Diagnosis and management of pediatric glaucoma.

Appropriate diagnosis of pediatric glaucoma in toddlers and school-aged children is aided by an understanding of the signs and symptoms of infantile-onset glaucoma, along with its associated conditions. Unlike adults with glaucoma, the management of pediatric glaucoma is frequently surgical, with medical therapy playing an adjunctive role. The ultimate goal of pediatric glaucoma management is not control of IOP but preservation of vision. The visual prognosis in children with glaucoma is correlated with the severity of the associated ocular pathology. Primary congenital glaucoma has the best visual prognosis, with 52% to 79% having visual acuity of 20/50 or better. Glaucomas associated with congenital ocular anomalies and secondary glaucomas have a worse visual prognosis, with 30% to 50% of eyes noted to be 20/50 or better. Amblyopia and uncontrolled glaucoma are the two main factors associated with reduction in vision. Control of the glaucoma by medical and surgical means and treatment of amblyopia during susceptible ages are the essential factors in the management of pediatric glaucoma.

Pathologic findings in late endophthalmitis after glaucoma filtering surgery.

OBJECTIVE: To report the clinicopathologic features of four eyes enucleated for late-onset bleb-related endophthalmitis. STUDY DESIGN: Retrospective case series. MATERIALS: Four enucleated eyes. METHODS: The clinical and histopathologic features of four patients who underwent enucleation for late-onset endophthalmitis after glaucoma filtering surgery were reviewed. RESULTS: The eyes were enucleated for endophthalmitis one to five years after trabeculectomy. Two of the four eyes had trabeculectomy with adjunctive mitomycin-C. All four eyes had streptococci cultured from the aqueous and/or vitreous. Common pathologic features included inflammation involving the anterior segment, lens and choroid. One eye exhibited focal granulomatous uveitis. CONCLUSIONS: Late-onset endophthalmitis after glaucoma filtering surgery is often due to streptococcal species and rapidly progresses over a few days. Phacoanaphylaxis with associated granulomatous uveitis may contribute to the poor prognosis in this setting.

Long-term surgical and visual outcomes in primary congenital glaucoma: 360 degrees trabeculotomy versus goniotomy.

PURPOSE: To compare the visual outcome and refractive status of children with primary congenital glaucoma who underwent 360 degrees trabeculotomy or goniotomy as an initial surgical procedure. METHODS: This retrospective study describes 24 eyes (15 patients) with primary congenital glaucoma that underwent 360 degrees trabeculotomy as the initial procedure and 40 eyes (23 patients) that underwent goniotomy as the initial procedure. Inclusion criteria were: (1) diagnosis of primary congenital glaucoma and initial angle surgery before 1 year of age, (2) no other ocular or systemic diseases, (3) 360 degrees trabeculotomy or goniotomy as the first surgical procedure, and (4) ability to obtain an Allen or Snellen visual acuity. A postoperative vision of 20/50 or better was considered good. Surgical success was defined as an intraocular pressure (IOP) less than 22 mm Hg with or without medication and without evidence of a progressive optic neuropathy. RESULTS: The IOP was successfully controlled in 92% of eyes in the trabeculotomy group and in 58% of eyes in the goniotomy group (P =.004). Of eyes in the trabeculotomy group, 79% had vision of 20/50 or better compared with 53% in the goniotomy group (P =.03). High myopia was more prevalent in the goniotomy group, but this difference was not statistically significant (P =.16). A poor visual outcome was associated with failure of the angle surgery or poor compliance with follow-up and amblyopia therapy. CONCLUSION: For primary congenital glaucoma, 360 degrees trabeculotomy is a highly effective procedure that results in excellent pressure control and is at least as successful as multiple standard procedures. In this study, 360 degrees trabeculotomy resulted in better vision than what is reported in the literature for standard angle procedures.

Trabeculectomy with adjunctive mitomycin C in pediatric glaucoma.

PURPOSE: To determine the safety and efficacy of trabeculectomy with adjunctive mitomycin C in patients 17 years of age or younger, and to identify risk factors for failure of this surgical technique. METHODS: Retrospective review of consecutive cases of pediatric glaucoma that underwent mitomycin C augmented trabeculectomy between January 1991 and December 1995. Forty-nine patients (60 eyes) with a mean age of 7.6 years (range, 6 weeks to 17.6 years) were identified and followed up until repeat glaucoma surgery, or after a minimum of 6 months. Success was defined as intraocular pressure control of 22 mm Hg or less with or without topical glaucoma control medication, no evidence of glaucoma progression, no further glaucoma surgery necessary, and no visually devastating complication. RESULTS: Cumulative probabilities of success +/- SD for 49 eyes (one eye per patient) were 67% +/- 13% at 12 months and 59% +/- 15% at 24 months. Multivariate regression analysis yielded the following characteristics as significantly increased risk for failure: age of less than 1 year at time of surgery (risk ratio, 5.6; confidence interval, 2.1 to 14.7; P = .0005), and aphakia (risk ratio, 2.7; confidence interval, 1.1 to 6.9; P = .0364). Shallow anterior chamber (17 [28%] of 60 eyes) and serous choroidal detachment (13 [22%] of 60 eyes) were the most common complications. Four (11%) of 38 eyes with obtainable Snellen acuity were noted to have a decrease in best-corrected visual acuity of more than 2 Snellen lines or loss of light perception. In 5 (8%) of 60 eyes bleb-related endophthalmitis was noted. CONCLUSIONS: Trabeculectomy with adjunctive mitomycin C is generally effective for the treatment of pediatric glaucoma, especially in phakic children over 1 year of age. However, late-onset bleb-related endophthalmitis is a substantial risk in this patient population.

Angle-closure glaucoma in a 10-year-old girl.

PURPOSE: To report a case of angle-closure glaucoma in a 10-year-old girl with ocular albinism. METHODS: Case report. A 10-year-old girl with autosomal recessive ocular albinism was examined and treated for subacute angle-closure glaucoma of the right eye. RESULT: The patient was successfully treated with Nd:YAG laser iridotomy of the right eye. CONCLUSIONS: Angle-closure glaucoma may rarely occur in young or adolescent children. Gonioscopy of children with shallow anterior chambers is recommended.

Blebitis, early endophthalmitis, and late endophthalmitis after glaucoma-filtering surgery.

PURPOSE: The differentiating characteristics in blebitis and early and late endophthalmitis after glaucoma filtration surgery are reviewed. METHODS: All admission records and operative reports, as well as available office notes, on patients with blebitis or bleb-associated endophthalmitis admitted to a large referral eye center from 1985 to 1995 were reviewed retrospectively. RESULTS: Ten cases of blebitis and 33 cases of bleb-associated endophthalmitis were identified. One patient with blebitis progressed to culture-positive endophthalmitis. Of the 33 cases of bleb-associated endophthalmitis, there were 6 cases of early endophthalmitis (before postoperative week 6) and 27 cases of late endophthalmitis. In early endophthalmitis, Staphylococcus epidermidis was isolated on vitreous culture in 4 (67%) of 6 cases, whereas in late endophthalmitis, this organism was isolated in only 1 (4%) of 27 cases. In the 27 late cases, Streptococcus species and gram-negative organisms comprised 48% of isolates; of 33 cases of endophthalmitis, 15 (45%) demonstrated no growth on vitreous culture. Patients with endophthalmitis fared more poorly than those with blebitis in terms of visual outcome. CONCLUSIONS: Because blebitis may be prodromal to endophthalmitis, aggressive antimicrobial therapy, perhaps with oral quinolones, is warranted. In addition, patients with blebitis should be observed closely to identify extension into the vitreous cavity so that intravitreous antibiotics can be administered in a timely fashion. Finally, clinicians should not extrapolate the results of the Endophthalmitis Vitrectomy Study to the postfiltration surgery endophthalmitis given the differing pathogenesis and unique spectrum of organisms.

Preliminary study of health value as a moderator of the link between age and life satisfaction.

In the present study of the influence of health value as a potential moderator of age and life satisfaction. 157 undergraduate students (M = 20.8 yr.) completed a battery in which they provided demographic information and completed a number of different self report measures, including the Satisfaction With Life Scale and the Health Value Scale. A 2 (younger vs older) x 2 (high vs low health value) analysis of variance with life satisfaction as the dependent variable showed a significant man effect for health value and a significant interaction between age and health value but no man effect for age. These findings support health value as a moderator of the relation between age and psychological well-being. Implications for research and practice are discussed.

How the value of health moderates the link between age and depressive symptoms: further evidence.

To extend earlier findings, this pilot study explored the role of self-reported value of health as a moderator between age and scores on the Beck Depression Inventory. 157 undergraduate students completed the Health Value Scale and the Beck inventory. There was no significant main effect for age with scores on the Beck inventory; however, scores on the Health Value Scale and their interaction with age were significant contributors to scores on the Beck Depression Inventory. These results are consistent with earlier findings. Implications for research and development are discussed.

360 degrees trabeculotomy for primary congenital glaucoma.

We have refined a technique for performing 360 degrees trabeculotomy in a single procedure using a 6-0 polypropylene (Prolene) suture fragment and have used it in 15 patients (26 eyes) with primary congenital glaucoma. The refined technique can be performed via a single nasal surgical site. This procedure avoids many of the difficulties encountered with metal trabeculotomes and preserves conjunctiva should further glaucoma surgery be necessary.

Optic nerve enlargement and chronic visual loss.

We present four patients with sarcoidosis of the anterior visual pathways. The first patient presented with unilateral visual loss, a mass lesion at the optic nerve head, and an enlarged orbital optic nerve. The second patient presented with bilateral progressive painless visual loss, associated with optic nerve pallor and visual field loss. In these two patients, optic nerve biopsy was diagnostic of sarcoidosis. The third patient developed optic nerve and chiasmal involvement after sarcoidosis was established by lacrimal gland biopsy. The fourth patient had optic nerve, pulmonary, and lymph node involvement with sarcoidosis. A conjunctival and lung biopsy were diagnostic. Computed tomography and magnetic resonance imaging have greatly facilitated diagnosis of sarcoidosis of the anterior visual pathways. Sarcoidosis of the anterior visual pathways may occur alone or in association with other ocular or systemic manifestations. A conjunctival or lacrimal gland biopsy may be preferable as the initial diagnostic approach. Treatment of patients with this condition may require systemic immunosuppression, in addition to corticosteroids, to prevent permanent visual loss.

Sensory thresholds and motor responsiveness in thyroid disease: their responses to treatment and warming.

It has been our clinical observation that patients with hypothyroidism are relatively insensitive to the discomfort of venepuncture, whereas thyrotoxic patients seem to have a heightened sensitivity. In an initial study we have measured the sensory thresholds of perception along with motor responsiveness in hypothyroid, thyrotoxic and euthyroid subjects, employing a simple and readily reproducible technique. Sensory thresholds were elevated and motor responsiveness impaired in hypothyroid subjects as compared to euthyroid controls. In thyrotoxic subjects, motor responsiveness was significantly enhanced, but sensory thresholds did not differ from control values. In a subsequent study the threshold abnormalities of thyroid dysfunction were corrected by rendering the patients euthyroid with appropriate therapy. Warming a further group of untreated hypothyroid patients produced a similar improvement in motor responsiveness to that seen in the L-thyroxine-treated group, thus implying that this parameter is at least, in part, temperature dependent. Sensory thresholds would seem to be reliable reflectors of tissue thyroid status in hypothyroidism, whereas motor responsiveness seems the better guide to thyroid status across the whole spectrum of thyroid function.

Morphologic changes of the vas deferens after vasectomy and vasovasostomy in dogs.

The fine structure of the vas deferens was studied by SEM and TEM after vasectomy and delayed vasovasostomy in 18 dogs. Mucosal changes were observed in the testicular end of the vas deferens after vasectomy. Identical changes have been observed in the vas deferens in humans after vasectomy. Microsurgical vasovasostomy resulted in reappearance of normal epithelial cells lining the lumen of the vas deferens by means of squamous metaplasia. In six dogs, prevasectomy and postvasovasostomy sperm counts were compared. These counts returned to normal levels, but they never reached or exceeded the prevasectomy values.

The effect of vasovasostomy upon the structure of the vas deferens in rats.

The reasons for the discrepancy between reappearance of sperm in the ejaculate following vasovasostomy and pregnancy rates remain obscure. To determine the possible adverse effects of reanastomosis upon the structure of the vas deferens, immediate microsurgical vasovasostomy was performed on 60 adult Sprague-Dawley rats. The fine structure of the mucosa, as seen by scanning electron microscopy, showed only subtle, transient changes with return to normal architecture within 3 months. Luminal dilatation, rather than stenosis, was a constant late finding. It is concluded that microsurgical reanastomosis has little, if any, permanent deleterious effect upon the structure of the vas deferens.

Chart review skills: a dimension of clinical competence.

A study of undergraduate medical students' abilities to identify salient information in reviewing patient charts was conducted by members of the Department of Surgery at Southern Illinois University School of Medicine. Specific goals of the two-year study were to develop and test a method for assessing chart skills and to test the following hypotheses: (a) knowledge base is a component of chart review skill; (b) chart skills are related to basic observational skills; (c) performance on one chart is positively correlated with performance on other charts; (d) chart performance is affected by distraction and time pressure; and (e) chart performance improves with clinical experience. Evaluation instruments and methodology are described. Hypotheses a, b, and e and the time effect hypothesized in d were supported; hypothesis c was not supported. Results of the study provide a foundation for further research exploring the effect of instruction on chart performance and investigating the relationships between chart performance and other measures of clinical competence.

Modified technique for microsurgical vasovasostomy.

A modified technique of two-layer microsurgical vasovasostomy is described which permits continuous inspection of the lumen. A stricture-free anastomosis was documented in experimental animals by mating and scanning electron microscopic studies. The success of this procedure is attributed to precise placement of fine mucosal sutures, minimal fibrosis, and a fluid-tight anastomosis.

PIP: 25 Sprague-Daveley rats had bilateral division of the vas deferens with immediate microsurgical anastomosis. The 2-layer microsurgical vasovasostomy as described in detail tin this report permits continuous imspection of the lumen. To determine the efficacy of this procedure, all the animals were mated and the anastomotic sites studied by scanning electron microscopy (EM) 2 to 4 months after surgery. Overall pregnancy rate was 50%. Early failure in the series was attributed to technical ineptitude and failure to appreciate the importance of a blood-free field. The last 10 animals had a pregnancy rate of 80%. Scanning EM showed near total, bilateral occlusion in the sterile rats, as contrasted to the widely patent lumen of animals with documented fertility. By 2 months, the luminal sutures were covered by regenerating mucosa. Fibrosis was observed in areas immediately surrounding mucosal and muscular sutures. Precisely placed mucosal sutures which evert the mucosa and decrease stenosis are critical to a stricture-free anastomosis. Expert handing of fine sutures, small needles and delicate microsurgical instruments accounted for lack of fibrosis after vasovasostomy was performed.

Resection of the suprarenal inferior vena cava for retroperitoneal malignant disease.

Minimal renal dysfunction was noted in 4 of 5 patients undergoing right nephrectomy with resection of the inferior vena cava and ligation of the left renal vein. However, the results of this series confirm previous reports that patients with locally advanced right renal carcinoma requiring vena caval resection are cured rarely by an operation alone. In the absence of effective adjunctive therapy for renal cell carcinoma this procedure will most likely benefit patients with neoplasms responsive to either chemotherapy or radiation therapy.

Renal cell carcinoma involving the inferior vena cava: radiologic evaluation and surgical management.

The evaluation and management of 3 patients with renal cell carcinoma and varying degrees of vena caval involvement are described. Extrinsic compression, intraluminal tumor thrombus and direct invasion have characteristic features on the inferior venacavograms. With knowledge of the nature and extent of vena caval disease total removal of the tumor is possible in most cases with an acceptably low morbidity. Extensive vena caval pathology by no means precludes long-term survival and should not be regarded as a sign of inoperability.