Outcome of Primary Monocanalicular Stent Placement in Pediatric Down Syndrome Patients with Congenital Nasolacrimal Obstruction.

PURPOSE: Congenital Nasolacrimal duct obstruction (CNLDO) is a relatively common problem in children with Down syndrome (DS). Probing and irrigation (PI) with monocanalicular stent intubation may be less successful than in non-DS patients, thus raising some concerns regarding the preferred treatment in this population. We aimed to analyze the surgical outcome of PI along with monocanalicular stent intubation in children with DS compared with non-DS patients. METHODS: Retrospective cohort study. Thirty-five eyes of 19 children with DS and 1,472 eyes of 1,001 children without DS underwent PI-monocanalicular stent intubation as a primary treatment for CNLDO. All patients were operated on by a single surgeon at the Children's Hospital of Philadelphia between 2009 and 2020. The main outcome measure was a surgical success, defined as the resolution of symptoms after surgery. RESULTS: A total of 1,020 patients were included, 48% females; mean age of 1.9 ± 1.4 years. The mean follow-up time was 35.0 months. The DS patients group consisted of 19 patients. Higher rates of right nasolacrimal duct obstruction and bilateral obstructions were observed in the DS group (100% vs. 73.2%; p = 0.006, and 84.2% vs. 46.8%; p = 0.001, respectively). Patients with DS had a lower success rate (57.1% vs. 92.4%; p < 0 .0001). The median time to failure was 3.1 months in the DS group, and 5.2 months in the group of patients without DS. The hazard ratio comparing DS to the no-DS outcome was 6.6 (95% CI: 3.2-13.7; p < 0.001). CONCLUSIONS: CNLDO in DS is more likely to be bilateral and less likely to resolve after primary monocanalicular stent placement.

Primary Monocanalicular Stent Intubation for Children With Congenital Nasolacrimal Duct Obstruction: Surgical Outcome and Risk Factors.

PURPOSE: To determine the risk factors impacting the surgical success of primary monocanalicular stent intubation for congenital nasolacrimal duct obstruction (CNLDO). METHODS: This is a retrospective interventional case series of patients 18 years and younger treated more than a 12-year period with monocanalicular stent intubation with inferior turbinate fracture for CNLDO by a single surgeon. Patients with dacryocystoceles, dacryocystitis, Down syndrome and previous tear duct surgery were excluded. An intraoperative grading scale of tear duct stenosis, date of stent removal, stent length, and postoperative symptoms were recorded. Surgical success was defined as the complete resolution of symptoms. RESULTS: One thousand four hundred sixty-nine stents were placed in 1,001 pediatric participants (533 unilateral, 468 bilateral). The mean age at surgery was 1.86 years (0.1-18.07). The mean follow up was 34.99 months (0.43-134.3) with mean in-office stent removal at 3.41 months (0.63-36.9). Early stent loss occurred in 14.8% intubations (217/1,469). The overall success rate was 92.4% (1,357/1,469 eyes). Subjects less than the age of 4 years had a success rate of 92.8% (1,296/1,397) compared with 84.7% (61/72) in children more than 4. In multivariable analysis, bilateral surgery, severe tear duct stenosis, and early stent loss were significantly associated with higher risk of surgical failure. CONCLUSIONS: Severe tear duct stenosis, early stent loss, and bilateral surgery were significant risk factors for surgical failure. While the success rate stratified by age at surgery suggested a lower success after the age of 4. Primary monocanalicular stent intubation is an effective and safe treatment for CNLDO sparing a child the need for multiple staged surgeries.

Transient crystalline lens deposits following the insertion of a phakic sulcus-fixated collamer intraocular lens in a hyperopic eye.

PURPOSE: The purpose of this study was to report crystalline lens deposit formation following ICL implantation for the correction of hyperopia. OBSERVATIONS: A 23-year-old male presented at the American University of Beirut Medical Center in 2008 seeking refractive surgery for hyperopia. His cycloplegic refraction was +7-1.25 × 115° and +7-1.00 × 115° in the right and left eyes, respectively, yielding a vision of 20/20 bilaterally. The patient underwent right eye insertion of a non-toric phakic sulcus-fixated collamer lens 2 weeks after undergoing peripheral iridotomies. The early postoperative course was complicated by anterior chamber inflammation and the appearance of diffuse whitish precipitates on the anterior surface of the crystalline lens, hypotony, and a mid-dilated mildly reactive pupil. With the prompt administration of topical and systemic steroids, the anterior chamber reaction subsided, and the anterior capsular deposits gradually resolved peripherally with some remaining centrally over the course of several weeks. The patient's visual acuity at 6 months was 20/20. CONCLUSIONSAND IMPORTANCE: Adequate viscoelastic removal and minimal iris stimulation seem to be essential to avoid this condition in hyperopic implants that lack a central port. Additionally, prompt treatment can minimize visual impairment and hasten visual recovery.

Posterior Scleritis in Familial Mediterranean Fever.

PURPOSE: Familial Mediterranean fever (FMF) is a monogenic autoinflammatory disease presenting as sporadic paroxysmal attacks of fever and abdominal pain. The inflammation of serosal spaces, joints, and skin is caused by the production of an abnormal protein called pyrin. Ocular pathology is scarce in FMF. CASE REPORT: Herein we describe a case of FMF presenting with painful loss of vision in the left eye. Serous macular detachment assessed by OCT, leaky pinpoint subretinal foci temporal to the fovea examined by fluorescein angiography, scleral and choroidal thickening seen on ultrasonography, and a negative systemic workup for vasculitis established the diagnosis of FMF-related posterior scleritis. The posterior scleritis responded promptly to moderate-dose oral corticosteroids with return of vision to baseline and resolution of the subretinal fluid. CONCLUSIONS: FMF rarely involves the posterior pole. Visual loss in FMF results from either posterior scleritis or posterior uveitis. A high degree of suspicion of posterior scleritis is warranted in female patients with known FMF presenting with cloudy serous macular detachment.

Use of the Masterka for complex nasolacrimal duct obstruction in children.

BACKGROUND: The Masterka stent has been recommended solely for treatment of simple distal membranous nasolacrimal duct obstruction (NLDO). The purpose of this study was to evaluate the Masterka stent as a primary treatment in complex forms of NLDO, including bony ductal stenosis and proximal and serial membranous obstruction. METHODS: The medical records of patients who underwent treatment for congenital nasolacrimal duct obstruction with the monocanalicular Masterka stent were reviewed retrospectively. Both simple and complex forms of NLDO were primarily treated with probing and irrigation, followed by placement of the Masterka stent. RESULTS: A total of 72 eyes (53 patients) were included: 17 cases were simple forms of NLDO; and 55 were complex. Success was achieved in 15 of 17 simple cases (88%) and 39 of 55 complex cases (71%); the overall success rate was 75%. In patients <24 months of age, success rates were 100% for simple and 78% for complex forms. CONCLUSIONS: The Masterka stent can be useful in a younger subset of patients with more complex forms of congenital NLDO. A lower success rate is noted in children >2 years of age and complex forms of NLDO, especially those with bony stenosis.

Is Inferior Oblique Overaction Associated With Astigmatism?

PURPOSE: To study the relationship between inferior oblique muscle overaction and astigmatism, and to explore any change in astigmatism after surgery. METHODS: This was a retrospective chart review of patients undergoing strabismus surgery. Demographic data collected included age, diagnosis, preoperative refraction, presence of inferior oblique overaction, surgery performed, and postoperative refraction. Patients were divided into three groups: those having only horizontal strabismus without inferior oblique overaction (no inferior oblique group) as a control group, those having bilateral inferior oblique overaction (bilateral inferior oblique group), and those having unilateral inferior oblique overaction (unilateral inferior oblique group). Right eyes of the bilateral inferior oblique and no inferior oblique groups were chosen for analysis, whereas the eye with inferior oblique overaction was included in the unilateral cases. Refractions were converted to power vector coordinates for comparison. Statistical analysis was performed to compare the power vectors among groups using the no inferior oblique group as controls and to explore any postoperative change in astigmatism. RESULTS: One hundred eighteen patients undergoing strabismus surgery were included (60 males and 58 females; mean age: 11.31 ± 10.59 years). Patients were divided into three groups: those having only horizontal strabismus without inferior oblique overaction (no inferior oblique group; 60 patients) as controls, those having bilateral inferior oblique overaction (bilateral inferior oblique group; 41 patients), and those having unilateral inferior oblique overaction (unilateral inferior oblique group; 17 patients). Preoperatively, there were no differences in astigmatism when comparing eyes with and without inferior oblique overaction. Postoperatively, both the no inferior oblique group and the bilateral inferior oblique group equally showed an increase in with-the-rule cylinder power (P = .02 and .01, respectively). CONCLUSIONS: Inferior oblique muscle overaction did not result in an increased prevalence of astigmatism along the axis of the overacting muscle.

Vitrectorhexis and lens aspiration with posterior chamber intraocular lens implantation in spherophakia.

UNLABELLED: We describe a technique that uses the vitrector to perform successful lens aspiration and posterior chamber intraocular lens (IOL) implantation in children with spherophakia and anterior lens subluxation. After an anterior chamber maintainer is placed, the ocutome is introduced through a limbal incision to perform a circular vitrectorhexis to avoid excessive manipulation of the unstable lens followed by gentle cortex aspiration. A foldable IOL is injected into the sulcus (3-piece IOL) or bag (1-piece IOL) if the capsule is sufficiently stable. Through a pars plana incision, the ocutome is then used to perform a posterior capsulotomy to prevent late posterior capsule opacification. In our patient, sulcus IOL placement was more stable than in-the-bag placement. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Abnormal binocular vision: monocular diplopia of physical origin: two case reports. Its relationship to the physiology and arrangement of the visual directions of the retinal areas; binocular triplopia.

BACKGROUND AND PURPOSE: Monocular diplopia is an infrequent but disabling complication following laser peripheral iridotomy, or following cataract surgery. Our purpose is to clarify the intraocular mechanism of monocular diplopia (and binocular triplopia) of physical origin and its relation to the physiology and arrangement of the visual directions of the retinal areas in each eye. CASE REPORTS: This is a report of one patient who developed monocular diplopia following an "exposed" laser peripheral iridotomy, and of a second patient who developed monocular diplopia due to a swollen opacified central posterior capsule following cataract surgery. CONCLUSION: Monocular diplopia of physical origin results from stimulation, by an object of regard, of two separate retinal areas that have two different visual directions due to optical ocular pathology.

Isolated inferior rectus paresis with falling eye phenomenon of the contralateral eye in a patient with pineal tumor: a case report.

UNLABELLED: PRUPOSE: To report a patient who developed an isolated inferior rectus paresis due to a pineal gland tumor, and to our knowledge never reported before. Our purpose is also to demonstrate that, even in partial and mild inferior rectus muscle paresis, the findings of the inhibitional palsy described by Chavasse and the downshoot of the fellow eye in adduction help determine the diagnosis. CASE REPORT: A patient with pineal gland tumor demonstrated findings characteristic of unilateral isolated inferior rectus paresis. CONCLUSION: Although bilateral sixth nerve paresis and Parinaud's syndrome are commonly reported in pineal gland tumors; in the the presence of an isolated inferior rectus palsy, one should also consider the pineal gland as the causative factor.

Leishmaniasis of the auricle mimicking carcinoma.

Leishmaniasis of the auricle has been rarely reported in our region of the world, where it is labeled as "Old World Leishmaniasis." It may mimic other pathologies, such as malignancies or other infectious processes. We present a case of an auricular Leishmania lesion which was first suspected to be a carcinoma. Four previous auricular Old World Leishmania cases have been reported. The epidemiology, clinical presentation, diagnosis, and treatment of this entity are briefly reviewed.