Bilateral lateral rectus resection for residual esotropia.

PURPOSE: Residual or recurrent esotropia is a common problem following bilateral medial rectus recessions for esotropia, and various surgical techniques have been advocated. We have favored bilateral lateral rectus resections. METHODS: We reviewed our results in 25 patients, aged 7 to 89 months (mean 27 months), with a follow-up of 7 to 95 months (mean 39 months) following the second surgery. Survival analysis was used, with success (survival) defined as alignment within 10 PD at last follow-up. RESULTS: Median survival was 84 months with an estimated mean survival of 55 months. There are 15 of 25 patients (60%) currently successful. There were 8 undercorrections and 2 overcorrections. Three patients, included among those not successful, required a third procedure. Survival was similar to previous reports of primary esotropia and consecutive exotropia. CONCLUSIONS: Our results suggest that bilateral lateral rectus resection is a reasonable surgical option in the treatment of residual esotropia following recessions of both medial recti.

Incidence of endocrine disease among residents of New York areas of concern.

There are six Areas of Concern, as identified by the International Joint Commission, located in New York State. Three are contiguous in western New York and have similar contaminants (Buffalo River, Niagara River, and 18 Mile Creek). We used the Statewide Planning and Research Cooperative System database, which records diagnoses according to the (italic)International Classification of Disease, Ninth Revision(/italic) codes for all patients admitted to state-regulated hospital facilities, to compare incidence of selected diseases reported in hospitalized patients who reside in ZIP codes that are within 15 miles of any of these sites to those of residents of three different control populations: all residents of the rest of New York State (including New York City), all residents of ZIP codes outside New York City that do not contain any site identified as a federal or state Superfund site, and all residents of ZIP codes outside New York City that contain a federal or state Superfund site that does not have one or more persistent organic pollutants listed as a major contaminant. We found a significant elevation of disorders of the thyroid gland in women, but not in men, of all ages greater than 25 years on all three comparisons, as well as an increased incidence of morbidity from diseases of the female genital tract in women between age 25 to greater than 75 years for all comparison groups. There was also a significant elevation in incidence of endometriosis in women 25-44 years of age. All these elevations were significant at the 99% confidence level. Incidence of diseases of ovaries and testes and female infertility were not different from those in the rest of New York State. Although many factors influence incidence of thyroid and genital diseases, our results are consistent with the hypothesis that exposure to environmental contaminants through residence near polluted sites may be a factor.

Acquired esotropia: subjective and objective outcomes.

PURPOSE: The measurement of outcomes of pediatric therapy will be increasingly important to third-party payers as they allocate health care resources. We undertook this study to assess the effectiveness of treatment of acquired esotropia, as measured subjectively by parents and objectively by examination. METHODS: A chart review was used to gather objective clinical data from all patients presenting between 1994 and 1995 with esotropia after their first birthday. Parents' impressions of the quality and impact of treatment were tabulated by using a telephone questionnaire. RESULTS: Of 48 patients studied (mean age, 3.8 years; 44 months' follow-up), the 26 with amblyopia were effectively treated in 81% of cases. Mean esotropic angles decreased, with glasses and/or surgery, from 33.1 to 4.9 PD at distance and from 40.0 to 11.4 PD at near. The average estimated cost of care was 547 dollars per patient per year. Parents considered treatment "extremely important" to their child's future happiness and success in 90% of cases. CONCLUSION: Our experience has shown that treatment of acquired esotropia in childhood, while relatively inexpensive, is highly effective, both objectively and subjectively.

Bilateral lateral rectus recession for consecutive exotropia.

INTRODUCTION: Treatment of consecutive exotropia after bilateral medial rectus recessions has been rarely studied. Though several series have reported results of medial rectus advancement, none has described results of lateral rectus recessions. METHODS: We reviewed our results in 31 patients who underwent bilateral lateral rectus recessions for consecutive exotropia after bilateral medial rectus recessions. Mean follow-up was 30 months (range, 1-140 months) after the exotropia repair. RESULTS: At last follow-up, 20 of 31 patients (65%) had deviations of less than or equal to 10 PD. Limitation of adduction was not apparent. DISCUSSION: Cooper's dictum states that lateral rectus recession should be performed instead of medial rectus advancement. Our results suggest that this approach is generally successful. The outcome after exotropia repair in consecutive deviations is comparable to that after repair of primary exotropia.

Correlation of the vision-related functional impairment associated with blepharoptosis and the impact of blepharoptosis surgery.

OBJECTIVE: To assess the effect of blepharoptosis on patients' visual function and health-related quality of life and to determine what measures are associated with postsurgical change in functional status. DESIGN: Prospective, observational case series. PARTICIPANTS: One hundred patients with unilateral or bilateral blepharoptosis. INTERVENTION/MAIN OUTCOME MEASURES: Preoperative and postoperative upper eyelid position (i.e., margin reflex distance [MRD]) and superior visual field (SVF) height, as well as subjective visual function and health-related quality-of-life functional status before and after ptosis surgery. RESULTS: There was a mean 30-point increase in functional index score after ptosis repair (P < 0.001). Lower (more ptotic) preoperative upper eyelid position and SVF (combined eye) were associated with greater change in functional index after surgery (r = -0.290, P = 0.007 and r = -0.39, P = 0.003, respectively). Preoperative visual field testing with manual lid elevation was not significantly correlated to the postoperative change in functional index (P > 0.100). The strongest correlation of postoperative functional index change was with the preoperative functional status (r = -0.79, P < 0.001). CONCLUSIONS: Patients' functional status is reduced by blepharoptosis, and surgical repair results in measurable increase in health-related quality of life. Patients' self-reported preoperative functional impairment is most strongly associated with the degree of postsurgical functional improvement.

Changes in dental fluorosis and dental caries in Newburgh and Kingston, New York.

OBJECTIVES: This study sought to determine whether the prevalence of dental fluorosis and dental caries had changed in a fluoridated community and a nonfluoridated community since an earlier study conducted in 1986. METHODS: Dental fluorosis and dental caries data were collected on 7- to 14-year-old lifelong residents (n = 1493) of Newburgh and Kingston, NY. RESULTS: Estimated dental fluorosis prevalence rates were 19.6% in Newburgh and 11.7% in Kingston. The greatest disparity in caries scores was observed between poor and nonpoor children in nonfluoridated Kingston. CONCLUSIONS: The prevalence of dental fluorosis has not declined in Newburgh and Kingston, whereas the prevalence of dental caries has continued to decline.

Evaluation of a school-based sealant program in New York State.

This study evaluated the outcome of a targeted dental sealant program by comparing the survival probabilities of sealed high-risk first molar tooth sites to unsealed low-risk tooth sites in 1,122 children enrolled in a school-based sealant program. A comparison of the survival probabilities between low-risk first molar teeth that did not receive sealants and the sealed high-risk first molar teeth did not show significant differences. The results suggest that the protocol used by the program provides a satisfactory method for identification of children who could best benefit from sealants in a school-based situation.

Subjective and objective outcomes of strabismus surgery in children.

BACKGROUND: The negative psychosocial impact of strabismus in adults has been well documented. Despite the increasingly recognized importance of outcomes research, parents' satisfaction with strabismus treatment in childhood and their assessment of its functional impact and "quality of life" impact have not been investigated. METHODS: A survey instrument was designed to assess parents' perceptions of preoperative, surgical, and postoperative phases of the clinical experience, including the long-term impact of surgery on their children. RESULTS: Overall satisfaction with the surgical result was rated "good" or "very good" in 85% of 77 children under age 6. The correlation between subjective satisfaction and objective alignment within 10 prism diopters (delta) of orthophoria was significant (P < .001). Parents of children under age 4 noted improved eye contact (61%) and appearance (94%). Parents of older children noted improved interactions with others (47%) and self-esteem (55%). Coordination was considered improved in 56% of the entire group. Subjective satisfaction and psychosocial benefits often occurred even in cases deemed objectively unsuccessful. CONCLUSION: Surgical correction of strabismus in childhood is clearly perceived by parents to be both successful and important to them and their children.

Alignment success following medical rectus recessions in normal and delayed children.

Others have suggested that developmentally delayed children, who are frequently esotropic, have a poor prognosis following esotropia surgery. To date, no comparison of success rates in normal and delayed children following similar surgery has been made. We compared our long-term results following graded bilateral medial rectus recessions in consecutive normal (n = 62) and delayed (n = 29) children. We defined success as alignment maintained within 10 delta of orthophoria. Survival curves were compared using the Mantel-Haenszel statistic. Delayed children had a significantly poorer outcome (p = .05) throughout follow up, which ranged from 12 to 120 months (mean = 24 months). Early in the period of study, we observed a large proportion of overcorrections among the delayed children. Subsequent modification in the amount of surgery performed appeared to improve the initial and long-term success in these children. We conclude that delayed children do have a poorer prognosis than normal children following medial rectus recession. This prognosis may be improved by more conservative amounts of surgery.

Exaggerated effect of bilateral medial rectus recession in developmentally delayed children.

Many have suggested that the esotropia associated with developmental delay should be considered separately. However, the esotropia surgery recommended for developmentally delayed children has been similar to that performed in normal children. We have noticed a tendency for developmentally delayed children to develop consecutive exotropia following bilateral medial rectus recessions. Of 94 children undergoing such surgery between 1981 and 1991, 31 were developmentally delayed. Follow up ranged from 7 months to 202 months (mean 24 months). Surgical effect, defined as the change in alignment following each amount of surgery, was greater in the developmentally delayed group than in control subjects (P = .002). The increase in effect of the same amount of surgery in a developmentally delayed patient averaged 5.28 prism diopters, but was much larger in specific instances. Variability of effect was more marked among developmentally delayed children. We conclude that bilateral medial rectus recessions in developmentally delayed children may be better postponed in some cases, deferred for smaller angles, or decreased in amount.

Bilateral lateral rectus recession for exotropia: a survival analysis.

Exotropia may progress during the childhood years, and the ideal time for surgical intervention remains uncertain. We reviewed our results following bilateral lateral rectus recession in 57 consecutive patients. In order to identify possible predictive covariates, we performed survival analysis using survival time as the time from surgery to failure. The patients' age at the time of surgery ranged from 11 months to 50 years (mean, 68 months). Follow up after surgery ranged from 1 to 105 months (mean, 47 months). Outcomes were considered failures if there was (1) a distance exodeviation greater than 10 prism diopters at any time after surgery, (2) a distance esodeviation greater than 10 delta more than 6 months postoperatively, or (3) further surgery for exotropia or esotropia. By these criteria, surgery was successful in 58% of cases. Results of the survival analysis indicated an estimated mean time to failure of 68 months. Patients with intermittent exotropia were more likely to remain aligned postoperatively than were those with constant deviations. The age at onset of exotropia, age at surgery, angle of deviation at different fixation distances, early postoperative alignment, and presence of symptoms, amblyopia, anisometropia, or incomitance before surgery were not predictive of success. We conclude that exotropia surgery may be performed with the same likelihood of success at any age, but patients with intermittent deviations do better.

Evaluating the visual field effects of blepharoptosis using automated static perimetry.

BACKGROUND: Quantitation of the effects of blepharoptosis on the visual field has largely been limited to manual kinetic perimetry using a single peripheral isopter. The authors evaluated the visual dysfunction caused by blepharoptosis using automated static full-threshold perimetry. METHODS: A custom static full-threshold 60 degrees test strategy on the Humphrey field analyzer was used to assess the visual fields of 20 volunteers at their normal baseline and after inducing mild and moderately severe blepharoptosis by applying gold weights to the eyelids. Threshold sensitivities were measured at points along the eight principal meridians, separated by 45 degrees, traditionally used to assess visual field impairment. RESULTS: For mild blepharoptosis, essentially all test points along the superior meridian were significantly depressed (P < 0.01), with an increase in slope secondary to greater decreases in sensitivity at more eccentric points. For moderately severe blepharoptosis, depression of the superior meridian was expectedly greater than that seen with mild blepharoptosis. Additionally, depression of the horizontal meridians and to a lesser extent the lower meridians also was noted. CONCLUSIONS: These results suggest that even mild blepharoptosis may be associated with depression of the superior visual field extending close to fixation. Ophthalmologists should be aware of the effect of blepharoptosis when testing for other ophthalmic or neurologic disorders using automated static perimetry. Full-threshold static perimetry can be used to quantitate the visual field loss associated with blepharoptosis as a means of evaluating visual impairment.

Recognized scleral perforation during eye muscle surgery: incidence and sequelae.

Inadvertent perforation of the sclera is a widely recognized complication of eye muscle surgery. In the 1960s and 1970s, it was estimated to occur in 9% to 12% of patients operated. Fortunately, dreaded vision-threatening sequelae have been much less common. To better define the occurrence and sequelae of this complication, we sent a questionnaire to all 342 members of the American Association for Pediatric Ophthalmology and Strabismus. Scleral perforations, defined to include known retinal damage, occurred in 728 of nearly 554,000 eye muscle procedures performed by 223 surgeons. Perforations were two times more common with residents or fellows operating. They occurred not only during muscle reattachment (633 cases), but also during muscle disinsertion (24 cases), muscle dissection (6 cases), passage of traction sutures beneath the lateral rectus (5 cases), and preplacement of muscle sutures (5 cases). Many other perforations may have been unrecognized and uncounted. Visual loss was uncommon, occurring in only nine patients. Fourteen retinal detachments included four cases with partial and two with total loss of vision. Only three cases of endophthalmitis occurred, one resulting in partial visual loss and two in total visual loss. Techniques suggested by respondent surgeons to avoid perforations are discussed.

Glaucoma after pediatric lensectomy/vitrectomy.

Glaucoma after pediatric cataract surgery, once well recognized, now occurs only rarely after modern lensectomy/vitrectomy. The authors performed directed glaucoma evaluations of 34 eyes of 26 children. Based on intraocular pressures of 26 mmHg or greater, glaucoma was diagnosed in 8 (24%) eyes of 7 (27%) children. Glaucoma was found more commonly among children followed more than 60 months and was diagnosed up to 105 months after surgery. Typically, the glaucoma was open angle and asymptomatic. Four children had had previously normal pressures recorded. With longer follow-up, it is likely that more children will be diagnosed with glaucoma after lensectomy/vitrectomy procedures. The authors believe such patients should be followed as glaucoma suspects for the rest of their lives.

Application of the Cox model as a predictor of relative risk of coronary heart disease in the Albany Study.

Patients in long term studies of coronary heart disease may have different levels of risk during the course of study. Smoking habits, blood pressure, and obesity may change drastically during this period. The multiple logistic model, the most commonly used model for the analysis of coronary heart disease studies, does not consider survival time in assessment of the dependent covariates and does not account for the censoring which usually occurs in such studies. We propose a Cox model with time-dependent covariates to model the risk of coronary heart disease in the Albany study. The Cox model we fitted evaluates the patients' risk on the basis of the data at the last visit. With this methodology, we can evaluate whether it is advantageous for individuals to modify their risk of disease by their effecting changes in their covariates, that is to stop smoking, lose weight, change diet and so on. The important covariates that explain the risk of coronary heart disease were the same in our model as in the models used in the earlier reports. The estimated relative risks were slightly higher in most cases and lend more support to the need to encourage patients to achieve a better covariate state.

Serum folate and vitamin B12 levels in patients with small cell lung cancer.

Serum folate and vitamin B12 levels were evaluated in 80 patients with small cell lung cancer at diagnosis and during therapy over a 30-week period. Approximately one half of the patients were randomized to receive hyperalimentation. Folate and vitamin B12 intake was adequate without parenteral nutrition in these cancer patients. Serum folate and Vitamin B12 levels did not correlate with disease extent. At the initiation of therapy, serum folate declined with increasing weight loss. During therapy, the intake of folate was adequate to maintain a normal serum folate despite marked weight loss.