Effect of vertical central plication on vertical deviations.

PURPOSE: To evaluate the surgical effect of the Wright central plication on vertical rectus muscles to correct vertical strabismus. METHODS: In this multicenter, retrospective, observational outcomes study, data were collected from two surgeons in different practice settings (2017-22). All patients who underwent vertical rectus central plication were included; those undergoing any concurrent strabismus surgery for vertical strabismus were excluded. Primary outcome was amount of strabismus correction in prism diopters per vertical rectus central plication. Secondary outcome was to determine factors associated with better or worse surgical outcomes and patient and patient responses. Data were analyzed using descriptive and bivariate statistics. RESULTS: A total of 36 patients were included. Mean age was 60 years. Mean follow-up was 8.4 months. Of the 36 patients, 11 (31%) had idiopathic strabismus, and 7 (19%) had congenital superior oblique palsy. The remainder had a history that included prior ocular surgery, trauma, and Brown syndrome; 16 (44 %) had prior strabismus surgery. Of 31 patients with preoperative diplopia, 23 (74%) had postoperative resolution of diplopia, and 10 of 16 patients with preoperative prisms (63%) no longer required prisms postoperatively. Mean vertical deviation change was 4.7Δ. Subgroup analysis removing patients with congenital superior oblique palsy showed a larger response of 5.5Δ. 78% of patients had a final deviation <5Δ. No complications or induced postoperative diplopia was reported. CONCLUSIONS: In our study cohort, vertical rectus central plication corrected approximately 5Δ (range, 4.5Δ-5.5Δ) of vertical strabismus due to a variety of causes.

Pathophysiology of retinopathy of prematurity.

Retinopathy of prematurity (ROP) is a vasoproliferative disease occurring in premature infants that affects the blood vessels of the developing retina. ROP results in the development of vascular shunts, neovascularization, and in its most severe form tractional retinal detachment. The development of retinal vascular shunts and neovascularization in ROP is related to local ischemia in the immature and incompletely vascularized retina. Understanding the pathophysiology of ROP helps physicians both in the prevention and treatment of ROP and will be discussed in this review article. The role of oxygen in the pathophysiology of ROP will be reviewed with recent studies discussed.

Wright hang-back recession with fibrin glue compared with standard fixed suture recession for the treatment of horizontal strabismus.

OBJECTIVE: To evaluate the clinical safety and efficacy of the novel Wright hang-back recession with fibrin glue for the treatment of horizontal strabismus. STUDY DESIGN: Retrospective, case-controlled clinical study comparing surgical outcomes of the Wright hang-back rectus recession with fibrin glue (WHBG) versus standard fixed suture rectus recession (SFR). METHODS: Medical records of all patients who underwent strabismus surgery by one strabismus surgeon between 2016 and 2018 for horizontal deviations only, including cases of WHBG (group 1) or SFR (group 2), were reviewed. Good surgical outcome was defined as a postoperative deviation ≤10 prism diopters (PD) at a minimum 2 months of follow-up. RESULTS: 32 eyes of 17 patients underwent WHBG and 32 eyes of 17 patients underwent SFR; in each group, 35% had esotropia and 65% had exotropia. Mean preoperative deviations between groups were similar: esotropia 25.5 PD and exotropia 26.6 PD in WHBG; esotropia 28.3 PD and exotropia 23.8 PD in SFR. The mean postoperative deviation was <7 PD for both groups. Good surgical outcomes were similar between groups, 16/17 (94%) in WHBG and 15/17 (88%) in SFR, with no complications. CONCLUSIONS: WHBG was safe and effective with postoperative results similar to SFR. WHBG has an important advantage, eliminating the complication of retinal perforation that can occur with SFR while avoiding under- or overcorrection that can occur with traditional hang-back recession. This technique increases patient safety without sacrificing surgical outcomes and is especially useful in patients with thin sclera such as patients with high myopia or with difficult posterior exposure.

Validation of a novel strabismus surgery 3D-printed silicone eye model for simulation training.

PURPOSE: To demonstrate the validity of a new 3D-printed silicone model for practicing strabismus surgery, compared with the rabbit head, in terms of simulator fidelity. METHODS: In this multicenter study, a validated questionnaire was developed to assess fidelity of the model and rabbit head. Participants were asked to rate overall globe, conjunctiva, muscle, and scleral fidelity using a 5-point scale. The survey instrument was disseminated at three strabismus instruction courses: at two meetings, participants practiced on the model and rabbit head prior to completing the questionnaire; at the third, instructors demonstrated advanced surgical skills using only the model and then completed the questionnaire. Repeated measures analysis of variance compared ratings. Pearson's or Spearman's correlation evaluated correlation between years of experience to participants' responses. Qualitative data were coded into themes. RESULTS: A total of 47 participants completed the questionnaire. The model rated 18% higher than rabbit head for anatomical accuracy (mean difference, 0.667; P = 0.001) and 25% higher for position of eyes within the head (mean difference, 0.867; P = 0.006). More experienced participants were more likely to strongly agree that the silicone conjunctiva effectively mimics real conjunctiva (ρ = 0.337; P = 0.036) and that scleral tissue effectively mimics real sclera (ρ = 0.298, P = 0.042). Qualitative data supported the model. CONCLUSIONS: This study demonstrated the validity of the surgical model in terms of fidelity compared to the rabbit head.

Wright central plication of lateral rectus versus standard medial rectus recession in adult divergence insufficiency esotropia.

PURPOSE: Wright central plication is a minimally invasive tightening procedure described for the first time by Wright and colleagues in 2012. We compare outcomes of lateral rectus central plication (LRCP) to medial rectus recession (MRR) in the treatment of adult divergence insufficiency esotropia (ADIE). METHODS: A retrospective chart review of 30 consecutive patients with ADIE, who underwent either LRCP or MRR between 2010 and 2015 was performed. INCLUSION CRITERIA: age ≥45 years, LRCP or MRR surgery fixed suture technique, esotropia (ET) at least 10Δ greater at distance than at near, subjective diplopia at distance, fusion at near fixation, follow-up of at least 6 months. Primary outcome was postoperative single binocular vision. Secondary outcome was postoperative deviation of <5Δ. RESULTS: A total of 28 patients (15 females) met inclusion criteria: 15 had LRCP and 13 MRR. Primary outcome of no diplopia was not significantly different between LRCP and MRR group having a success rate of 93.3% versus 92.3%, respectively (P ≤ 0.01). Secondary outcome of a deviation of ≤5Δ at distance was better in the LRCP group than the MRR group (15/15 vs 11/13 [P ≥ 0.01]). One patient in LRCP group had an early overcorrection corrected by in-office suture lysis. CONCLUSIONS: Both procedures had excellent primary outcomes eliminating diplopia in over 90% of cases. The LRCP group had statistically better postoperative alignment of <5Δ. The Wright LRCP has the advantage of being minimally invasive, semi-reversible, vessel sparing, and can be done with topical anesthesia.

Pediatric adenoid cystic carcinoma of the lacrimal gland treated with intra-arterial cytoreductive chemotherapy.

Adenoid cystic carcinoma (ACC) of the lacrimal gland is the most common primary malignant tumor of the lacrimal gland. It typically affects patients in the fifth decade of life and presents with rapid progression of pain, ptosis, motility disturbances, and sensory deficits of less than 1 year's duration. ACC is rare in children. Due to early, aggressive perineural and bony spread, there is a high risk of intracranial extension. Additionally, due to frequent hematogenous and lymphatic spread, there is a high rate of distant metastases even after treatment, which can occur late up to a decade or more. The currently accepted treatment for ACC is radical exenteration with orbitotomy and adjuvant chemotherapy and/or radiation therapy. Recently, intra-arterial cytoreductive chemotherapy (IACC) has been investigated as a neoadjuvant treatment modality. It has the advantage of increasing local concentration at the target tissue and decreasing systemic distribution. We report the first known pediatric case of ACC treated with IACC, followed by exenteration, radiation, and adjuvant intravenous chemotherapy. The patient was followed for 4 years, with no recurrence and no known complications.

C.57 C > T Mutation in MIR 184 is Responsible for Congenital Cataracts and Corneal Abnormalities in a Five-generation Family from Galicia, Spain.

A c.57 C > T mutation in the seed region of MIR184 located at the 15q25.1 chromosomal region has been independently associated with autosomal dominant keratoconus with early-onset anterior polar cataract in the Northern Irish family and with autosomal dominant EDICT (Endothelial Dystrophy, Iris hypoplasia, Congenital cataracts, and stromal Thinning) syndrome. In this study we report a five-generation family originating in Galicia, Spain with early onset cataracts and variable corneal abnormalities which include non-ectatic corneal thinning and severe early-onset keratoconus. We identified a heterozygous c.57 C > T mutation in miR-184 in the proband and two additional affected relatives on the maternal side. This finding represents a third independent occurrence of this mutation in familiar ocular disease thus strengthening the link between miR-184 abnormalities and inherited eye defects.

Bilateral canalicular and nasolacrimal duct obstruction in congenital erosive and vesicular dermatosis: a case report and review of the literature.

We report the ocular findings in a 2.5-year-old girl with a history of congenital erosive and vesicular dermatosis at birth. We highlight the complexity of the associated nasolacrimal duct obstruction with canalicular scarring and review the ocular manifestations of this rare disease.

Mini-plication to treat small-angle strabismus: A minimally invasive procedure.

BACKGROUND: Mini-plication is a new rectus muscle tightening procedure for the correction of small-angle strabismus that can be performed under topical anesthesia. The purpose of this study was to report the outcomes of mini-rectus muscle plication. METHODS: We retrospectively reviewed the medical records of patients who underwent mini-plication. In this procedure, 6-0 polyglactin 910 suture was secured to the central 3 to 4 mm of the muscle belly 5 mm posterior to the insertion and was then passed through the sclera just anterior to the muscle insertion to plicate the central portion of the muscle. This differs from the standard procedure, in which the entire width of the muscle is plicated. Two groups were analyzed: those who underwent mini-plication alone and those who underwent mini-plication after prior antagonist muscle-weakening surgery. RESULTS: Our review identified nine patients aged 5 to 78 years. Topical anesthesia was used for all adults, who experienced no local or systemic complications. Mini-plication reduced vertical and horizontal deviations an average (± SD) of 6.7(Δ) ± 3.5(Δ). The mini-plication-only group (3 patients) had an average postoperative correction of 5.5(Δ) ± 2.6(Δ); the prior surgery group (6 patients), an average of 9(Δ) ± 2.7(Δ). Diplopia was noted in 50% of the adults preoperatively and none postoperatively. All patients experienced a decrease in strabismus, with an average outcome of <5(Δ) of postoperative deviation. CONCLUSIONS: Mini-plication, which can be performed under topical anesthesia, corrected small deviations and was especially useful for adult strabismus patients with diplopia.

Amniotic membrane transplantation for restrictive strabismus.

PURPOSE: To report the use of amniotic membrane transplant in patients with restrictive strabismus. DESIGN: Retrospective, interventional case series. PARTICIPANTS: Patients with restrictive strabismus treated with amniotic membrane transplantation. METHODS: Chart review of 7 consecutive patients (8 eyes) who developed restrictive strabismus after periocular surgery and were treated with surgical removal of restrictive adhesions and placement of an amniotic membrane transplant. MAIN OUTCOME MEASURES: Intraoperative findings to explain the mechanism of restrictive strabismus, and clinical postoperative results, including ocular alignment, ductions and versions, symptom relief, and resolution of diplopia. RESULTS: Restrictive strabismus occurred after surgery for pterygium, retinal detachment, orbital floor fracture, dermoid cyst, and dermatochalasis. Restrictive strabismus was due to a combination of conjunctival contracture, fat adherence, or rectus muscle contracture. All patients developed postoperative scarring, with failed additional standard surgery to remove the adhesions, including 1 patient treated with mitomycin C for recurrent scarring after pterygium. Reoperation using amniotic membrane transplantation was associated with improvement of ocular motility in 6 of the 7 patients; 1 patient had recurrence of scarring with persistent diplopia. The remaining 6 of 7 patients had no significant recurrence of scarring, and motility remained stable during the follow-up period of 5 to 13 months. CONCLUSIONS: Amniotic membrane transplantation seems to help prevent recurrence of adhesions in patients with restrictive strabismus caused by conjunctival scarring, fat adherence syndrome, or rectus muscle contracture. Use of an amniotic membrane transplant should be considered as a treatment option for these difficult cases of restrictive strabismus. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

A biodegradable filament for controlled drug delivery.

Biodegradable filaments (diameters of 250-300 microm) for the controlled delivery of dexamethasone or levofloxacin are described. Filaments are prepared by wet-spinning solutions of poly(lactide-co-glycolide) (PLGA) and drug dissolved in dimethyl sulfoxide (DMSO) into a coagulation bath of water. Compositional analyses of the filaments by independent measurements of drug, DMSO, water, and polymer give drug loadings up to 40% of filament mass and drug retention (drug in filament per drug in solution) greater than 40%. Drug release kinetics, and thermal and mechanical properties, of the filaments are reported. Three filaments with levofloxacin contents of 46+/-2, 85+/-4, and 36+/-2 microg/cm (denoted 506-L1, 506-L2, and 506-L3, respectively) are implanted in the conjunctiva of New Zealand white rabbits. The time dependent, in-vivo tear concentrations of levofloxacin from filament implants in New Zealand white rabbit eyes are in general agreement with the results from the in-vitro release profiles, with one of the filaments (506-L1) showing effective levels of levofloxacin in the tears for 6 days. The filaments are generally well tolerated by the rabbits. Filament failure occurs at 6-8 days within the rabbit eyes, essentially the same time to failure observed from in-vitro mechanical properties testing results.

Mini-tenotomy procedure to correct diplopia associated with small-angle strabismus.

PURPOSE: The mini-tenotomy is a novel minimally invasive surgical technique that weakens rectus muscles to treat small-angle strabismus. The mini-tenotomy is an alternative to the standard rectus muscle recession that requires hooking the muscle, suturing the muscle, removing the muscle from sclera, and reattaching the muscle to sclera. METHODS: This is a retrospective chart review of outcomes of the mini-tenotomy procedure on 15 consecutive adult patients. A central tenotomy of 3 mm was performed cutting through intact conjunctiva using a blunt Westcott scissors. RESULTS: Preoperatively 6 patients were esotropic, measuring between 2 and 16Delta (mean, 8Delta), and 9 patients had vertical deviations that measured between 2 and 6Delta (mean, 3.5Delta). Final postoperative esodeviations ranged from 1 to 8Delta (mean, 5.8Delta), and hyperdeviations ranged from 0 to 4Delta (mean, 1.3Delta). Final improvement of the deviation was larger for hypertropia, with a mean of 2.3Delta, vs esotropia, with a mean of 1.3Delta. CONCLUSION: The mini-tenotomy is a safe and effective treatment for diplopia caused by a small-angle hypertropia or esotropia. It is a minimally invasive surgery that can be done in office with topical anesthesia. As with any strabismus procedure, more than one surgery may be necessary.

Infantile esotropia with nystagmus: a treatable cause of oscillatory head movements in children.

OBJECTIVE: To document the resolution of oscillatory head movements following surgical realignment of the eyes in children with infantile esotropia and nystagmus. METHOD: Retrospective review of 3 children who had infantile esotropia, nystagmus, and unexplained head shaking or head nodding. RESULTS: Strabismus surgery restored ocular alignment and produced resolution of the head shaking in all patients. In 1 patient, head shaking accompanied recurrence of the esotropia and again resolved following surgical realignment of the eyes. CONCLUSIONS: Head shaking or head nodding can rarely be associated with infantile esotropia and nystagmus. In this syndrome, surgical realignment of the eyes may produce simultaneous resolution of the head oscillations.

Evidence of binocular fusion in a 3-week-old infant with transient abducens nerve paresis.

We report an infant with clinical evidence of binocular fusion at 3 weeks of life. To the best of our knowledge, this is the first report providing evidence of binocularity in the first month of life.

A physiologic reduced oxygen protocol decreases the incidence of threshold retinopathy of prematurity.

PURPOSE: To report the incidence of threshold retinopathy of prematurity (ROP) in very low birth weight premature infants from three neonatal intensive care units (NICUs) before and after implementation of a physiologic reduced oxygen protocol (PROP). METHODS: PROSPECTIVE, OBSERVATIONAL STUDY OF DATA FROM THREE NICUS: Cedars-Sinai Medical Center (CSMC), Los Angeles; Good Samaritan Hospital (GSH), Los Angeles; and National University Hospital (NUH), Singapore. PROP was implemented to keep oxygen saturation values by pulse oximeter (SpO2) between 83% and 93% (as described in Pediatrics 2003;111:339-345). The incidence of threshold ROP in the year before and the year after implementation of PROP was compared. Data from the transition year were not included in the analysis. RESULTS: THE INCIDENCE OF THRESHOLD ROP DECREASED IN EACH CENTER: CSMC, 3.3% to 0.0% (3/92 to 0/88); GSH, 14.8% to 4.9% (8/54 to 2/41); and NUH, 6.7% to 0.0% (3/45 to 0/30). Overall, the incidence of threshold ROP decreased from 7.3% to 1.3%. (P <.05). The 95% confidence interval was 4.3% to 12% for the pre-PROP group and 0.05% to 4.76% for the post-PROP group. CONCLUSIONS: Physiologic hypoxia is the normal fetal state. Exposure of newborn premature infants to hyperoxia down-regulates retinal vascular endothelial growth factor. This arrests the normal retinal vascular migration and causes vaso-obliteration, the first phase of ROP. The hypothesis is that maintaining SpO2 values between 83% and 93% in the immediate postgestation life, combined with strict control of oxygen fluctuations, prevents the early vaso-obliterative phase and subsequent development of severe ROP. Significant reduction of threshold disease after implementation of PROP in all three centers supports the hypothesis.

Comparison of visual acuity levels in pediatric patients with amblyopia using Wright figures, Allen optotypes, and Snellen letters.

PURPOSE: To compare and correlate the clinical performance of Wright figures in visual acuity assessments of pediatric patients with amblyopia to those obtained through Allen cards and Snellen letters. SUBJECTS AND METHODS: Best-corrected visual acuity of 26 amblyopic children were measured with the Wright figures(c), Snellen letters, and isolated Allen optotypes, respectively. Amblyopia was defined as two lines of visual acuity difference or a visual acuity level of 20/30 or lower as determined by Snellen chart. The results were evaluated for statistical intergroup differences using the Wilks' Lambda multivariate analysis of variance and for correlation using the Pearson correlation coefficient test. RESULTS: The mean age of the subjects was 8.27 +/- 2.46 years (range: 5 to 15 years). The mean logMAR values for the Wright figures(c), Snellen letters, and Allen optotypes were 0.40 +/- 0.20, 0.47 +/- 0.23, and 0.29 +/- 0.28, respectively. When compared with Snellen letters, the Wright figures correlated to a higher degree ( r = 0.46, P < 0.001) than Allen optotypes ( r = 0.67, P < 0.001). With a visual acuity of 20/40 or worse on Snellen letter testing, the sensitivity of Wright figures(c) and Allen cards in diagnosing amblyopic eyes was 87.0 and 56.5%, respectively ( P = 0.016). CONCLUSIONS: Wright figures, designed primarily to evaluate the vision in the preliterate pediatric population, correlate more closely to Snellen letters and have a higher rate of correctly identifying amblyopia than isolated Allen optotypes in pediatric patients.