Methadone for Emergence Delirium in Ambulatory Pediatric Strabismus Surgery.

Background: Emergence delirium in children following strabismus surgery is a distressing and potentially dangerous condition and is likely attributable to visual disturbances, pain, and anesthetic gases. We explored whether a single intraoperative dose of methadone could reduce emergence delirium. Methods: Our study was an institutional review board-approved prospective, controlled, before-and-after investigation. Inclusion criteria were age <18 years and American Society of Anesthesiologists (ASA) classification 1 or 2. Patients were excluded for obesity, documented sleep apnea, significant neurologic disease, or inpatient status. Control group patients were recruited sequentially, and the anesthetic was performed per preference. The study group was recruited similarly and received an intravenous dose of methadone 0.15 mg/kg at induction. The primary outcome was peak score on the Pediatric Anesthesia Emergence Delirium (PAED) scale. Secondary outcomes included time to anesthetic emergence, postoperative pain scores, postanesthesia care unit (PACU) length of stay, and postdischarge respiratory complications. Results: Forty-nine control group and 55 study group patients were recruited. No significant differences were found between groups for age, sex, weight, ASA classification, or duration of surgery. The control group received more preoperative midazolam, intraoperative fentanyl, and intraoperative ketorolac. Compared to the control group, the study group had 42% and 85% reductions in peak and severe PAED scale scores, respectively, in the PACU and required less rescue pain medications. Anesthetic emergence time and length of stay were not different between the groups. No significant postoperative complications occurred. Conclusion: Emergence delirium following outpatient pediatric strabismus surgery was substantially mitigated by the use of intraoperative methadone without affecting PACU throughput. No significant complications occurred. Further study is warranted to corroborate routine use of this drug for emergence delirium.

Subretinal Abscess Complicated by Post-infectious Retinal Vasculitis Following Strabismus Surgery.

An 8-year-old girl presented with a subretinal abscess after strabismus surgery. This was treated successfully with medial rectus suture removal, pars plana vitrectomy, intravitreal antibiotics, and intravenous antibiotics. Recovery was complicated by acute post-infectious retinal vasculitis after tapering high-dose corticosteroids, requiring an extended corticosteroid regimen over 2 months until resolution. [J Pediatr Ophthalmol Strabismus. 2023;60(3):e26-e30.].

A Rare Case of Congenitally Acquired Ocular Toxocariasis in A Five-Week-Old Infant.

PURPOSE: To report a case of strabismus in a five-week-old infant, likely secondary to a rare occurrence of congenitally acquired ocular toxocariasis. METHODS: Retrospective case report. RESULTS: A five-week-old male infant with left exotropia was referred to pediatric ophthalmology and to a vitreoretinal specialist. Fundoscopic examination revealed a granuloma with associated retinal folds and tractional retinal detachment typical for ocular toxocariasis. Serology revealed positivity for Toxocara antibodies, consistent with the clinical diagnosis of ocular toxocariasis. CONCLUSION: Ocular toxocariasis is typically thought to be secondary to acquired Toxocara infection secondary to fecal-oral transmission. In this case of early-onset strabismus secondary to ocular toxocariasis, it is hypothesized that this is a presentation of congenitally acquired toxocariasis.

Accommodative Esotropia Treatment Plan Utilizing Simultaneous Strabismus Surgery and Photorefractive Keratectomy.

PURPOSE: Accommodative esotropia is a common cause of acquired esotropia. Pathogenesis varies among patients but usually includes excessive hyperopia and a high accommodative convergence/accommodation ratio or tight medial recti. The present study reviews an individualized treatment plan combining photorefractive keratectomy (PRK) and strabismus surgery to correct these problems. DESIGN: This study is a retrospective, interventional case series. METHODS: Records for 15 patients who were treated for accommodative esotropia were reviewed. Patient ages ranged from 11 to 19 years. PRK and strabismus surgery were performed on 11 patients, and PRK only on 4 patients. The goal was to create a physiologic refractive error, good visual acuity (VA), and straight eyes without correction. RESULTS: All patients were spectacle free at 6-month follow-up. Twenty-four of 30 eyes had VA equal to preoperative VA without correction. Three eyes had a 1-line reduction and 2-line reduction in VA. The alignment results were ±10 prism diopters in 13 of 15 patients. Spherical refractive outcomes were 18 of 30 eyes within 1 diopter (D) of target and 12 of 30 eyes within 2 D of target. Astigmatism refractive outcomes were 21 of 30 eyes <1 D, 7 eyes 1-2 D, and 2 eyes >2 D. Two patients complained of halos at night, and 1 patient had peripheral corneal haze. CONCLUSION: Simultaneous PRK and strabismus surgery is safe and effective in treating accommodative esotropia. An individualized treatment plan can result in a physiologic refractive error, good VA, and a spectacle-free existence.

The Treatment of Congenital Nasolacrimal Duct Obstruction in Children: A Retrospective Review.

PURPOSE: To compare success and extrusion rates of the monocanalicular and bicanalicular Crawford intubation systems (JEDMED Instrument Company, St. Louis, MO). METHODS: A retrospective review of all children who were diagnosed as having congenital nasolacrimal duct obstruction and treated with lacrimal intubation from 2005 to 2014 was performed. The total number of eyes included was 168 (75 and 93 right and left eyes, respectively). Bicanalicular intubation was used in 80 eyes (bicanalicular group) and monocanalicular intubation was used in 88 eyes (monocanalicular group). RESULTS: Success occurred in 63 (78.75%) and 82 (93.18%) eyes in the bicanalicular and monocanalicular groups, respectively (P = .00653). Extrusion occurred in 24 (30%) and 11 (12.5%) eyes, respectively (P = .00528). CONCLUSIONS: Monocanalicular intubation for congenital nasolacrimal duct obstruction is superior to bicanalicular intubation. Extrusion and reoperation rates are significantly lower. [J Pediatr Ophthalmol Strabismus. 2018;55(1):65-67.].

Development of Monofixation Syndrome After Extraction of Dense Cataracts.

PURPOSE: If the interruption of macular fusion for an extended period of time is the key event that results in the development of monofixation syndrome, then the decreased macular input caused by dense cataracts may cause monofixation syndrome in adults. This study was designed to test this hypothesis. METHODS: The study design was a retrospective chart review that identified patients with unilateral cataracts at two southern Louisiana medical centers. Patients were assigned to the dense cataract group if a unilateral cataract had been present for at least 3 months and led to a visual acuity of worse than 20/200. Patients in the control group had a unilateral cataract for more than 3 months and visual acuity better than 20/200 in the affected eye. Stereoacuity was assessed using the Titmus or Randot stereo test. A Worth 4-dot test viewed at a distance of 20 feet was used to assess the presence of a macular scotoma. The criteria for monofixation syndrome were met if stereoacuity was less than 60 seconds and the Worth 4-dot test demonstrated central macular scotoma at 20 feet. RESULTS: The dense cataract group's association with monofixation syndrome was statistically significant when compared to the control group (P < .0001). CONCLUSIONS: This study adds dense adult-onset cataracts to the list of causes of monofixation syndrome and reduced stereoacuity. A delay in treating dense lens opacities can result in good visual outcome but an inferior binocular visual outcome (poor stereoacuity). [J Pediatr Ophthalmol Strabismus. 2017;54(1):39-42.].

Botulinum toxin injection into the lacrimal gland for treatment of proximal nasolacrimal duct obstructions in children.

The authors retrospectively evaluated the use of botulinum toxin injections to treat epiphora in children secondary to proximal obstruction of the nasolacrimal drainage system. Three patients (ages 8, 9, and 16 years) received botulinum toxin injections in the palpebral portion of the lacrimal gland. Two patients experienced symptomatic relief immediately following botulinum toxin injection. Both required subsequent injections, with an average symptomatic relief lasting 7 months. The only noted side effect was papillary conjunctivitis in one patient that resolved without treatment. The third patient was lost to follow-up. Although conjunctival dacryocystorhinostomy with Jones tube is the surgical procedure of choice for treating proximal lacrimal system obstruction, complication rates in children are high. Botulinum toxin injections provide a safe and effective alternative.

Suture contamination in strabismus surgery.

PURPOSE: To document the contamination rate of sutures used in strabismus surgery and evaluate the reduction of contamination using antibiotic-coated and antiseptic/antibiotic-coated sutures. METHODS: This was a prospective randomized analysis of suture contamination and potential prophylaxis measures after strabismus surgery. Muscle sutures (6-0 polyglactin) used in 302 consecutive cases of strabismus from October 2008 to May 2009 were collected and randomly assigned to three groups: (1) a control without pretreatment sutures (61); (2) antibiotic/steroid-coated sutures (200); and (3) antiseptic-soaked and antibiotic/steroid-coated sutures (141). The sutures were used under sterile conditions and then cut into pieces and transferred to blood agar plates, which were incubated for 48 hours and then checked for growth. RESULTS: Group 1 had bacterial growth in 17 of 61 (28%) sutures; group 2 had growth in 44 of 200 (22%) sutures; and group 3 had growth in 12 of 141 (9%) sutures. The reduction in bacterial growth using the antibiotic/antiseptic coating was significant (P = .006). One patient developed coagulase-negative Staphylococcus epidermidis endophthalmitis 1 week after surgery, which was promptly diagnosed and successfully treated. No complications from the antibiotic-coated or antiseptic-soaked sutures were noted. CONCLUSIONS: Although endophthalmitis after strabismus surgery is rare, estimated at 1 in 35,000 to 1 in 185,000, visual outcome is uniformly poor. The authors hypothesize that strabismus sutures can be contaminated via contact with the eyelashes and skin, providing a possible conduit for endophthalmitis. Bacterial contamination of strabismus sutures is high (28%) and can be reduced significantly if sutures are soaked in antiseptic before use.

Corneal abrasions associated with Crawford mono-canalicular tubes.

Corneal abrasions are a known complication of lacrimal intubation. The authors describe two consecutive patients in which this occurred using the JEDMED (St. Louis, MO) mono-canalicular tube, and propose a mechanism, based on the flange design, as an explanation.

Corneal keloid in Lowe syndrome.

We describe a 3-year-old boy with Lowe syndrome who previously underwent bilateral cataract surgery with intraocular lens implantation and strabismus surgery and developed an inferior corneal keloid. The lesion was resected. We report the results of immunohistochemistry analysis of the specimen, as well as alternative treatment modalities for this rare condition.

Postoperative results of absorbable, subconjunctival adjustable sutures.

BACKGROUND: Adjustable sutures have improved our ability to treat patients with strabismus. Inherent with its use, however, is the postoperative chore of dealing with the exposed sutures necessitating intervention in all patients. We describe a new surgical technique that utilizes a fornix incision in which absorbable sutures are placed in the subconjunctival space. METHODS: We conducted a retrospective review of patients in which this technique was utilized. Thirty patients were identified. RESULTS: Twenty-one patients required postoperative manipulation; ten were aligned in the postoperative recovery area in the period prior to discharge and eight in an office setting between days 1 and 4 postoperatively. Three patients were adjusted at both times. The patients adjusted in the immediate postoperative period experienced slightly less discomfort. Twenty-seven of the 30 patients (90%) had successful surgical outcome. Postoperative complications included more tissue response than is normally seen: four patients had a suture granuloma and two patients had a subconjunctival infection postoperatively. CONCLUSION: The use of absorbable subconjunctival sutures in strabismus surgery reduces the need for postoperative manipulation in some patients and allows for delayed adjustment in other patients.

Combined use of cryotherapy and diode laser photocoagulation for the treatment of threshold retinopathy of prematurity.

PURPOSE: Cryotherapy and indirect laser retinal photoablation are both effective in the treatment of retinopathy of prematurity (ROP). We describe the safety, efficiency, and effectiveness of combined cryotherapy and diode laser photocoagulation to treat threshold ROP. METHODS: Records of patients developing threshold ROP from January 1, 1996 through December 31, 1998, were retrospectively reviewed to identify those treated with combined cryotherapy and photocoagulation and followed up for at least 45 days postoperatively. Diode laser was used to ablate posterior avascular retina, and cryotherapy was used for anterior retina. Data reviewed included ocular and systemic complication rates, treatment duration, number of laser burns, most recent fundus examination, visual acuity, and refraction. RESULTS: In 13 patients, 23 eyes received combined treatment. No intraoperative complications occurred. Mean duration of anesthesia and treatment was 35 +/- 8 minutes/eye. A mean of 117 +/- 84 laser burns/eye were applied. In 20 of 23 eyes (87.0%), anatomic outcome was favorable at last examination. In 13 of 16 eyes (81.3%), functional (visual acuity) outcome was favorable (visual acuity better than 20/200) at 1 year. At 6 months or later, 14 of 16 eyes (87.5%) measured were myopic, of which 5 (31.3%) were highly myopic (> 6 diopters). CONCLUSIONS: The effectiveness of treating ROP with combined cryotherapy and diode laser photocoagulation compares with that of either modality alone. By decreasing the number of laser applications, combined therapy may be faster and technically easier for eyes with very posterior ROP. This may decrease the number of complications seen when either excessive cryotherapy or laser retinal photoablation is used.