Infection following strabismus surgery.

PURPOSE OF REVIEW: To provide the most up to date information on postoperative infection associated with strabismus surgery, its diagnosis, management, and prevention. RECENT FINDINGS: Recent studies show that topical povidone-iodide is effective in reducing the bacteria colony count at the incision site and preventing contamination during strabismus surgery. Repeating povidone-iodide 5% drops after surgical preparation and presoaking the sutures in povidone-iodide reduces bacterial contamination further. There is no single postoperative day that would be best to detect the onset of a postoperative infection. Infection can follow a normal postoperative visit. SUMMARY: Infection continues to be a concerning complication of strabismus surgery. Early detection and treatment is needed to obtain a good outcome. Patients and their families should be educated on the early signs and symptoms of postoperative infection and to contact their ophthalmologist if any occur.

Pediatric nasolacrimal duct obstruction.

PURPOSE OF REVIEW: Review the current management for pediatric nasolacrimal duct obstruction and congenital dacryocele. RECENT FINDINGS: Early probing in the office, and probing beyond 1 year of age in a facility with general anesthesia are equally effective. Congenital nasolacrimal duct obstruction is associated with anisometropic amblyopia. Infants with unilateral dacryocele are at risk for developing a dacryocele on the unaffected side. SUMMARY: The decision to probe early in the office or continue medical management and probe beyond a year of age in a facility with a general anesthetic is at the discretion of the ophthalmologist. Failed probings should be treated in a facility under general anesthesia with a balloon catheter or intubation. Children with congenital nasolacrimal duct obstruction need to be followed to make certain they do not develop anisometropic amblyopia.

Visual acuity improvement in the amblyopic eye of a 50-year-old man following strabismus surgery.

It is generally believed that the visual acuity of an amblyopic eye cannot improve significantly in adulthood. However, there have been reports of this occurring following visual loss in the fellow eye. Best-corrected visual acuity improvement in amblyopic eyes of children with strabismic amblyopia following strabismus surgery has also been reported. We present the case of an adult whose visual acuity in his amblyopic eye improved 4 Snellen lines over 28 months following strabismus surgery.

Factors Affecting the Perception of Strabismus Among Pediatric Ophthalmologists.

PURPOSE: To define potential factors that influence the perceived urgency of strabismus surgery with a specific focus on the contributions of gender, degree of strabismus, and direction of strabismus. METHODS: An electronic survey was sent to members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). Respondents provided demographic information and ranked eight photographs of adults digitally altered to create varying degrees of strabismus according to perceived urgency for surgery. RESULTS: Pediatric ophthalmologists ranked deviations of increasing size with increasing treatment urgency. Men were perceived with higher urgency for treatment compared to women in the smaller angles of strabismus. No consistent preference for type of deviation was found. CONCLUSIONS: The gender of the patient and the amount of misalignment may influence the urgency of surgical management among strabismus surgeons. [J Pediatr Ophthalmol Strabismus. 2023;60(4):257-262.].

Economic Impact of the COVID-19 Pandemic Post-Mitigation on Pediatric Ophthalmologists.

PURPOSE: To create a survey to assess the economic impact that the coronavirus disease 2019 (COVID-19) pandemic post-mitigation (post-shutdown) has had on pediatric ophthalmologists. METHODS: A 14-question survey was disseminated to United States-based pediatric ophthalmologists on the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) discussion board and on social media. Demographic data and data on the economic effect of the COVID-19 pandemic post-mitigation were collected. RESULTS: A total of 129 pediatric ophthalmologists completed the survey. Eighty-four (65.1%) respondents reported a clinical revenue decrease of greater than 10%, 83 (64.3%) a surgical decrease of greater than 10%, and 66 (51.2%) an income decrease of greater than 10%. Fifteen (11.6%) respondents reported limiting the number of Medicaid patients. This was more prevalent among those in private practice (P = .027). Twenty-seven (20.9%) pediatric ophthalmologists responded that they planned to retire earlier than anticipated because of the pandemic and 2 (1.6%) responded that they have retired since the start of the pandemic. Six (4.7%) respondents reported that they have sold their practice since the start of the COVID-19 pandemic. CONCLUSIONS: Pediatric ophthalmologists continue to face economic challenges introduced by the COVID-19 pandemic. Reduced revenue may represent a new normal for the near future in pediatric ophthalmology. These unprecedented economic upheavals come at a time when the field of pediatric ophthalmology already faces difficulties with low reimbursement and attracting new trainees. This multitude of issues may escalate into a crisis in providing appropriate pediatric ophthalmic care. [J Pediatr Ophthalmol Strabismus. 2022;59(5):291-295.].

Anterior Segment Optical Coherence Tomography in Locating the Insertion of Horizontal Extraocular Muscles After Strabismus Surgery.

PURPOSE: To evaluate the accuracy of anterior segment optical coherence tomography (AS-OCT) for locating horizontal extraocular muscle (EOM) insertion after strabismus surgery. METHODS: The distance from the limbus to the postoperative muscle insertion was measured with calipers intraoperatively and by AS-OCT during the postoperative visit of adults undergoing strabismus surgery. Images were collected by masked technicians. Intraclass correlation coefficients (ICC) were used to evaluate the agreement between measurements. RESULTS: Twenty-eight patients were recruited. Measurements were taken from 31 eyes, including 17 lateral and 14 medial rectus muscles. EOM insertion was successfully identified by AS-OCT for 14 (45%) cases. The ICC between intra-operative and AS-OCT measurement was 0.886 when the distance from the limbus to the insertion of EOM was less than 8 mm and 0.001 when the distance from the limbus was between 8 and 10 mm. EOM insertion was undetectable if distance to the limbus was greater than 10 mm. CONCLUSIONS: AS-OCT can accurately identify post-surgical horizontal muscle insertion if the insertion is less than 8 mm from the limbus. [J Pediatr Ophthalmol Strabismus. 2021;58(1):62-65.].

Visual improvement in amblyopic eye following treatment-induced vision loss in dominant eye with uveal melanoma.

OBJECTIVE: To determine the frequency and amount of visual improvement in amblyopic eyes of adults following visual loss in the dominant eye resulting from treatment of uveal melanoma. METHODS AND ANALYSIS: Retrospective case series of adult patients with amblyopia and dominant eye visual loss resulting from treatment of uveal melanoma. Review of best-corrected visual acuity (BCVA) in each eye (amblyopia eye vs melanoma eye) at date first seen and over time following treatment of uveal melanoma. BCVA in each eye was graded as improved (>2 logarithm of minimal angle of resolution (logMAR) lines) or unimproved (<2 logMAR lines). RESULTS: Twenty-one patients that met the inclusion criteria. Mean age at presentation was 56 years (range 39-73 years). Following treatment of the uveal melanoma and decline of BCVA in the dominant, the BCVA in the amblyopic eye improved in 11/21 (52%; 95% CI 30% to 74 %) patients. The degree of visual loss in the melanoma eye was to the level of the amblyopic eye or worse in 14 patients. In this group, BCVA improved in the amblyopic eye in 9/14 (64%; 95% CI 35% to 87 %) patients. Of these nine with improved eyes, the mean starting visual acuity was logMAR 0.6 (20/80) with mean improvement of logMAR 0.4 (4 lines±0.13 (range 0.2-0.6). Eight of nine eyes achieved a BCVA of 20/25 (n=3) or 20/20 (n=5). CONCLUSION: Visual acuity in the amblyopic eye of adults can improve following visual loss in the contralateral dominant eye associated with treatment for uveal melanoma.

Rate of Spontaneous Resolution of Congenital Nasolacrimal Duct Obstruction Prior to Scheduled Probing in Children Older Than 1 Year.

The authors conducted a 10-year retrospective review of all patients within one physician's practice to determine the frequency of spontaneous resolution of congenital nasolacrimal duct obstruction in children older than 1 year during the interval between scheduling and date of probing. This review found 4.4% of eyes resolved within an average interval period of 39 days. [J Pediatr Ophthalmol Strabismus. 2019;56:e31-e33.].

Strabismus Surgery Infection Prophylaxis and Timing of First Postoperative Visit.

PURPOSE: To characterize the practice patterns of pediatric ophthalmologists regarding infection prophylaxis for strabismus surgery and timing of the first postoperative visit. METHODS: A ten-question multiple-choice, close-ended questionnaire was e-mailed to members of the American Association for Pediatric Ophthalmology and Strabismus listserv. Survey responses were summarized using frequencies and percentages. Univariable tests of association between prophylactic measures and surgeons reporting a prior episode of postoperative cellulitis or endophthalmitis were performed. RESULTS: Three hundred eighty pediatric ophthalmologists completed the survey. Most ophthalmologists instill 5% povidone-iodine solution during surgical preparation (88.4%), use topical antibiotics with or without steroids at the conclusion of surgery (90%), and prescribe oral or topical antibiotics postoperatively (85.5%). Eighty-five percent of strabismus surgeons routinely see patients for the first postoperative visit within the first week, although there is no consensus as to which day is preferred. Responders previously reporting experience with a postoperative infection were more likely to use intraoperative intravenous antibiotics (P = .002) and Tegaderm tape (3M, St. Paul, MN) or other adhesive drape to isolate the eyelids/eyelashes (P = .047). CONCLUSIONS: A common practice pattern appears to exist regarding the use of 5% povidone-iodine solution in surgical preparation, application of topical antibiotics at the end of surgery, and a postoperative regimen of topical antibiotics/steroids. There is no prevailing practice pattern regarding the timing of the first postoperative visit. Previous experience with postoperative cellulitis or endophthalmitis may lead to the adoption of more formidable infection prophylaxis measures such as intravenous antibiotics prior to surgery. [J Pediatr Ophthalmol Strabismus. 2019;56(6):354-359.].

Inconsistent diagnostic criteria for convergence insufficiency.

BACKGROUND: Convergence insufficiency (CI) is a common entity but seems to be an ill-defined diagnosis that incorporates many near-vision symptoms. The current literature often varies in its criteria for diagnosis. Without a clear definition and standardization of the clinical examination, there is the potential for misdiagnosis and/or the inclusion of other diagnoses as CI. The purpose of this study was to assess the uniformity of diagnostic criteria in a well-defined practice environment. METHODS: The medical records of individuals diagnosed with CI between June 2007 and November 2014 who were patients of 6 fellowship-trained strabismologists in private practices and at Wills Eye Hospital clinics were reviewed retrospectively. Exclusion criteria included any previous treatments for CI, prior strabismus surgery, or other causes for strabismus, including cranial nerve palsies. The following data were collected: age, sex, race, age at diagnosis, past medical and family history, relevant symptoms, visual acuity, near point of convergence (NPC), strabismus measurements, and fusional amplitudes at distance with base-out and base-in prisms. RESULTS: A total of 387 patients fit our inclusion criteria and were analyzed in our study. There was no uniformity across clinicians in the clinical evaluation and diagnosis of patients with CI. The amplitude of the NPC was highly variable, and most clinicians did not assess the quality of the convergence movement or perform convergence fusional amplitude testing in making the diagnosis of CI. CONCLUSIONS: Our review has demonstrated the range of criteria within one group of practitioners to diagnose CI. This may reflect our current understanding and the need for an evidence-based definition of the disease and its diagnosis.

A pilot study using electronic reminders for amblyopia treatment.

Treatment compliance is the most important factor for predicting a successful outcome in amblyopia treatment. Electronic applications have been successfully employed in other medical conditions in an effort to improve compliance.Aim: To determine whether a smartphone medical adherence application (app) (RxmindMe® Prescription/Medicine Reminder and Pill Tracker) may be successfully incorporated into the treatment plan of patients 3-7 years of age who have not previously been treated for amblyopia.Methods: Children 3-7 years of age were randomized to receive electronic reminders (reminders group) or standard instructions (control group). Visual acuity and compliance with treatment was assessed at the first follow-up visit. The child's adherence with the prescribed treatment was calculated as the reported number of hours of patching performed divided by the number of hours prescribed or compliance percentage. The validated "Amblyopia Treatment Index Parental Questionnaire" was administered to the parent/guardian to assess any differences in the compliance subscale between the two treatment groups. Any difficulties encountered with the use of the reminder app were also recorded at the follow-up visit.Results: Twenty-four participants were enrolled. Twelve participants in the reminder group (eight female, four male; mean age 4.5 ± 1.3) were compared with 12 participants in the control group (five female, seven male; mean 4.8 ± 1.1). No significant differences were found between the two groups in terms of age (p = 0.62), gender (p = 0.22), or degree of amblyopia at the start of treatment (p = 0.99). Eleven of 12 participants in the reminders group were able to incorporate the reminder app into amblyopia treatment. No participant reported malfunction of the alarm portion of the reminder app. There was no significant difference seen in degree of visual acuity improvement, reported percentage compliance or effect on the compliance subscale as assessed by the ATI questionnaire. Several participants reported the app to be "helpful" in initiating treatment.Conclusion: Our findings indicate that use of a smartphone app is feasible in this patient population. Targeting the app to specific patient demographics or when difficulty with compliance is encountered needs to be further investigated.

Three novel mutations in KIF21A highlight the importance of the third coiled-coil stalk domain in the etiology of CFEOM1.

BACKGROUND: Congenital fibrosis of the extraocular muscles types 1 and 3 (CFEOM1/CFEOM3) are autosomal dominant strabismus disorders that appear to result from maldevelopment of ocular nuclei and nerves. We previously reported that most individuals with CFEOM1 and rare individuals with CFEOM3 harbor heterozygous mutations in KIF21A. KIF21A encodes a kinesin motor involved in anterograde axonal transport, and the familial and de novo mutations reported to date predictably alter one of only a few KIF21A amino acids--three within the third coiled-coil region of the stalk and one in the distal motor domain, suggesting they result in altered KIF21A function. To further define the spectrum of KIF21A mutations in CFEOM we have now identified all CFEOM probands newly enrolled in our study and determined if they harbor mutations in KIF21A. RESULTS: Sixteen CFEOM1 and 29 CFEOM3 probands were studied. Three previously unreported de novo KIF21A mutations were identified in three CFEOM1 probands, all located in the same coiled-coil region of the stalk that contains all but one of the previously reported mutations. Eight additional CFEOM1 probands harbored three of the mutations previously reported in KIF21A; seven had one of the two most common mutations, while one harbored the mutation in the distal motor domain. No mutation was detected in 5 CFEOM1 or any CFEOM3 probands. CONCLUSION: Analysis of sixteen CFEOM1 probands revealed three novel KIF21A mutations and confirmed three reported mutations, bringing the total number of reported KIF21A mutations in CFEOM1 to 11 mutations among 70 mutation positive probands. All three new mutations alter amino acids in heptad repeats within the third coiled-coil region of the KIF21A stalk, further highlighting the importance of alterations in this domain in the etiology of CFEOM1.

Impact of a Strabismus Surgery Suture Course for First- and Second-Year Ophthalmology Residents.

PURPOSE: To investigate the effectiveness of an eye muscle surgery course on first- and second-year postgraduate ophthalmology residents. METHODS: This prospective cohort pilot study invited first- and second-year ophthalmology residents to participate in a 2-hour strabismus surgery course at Wills Eye Hospital. The course consisted of a didactic session followed by a wet laboratory session. The wet laboratory session simulated strabismus surgery using a model constructed of chicken breast followed by partial-thickness scleral suture passes in pig eyes. A structured self-assessment evaluation form and a questionnaire in the validated Ophthalmology Surgical Competency Assessment Rubric approved by the International Council of Ophthalmology (ICO-OSCAR:strabismus) were used to assess the effectiveness of the course. RESULTS: A total of 12 residents, 8 (67%) first-year and 4 (33%) second-year, were enrolled for this survey. Following the course, most residents felt less anxious (73%). All residents responded that the course was helpful or somewhat helpful in preparation for strabismus surgery. Regarding the distribution of ratings on questions of subjective experience, knowledge of steps, and understanding of potential complications, the residents gave significantly higher ratings after the course (P < .029). The change in the modified ICO-OSCAR:strabismus assessment's mean score was statistically significant before and after training (P = .038). CONCLUSIONS: A strabismus course can play an important role in preparing residents for strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2017;54(6):339-345.].

Unilateral clinical anophthalmia with optic nerve hypoplasia in the fellow eye.

We present the clinical and radiologic findings of two cases of clinical anophthalmia in one eye and optic nerve hypoplasia in the other eye. We propose possible causes of this rare finding.

Clinical Evaluation of Four-Muscle Tenotomy Surgery for Nystagmus.

PURPOSE: To document prospectively the effect of four-muscle tenotomy surgery on visual acuity (VA) and nystagmus intensity and assess, by the use of a questionnaire, the experience of adult patients and the parents of children who have had the four-muscle tenotomy procedure for nystagmus in the absence of strabismus or an anomalous head position. The qualitative perceived benefits or lack thereof from the procedure were compared to the subjective effects on nystagmus intensity and VA. METHODS: Fifteen patients diagnosed as having congenital/infantile or acquired nystagmus, including albinism or other visual sensory disorders without anomalous head positions or coexisting strabismus, were included in this study. The changes in preoperative and postoperative VA and nystagmus were evaluated based on clinical and perceptual measurements and video recordings. RESULTS: All 15 patients had preoperative and postoperative ophthalmological examinations. One patient had a postoperative conjunctival cyst, which was successfully removed. Fourteen patients (93%) showed clinical VA improvement in at least one eye. Fourteen patients were video recorded preoperatively and postoperatively to analyze their nystagmus intensity; case 9 was not included. Postoperatively, 10 patients (71%) showed a decrease in nystagmus intensity. Thirteen patients (87%) perceived vision improvement and 11 patients (73%) perceived a decrease in nystagmus intensity. All patients experienced either clinically improved VA or a decrease in nystagmus intensity. Fourteen patients (93%) perceived either improved VA or a decrease in nystagmus intensity. The preoperative and postoperative changes in VA (P = .002) and nystagmus intensity (P = .043) were both statistically significant. CONCLUSIONS: The authors have shown that four-muscle tenotomy surgery for nystagmus can improve VA and decrease nystagmus intensity. The study yielded subjective patient satisfaction, modest objective improvement in VA, and no significant complications.

Risk factors for amblyopia in congenital anterior lens opacities.

PURPOSE: We sought to identify the features of congenital anterior lens opacities (CALOs), which are associated with increased risk for amblyopia. METHODS: We undertook a retrospective study of 59 patients with CALO from 3 clinical practices. The following variables were examined: type (polar, subcapsular, or pyramidal), location (central, paracentral, or peripheral), diameter, presence of adherent iris tissue, anisometropia (spherical equivalent), unilateral versus bilateral, and presence or absence of amblyopia. Pearson chi-square and independent sample t-tests were conducted to evaluate if any of the aforementioned variables were independently associated with amblyopia. Relative risk was then calculated for significantly related variables (P < 0.05). RESULTS: Amblyopia was present in 17 of 59 patients (28.8%). Patients with amblyopia had a mean anisometropia of 1.23 diopters whereas nonambyopic patients had a mean anisometropia of 0.25 (P = 0.023). The relative risk for amblyopia with anisometropia of one diopter or greater was 6.5 (95% confidence interval = 3.79-7.45). The mean cataract size in the amblyopic eyes was 1.22 mm (range, 0.7-2.0 mm). Mean cataract size in the nonamblyopic eyes was 0.95 mm (range, 0.5-2.0 mm). This difference in mean cataract size was significant with independent sample t-tests (P = 0.02); however, this difference did not remain significant with logistic regression. Cataract size was not a significant relative risk factor for amblyopia. CONCLUSIONS: Our overall incidence of amblyopia was 28.8%. The only variable associated with increased relative risk for amblyopia in this group of patients was anisometropia. Patients with CALO who have anisometropia of 1 diopter or greater are 6.5 times more likely to develop amblyopia.

Visual outcome and success of amblyopia treatment in unilateral small posterior lens opacities and lenticonus initially treated nonsurgically.

PURPOSE: We sought to assess the success of amblyopia treatment in patients with small posterior lens opacities as well as the factors associated with a good visual outcome. METHODS: This was a retrospective study of patients with posterior lens opacities that initially were thought to be too small in size to warrant cataract surgery. The following variables were examined: cataract type, location, diameter, persistent hyaloid vessel, anisometropia, strabismus, and age of detection. Success of treatment of amblyopia was defined as improvement by at least 0.3 logMAR units. Good visual outcome was defined as 20/40 or better. Amblyopia was treated by glasses, patching, and/or atropine. Patients who failed with conservative treatment or had an increase in cataract size underwent surgery. RESULTS: Forty-eight (91%) of 53 eyes were amblyopic. Thirty amblyopic eyes had pre- and post-treatment Snellen acuities. Twenty (67%) had their visual acuity (VA) improved by 0.3 logMAR units or greater. None of the measured variables were associated with successful amblyopia treatment. Twenty-five (49%) of 51 patients had a final VA of 20/40 or better. The only variable associated with good visual outcome was cataract type: 18 of 25 (72%) posterior subcapsular cataract and 6 of 23 (32%) posterior lenticonus eyes achieved VA of 20/40 or better (P = 0.008). Six patients who went on to have cataract surgery experienced a larger improvement in BCVA (4.50 logMar units +/- 2.52 lines) compared with patients treated without cataract surgery (2.36 logMar units +/- 3.11 lines). DISCUSSION: Amblyopia treatment was successful in most cases. A small group of patients who underwent cataract surgery experienced a greater VA improvement; however, it was not statistically significant. Further studies are needed to determine which patients would benefit from cataract surgery.