontal rectus muscles appears to be highly effective in the treatment of the hypertropia and infraduction deficit produced by rupture of the inferior rectus muscle. It also appears to be suitable for use in situations when other rectus muscles are absent or unavailable for surgical manipulation.

Threshold retinopathy of prematurity in neonates less than 25 weeks' estimated gestational age.

INTRODUCTION: The survival rate of extremely premature infants has increased. No recent study has investigated the characteristics of retinopathy of prematurity (ROP) or the incidence of threshold ROP in the most severely premature infants. We undertook this study to determine the risk of developing ROP and threshold ROP in the growing sub-population of infants <25 weeks' estimated gestational age (EGA). METHODS: A retrospective review of infants born before the 25th week of gestation between the years 1994 and 1997 was performed. Of 49 infants examined (97 eyes), 42 were born in the 24th week of gestation and 7 were born in the 23rd week. Mean follow-up was 6.3 months (range, 2.5-37 months). Ophthalmology screening examinations were initiated at 5 weeks of age and continued until the infants were no longer at risk for serious ROP. RESULTS: ROP developed in all (97) eyes. Thirty-nine of 97 (40%) eyes in 20 of 49 (41%) infants developed threshold ROP, diagnosed at a mean post-conceptional age of 34 weeks. Thirteen (13%) eyes of 7 (14%) patients developed prethreshold disease and regressed without treatment. CONCLUSION: There is an increased incidence of threshold disease in infants

Ophthalmologic findings in children with congenital cytomegalovirus infection.

BACKGROUND: Cytomegalovirus (CMV) infection is the most common congenital viral infection in the United States, affecting 0.5% to 2% of live births. Approximately 90% of infected infants are asymptomatic at birth. We undertook this study to determine the incidence and etiology of visual impairment and other ophthalmologic abnormalities in children with congenital CMV infection. METHODS: We prospectively evaluated 42 symptomatic and 83 asymptomatic children with congenital CMV infection, along with 21 control patients. One or more comprehensive ophthalmologic examinations were performed on each patient. The frequency and etiology of visual impairment and other ophthalmologic problems were tabulated for each patient. RESULTS: Nine of 42 (22%) patients in the symptomatic group had moderate to severe visual impairment in 16 eyes. Visual impairment was primarily due to optic atrophy in 6 of 16 (37%) eyes, macular scars in 2 of 16 (13%) eyes, and cortical visual impairment in 8 of 16 (50%) eyes. In comparison, none of 83 asymptomatic patients had severe visual impairment (P <.001). One asymptomatic patient had mild unilateral visual impairment caused by a macular scar. Strabismus developed in 12 of 42 (29%) symptomatic patients compared with 1 of 83 (1.2%) asymptomatic patients (P <.001). CONCLUSIONS: Visual impairment and strabismus are common in patients with symptomatic congenital CMV infection and rare in patients with asymptomatic congenital CMV infection. Visual impairment may be caused by cortical, optic nerve, and/or retinal abnormalities. Infants with symptomatic congenital CMV infection should undergo careful ophthalmologic screening and follow-up examinations.

Management and complications of congenital dacryocele with concurrent intranasal mucocele.

INTRODUCTION: The association of dacryocele and intranasal mucocele has been previously reported. Its incidence and optimal treatment are unknown. PATIENTS AND METHODS: A retrospective review of 22 patients with 30 dacryoceles was performed to determine the mean age at presentation, sex distribution, and prevalence of associated intranasal mucocele, associated dacryocystitis, and respiratory distress. The components of the examination, ancillary tests, treatment modalities, and treatment outcomes were then summarized. RESULTS: Unilateral dacryoceles were seen in 16 (73%) of the infants, and bilateral dacryoceles were seen in 6 (27%) of the infants. Four (25%) of the 16 patients who initially had unilateral dacryoceles later developed bilateral dacryoceles. Dacryocystitis, preseptal cellulitis, or both were present on presentation or developed in 18 (60%) of 30 dacryoceles. Nasal endoscopy was performed on 13 (59%) of 22 patients. Nasal examination with nasal speculum and headlight was performed on 7 patients (32%). A concurrent intranasal mucocele was diagnosed in 23 (77%) of 30 dacryoceles. Respiratory distress arose in 5 (71%) of 7 patients with bilateral intranasal mucoceles and in 2 (22%) of 9 patients with a unilateral intranasal mucocele. Thirty-four procedures were performed. Seven dacryoceles (21%) were treated with nasolacrimal duct probing under topical anesthesia. Another one (3%) was treated with needle aspiration with later definitive therapy. All other procedures were managed under general anesthesia. These included 2 nasolacrimal duct probings (6%), 2 probings with silicone tube placement (6%), 10 probings with intranasal mucocele marsupialization and silicone tube placement (29%), and 12 probings with marsupialization alone (35%). Two (29%) of the 7 probings performed under topical anesthesia failed, whereas all other procedures were successful. One dacryocele spontaneously resolved. CONCLUSIONS: Congenital dacryoceles are commonly associated with intranasal mucoceles, dacryocystitis, and preseptal cellulitis. Respiratory distress is common in bilateral cases. Bilateral nasolacrimal duct probing should be considered in unilateral cases because of the high incidence of occult contralateral involvement.

Impact of large angle horizontal strabismus on ability to obtain employment.

OBJECTIVE: To determine if large angle esotropia and exotropia could impact a person's ability to obtain employment. DESIGN: Laboratory experiment. PARTICIPANTS: Seventy-nine respondents unaware of the purpose of the study. METHODS: Photographs of two men and two women were digitally altered to create photographs of the same individual in an orthotropic, esotropic, and exotropic state. The photographs were then randomly affixed to similarly qualified job resumes. The 79 study respondents, unaware of the purpose of the study, were asked to (1) rate each individual applicant on selected job qualification variables, and (2) rank the applicants against each other in order of hiring preference. MAIN OUTCOME MEASURES: Individual applicant rating and hiring preference scores. RESULTS: Women with normal ocular alignment received greater hiring preference scores than did strabismic women (P = 0.007). No difference in hiring preference scores was noted between strabismic and non-strabismic male applicants (P = 0.47). CONCLUSIONS: Large angle horizontal strabismus appeared to be vocationally significant for female applicants, reducing a strabismic female applicant's ability to obtain employment. The presence of strabismus did not appear to influence hiring decisions of male applicants.

Obtaining maximal optic nerve length during enucleation procedures.

OBJECTIVE: To determine optimal scissor blade design and surgical approach to facilitate obtaining a long optic nerve segment during enucleation procedures. METHODS: Two hundred mock enucleations were performed with the use of a human child skull model and a silicone sphere to simulate an eye. Temporal and nasal approaches with scissor blades with noncurved, mildly curved, or strongly curved blades were tested. RESULTS: Longer optic nerve segments were obtained with mildly curved scissor blades from both temporal and nasal surgical approaches. Strongly curved scissor blades uniformly produced smaller specimens. CONCLUSIONS: Mildly curved scissors should be used for enucleation when a long optic nerve specimen is desired. Strongly curved scissors should be avoided.

Therapeutic outcomes of cryotherapy versus transpupillary diode laser photocoagulation for threshold retinopathy of prematurity.

INTRODUCTION: We undertook this study to compare the clinical outcomes in patients treated for threshold retinopathy of prematurity (ROP) with transpupillary diode laser photocoagulation versus transscleral cryotherapy. METHODS: A retrospective chart review was performed of patients treated for threshold ROP at our institution between 1988 and 1997. Cryotherapy was used to treat patients before 1992, and diode laser was used thereafter. One hundred fifteen eyes of 63 patients underwent cryotherapy, and 130 eyes of 70 patients underwent laser treatment. Because strong concordance exists between fellow eyes treated for ROP, statistical analysis was done for right eye outcomes only. Demographics, short-term complications, and treatment parameters were compared on the entire cohort of patients. Structural outcomes were compared between a group of 79 cryotreated eyes (39 OD, 40 OS) and a group of 113 laser-treated eyes (56 OD, 57 OS). Mean cycloplegic refraction was compared between a group of 38 cryotreated eyes (18 OD, 20 OS) and a group of 90 laser-treated eyes (46 OD, 44 OS). Visual acuity for preverbal and nonverbal children was estimated and converted to a Snellen visual acuity equivalent. Geometric mean visual acuity was then compared between a group of 44 cryotreated eyes (22 OD, 22 OS) and a group of 92 laser-treated eyes (47 OD, 45 OS). Patients were included in each outcome analysis if adequate documentation was present in the patient record. RESULTS: Demographics and short-term complications were not significantly different between the 2 groups. In the statistical group, 22 of 39 right eyes (56.4%) in the cryotherapy group versus 49 of 56 right eyes (87.5%) in the laser group had resolution of ROP after treatment (P = .0008). Mean spherical equivalent cycloplegic refraction at 12 months of age and over the follow-up period was not significantly different between the cryotherapy and laser groups. Estimated geometric mean visual acuity in the cryotherapy group was 20/103 and in the laser group was 20/49 at 12 months of age (P= .0099). CONCLUSIONS: Diode laser photocoagulation was associated with a better long-term structural outcome and visual acuity compared with cryotherapy for the treatment of threshold ROP. Refractive error was not significantly different between the 2 groups over an equivalent follow-up period.

Incidence of presumed cytomegalovirus retinitis in HIV-infected pediatric patients.

INTRODUCTION: Large population studies of adult patients suggest an incidence of cytomegalovirus (CMV) retinitis as high as 19% to 20% as a late complication of adult HIV infection. We conducted this prospective study of a large cohort of HIV-infected children to determine the incidence of CMV retinitis in HIV-infected children. METHODS: From January 1984 to August 1997, 173 HIV-infected children were followed up for an average of 55.3 months (13-164 months). The patients were seen in the Department of Pediatrics at least once every 6 months. Ophthalmologic examinations were initiated when a patient's CD4 count dropped below 50 or sooner if required for ophthalmologic or other indications. Ophthalmologic examination was then repeated every 6 months. RESULTS: A total of 116 (67%) of 173 patients underwent ophthalmologic examination. Four (3.4%) of 116 patients had CMV retinitis at a mean time of 17.3 months (8-38 months) after their CD4 counts dropped below 20. None of the 4 patients with CMV retinitis had subjective visual complaints despite advanced retinitis. Three patients had bilateral and 1 patient had unilateral CMV retinitis. CONCLUSIONS: CMV retinitis occurred infrequently in HIV-infected pediatric patients and was diagnosed only in patients with a CD4 count below 20. Routine ophthalmologic screening examinations may not be necessary in pediatric patients until the CD4 count is below 20. Because children may not complain of decreased vision, at-risk children should undergo frequent ophthalmologic examination.

PHACE: a neurocutaneous syndrome with important ophthalmologic implications: case report and literature review.

OBJECTIVES: To introduce PHACE syndrome (Posterior fossa malformations, Hemangiomas, Arterial anomalies, Coarctation of the aorta and other cardiac defects, and Eye abnormalities) to the ophthalmologic literature; to report the first case of PHACE syndrome associated with congenital glaucoma; and to review the ocular and systemic findings that may occur in this entity. DESIGN: Case report and literature review. METHODS: The authors report a child with PHACE syndrome and congenital glaucoma and review the ophthalmologic and systemic manifestations of this syndrome. RESULTS: A 9-month-old girl with PHACE syndrome was treated. She had a large right facial hemangioma, central nervous system (CNS) abnormalities, and cardiac anomalies. Glaucoma was detected in her left eye, and she underwent glaucoma surgery. She did well following two glaucoma procedures, and the facial hemangioma is responding to medical treatment. CONCLUSIONS: Ophthalmologists who examine children with large facial hemangiomas should consider PHACE syndrome in the differential diagnosis and should obtain appropriate CNS imaging studies and cardiac evaluation when the diagnosis is suspected. Congenital glaucoma should be added to the list of PHACE-associated ocular anomalies.