Ocular morbidity and co-morbidities in children attending a nodal district early intervention center in Uttar Pradesh

Purpose: To obtain epidemiological data on children with ocular morbidity attending a nodal district early intervention center (DEIC). Methods: After parental consent, we recruited children with ocular morbidity. After detailed history and clinical evaluation, along with pediatric consultation and relevant neuro?radiological and ancillary investigation, information was entered in a pretested proforma: especially looking for perinatal morbidity, including developmental delay (DD). Visual acuity (VA) was assessed by age?appropriate means by an ophthalmic assistant trained to work with children with special needs. We diligently looked for strabismus and performed dilated ophthalmoscopy. Using JASP, we summarized data as means and proportions and reported 95% CIs. We explored the association of disability percentage with possible predictor variables using regression. Results: We enrolled 320 children, with a mean age of 34.43 ± 31.35 months; two?thirds were male; one?third belonged to lower socioeconomic status (36%), with most parents being illiterate. The mean presenting VA was 1.8 logMAR for both eyes, range: 0 to 3. Sixty?one percent were hyperopic and 27% were myopic. High refractive error, (>±6D) occurred in nine; anisometropia in one; strabismus in 149, mostly esotropia; congenital cataract in 25, whereas 63 had abnormal fundus. Seventy?six received a diagnosis of cerebral visual impairment (CVI). On multivariate linear regression (MLR), younger age, presence of DD, and CVI significantly predicted a higher disability percentage. Logistic regression revealed that statutory disability is likely associated with DD (odds ratio [OR]:13.43); whereas older age was protective (OR: 0.977). Conclusion: Our study suggests that in DEIC children with ocular morbidity, younger children, and the presence of DD significantly predict both greater disability and the likelihood of statutory levels

Half Minimally Invasive Strabismus Surgery (MISS): A single para-muscular approach to horizontal muscle strabismus surgery

Purpose: Minimally invasive surgeries are gaining popularity. We compared two different approaches to rectus muscles: namely the standard para limbal (SPL) and the single para?muscular (SPM). Methods: Thirty?six patients planned for monocular horizontal strabismus surgery were block randomized to SPL and SPM approach. SPM approach involved a single para?muscular 10?mm conjunctival incision levelled at the inferior border of rectus muscle. We compared the post?operative grades of redness, congestion, chemosis, foreign body sensation, and drop intolerance at day 1, 2 weeks, and 6–8 weeks; scar visibility and success rates at 6–8 weeks and operation duration in minutes. We compared the results using Mann–Whitney U?test for inflammatory grades, Fisher’s exact test for proportions, and t?test for parametric measures. Significance was set at P < 0.05. Results: On postoperative follow-up at any time point, no significant difference was found on comparing inflammatory grades, scar visibility, and success rates. In terms of duration, SPL approach was on an average 21.5 minutes quicker than SPM (P = <0.001). Conclusion: The SPM is comparable to the SPL approach in terms of postoperative comfort and appearance, but takes significantly longer to accomplish.

Pattern of ocular morbidity in school children and its association with academic achievement

Background: Ocular morbidity describes any eye disease regardless of resultant visual loss. India is plagued by ocular morbidities in school going children. Refractive error is considered to be the major cause of visual impairment. The objectives of the present study were to compare the pattern of ocular morbidity in urban and rural school children, to study the association of academic achievement with ocular morbidity in study population and to suggest appropriate recommendations for addressing the problem of ocular morbidity in school children.Methods: A cross sectional study was conducted in the 9 primary and 5 junior high schools of field practice areas of Rural Health Training Centre and Urban Health Training Centre respectively, under Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh from September 2005 to August 2006.Results: Prevalence of ocular morbidity in the present study was 23.3%. Maximum prevalence of 28.7% of ocular morbidity was seen in the age group of 14-16 years. Prevalence of ocular morbidity was found to be 100 (51.6%) in males and 64 (40.1%) in females. 29.3% of the 164 school children having ocular morbidity showed poor academic achievement compared to 18.7% of the 541 children not having ocular morbidity and the association was found to be statistically significant.Conclusions: Refractive error was one of the major causes of ocular morbidity among school going children but most of them were of mild degree. Ocular morbidity was found to affect the academic achievement of school going children.

Gain beyond cosmesis: Demonstration of psychosocial and functional gains following successful strabismus surgery using the adult strabismus questionnaire adult strabismus 20.

Background: Strabismus adversely affects psychosocial and functional aspects; while its correction impacts positively. Aim: The aim was to evaluate the gains in scores: Overall scores (OASs), psychosocial subscale scores (PSSs) and functional subscale scores (FSSs) following successful surgical alignment. Settings and Design: We evaluated changed scores in the adult strabismus 20 (AS-20) questionnaire, administered before and after successful surgery. Materials and Methods: Thirty adults horizontal strabismics, were administered the AS‑20, at baseline, and at 6‑week and 3‑month. Group‑wise analysis was carried out based on gender, strabismus type (esotropia [ET] or exotropia [XT]), back‑ground and amblyopia. Statistical Analysis: We used Wilcoxon, and Mann-Whitney U‑tests. Significance was set at P ≤ 0.05. Results: At baseline, there were no significant differences within the groups, except that those with amblyopia significantly scored less than nonamblyopes in OAS (median scores: 53.8 vs. 71.3; P = 0.009) and FSS (56.3 vs. 85.3; P = 0.009). OAS, PSS and FSS showed significant gains at 6‑week and 3‑month (all Wilcoxon P < 0.001). Compared with males, females showed significantly more gain at 3‑month (OAS: 37.9 vs. 28.7; P = 0.02), on account of PSS gain (49.6 vs. 37.5; P = 0.01). The ET performed better than XT only on the FSS at 6‑week (28.7 vs. 15.0; P = 0.02). Vis‑à‑vis the nonamblyopes, the amblyopes showed significantly more benefit at 6‑week alone (OAS: 18.7 vs. 28.7; P = 0.04), largely due to gains in PSS. Conclusions: Successful strabismus surgery has demonstrated significant gains in psychosocial, functional and overall functions. There is some evidence that gains may be more in females; with a trend to better outcomes in ET and amblyopes up to 6‑week.

Minimally invasive strabismus surgery versus paralimbal approach: A randomized, parallel design study is minimally invasive strabismus surgery worth the effort.

Introduction: Minimal access surgery is common in all fields of medicine. We compared a new minimally invasive strabismus surgery (MISS) approach with a standard paralimbal strabismus surgery (SPSS) approach in terms of post‑operative course. Materials and Methods: This parallel design study was done on 28 eyes of 14 patients, in which one eye was randomized to MISS and the other to SPSS. MISS was performed by giving two conjunctival incisions parallel to the horizontal rectus muscles; performing recession or resection below the conjunctival strip so obtained. We compared post‑operative redness, congestion, chemosis, foreign body sensation (FBS), and drop intolerance (DI) on a graded scale of 0 to 3 on post‑operative day 1, at 2‑3 weeks, and 6 weeks. In addition, all scores were added to obtain a total inflammatory score (TIS). Statistical Analysis: Inflammatory scores were analyzed using Wilcoxon’s signed rank test. Results: On the first post‑operative day, only FBS (P = 0.01) and TIS (P = 0.04) showed significant difference favoring MISS. At 2‑3 weeks, redness (P = 0.04), congestion (P = 0.04), FBS (P = 0.02), and TIS (P = 0.04) were significantly less in MISS eye. At 6 weeks, only redness (P = 0.04) and TIS (P = 0.05) were significantly less. Conclusion: MISS is more comfortable in the immediate post‑operative period and provides better cosmesis in the intermediate period.

Beyond photography: Evaluation of the consumer digital camera to identify strabismus and anisometropia by analyzing the Bruckner's reflex.

Amblyopia screening is often either costly or laborious. We evaluated the Canon Powershot TX1 (CPTX1) digital camera as an efficient screener for amblyogenic risk factors (ARF). We included 138 subjects: 84‑amblyopes and 54‑normal. With the red‑eye‑reduction feature off, we obtained Bruckner reflex photographs of different sized crescents which suggested anisometropia, while asymmetrical brightness indicated strabismus; symmetry implied normalcy. Eight sets of randomly arranged 138 photographs were made. After training, 8 personnel, marked each as normal or abnormal. Of the 84 amblyopes, 42 were strabismus alone (SA), 36 had anisometropia alone (AA) while six were mixed amblyopes (MA). Overall mean sensitivity for amblyopes was 0.86 (95% CI: 0.83‑0.89) and specificity 0.85 (95% CI: 0.77‑0.93). Sub‑group analyses on SA, AA and MA returned sensitivities of 0.86, 0.89 and 0.69, while specificities were 0.85 for all three. Overall Cohen’s Kappa was 0.66 (95% CI: 0.62‑0.71). The CPTX1 appears to be a feasible option to screen for ARF, although results need to be validated on appropriate age groups.

Cut and paste: A novel method of re-attaching rectus muscles with cyanoacrylate during recessions in strabismus.

Aim: Bio-adhesives like cyanoacrylate offer an alternative to sutures to attach tissues, including in ophthalmology. This prospective trial evaluated the suitability and bio-tolerance of iso-amyl cyanoacrylate in rectus muscle recession surgery for strabismus. Materials and Methods: We randomized one eye in each of 10 cases of bilateral horizontal rectus recessions to 6/0 polyglactin and the other to iso-amyl-cyanoacrylate. We compared time to reattachment (from disinsertion), complications and inflammatory scores (0 to +3: nil, mild, moderate and severe) on Day One, at two and at four to six weeks post surgery. Results: There were no significant group differences in inflammatory scores (Wilcoxon, all values of P>0.05). All attachments held firm. Gluing took significantly longer by 5.24±1.91 min (95% CI for difference: 3.87-6.61). There were no complications. Conclusion: We feel that although it takes marginally longer, iso-amyl cyanoacrylate offers an effective and safe alternative to sutures for muscle recession in strabismus surgery. Since it is cheaper (vs. polyglactin) and offers multi-use possibility it may also prove to be cost-effective.

Gains beyond cosmesis: Recovery of fusion and stereopsis in adults with longstanding strabismus following successful surgical realignment.

We evaluated recovery of binocularity in 15 chronically strabismic, non-fusing (with neutralizing prisms) adults following successful surgical alignment. We included > or =12-year-olds, with best corrected visual acuity (BCVA) > or =20/60, and excluded those with: anisoacuity> 2 lines-Snellen; failed realignment judged by> 10 prism diopters (PD) horizontal and> 4 PD vertical. Six-week outcomes were: fusion by Worth Four-Dots (WFDT) and Bagolini striated glasses (BSG) and stereopsis by Titmus test and the Netherlands organisation for applied scientific research (TNO) test. Baseline data in medians (range): age 18 (12-40) years, strabismus 45 (19-95) PD, duration 14 (0.5-24) years, 12 females; 12 exotropes, three esotropes; visual acuity was 20/20 in 10, while none had BCVA < 20/60. Postoperative strabismus measured 6 PD (range:0-10). By six weeks none suppressed: WFDT findings showed eight fused at distance and 13 at near; and on BSG figures were 10 and 13 respectively. Stereopsis was demonstrated by 13 on Titmus and by 10 on TNO tests. It is concluded that longstanding strabismic adults with good vision can recover fusion and stereopsis following successful squint surgery.

Orbital amelanotic melanoma in xeroderma pigmentosum: a rare association.

Xeroderma pigmentosum (XP) is an autosomal recessive genetic disorder of DNA repair in which the body's normal ability to repair damage caused by ultraviolet light is deficient. This leads to a 1000-fold increased risk of cutaneous and ocular neoplasms. Ocular neoplasms occurring in XP in order of frequency are squamous cell carcinoma, basal cell carcinoma and melanoma. Malignant melanomas occur at an early age in patients with XP. We report a case of XP with massive orbital melanoma in an eight-year-old boy which is unique due to its amelanotic presentation confirmed histopathologically.

Topical diclofenac versus dexamethasone after strabismus surgery: a double-blind randomized clinical trial of anti-inflammatory effect and ocular hypertensive response.

BACKGROUND: Compared to steroids non-steroidal anti-inflammatory drugs offer comparable anti-inflammatory action without ocular side-effects. AIM: To compare the anti-inflammatory effect and effect on IOP (Goldmann) of topical diclofenac 0.1% with dexamethasone 0.1% after strabismus surgery. DESIGN: Prospective, randomized, double-blind, single-center, clinical trial. MATERIALS AND METHODS: Forty-three cases of constant horizontal strabismus, qualifying for standard uniocular recession-resection surgery on two horizontal rectus muscles were randomized to either the dexamethasone or diclofenac group. They were excluded if they had previous ocular surgery, recently used anti-inflammatory drugs and had a neurological, systemic or an ocular inflammatory condition. In addition all received ciprofloxacin 0.3% four times daily. Assessment was done on the first postoperative day and at two and four weeks. The inflammatory characteristics graded from nil (0) to severe (3) were: discomfort, chemosis, injection, discharge and drop-intolerance. Their sum provided the total inflammatory score (TIS). RESULTS: Dexamethasone group (n=21) was comparable in age, gender, preoperative IOP, strabismus, anesthesia administered and baseline IOP, to diclofenac (n=22). There were no significant differences in the inflammatory characteristics and TIS. The dexamethasone group had IOP significantly higher at two weeks (95% CI 0.17 to 3.25) and four weeks (95% CI 1.09 to 4.24) compared to diclofenac group and the net change of IOP at four weeks (95% CI 0.60 to 3.14). Compared to the baseline IOP. CONCLUSION: Topical diclofenac is comparable to dexamethasone in providing anti-inflammatory and analgesic effect with the advantage of significantly lesser IOP rise and should be preferred after strabismus surgery.