Management and Outcomes of Traumatic Cataract During Open Globe Repair.

PURPOSE: To compare outcomes of primary lensectomy (PL) versus no lensectomy (NL) during repair of zone I (involving cornea and limbus) and II (up to 5mm posterior to the limbus) open globe injuries (OGIs) with lens involvement. DESIGN: Retrospective clinical cohort study. METHODS: 107 patients with OGIs involving both blunt and penetrating injury to the lens who presented to Wills Eye Hospital between April 1, 2017 and August 31, 2022 were included. Data from presenting visit was collected including demographic information, time from injury to surgery, visual acuity (VA), intraocular pressure (IOP), injury characteristics, and years since residency graduation of surgeon. VA, IOP, retinal detachment (RD) rate, and endophthalmitis incidence were compared between PL and NL groups at postoperative week 1 (POW1) and postoperative month 1 (POM1). VA, peak IOP, need for further surgeries, and types of additional surgery were compared between the two groups at the final visit. RESULTS: 19 (17.8%) patients underwent PL. Age, sex, and initial VA were similar between groups (all p≥0.05). The PL group had surgery later from the time of injury (6.1±14.6 days vs. 1.3±1.9 days; p=0.010), higher IOP at presentation (12.9±11.6 mmHg vs. 7.7±11.3 mmHg; p=0.046), shorter wounds (2.3±1.4mm vs. 4.7±3.2mm; p=0.003), more frequent lens capsule violation (89.5% vs. 50%; p=0.010), increased likelihood of intraocular foreign bodies (52.6% vs. 17.0%; p=0.004), and were more likely to be operated on by surgeons with ≥ 5 years of experience post-residency (68.4% vs. 28.4%; p<0.001). At POW1, the PL group had significantly better logMAR VA (1.2±0.9 vs. 2.0±1.0; p=0.002), and this continued at POM1 (1.0±0.8 vs. 1.6±1.1; p=0.031) and the final visit (0.4±0.7 vs. 1.0±1.1; p=0.010). The PL group had lower IOP at POW1 (12.4±3.0 mmHg vs. 17.3±8.2 mmHg; p=0.005) than the NL group. There was no difference in RD or endophthalmitis rates between the two groups at POW1 or POM1 (p>0.05 for all). The NL group was more likely to require additional surgery by final follow-up (77.3% vs. 47.4%; p<0.001). In the multivariable analysis, PL had better final VA and decreased need for further surgery (both p<0.05). CONCLUSIONS: In the appropriate circumstance, PL during lens-involving anterior OGI repair may lead to improved patient outcomes.

Conjunctival and Lingual mucosal neuromas without multiple endocrine neoplasia type 2B.

Purpose: To report a patient with conjunctival and buccal neuromas and enlarged corneal nerves without Multiple Endocrine Neoplasia 2B (MEN2B). Observations: A 28-year-old female presented with progressively enlarging bilateral limbal conjunctival growths. Slit lamp examination was notable for enlarged corneal nerves and well-circumscribed gelatinous subepithelial limbal nodules. Systemic examination revealed similar lesions on the tongue. Conjunctival biopsy demonstrated a mucosal neuroma. The patient underwent endocrine workup for MEN2B and genetic testing for the RET-proto oncogene mutations, all of which were negative. Conclusions and Importance: The findings in our patient may be compatible with pure mucosal neuroma syndrome. The pattern of conjunctival neuromas and enlarged corneal nerves should raise concern for MEN2B, a hereditary tumor predisposition syndrome with almost 100% incidence of medullary thyroid cancer, unless prophylactic thyroidectomy is performed. Accurate diagnosis and prompt referral for endocrine and genetic testing is critical. Isolated mucosal neuromas without endocrine manifestations of MEN2B can rarely occur in a "pure mucosal neuroma syndrome," which is a diagnosis of exclusion in a setting of a negative workup.

Effect of Sequential and Simultaneous Patching Regimens in Unilateral Amblyopia.

PURPOSE: Many clinicians treat unilateral amblyopia with glasses alone and initiate patching when needed; others start glasses and patching simultaneously. In this study, we reviewed the outcomes of the two approaches at our institution. DESIGN: Retrospective nonrandomized clinical trial. METHODS: Setting: Institutional practice. PATIENT POPULATION: All patients diagnosed with amblyopia at Boston Children's Hospital between 2010 and 2014. INCLUSION CRITERIA: Unilateral amblyopia (visual acuity (VA) 20/40 to 20/200 with interocular difference ≥3 lines,) age 3 to 12 years, with a 6-month follow-up visit. EXCLUSION CRITERIA: Deprivation amblyopia, prior amblyopia treatment, treatment other than patching, surgery. Patients were categorized as "simultaneous treatment" (concurrent glasses and patching therapy at their first visit) or "sequential treatment" (glasses alone at first visit, followed by patching therapy at second visit.) Observation procedures: Patient demographics, VA, and stereopsis were compared. OUTCOME MEASURES: VA and stereopsis at the last visit on treatment. RESULTS: We identified 98 patients who met inclusion criteria: 36 received simultaneous treatment and 62 sequential treatment. Median amblyopic eye VA improved similarly between the simultaneous (∆0.40; interquartile range [IQR], 0.56-0.30 logMAR) and sequential (∆0.40; IQR, 0.52-0.27 logMAR) groups. Patients without stereopsis at first visit had better stereopsis outcomes with sequential treatment (5.12 [IQR, 4.00-7.51] log stereopsis) compared with simultaneous treatment (8.01 [IQR, 5.65-9.21]) log stereopsis, P = 0.046). CONCLUSIONS: VA improved approximately 4 lines regardless of treatment type. For children without stereopsis at first presentation, sequential patching yielded better stereopsis outcomes. These findings require further validation and highlight the importance of evaluating stereopsis in future studies.

The User Experience on a 3-Dimensional Heads-Up Display for Vitreoretinal Surgery Across All Members of the Health Care Team: A Survey of Medical Students, Residents, Fellows, Attending Surgeons, Nurses, and Anesthesiologists.

Purpose: This work assesses the educational use of a 3-dimensional (3D) heads-up visualization system for vitreoretinal surgery. Methods: A cross-sectional survey was performed among 18 medical students, 18 residents, 7 VR fellows, 6 nurses, 4 anesthesiologists, and 3 surgeons on their experience with the Ngenuity 3D Visualization System (TrueVision and Alcon) compared with the standard microscope. Results: Most medical students (88%) reported better identification of surgical landmarks; 63% ranked the Ngenuity as their preferred method of learning (vs microscope or 2-dimensional display). Residents reported a superior understanding of anatomy (69%), an increased ability to ask questions (63%), and improved ergonomics (94%). Epiretinal membrane peel, internal limiting membrane peel, and core vitrectomy were most enhanced (69% to 77%) for residents. Fellows' experience with trocar placement, vitrectomy, and oil/gas insertion was the same as before (67% to 100%), whereas endolaser and closing were worse (67% to 100%). Regarding autonomy, 83% of fellows reported no change, whereas 17% reported increased levels. Nurses were better able to track case progress (67%) and anticipate which tools were needed (50%). All anesthesiologists reported the same or worse engagement in cases, noting it was difficult to switch between the 3D screen and the anesthesia equipment. All surgeons reported a better awareness of trainees in the room and an improved ability to point out landmarks; 67% reported being more comfortable with resident and fellow autonomy. Conclusions: The Ngenuity is most helpful to students and residents. Integrating 3D displays into the surgical curriculum is beneficial, with care to ensure nurse and anesthesiologist satisfaction.

Anomalous superior oblique muscles and tendons in congenital fibrosis of the extraocular muscles.

PURPOSE: To evaluate the finding of anomalous superior oblique muscles in congenital fibrosis of the extraocular muscles (CFEOM), a feature not previously emphasized in this condition. METHODS: The medical records of all patients clinically or genetically diagnosed with CFEOM at Boston Children's Hospital between 2010 and 2018 were reviewed retrospectively. Those who underwent strabismus surgery during the study period were included in the analysis. Baseline patient characteristics, type of CFEOM, results of genetic testing, and intraoperative features of the superior oblique muscle or tendon were recorded. RESULTS: Of 24 patients identified (age range, 1 month to 62 years), 10 (42%) had genetically confirmed CFEOM, and 22 underwent strabismus surgery, 14 (64%) involving the superior oblique muscle. Of these, 7 (50%) had anomalously inserted tendons (most commonly attached nasal to the superior rectus muscle), whereas 7 (50%) had increased superior oblique muscle tension. CONCLUSIONS: Half of CFEOM patients who underwent superior oblique surgery had abnormally inserted superior oblique tendons, and 50% had tight muscles or abnormally thin tendons, findings that have not been well-characterized in this condition. The findings suggest that abnormal insertion of the superior oblique muscles and tendons are additional features of the disease process in CFEOM that have not been described previously. These features may contribute to the severe upgaze limitation in CFEOM and highlight the importance of superior oblique tenotomy in surgical management.

Peripheral Vestibular Disorders in Children and Adolescents with Concussion.

Objective To review peripheral vestibular disorders in pediatric patients with dizziness following concussion. Study Design Case series with chart review. Setting Pediatric vestibular clinic and pediatric multidisciplinary concussion clinic at a tertiary level pediatric hospital. Subjects and Methods We retrospectively reviewed 109 patients seen for dizziness following a concussion between September 2012 and July 2015. Patients were ≤20 years of age at the time of concussion. Incidences of specific peripheral vestibular disorders were assessed along with timing of diagnosis relative to the date of injury, diagnostic test findings, and treatment interventions associated with those diagnoses. Results Twenty-eight patients (25.7%) were diagnosed with peripheral vestibular disorders. None of these disorders were diagnosed prior to evaluation in our pediatric vestibular clinic or our multidisciplinary concussion clinic, which occurred a mean of 133 days (95% confidence interval, 89.2-177.3) after injury. Benign paroxysmal positioning vertigo was diagnosed in 19 patients, all of whom underwent successful canalith repositioning maneuvers. Other diagnoses included temporal bone fracture (n = 3), labyrinthine concussion (n = 2), perilymphatic fistula (n = 2), and superior semicircular canal dehiscence (n = 2). Both patients with perilymphatic fistula and 1 patient with superior semicircular canal dehiscence underwent successful surgical management, while 1 patient with superior semicircular canal dehiscence was managed nonsurgically. Conclusion Peripheral vestibular disorders may occur in pediatric patients with dizziness following concussion, but these disorders may not be recognized until symptoms have persisted for several weeks. An algorithm is proposed to guide the diagnosis and management of peripheral vestibular disorders in pediatric patients with concussion.