One-Month Postoperative Horizontal Strabismus Surgery Outcomes Using Adjustable and Nonadjustable Sutures.

INTRODUCTION: Previous series suggest adjustable sutures (AS) in adult strabismus surgery yield improved ocular alignment and better success rates compared to nonadjustable sutures (NAS). We questioned whether these differences are clinically significant and whether they justify the added time and discomfort required for AS. METHODS: We reviewed all available records of adults undergoing horizontal strabismus surgery by the last two authors between 2000 and 2014. Independently, the two surgeons developed a preference for NAS midway through the study period, permitting comparisons between two treatment groups. Results were assessed at one to two months postoperatively. The primary outcome was alignment in primary position at one to two months postoperatively. The secondary outcome was success rate, defined as <10PD residual or consecutive deviation. RESULTS: We included 184 patients, 68 with AS and 116 with NAS. No significant difference in primary position alignment at 1-2 months was noted between AS and NAS for esotropia (P = .26) or for exotropia (P = .10). Success rates were similar (P = .58 for esotropia and P = .34 for exotropia). DISCUSSION: Although we acknowledge limitations in this retrospective study, our results suggest that AS overall was not associated with improved alignment or success rates, compared to NAS, at 1- to 2- months postoperatively. CONCLUSIONS: Although adjustable sutures represent a valuable surgical option at the discretion of individual surgeons and their patients, we no longer routinely use AS in all adult cases. A prospective study to evaluate long-term outcomes would be helpful.

Short-term retinal detachment risk after treatment of type 1 retinopathy of prematurity with laser photocoagulation versus intravitreal bevacizumab.

PURPOSE: To perform a stratified comparison of the short-term risk of retinal detachment after treatment of type 1 retinopathy of prematurity treated with panretinal photocoagulation laser versus intravitreal bevacizumab. METHODS: The medical records of consecutive infants treated for type 1 ROP between 2010 and 2018 were retrospectively reviewed. An a priori decision was made to divide infants into two groups, those treated before postmenstrual age (PMA) of 36 0/7 weeks and those treated at or after PMA of 36 0/7 weeks. The primary outcome was presence of any retinal detachment (stage 4A, 4B, or 5) during the 8 weeks following treatment. RESULTS: A total of 222 eyes of 115 infants were included. In eyes treated before 36 0/7 weeks' PMA, retinal detachment occurred in 0 of 34 eyes treated initially with bevacizumab compared with 9 of 56 (16%) treated with laser (P = 0.0112); in eyes treated at or after 36 0/7 weeks, in 0 of 2 eyes treated with bevacizumab and 1 of 130 eyes (0.8%) treated with laser. CONCLUSIONS: The short-term risk of retinal detachment among infants requiring treatment for type 1 ROP prior to 36 0/7 weeks' PMA was lower in eyes treated with intravitreal bevacizumab than in eyes treated with laser, presumably due to the faster effect of bevacizumab in eyes that have more aggressive ROP.

Acquired, Comitant, Non-Accommodative Esotropia (ANAET): Evaluation, Treatment, and Prognosis.

Children presenting in later childhood with isolated, acquired, comitant non-accommodative esotropia (ANAET) form an unusual clinical group whose evaluation, treatment, and prognosis are unclear. We identified 9 such patients with no evidence of intracranial pathology whose outcomes following standard bilateral medial rectus recessions were excellent.

Long-Term Follow-up of Spasmus Nutans.

PURPOSE: Spasmus nutans is an acquired form of nystagmus that is classically associated with torticollis and titubations of the head, often presenting in the first year of life and spontaneously resolving within the next 2 years. The purpose of our study was to record and characterize the long-term prognosis of children diagnosed with spasmus nutans. METHODS: All patients under the age of 21 years with a diagnosis of spasmus nutans were included. Parameters of age, nystagmus symmetry and quality, presence of titubations, torticollis, and strabismus, and findings on CT or MRI were recorded. RESULTS: Our 22 patients had an average age of onset of 9.8 and a follow-up of 62.6 months. Nystagmus was unilateral in 5 children, asymmetric in 5, symmetric in 10, and inapparent in 2. Titubations were identified in 10 and torticollis in 7. Nystagmus persisted in 16 of 20 children, titubations in 3, and torticollis in 6. Neuroimaging, performed on 17 of the 22 children, was negative for any space-occupying lesions. CONCLUSION: In conclusion, we are reluctant to assure parents of children who have even the most typical spasmus nutans that their child will be normal after a predictable interval. Instead, we advise them that many children do well, assuming normal imaging, but that nystagmus, torticollis, and even titubations may persist. Follow-up, especially for strabismus and amblyopia, should be continued throughout childhood.

Conservative Management of Lower Eyelid Epiblepharon in Children.

PURPOSE: Although much literature has focused on various techniques to repair epiblepharon, no study has addressed how frequently surgical intervention is required. METHODS: The authors tabulated data from all patients with epiblepharon seen over the past 15 years. RESULTS: Eighty-nine patients were included, 61 (69%) with tearing, discharge, conjunctival injection, or eye rubbing. Trichiasis was present in 15 cases (17%), 6 (7%) with corneal staining. In all cases, the initial treatment was conservative: antibiotic ointment or tear substitutes in 73 cases with trichiasis, symptoms of irritation, or corneal changes and observation in the remaining 16 cases. Three children (3%) were referred for eyelid surgery because of persistent symptoms. No patient had corneal scarring or long-term complications. CONCLUSIONS: Although vision-threatening complications can result, a trial of topical antibiotic ointment and/or ocular lubricants was effective in nearly all patients. Most resolved with minimal symptoms. The few eventually requiring eyelid surgery suffered no long-term complications. The authors recommend a trial of conservative treatment before eyelid surgery is undertaken. [J Pediatr Ophthalmol Strabismus. 2017;54(1):15-16.].

Episodic Excessive Blinking in Children.

PURPOSE: Many children present with excessive blinking. Categorization, associated conditions, and prognosis are controversial. METHODS: All children with excessive blinking were reviewed, excluding those with known uveitis, glaucoma, or obvious eyelid abnormalities. Parents were telephoned for follow-up. RESULTS: No ocular pathology was identified in 31 of 34 children with excessive blinking (91%). Parents were able to report a specific cause of blinking in 7 (21%). In 24 of 34 (71%), parents reported complete resolution of excessive blinking. No new ophthalmologic diagnoses were uncovered on follow-up. CONCLUSIONS: Episodes of excessive blinking rarely indicate neurologic disorders and frequently resolve spontaneously.

Headache and refractive errors in children.

PURPOSE: To investigate the association between uncorrected or miscorrected refractive errors in children and headache, and to determine whether correction of refractive errors contributes to headache resolution. METHODS: Results of ophthalmic examination, including refractive error, were recorded at initial visit for headache. If resolution of headache on subsequent visits was not documented, a telephone call was placed to their caregivers to inquire whether headache had resolved. RESULTS: Of the 158 patients, 75.3% had normal or unchanged eye examinations, including refractions.Follow-up data were available for 110 patients. Among those, 32 received new or changed spectacle correction and 78 did not require a change in refraction.Headaches improved in 76.4% of all patients, whether with (71.9%) or without (78.2%) a change in refractive correction. The difference between these two groups was not statistically significant (P = .38). CONCLUSIONS: Headaches in children usually do not appear to be caused by ophthalmic disease, including refractive error. The prognosis for improvement is favorable, regardless of whether refractive correction is required.

Treatment of consecutive exotropia: unilateral lateral rectus recession combined with medial rectus advancement or resection.

PURPOSE: Consecutive exotropia presents a difficult clinical problem, especially when previously recessed medial recti are to be strengthened. Surgical options include advancement, typically with a small resection, and resection alone. METHODS: The authors retrospectively reviewed records of all patients who underwent a second two-muscle surgery on a single eye for consecutive exotropia. Patients with paralytic strabismus and those with less than 1 month of postoperative follow-up were excluded. In 2003, one of the authors began medial rectus resections without advancements in most cases, whereas a second author continued to perform advancements. Two treatment groups were thus reviewed. RESULTS: Forty-two patients qualified for inclusion, including 23 for the resection group and 19 for the advancement group. Preoperative deviations were similar (P = .35, 95% confidence interval: -2.64 to 9.82). Postoperative deviations averaged 11.4 prism diopters (PD) in the resection group and 11.5 PD in the advancement group (P = .98, 95% confidence interval: -12.2 to 12.3). Forty-eight percent of the resection group and 63% of the advancement group achieved alignment within 10 PD of orthophoria (P = .33, 95% confidence interval: -9.0% to 39%). CONCLUSIONS: Surgical results were favorable following both techniques. Although both techniques appear to be adequate, resection of previously recessed medial recti may be preferable because they allow use of standard surgical tables and avoid advancement of inflamed tissue into the palpebral fissure.

Left-Sided Predominance in Pseudo-esotropia.

Pseudo-strabismus, or more precisely, pseudo-esotropia, is commonly encountered in pediatric ophthalmology. In our practice, the left eye was reported by parents as being deviated more frequently than the right eye. We attribute this laterality to the fact that most parents are right handed. They therefore tend to hold their children with their left arm, and to feed them with their right hands, in both cases viewing the left eye of the child in the adducted position.

The association of refractive error, strabismus, and amblyopia with congenital ptosis.

PURPOSE: To determine the frequency of amblyopia and its associations among children with congenital ptosis. METHODS: A retrospective chart review of 92 active patients with congenital ptosis in the practices of 2 of the authors. The main outcome measures were relative eyelid ptosis severity, presence and type of strabismus, refractive error, and amblyopia. RESULTS: Amblyopia was identified in 22 of 92 patients (23.9%), in almost every case occurring in the context of coexisting anisometropia or strabismus and affecting the eye with the more severe ptosis (P = 0.0001). Amblyopia was more likely to occur in cases with greater relative eyelid asymmetry and did not develop in children with symmetric ptosis. In several cases, anisometropia and amblyopia were not initially apparent but progressively developed during follow-up. CONCLUSIONS: Children with congenital ptosis are at risk of anisometropic and strabismic amblyopia, which may progress during early development. Patients should be examined at regular intervals to evaluate and treat these potential complications.

Eye pain in preschool children: diagnostic and prognostic significance.

BACKGROUND: Preschool children often present for ophthalmologic examination because of eye pain. Although the differential diagnosis includes serious conditions, the diagnostic and prognostic importance of apparently isolated eye pain are unknown. METHODS: We reviewed records of 80 consecutive patients presenting between 2 and 6 years of age with eye pain but without a red eye or a history of an obvious cause of pain. Families of children seen in the office only once were contacted by phone to obtain follow-up information. RESULTS: Functional eye pain was diagnosed in 73 of 80 patients (91%). Of the 64 patients with follow-up between 1 week to 4 years (mean, 21 months), 56 (88%) had no other cause of eye pain. Dry eyes, allergic conjunctivitis, blepharitis, corneal foreign body, sinusitis, and trichiasis were diagnosed in 7 patients. Other children were found to have refractive error, amblyopia, blepharospasm, and nystagmus--all considered unlikely to cause eye pain. CONCLUSIONS: Absent a preexisting or obvious cause of eye pain, the symptom is usually functional in preschool children who may have difficulty communicating vague visual symptoms to caregivers. However, such children deserve examination, not only so that unapparent causes can be excluded but also because unrelated conditions may require further evaluation and treatment. Parents can be reassured that if no abnormality is found on initial ophthalmologic examination, children with eye pain are unlikely to have subsequent diagnoses.

Performance of strabismic subjects using a validated surgical training module: a pilot study.

PURPOSE: To compare the performance of patients with strabismus to that of age-matched controls in a validated surgical training module. METHODS: A prospective experimental study was conducted of 14 adult patients with strabismus since childhood and absent stereopsis and of 14 age-matched controls with normal stereopsis. Each participant received instruction in the task of peg transfer on a validated surgical training device and then completed 10 consecutive timed trials. The means of the best 5 scores were compared using the 2-sample Wilcoxon rank-sum test. RESULTS: The average age of cases was 34.8 years (range, 15-51 years) compared with 37.8 years (range, 14-56 years) for controls. The scores for the strabismic patients ranged from 50.8 to 151.4 seconds, with a mean of 82.5 +/- 26.7 seconds. Controls ranged from 43.2 to 129 seconds, with a mean of 64.7 +/- 23.9 seconds. The Wilcoxon rank-sum test showed significantly better performance among controls (p = 0.022). CONCLUSIONS: Patients with strabismus performed more poorly than did age-matched controls in this model of hand-eye coordination. However, there was significant overlap between groups and several patients with strabismus performed better than the mean of the control group. Further investigation is required to elucidate the impact of strabismus on surgical performance.

The American Association for Pediatric Ophthalmology and Strabismus workforce distribution project.

PURPOSE: To describe data sources and functional utility of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) workforce database and associated map files. METHODS: Population data from the 2000 U.S. Census and current listings from the AAPOS and American Academy of Ophthalmology (AAO) databases were organized to demonstrate and analyze practitioner-to-population relationships for metropolitan statistical areas nationwide. An interactive map was developed to provide an intuitive graphical display of the data. RESULTS: A total of 749 active AAPOS members were distributed in 154 of 280 defined metropolitan statistical areas. Within these areas, a 0- to 20-year age subgroup varied from 17.8% to 42.6%, with an average of 30.4%. The AAPOS member-to-million-person ratio varied from 1.3 to 27, with higher numbers generally representing regions with population bases inadequately defined by Census Bureau statistical area definitions. Ratios for a majority of larger, better-defined areas ranged from 3 to 4 AAPOS members per million persons. Sizable areas with no AAPOS member presence were identified and tabulated. AAO members with a specified pediatric practice focus who were not AAPOS members were identified in 103 areas, possibly influencing patient choices and practitioner referrals for these regions. CONCLUSIONS: The AAPOS workforce database and related interactive map display practitioner and population data that may assist physicians and planners in targeting practice development and identifying potentially underserved areas.

Stepwise treatment paradigm for congenital nasolacrimal duct obstruction.

PURPOSE: To compare the outcomes achieved by a series of patients treated in a stepwise fashion who presented with congenital nasolacrimal duct obstruction. METHODS: In this retrospective interventional case series, 127 patients, ranging in age from 1 month to 81 months, with 173 lacrimal systems diagnosed with congenital nasolacrimal duct obstruction, were treated in a stepwise fashion. A treatment paradigm was evaluated that prescribed probing as an initial procedure regardless of age. Those who failed probing received balloon catheter dilation. Those who failed probing and balloon catheterization received silicone intubation. Dacryocystorhinostomy was reserved for patients failing the above treatments. Clinical success was defined as complete resolution of symptoms. Success rates at each step were evaluated, and a cost analysis was performed. RESULTS: Lacrimal probing was successful in 134 of 173 (76.9%) cases. Of the 39 probing failures, 32 (82.1%) were cured with balloon catheterization. All 7 cases (100%) that failed probing and balloon catheterization were cured with silicone intubation. No patient in this series required dacryocystorhinostomy. CONCLUSIONS: A stepwise approach to the treatment of congenital nasolacrimal duct obstruction is a clinically and financially effective model for treatment.

The management of strabismus in adults--III. The effects on disability.

INTRODUCTION: This is the third article in a series on the various facets of the management of strabismus in adults. Here, we give a broad overview of the types and severity of disability and provide initial validation of an instrument (questionnaire) to assess these disability aspects. METHODS: After undergoing strabismus surgery, 101 patients from 6 centers completed a 6-item questionnaire in which they rated both the before-surgery and after-surgery severity of problems associated with their strabismus, ranging from specific health, daily functioning, social interaction, concerns about the future, and self-image to job-related difficulties. RESULTS: The before-surgery outcomes showed significant variation across the 6 types of problems (P < 0.001), with "specific health" and "daily tasks" yielding the highest problem rating. Patients with diplopia reported more severe problems with "daily tasks" (P = 0.004) and "concerns about the future" (P = 0.026) than patients without diplopia. Overall, all problem ratings declined after surgery (P < 0.001), but patients who were not successfully aligned were left with higher problem ratings on "specific health" (P = 0.005), "daily tasks" (P = 0.003), and "social interaction" (P = 0.024). CONCLUSIONS: The results indicate a wide range of disability aspects in adult patients with strabismus, with moderate differences between patients with or without diplopia. Improvements in disability after surgery, as reflected by these ratings, should be taken into account when assessing the health value of adult strabismus management.

Eyelid abscess as a presenting sign of occult sinusitis.

PURPOSE: To describe 5 patients who presented with eyelid abscesses whose subsequent workup revealed occult sinusitis. METHODS: We reviewed the medical records of 5 patients who presented with eyelid abscess. Common presenting signs and symptoms were identified. Successful diagnosis and treatment was accomplished in each case. RESULTS: All patients were in good general health and did not appear to be systemically ill. Eyelid swelling was the chief presenting complaint of each patient. None of the patients complained of fevers or chills. Each patient had an upper eyelid abscess. Symptoms suggestive of sinusitis included purulent nasal discharge and headache. With appropriate radiologic studies, extensive occult sinusitis was identified in each case. Two patients demonstrated a small defect in the bone between the infected frontal sinus and the eyelid. All patients received intravenous antibiotics followed by oral antibiotics, incision and drainage of the abscess, and, after ENT consultation, functional endoscopic sinus surgery. All patients improved after treatment, and none had permanent visual loss. CONCLUSIONS: Clinical suspicion of sinusitis may be aroused with a thorough history and examination. Radiographic evaluation and prompt treatment of both the eyelid abscess and the sinusitis can result in good outcomes for such patients.

Central corneal thickness and glaucoma in aphakic and pseudophakic children.

BACKGROUND: The risk of glaucoma among aphakic children is as high as 32%, based primarily on intraocular pressure (IOP) measurements. Although IOP may be falsely elevated by increased central corneal thickness, central corneal thickness (CCT) values have not been reported in this population. METHODS: Patients from the practices of 2 pediatric ophthalmologists and 2 glaucoma specialists had measurements of CCT, IOP, and optic nerve cupping, with visual field analysis when possible. Normal fellow eyes of unilateral aphakes and pseudophakes were included as controls. RESULTS: In 36 aphakic and 6 pseudophakic eyes CCT averaged 660 microns compared with 576 microns for phakic fellow eyes (P < 0.0001). Glaucoma, defined by IOP at least 35 mm Hg or by IOP at least 22 mm Hg associated with optic nerve changes, occurred in 21% of 28 aphakic patients but in no pseudophakic patient. CONCLUSIONS: CCT in aphakic/pseudophakic children is substantially increased compared with control patients. These values may be important in interpreting IOP measurements in these children.

The management of strabismus in adults--II. Patient and provider perspectives on the severity of adult strabismus and on outcome contributors.

PURPOSE: As part of a larger study intended to evaluate the management of strabismus in adults, we documented and compared patient and provider perspectives on the various factors that may contribute to treatment outcome and value of strabismus care. METHODS: By completing a questionnaire, 170 patients with strabismus (ages 19 to 87 years) and 11 strabismus specialists who performed surgery on these patients each indicated the relative weight of several disease- and treatment-related contributors to the outcome and value of care. In addition, each respondent rated the severity of the strabismus before and after surgery. RESULTS: Overall severity ratings improved as a result of surgery. The improvement perceived by the physicians was 5.1 +/- 1.7 on a 10-point scale and was larger than the 2.6 +/- 3.6 points improvement perceived by the patients ( P < 0.001). Patients and physicians expressed different views on the relative contributions to outcome and value (overall P < 0.001). Both groups indicated "the condition," "the physician," and "the procedures" as the largest contributors, but "condition" was perceived as more important by the physicians than by the patients ( P < 0.001), and "physician" was more important to the patients than to the physicians ( P < 0.001). CONCLUSION: Although in approximate agreement on the main contributors to outcome and value, discrepancies exist between perspectives of patients and physicians on the relative weights of those contributors. Public information, education, and counseling may bring these perspectives better in line and ultimately improve both quality and patient satisfaction.

Vitrectomy for dense vitreous hemorrhage in infancy.

PURPOSE: To report clinical data, including etiology and visual outcome, in newborns requiring vitrectomy for dense vitreous hemorrhage. METHODS: In this retrospective case series, we surveyed subscribers to the American Association for Pediatric Ophthalmology and Strabismus ListServe regarding patients under their care. RESULTS: A total of 28 eyes of 21 patients were included. Most common etiologies were thrombocytopenia, shaken baby syndrome, and birth trauma. In 9 cases (12 eyes), the vitreous hemorrhage was idiopathic. Mean time between diagnosis and surgery was 1.4 months. Complications included strabismus, cataract, glaucoma, high myopia, and retinal detachment. Recognition visual acuities were available for 8 eyes: 20/25 (2 eyes), 20/30, 20/40 (2 eyes), 20/60 (2 eyes), and 20/100. One eye had no light perception. CONCLUSIONS: The etiologies encountered in our patients were similar to those reported previously. Visual outcomes were much worse in cases with retinal complications. Other patients had better visual outcomes. Despite potential surgical and postoperative complications, this series demonstrates favorable visual outcomes can be achieved following early vitrectomy in this setting.

The management of strabismus in adults--I. Clinical characteristics and treatment.

INTRODUCTION: This is the first in a series of articles intended to evaluate the management of strabismus in adults, including clinical outcomes and the quality, cost, and value of treatment from the perspectives of patients and health care providers. Here we present clinical characteristics, complexity of surgery, treatment success, and resolved complaints in a group of adult patients who underwent strabismus surgery. METHODS: This is a multicenter retrospective study analyzing the type and amount of ocular misalignment before and after surgery in adult patients with strabismus onset before (BVM, or age < 9 years) or after (AVM, or age >/= 9 years) visual maturation. Success was evaluated in terms of alignment, motility, and the presence of diplopia; subjective success was measured in terms of resolved complaints. The complexity of surgery was determined using the Intensity/Complexity Index and compared with success rates. RESULTS: Data are reported on 299 patients (90 BVM and 145 AVM) whose eyes were successfully aligned in 63% of the BVM cases and 81% of the AVM cases. Subjective complaints resolved at similar rates in the BVM and AVM subgroups. Successful alignment was not correlated with complexity of surgery, but motility and sensory success rates were correlated with complexity of surgery. CONCLUSION: Within each of the BVM and AVM subgroups, this study of adult strabismus showed similar surgical success rates compared with published data. This qualifies these patient groups as clinically typical of adults undergoing strabismus surgery. Additional studies will expand on health value analyses.