Causes and treatment outcomes of third, fourth and sixth cranial nerve palsy.

OBJECTIVE: To evaluate the causes and the treatment outcomes of third, fourth and sixth cranial nerve palsy MATERIAL AND METHOD: Medical records of 157 cases with extra-ocular muscle palsy from third, fourth or sixth cranial nerve palsy between January 1995 and December 2009 were reviewed. Demographic data, age, causes of extra-ocular muscle palsy and treatment outcomes were record and analyzed. The patients who were followed-up less than 6 months, myasthenia gravis and extra-ocular muscles fibrosis were excluded from the present study. RESULTS: One hundred and fifty-seven cases from 600 cases were included in the present study. The most common cranial nerve palsy was the sixth cranial nerve with 63 cases (40.1%). Of 157 cases, the causes were trauma 41 cases (26.1%), microvascular occlusion cause 34 cases (21.7%) and congenital cause 21 cases (13.4%). Cranial nerve palsy patients from microvascular occlusion cause spontaneously improved 25 of 34 cases (73.50%) in 6 months. All patients (21 cases)from congenital cranial nerve palsy had extra-ocular muscle surgery and 17 patients (80.9%) were successful. CONCLUSION: Sixth cranial nerve palsy was the most common cranial nerve palsy. Most patients with cranial nerve palsy from vascular cause spontaneously improved in 6 months. Congenital cranial nerve palsy patients need extra-ocular muscle surgery and most cases were successful

Epidemiology of Pediatric Open Globe Injuries in a University Hospital in Thailand.

OBJECTIVE: To describe the epidemiology, clinical characteristics, and clinical outcomes of pediatric traumatic open globe injuries and to determine the risk factors for poor visual outcome. METHODS: The medical records of patients aged younger than 15 years of age who were diagnosed with open globe injuries from January 2005 to December 2015 were retrospectively reviewed. The patients' demographic data were collected, including age, sex, injury date, place of injury, mechanism of injury, cause of injury, and the activity related to the injury. Clinical data were recorded, including initial visual acuity (VA), wound size, wound location, associated ocular findings at presentation, and complications. The prognostic factors for a poor visual outcome were assessed. RESULTS: In total, 46 pediatric patients were included in this study. The mean age was 6.8 years old. Most patients were male (65.2%). The most common type of injury was penetrating injury (60.9%) and mostly occurred during playing (60.9%). Household appliances/furniture and scissors/knives were common causes of injuries (17.4%, 15.2%, respectively). Poor final VA worse than 6/60 was found in 17 patients (37%). Wound location and retinal detachment (RD) at the time of presentation were significant prognostic factors for a poor visual outcome according to the univariate analysis (p = 0.008, <0.001). Only wound location at zone II and III was found to be significantly correlated with poor final VA in the multivariate analysis (adjusted risk ratio (RR) = 2.87, 95% confidence interval (CI), 1.26-6.55, p = 0.012). Traumatic cataract was the most common associated injury (45.7%). CONCLUSIONS: One-third of pediatric patients with open globe injuries had a poor visual outcome. Wound location at zone II and III significantly correlated with a poor visual outcome in pediatric open globe injuries. The parents and caregivers should be made aware of the seriousness of open globe injuries in order to prevent children from possible injuries.

Unilateral vertical nystagmus: the Heimann-Bielschowsky phenomenon.

OBJECTIVE: To present clinical feature of Heimann-Bielschowsky phenomenon and strabismus association. DESIGN: Retrospective case series. MATERIAL AND METHOD: Medical records of cases between January 2004 and January 2008 were reviewed. Eight cases met the criteria. Age, sex, visual acuity, and eye examination data were collected. RESULTS: Six cases were male and two cases were female. Age at presentation ranged from 4 to 45 years old. Seven cases had vision of 6/60 or worse. Only one case had visual acuity 6/36. Strabismus was seen in five cases (exotropia 4 cases and esotropia 1 case). No one had symptoms of diplopia or oscillopsia. All cases had unilateral coarse, slow, pendular vertical oscillations occurring in the poor vision eye. CONCLUSION: Monocular vertical oscillation may develop in an eye with reduced vision. It may be a common condition but under diagnosed.

Visual electrophysiology in congenital nystagmus with normal fundus.

OBJECTIVE: To identify the ophthalmic causes of congenital nystagmus with normal eye examination by visual electrophysiologic tests. MATERIAL AND METHOD: Medical records of patients who presented with nystagmus and no other neurological sign before 6 months of age with normal eye examination, between February 2004 and February 2005, were reviewed Complete ophthalmic examination and visual electrophysiologic tests were performed to identify the ophthalmic causes of congenital nystagmus. RESULTS: Thirty-four patients had met the criteria. Leber's congenital amaurosis was diagnosed in 13 patients (38.2%) by non-recordable electroretinography (ERG) and normal visual evoked potential (VEP). Idiopathic infantile nystagmus was diagnosed in 12 patients (35.3%) by normal ERG and VEP. Achromatopsia was diagnosed in 8 patients (23.5%) by flat retinal cone ERG but normal rod ERG and VEP. Rod-cone dystrophy was diagnosed in one patient (3%) by abnormal rod and cone ERG CONCLUSION: Visual electrophysiologic study is helpful to identify the ophthalmic causes of congenital nystagmus. Leber's congenital amaurosis is a common cause in congenital nystagmus.

Scleral penetrations and perforations in strabismus surgery: incidence, risk factors and sequelae.

OBJECTIVE: To evaluate the incidence and identify associated risk factors and sequelae of scleral penetrations and perforations during strabismus surgery. MATERIAL AND METHOD: Medical records of patients who underwent strabismus surgery at Siriraj Hospital between June 2001 and May 2006 were reviewed. Strabismus operations were performed by residents in ophthalmology training, pediatric ophthalmology fellows, or attending physicians. The authors documented demographic data, surgical techniques, and management of the scleral penetrations and perforations. All patients with scleral penetrations or perforations were examined intraoperation by indirect ophthalmoscopy and followed up for at least 6 months to determine late sequelae of this complication. RESULTS: Of the 1025 patients and 2195 procedures, scleral penetrations (full thickness scleral pass without retinal break) were recognized in 15 procedures (0.68%). No scleral perforation (full thickness scleral pass with retinal break) was found. The mean age of these complications during strabismus operations was 14.26 years. Scleral penetrations were more likely to occur with rectus muscle recession than rectus muscle resection. All sclera penetrations occurred while rectus muscles were recessed and reattached to the new insertions. All 15 scleral penetrations were performed by residents in training or pediatric ophthalmology fellows. Re-operation in the same extraocular muscle was not a risk factor for this complication. All patients with scleral penetrations were managed by dilated pupils and fundus examinations and the authors applied cryotherapy or indirect ophthalmoscopic laser to the retinal lesions. Retinal detachment, vitreous hemorrhage, and endophthalmitis were not found in the present study. CONCLUSION: The incidence of scleral penetrations in the present study was 0.68%. Risk factors of scleral penetrations in strabismus surgery are rectus muscle recession and surgeon factors. No serious complications such as retinal detachment or endophthalmitis were found in this study.

Treatment of cytomegalovirus (CMV) retinitis with intravitreous ganciclovir in HIV-infected children.

OBJECTIVES: To evaluate the efficacy, visual outcomes, and complications of intravitreous ganciclovir treatment in cytomegalovirus (CMV) retinitis in HIV-infected children. MATERIAL AND METHOD: The medical records of HIV-infected children who were screened for CMV retinitis from February 2002 to February 2005 were reviewed. The children with CD4+ < 15%, or with clinical category C would have complete ophthalmic examination every 3 months. Ganciclovir (4 mg/0.04 ml) was administered intravitreously to the eye with CMV retinitis every 2 weeks under general anaesthesia. After injection, fundi were examined immediately, 1 day, 14 days and every 2 weeks until the lesions were stable. RESULTS: Six (9 eyes) out of 45 children (13%) aged 2-12 years were found to have CMV retinitis. All CMV retinitis lesions were "cheese and ketchup like" (retinal hemorrhage and exudate) lesions and presented in the posterior pole. Bilateral CMV retinitis were found in 3 children. Intravitreous ganciclovir was injected in 4 children (5 eyes). The average number of intravitreous injections for each patient was 5.6 (3-7) times. All of the children received antiretroviral therapy and 3 children also received intravenous ganciclovir CMV retinitis lesions were improved in every eye. The visual acuity (VA) remained stable in 4 eyes, but endophthalmitis developed in one eye a few days after injection. The average duration of follow-up was 13.5 months (3-23 months). CONCLUSION: CMV retinitis was not uncommon. The authors found that intravitreous ganciclovir was effective but may cause complications. This treatment should be considered in a resource-limited setting.

Outcomes of cataract surgery in senile cataract patients at Siriraj Hospital: a prospective observational study.

The present study was done to assess the results of cataract surgery performed in Siriraj Hospital by comparing phacoemulsification and extracapsular cataract extraction techniques in senile cataract patients within a 3-month period. The prospective observational study of a representative sample of 379 patients (409 eyes) who underwent cataract surgery in Siriraj Hospital from January 1, 2004 to March 31, 2004. Identical clinical assessment protocol was used to compare the improvement of postoperative visual acuity and surgical complications between two surgical techniques and different surgeons. Of the 409 eyes, phacoemulsification was performed on 373 eyes (91.2%), and extracapsular cataract extraction was performed on 36 eyes (8.8%). Departmental staff operated on 326 eyes (79.7%) and ophthalmology residents operated on 83 eyes (20.3%). The primary outcome was postoperative visual acuity. Visual acuity was improved > or = 2 Snellen chart lines in 278 of 373 eyes (74.5%) in the phacoemulsification group, and > or = 2 lines in 31 of 36 eyes (86.1%) in the extracapsular cataract extraction group. A small risk of surgical complications was found in the present study. Posterior lens capsule rupture was the most frequent complication found (10/ 409 eyes), followed by corneal injury (9 of 409 eyes). Endophthalmitis was the most severe complication in the present study, occurring in 1 of 409 eyes. There was a significant difference in postoperative visual improvement between phacoemulsification and extracapsular cataract extraction techniques. Final visual acuity in the phacoemulsification group was better than in the extracapsular cataract extraction group.

Comparison of topical prednisolone acetate, ketorolac tromethamine and fluorometholone acetate in reducing inflammation after phacoemulsification.

AIMS: To compare the efficacy and ocular adverse effects of topical prednisolone acetate, ketorolac tromethamine, and fluorometholone acetate in reducing inflammation after phacoemulsification. METHOD: One hundred and twenty eyes were enrolled in a prospective, investigator-masked, randomized controlled trial. Each drug was prescribed 4 times a day for 28 days. The following data were recorded weekly: visual acuity, intraocular pressure, slit lamp biomicroscopy, grading of cells and flare in the anterior chamber, and ocular symptoms. RESULTS: The number of eyes with a minimal amount of cells in the anterior chamber in the ketorolac group was less than the prednisolone group on day 7 (11:20, p = 0.008) and day 14 (23:31, p = 0.015), and than fluorometholone group on day 7 (11:21, p = 0.011). Intraocular pressure in the prednisolone group was higher than the ketorolac group on day 21 (14.6:12.2 mmHg, p = 0.016). One eye in the prednisolone group had intraocular pressure of 32 mmHg. Burning sensation was reported frequently in the ketorolac group. CONCLUSION: All 3 drugs were effective in reducing post-operative inflammation. The efficacy of prednisolone acetate and fluorometholone acetate was comparable. Ketorolac tromethamine showed less efficacy than corticosteroids, however, it did not induce ocular hypertension.