Photorefractive keratectomy for the treatment of purely refractive accommodative esotropia: 6 years' experience.

AIMS: To report the long term outcomes of photorefractive keratectomy (PRK) for the treatment of hyperopia associated with purely refractive accommodative esotropia. METHODS: This study was a retrospective chart review of 40 patients aged 17-39 years who underwent PRK to eliminate their dependence on glasses. Pre- and postoperative best spectacle corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), refractive spherical equivalent (SEQ), ocular alignment and stereoacuity were reviewed. RESULTS: Forty patients (80 eyes) with a mean age of 27.9 years were treated for a mean preoperative SEQ of +3.06 D hyperopia. The mean final postoperative SEQ was +0.06 D. Preoperative BSCVA was 0.04 logarithm of the minimum angle of resolution (logMAR), and did not change postoperatively. Mean UCVA significantly improved from 0.30 logMAR preoperatively to 0.08 logMAR post-operatively. Mean pre-operative esotropia at distance and near was 18.6 prism D. All patients were orthophoric without correction at the 1 month, 1 year and final postoperative evaluations. Visual acuity, refractive error and alignment remained stable after the 1 year postoperative examination. Stereoacuity was unchanged in 80% of patients postoperatively. There were no complications. CONCLUSION: PRK can be used to treat low to moderate hyperopia associated with purely refractive accommodative esotropia in young adults.

Intermittent exotropia.

The ideal approach to the management of intermittent exotropia remains unclear. Well designed, prospective studies are limited. Furthermore, the criteria for success vary among health care professionals. Long-term outcomes of surgical intervention are not known, and the role of non-surgical treatment modalities has not been agreed upon. A multicenter study comparing surgical and nonsurgical treatment method has been proposed. If carried out, a study of this nature would greatly benefit many individuals affected by this common condition. Until then, intermittent exotropia will continue to be one of the most difficult problems to treat.

Ultranear testing in accommodative esotropia.

PURPOSE: To determine if patients with accommodative esotropia controlled with glasses maintain ocular alignment at viewing distances less than 1/3 m. DESIGN: Prospective case-control study. METHODS: Thirty children with refractive-type accommodative esotropia were evaluated for ocular alignment at 6 m, 1/3 m, and 1/6 m ("ultranear") using accommodative targets. Ten children without strabismus served as controls. RESULTS: Twenty-eight of 30 (93%) of children with otherwise controlled accommodative esotropia exhibited a manifest deviation of 5(Δ) to 16(Δ) when measured at ultranear. Excessive accommodation appeared to be present in at least some accommodative esotropes. Regardless of viewing distance, esophoria or esotropia was not elicited in control patients (P <0.0001). CONCLUSION: Children with refractive accommodation esotropia demonstrate excess convergence at very close testing distances. Excess accommodation may partly explain this observation.

Two-muscle surgery for congenital esotropia: rate of reoperation in patients with small versus large angles of deviation.

INTRODUCTION: Standard surgical treatment of congenital esotropia (CET) in patients with preoperative angles of deviation measuring 50 PD) CET. METHODS: Medical records of 102 patients who underwent bilateral medial rectus muscle recessions between January 1991 and December 1997 were reviewed. Patients were excluded if neurologic abnormalities or developmental delays were documented before the operation, if major structural abnormalities of the eye were present, or if less than 1-month follow-up after surgery was documented. The remaining 56 patients were assigned to either the larger angle (>50 PD) or smaller angle (< or =50 PD) group, based on the magnitude of their preoperative esotropia. Rates of reoperation for residual CET, for consecutive exotropia or dissociated horizontal deviation, or for dissociated vertical deviation with or without oblique muscle dysfunction were determined for each group. RESULTS: Forty of 56 patients (71%) were assigned to the smaller angle group and 16 of 56 patients (29%) to the larger angle group. In the larger angle group, 4 patients (25%) underwent surgery for residual esotropia. In the smaller angle group, 8 patients (19%) underwent surgery for residual esotropia, 8 (19%) underwent surgery for consecutive exotropia or dissociated horizontal deviation, and 8 (19%) underwent surgery for dissociated vertical deviation or oblique muscle dysfunction. CONCLUSION: The success rate for ocular realignment in patients with CET by using bilateral medial rectus muscle recession did not appear to diminish when applied to deviations greater than 50 PD as compared with smaller angle deviations. Surgery on 3 or 4 horizontal rectus muscles may be unnecessary in the treatment of patients with very large angles of CET.

Disinfection of eyelid specula with chlorhexidine gluconate (Hibiclens) after examinations for retinopathy of prematurity.

BACKGROUND: The preferred method of cleaning eyelid specula between examinations for retinopathy of prematurity is unknown. A previous study showed that disinfection with 70% isopropyl alcohol swabs fails to eliminate viruses and bacteria from the specula. OBJECTIVE: To determine if alternative sterilization procedures would allow multiple use of a single speculum without risking nosocomial infection. METHODS: In phase 1, 40 autoclave-sterilized eyelid specula were randomized into either "cleaned" or "patient control" groups after being used for routine retinopathy of prematurity examinations performed in the outpatient setting. Specula in the cleaned group were cleaned with chlorhexidine gluconate (Hibiclens). Specula in the patient control group were not cleaned after use. All study specula were placed into enriched culture media from which bacterial and fungal cultures were obtained. In phase 2, 20 autoclave-sterilized eyelid specula were inoculated with a clinically relevant dilution of adenovirus serovar 5 or herpes simplex type 2. Specula were randomized into either a cleaned or a control group, and cell cultures and immunofluorescence assays were used to document and confirm, respectively, viral growth. RESULTS: In phase 1, all 20 cultures from the patient control group grew bacteria compared with 0 (0%) of 20 cultures from the cleaned group and 0 (0%) of 5 from the cleaned control group. No fungi were isolated from any group. In phase 2, all 10 cultures from specula inoculated with adenovirus serovar 5 grew virus. None of the cultures from the 5 cleaned specula inoculated with herpes simplex type 2 grew virus. In contrast, all 5 cultures in the control group were positive for growth of herpes simplex type 2. CONCLUSIONS: Autoclave sterilization is the ideal method of sterilization of eyelid specula between neonate examinations. When an alternative disinfection technique is required, washing the speculum with chlorhexidine gluconate and tap water is preferred over wiping with a 70% isopropyl alcohol swab. Arch Ophthalmol. 2000;118:786-789

Outcomes from surgical treatment for dissociated horizontal deviation.

BACKGROUND AND PURPOSE: Long-term treatment results and recommendations for dissociated horizontal deviation (DHD) are sparse in the literature. We report the results of surgery for DHD with a mean of 48 months postsurgical follow-up. PATIENTS AND METHODS: Records were reviewed for 33 consecutive patients who underwent surgery to correct DHD between 1991 and 1997. Patient data were recorded, including age at time of DHD operation, initial diagnosis, history of prior surgery, number of operations related to DHD, amount of preoperative DHD for each operation, presence of concomitant esotropia or exotropia (XT), presence of amblyopia, type of operation performed, time interval between operations, and final alignment. RESULTS: Twenty-five patients (78%) underwent a single operation for DHD. Seven patients (22%) underwent 2 operations, and 2 of those 7 patients (6% of the total) underwent 3 operations to control DHD and/or horizontal strabismus accompanying the DHD. Most patients (75%) had a prior history of congenital esotropia, which had been previously corrected with bilateral medial rectus muscle recession. Patients with an XT and DHD required bilateral surgery more frequently to control their deviation. CONCLUSION: When DHD is prominent and manifests frequently, a surgical plan specific to the horizontal drift of the eyes is needed. Unilateral lateral rectus muscle recession appears to be adequate to control manifest DHD over time in most patients. Bilateral surgery will be needed occasionally for bilateral DHD when alternate fixation is present and frequently when XT and DHD coexist.

Color doppler imaging of the central retinal artery in premature infants undergoing examination for retinopathy of prematurity.

PURPOSE: Recent attempts have been made to quantify blood flow velocity in the central retinal artery (CRA) of adults using color Doppler imaging (CDI). Although retinal vascular abnormalities are the hallmark of severe retinopathy of prematurity (ROP), normal values have not been established for CRA blood flow velocity in premature infants. METHODS: CDI of the CRA was successfully performed on 43 eyes in 22 infants (postconceptional ages 32 to 39 weeks) before the infants underwent examination for ROP. Peak systolic velocity (PSV) and end diastolic velocity were recorded from at least 1 eye of each patient. Pourcelot's resistive index was then calculated for each eye studied. RESULTS: Mean PSV for patients with no ROP (n = 6) was 7.2 +/- 1.5 cm/s, whereas those with any degree of ROP excluding plus disease (n = 9) had a mean PSV of 8.9 +/- 1.8 cm/s. Of the patients with ROP and plus disease (n = 7), the mean PSV was 7.0 +/- 1.6 cm/s. There were no statistically significant differences among these 3 groups (P= .08). CONCLUSIONS: CDI can be successfully performed on preterm infants and yields values lower than those previously reported in healthy adult subjects. PSV in the CRA may be higher in subjects with ROP in the absence of plus disease; however, further study is needed to determine whether these differences are significant.

Sinus histiocytosis presenting as bilateral epibulbar masses.

PURPOSE: To report a case of sinus histiocytosis presenting as multiple, bilateral epibulbar masses. METHODS: We examined a 4-year-old child with a 2-month history of gradually enlarging, salmon-colored epibulbar masses. Excisional biopsies and a systemic evaluation were performed. RESULTS: Systemic evaluation was normal; no lymphadenopathy was documented. Histopathologic evaluation disclosed features consistent with sinus histiocytosis. Flow cytometry and gene rearrangement studies confirmed the benign nature of the disease. No tumor recurrence was noted. CONCLUSION: Sinus histiocytosis may present as isolated epibulbar masses that may be treated with surgical excision.

Outcomes and ocular growth rates after intraocular lens implantation in the first 2 years of life.

PURPOSE: To evaluate the outcomes and ocular growth after intraocular lens (IOL) implantation in the first 2 years of life. SETTING: University-affiliated eye institute. METHODS: The medical records of consecutive children under 24 months of age who had cataract extraction with IOL implantation were reviewed. Change in axial length over time, postoperative complications, need for additional surgery, predicted versus actual postoperative refraction, and visual outcomes were recorded. Complication rates were compared with those in a similar group of age-matched patients who were left aphakic at the time of surgery. RESULTS: Twenty-two eyes of 17 patients aged 12 days to 22 months had IOL implantation. Length of follow-up ranged from 2 to 36 months (mean 14 months). Visual acuity measurement, limited to fixation-preference testing in most patients, revealed amblyopia in the operated eye in the majority of cases. Postoperative refractive error, predicted using the Holladay formula, showed a mean error in prediction of 1.5 diopters (D) (range -1.8 to 4.1 D). Serial axial lengths in 11 patients with a mean follow-up of 20 months showed no significant difference in growth in the fellow versus the operated eye. There was no significant difference in complication rates between pseudophakic patients and the age-matched aphakic group. However, in 14 of 32 aphakic eyes (44%), a notation in the chart indicated that the patient had stopped wearing glasses or contact lenses for at least 2 months. CONCLUSION: Intraocular lens implantation appeared to be a safe and effective alternative to contact lens or spectacle correction of aphakia in children younger than 2 years of age. It may aid amblyopia treatment by eliminating periods of uncorrected aphakia.

Timing of initial screening examinations for retinopathy of prematurity.

OBJECTIVE: To test a screening protocol for retinopathy of prematurity (ROP) that uses the dual criteria of postconceptional age and chronological age, rather than a single parameter, to determine precisely when to begin eye examinations. METHODS: We retrospectively reviewed medical records of 179 infants (326 eyes) who had undergone laser treatment for threshold ROP. We entered their chronological and postconceptional ages at treatment into a database and evaluated various screening parameters to determine the combination of criteria that would allow us to safely postpone the initial eye examinations. RESULTS: Screening infants at 7 weeks of chronological age or 34 weeks of postconceptional age (whichever comes first), but not before 5 weeks of chronological age, seems to reliably detect the onset of threshold ROP while reducing the number of unnecessary early examinations. CONCLUSION: Simultaneously applied dual criteria of chronological age and postconceptional age may be a superior method of determining when to initiate ROP examinations and is preferable to using either chronological age or postconceptional age alone.

Acquired cataracts after argon laser photocoagulation for retinopathy of prematurity.

PURPOSE: Our purpose was to determine the incidence of cataract after argon laser photocoagulation of the retina in infants with retinopathy of prematurity (ROP). METHODS: We reviewed medical records of 189 consecutive infants undergoing argon laser photocoagulation for acute ROP between 1993 and 1996. Birth weight, estimated gestational age at birth, chronologic and postconceptional ages at the time of treatment, ROP outcome, and the postoperative occurrence of cataract were recorded. RESULTS: A total of 374 eyes in 189 infants were treated for threshold ROP. Mean birth weight was 916 gm (range 480 to 2500 gm), mean postconception age at birth was 26.4 weeks (range 23.5 to 34 weeks), and mean postconception age at surgery was 36.2 weeks (range 33 to 47 weeks). A favorable anatomic outcome occurred in 90% of eyes. However, severe macular traction, macular fold, or retinal detachment developed in 10% of eyes. A total of four eyes (1%) had cataracts. Laser-induced cataracts were diagnosed in only two eyes. A third eye had a posterior subcapsular cataract that may or may not have resulted from the laser treatment. In a fourth patient a unilateral punctate opacity judged to be visually insignificant was noted at surgery but it was not progressive. All patients who had cataracts had a persistent tunica vasculosa lentis; however, there was no statistically significant difference in the incidence of cataract formation in eyes with persistent tunica vasculosa lentis compared with eyes without it (p = 0.057). CONCLUSION: Argon laser photocoagulation remains an effective alternative to transscleral cryotherapy in the treatment of threshold ROP. The incidence of cataract formation is approximately 1% and may be more likely to occur when persistent hyaloidal vessels are present on the lens.

Myopic shift after intraocular lens implantation during childhood.

PURPOSE: The purpose of the study is to evaluate the myopic shift that occurs in children 3 to 9 years of age who undergo cataract extraction with primary intraocular lens (IOL) implantation. METHODS: A review of 18 children (mean, 6.3 +/- 0.5 year; range, 3-9 years) who had undergone primary IOL implantation was undertaken. Patients were observed for an average of 3.2 years. The initial and last postoperative refractive errors were compared. RESULTS: The mean myopic shift was -0.99 +/- 0.22 diopter (D) (median, 1.0 D) with a range of -3.25 to +0.38 D. The difference in the myopic shift of the children 3 to 5 years of age (-0.94 +/- 0.30 D) was not significantly different from the myopic shift occurring in the children 6 to 9 years of age (-1.07 +/- 0.35 D). The myopic shift was less than 1.5 D in 70% of the eyes and only 3 eyes had a myopic shift greater than 2 D. Ninety percent of the children achieved a visual acuity of 20/40 or better in their pseudophakic eye or eyes. CONCLUSIONS: Although each patient should be evaluated on an individual basis, the authors recommend undercorrecting most children 3 to 9 years of age by 1 D from the IOL power predicted to achieve emmetropia.

Familial bilateral perilimbal cystic benign melanosis with lipid keratopathy--a new entity?

We examined the clinicopathologic findings in two sisters with pigmented conjunctival lesions. Slit-lamp examination showed bilateral, circumferential cystic pigmented perilimbal lesion and prominent lipid keratopathy. The pigmented lesions were examined via biopsy, and histologic and ultrastructural examination of the biopsy specimens showed secondary melanosis of numerous conjunctival epithelial inclusion cysts. The two sisters have familial bilateral perilimbal cystic benign melanosis with lipid keratopathy, an idiopathic condition that requires no further surgical management.

Clinicopathologic features of surgically excised choroidal neovascular membranes.

PURPOSE: The purpose of this study is a descriptive correlation of the clinical, fluorescein angiographic, and pathologic features in a large series of patients who underwent surgical removal of choroidal neovascular membranes. METHODS: The patients' clinical data were recorded for each surgically removed choroidal neovascular membrane received in the authors' laboratory. Fluorescein angiographic characteristics of the membranes, including well-demarcated versus poorly demarcated preoperative appearance, postoperative choroidal atrophy, and membrane recurrence, were recorded whenever possible. The pathologic features of the membranes, including cellular and extracellular constituents, were determined on light and electron microscopic examination. RESULTS: A total of 123 membranes were studied. Underlying diseases in decreasing order of frequency were age-related macular degeneration, ocular histoplasmosis syndrome, myopia, idiopathic and pattern dystrophy. The cellular and extracellular constituents of the membranes were similar, regardless of underlying disease, with the exception of basal laminar deposit, seen almost exclusively in age-related macular degeneration. Well-demarcated membrane components were localized with a central subretinal pigment epithelium fibrovascular core. Poorly demarcated membranes were represented by a subneurosensory retinal (breakthrough) component, although most of these membranes had associated retinal pigment epithelium. Fragments of Bruch's membrane were common in specimens from patients with postoperative choroidal atrophy, and there was generally a lack of vascular channels in membranes that led to recurrence. CONCLUSIONS: This study suggests that choroidal neovascular membranes represent a stereotypic, nonspecific response, regardless of underlying disease. Most membranes are subretinal pigment epithelium, and what is recognized angiographically as a subneurosensory retinal component contains associated retinal pigment epithelium in most instances. Fragments of Bruch's membrane in the specimen correlate with postoperative choroidal atrophy. Lack of vascular channels in the surgical specimen may correlate with a risk for postoperative membrane recurrence.

Clinicopathologic features of excised mitomycin filtering blebs.

Using light and electron microscopy, we examined two conjunctival filtering blebs that had been treated with mitomycin just prior to trabeculectomy and were later excised due to ocular hypotony. Light microscopy showed attenuated epithelium, loosely arranged subepithelial connective tissue, and scattered acute and chronic inflammatory cells. Electron microscopy also showed these findings and demonstrated the presence of presumably viable activated fibrocytes in the subepithelial connective tissue. The presence of inflammatory cells in the blebs was attributed to concurrent infections and suggests that mitomycin does not completely suppress, but may attenuate, the inflammatory response. The mechanism of hypotony and bleb failure in the two eyes was most likely a combination of over-filtration and a persistent wound leak due to a lack of postoperative subconjunctival fibrosis secondary to treatment with mitomycin.