Vertical Muscle Transposition with Augmentation for Treatment of Exotropia Caused by Iatrogenic Lost Medial Rectus Muscle.

PURPOSE: To evaluate the results of vertical muscle transposition with augmentation in cases of exotropia caused by iatrogenic lost medial rectus muscle. METHODS: This is a retrospective review of 5 cases of lost medial rectus with exotropia and marked limitation of adduction that underwent surgery. All cases had a history of strabismus surgery on the medial rectus and failed attempt at retrieval of the lost muscle. RESULTS: Five patients fulfilled the criteria. Full tendon vertical muscle transposition with augmentation sutures was done for all cases. Surgery led to a significant reduction of the angle of exotropia 25.8±13.6 ?D (P=0.027) and improvement in adduction of 7.5±3.8 degrees (P=0.034). There were no complications. CONCLUSIONS: Isolated vertical muscle transposition with augmentation is a useful option to improve the exotropia and adduction deficit in patients with iatrogenic lost medial rectus muscle.

Comparison of materials used in frontalis suspension.

OBJECTIVE: To compare various materials used in frontalis suspension surgery for incidence of infection and/or granuloma formation and incidence of recurrent ptosis. DESIGN AND METHODS: A retrospective medical record analysis was performed for 102 frontalis suspension operations performed on 43 patients between January 1, 1991, and December 31, 1996, at Indiana University Medical Center, Indianapolis. Materials used for surgery were compared for incidence of infection and/or granuloma formation and incidence of recurrent ptosis. Materials included autogenous fascia lata, banked fascia lata, monofilament nylon, braided polyester, expanded polytetrafluoroethylene, and polypropylene. RESULTS: Infection and/or granuloma formation occurred in 10.8% of all frontalis suspensions and in less than 10.0% for each material used except expanded polytetrafluoroethylene. Five (45.5%) of the 11 frontalis suspensions using expanded polytetrafluoroethylene required removal of the material because of suspected infection. Ptosis recurred in 32 cases (31.4%). Low incidence of recurrence was found with autogenous fascia lata and expanded polytetrafluoroethylene. CONCLUSIONS: Of the materials compared in this study, autogenous fascia lata may be the material of choice for frontalis suspension surgery in congenital ptosis. Other materials are useful for temporary eyelid elevation. All materials carry the risk of potential infection and/or granuloma formation.

The relationship between nystagmus and surgical outcome in congenital esotropia.

PURPOSE: Congenital esotropia is often associated with congenital nystagmus. This study examines the relationship between the presence of nystagmus and surgical outcome in the treatment of patients with congenital esotropia. METHODS: In this institutional retrospective study, we reviewed the charts of 200 consecutive patients who underwent surgical correction for congenital esotropia between 1991 and 1995. Preoperative clinical characteristics and subsequent need for additional strabismus surgery for a residual or consecutive deviation were noted. Minimum follow-up was 6 months after the original operation. RESULTS: Of the 84 patients who met the inclusion criteria, 15 patients (18%) had latent or manifest latent nystagmus, and 69 patients (82%) had no nystagmus. Eight of the 15 patients with nystagmus had or required reoperation according to our criteria (53%). Nineteen of the 69 patients (28%) without nystagmus had or required reoperation (P =.155). CONCLUSIONS: Nystagmus, when associated with congenital esotropia, may increase the risk of requiring additional strabismus surgery for residual or consecutive deviations. Appropriate and complete preoperative counseling of patients with congenital esotropia who also have nystagmus should include this increased risk.

The IOLAB, Inc pediatric intraocular lens study. AAPOS Reasearch Committee. American Association for Pediatric Ophthalmology and Strabismus.

PURPOSE: This report is a summary of the data of the IOLAB, Inc pediatric intraocular lens (IOL) implantation investigation. The goal of this study was to evaluate the safety and efficacy of IOL implantation for the treatment of pediatric aphakia, pending approval by the Food and Drug Administration. METHODS: From May 1981 to July 1994, a total of 1260 pediatric eyes received 171 styles of IOLs implanted by 361 US investigators. Preoperative, operative, and postoperative status reports over the first year were required for each eye entered into the study. Annual visit reports were requested thereafter to determine the long-term effects. The study was terminated in November 1995. All IOLs were obtained from IOLAB, Inc (now Chiron Vision Corp). RESULTS: Reporting compliance was 98.3% for the preoperative and operative reports, 45.1% at 1 year, and 13.8% at 3 years. The subjects' ages ranged from younger than 1 yearto 17 years. Nine subjects (0.7%) were younger than 1 year, with the largest group of 533 subjects (42.3%) aged between 6 and 12 years atthe time of surgery. Cataract types were congenital (45.6%), traumatic (37.1%), secondary (11%), senile (0.95%), and unrecorded (5.4%). The IOL was implanted primarily in 74.8% of cases and secondarily in 21.4% of cases. There was no record in 3.8% of the cases. IOL types included anterior chamber (4.1%), iridocapsular (0.71%), posterior chamber (93.6%), and unrecorded (1.59%). There were 130 adverse reactions that required secondary surgical intervention. The most frequently performed surgical procedures included lens removal without replacement, vitrectomy, lens repositioning, and lens replacement. More than half (52%) of all eyes had a visual acuity of 20/200 or worse before surgery; amblyopia was reported in 21.1% of all participants at baseline. Postoperative visual acuity data were available on 563 eyes at 1 year after surgery. Overall, 52.8% of all eyes attained a visual acuity of 20/40 or better by the 1-year visit, and only 15.5% had visual acuity worse than 20/200. In general, the older patient, traumatic cataract, and secondary cataract categories were overrepresented in the better visual acuity outcome group. CONCLUSION: The IOLAB, Inc pediatric IOL study is the first multiple-practitioner, national study designed to evaluate the safety and efficacy of IOL implantation in children. The study results are compromised by the almost 50% loss of follow-up at the 1-year evaluation. Other variables that most likely influenced outcome results were the methods of cataract extraction, medical management, and IOL design, all of which evolved dramatically over the time course of the study. Despite these issues, pediatric IOL implantation seems to be a reasonable treatment modality for aphakia, on the basis of the available 1-year follow-up data of the remaining 45.1% of eyes in the study.

Results of early alignment of congenital esotropia.

OBJECTIVE: To determine the long-term motor and sensory results after early surgical correction of patients with congenital esotropia. DESIGN: Noncomparative interventional case series. PARTICIPANTS: Ten infants with congenital esotropia. INTERVENTION: Patients had bimedial rectus recession between 83 and 159 days of age; were re-examined in a regular follow-up program; and were retreated when required for strabismus, amblyopia, and refractive errors. MAIN OUTCOME MEASURES: Final alignment, stereo acuity, variations in vision, alignment, refraction, and number and types of retreatments required during the period of observation. RESULTS: All patients were aligned initially with bimedial rectus recession of 8.0 to 10.0 mm measured from the limbus. A total of 11 additional surgical procedures were performed on 7 patients to maintain alignment. Four patients required hyperopic spectacle correction to maintain alignment, and two patients required short periods of patching. Visual acuity was 20/40 or better in 19 eyes at the most recent examination, which was between 8.3 and 11.8 years after initial surgery. All patients had final alignment to within 10 prism diopters (PD) of orthotropia at either distance or near. Nine of ten patients had dissociated vertical deviation (DVD), and four of ten patients had latent nystagmus. Four patients had measurable stereo acuity at their last visit, with two achieving a stereo acuity of 3000 seconds (the Titmus fly), one 400 seconds, and one 140 seconds. CONCLUSION: Surgical alignment of congenital esotropia can be achieved in the 4-month-old with bimedial rectus recession, but this does not ensure continued alignment. At least one additional surgical procedure is required on average to maintain alignment in the first 10 years after initial successful surgery. These patients can also be expected to have one or more of the following: DVD, latent nystagmus, refractive component, or latent strabismus. Regardless of outcome, patients with congenital esotropia have optokinetic asymmetry. Attainment of stereo acuity, including high-grade stereo acuity, may be enhanced by attainment of orthotropia or small-angle esotropia but is likely to be ultimately dependent on constitutional factors rather than age of alignment.

Infantile esotropia in very low birth weight (VLBW) children.

VLBW children are known to have a high frequency of early onset strabismus, which is related to the high prevalence of pre- and perinatal cerebral disturbances reported in these children. It is unknown if the early onset strabismus in VLBW children has the characteristics of infantile esotropia. If so, then (acquired) cerebral damage may play an important role in the origin of this type of strabismus. For this reason, the charts of 265 VLBW children were retrospectively reviewed. Strabismus was present in 55 (20.7%) children. Mean follow-up was 75 weeks, with 29.8% of the children having a follow-up of less then 6 months. Only 5 children (1.9%) with characteristics of infantile esotropia could be identified. Another 8 children (3.0%) possibly had infantile esotropia, but follow-up had been too infrequent during the first year of life to determine the time of onset of strabismus precisely. The other 42 children with strabismus all had ophthalmological disorders (i.e. ROP, optic nerve atrophy, cortical blindness) explaining early disruption of binocular visual development. Therefore, VLBW children are at risk for early onset strabismus. However, infantile esotropia is not typical for VLBW children and may be an indication that early acquired cerebral damage does not play an important role in the pathogenesis of infantile esotropia.

Nystagmus.

Nystagmus continues to be a complex subject of study. Our ability to characterize nystagmus has improved, but our comprehension of the oculomotor control process underlying this condition remains vague. We review recent advances in the characterization, classification, and treatment of nystagmus. Congenital forms of nystagmus, nystagmus associated with strabismus, and available therapeutic options for congenital and acquired nystagmus are emphasized.

Early-onset refractive accommodative esotropia.

INTRODUCTION: We studied the natural history of pure refractive accommodative esotropia after spectacle correction in patients with onset before 1 year old to determine whether their outcomes and characteristics were different from those of patients with more typical age at onset of refractive accommodative esotropia. METHODS: We retrospectively reviewed the charts of 17 children with onset of refractive accommodative esotropia before 1 year old. Records of 26 children with onset after 2 years old were reviewed as controls. RESULTS: The mean ages at diagnosis were 9 months and 48 months for the study and control groups, respectively. All 17 study patients and all 26 control patients were initially well aligned with spectacles at distance and near. Follow-up averaged 34 months for study patients and 41 months for control patients. Three study patients (17.6%) and 1 control patient (3.8%) had eventual deterioration and required strabismus surgery (P = .28). None of the study patients developed amblyopia, whereas 42% of control patients did (P = .001). Seven of 15 (47%) of the study patients with known birth history were born prematurely, whereas only 3 of 24 (12%) control patients were born prematurely (P = .03). CONCLUSIONS: Refractive accommodative esotropia was diagnosed at as early as and age 4 months. Prematurity appeared to be a risk factor. Amblyopia was not detected in any patient with early-onset refractive accommodative esotropia. Treatment with full hyperopic spectacle correction led to long-term stable alignment, with relatively few patients requiring surgery.

Intraoperative sponge 5-fluorouracil to reduce postoperative scarring in strabismus surgery.

INTRODUCTION: To determine whether 5-fluorouracil is effective in reducing scarring after strabismus surgery we used rectus muscle surgery in experimental animals to compare a single intraoperative dose of 5-fluorouracil with mitomycin C and to compare results in similarly treated controls not receiving these antimetabolites. METHODS: Muscle resections were performed on eight rabbits (16 eyes). Four eyes had 5-fluorouracil (50 mg/ml), and four eyes received mitomycin C (0.2 mg/ml), each of which was applied during surgery on an ophthalmic sponge for 5 minutes. Eight eyes served as controls. Six weeks after surgery conjunctival vascularity, muscle length-tension curves, muscle disinsertion force, and the histologic degree of scarring were assessed. RESULTS: The mitomycin C-treated eyes clearly had more conjunctival avascularity and a lower disinsertion force. Both treated groups had flatter length-tension curves and less scarring on histologic examination than the control eyes. CONCLUSIONS: Antifibroproliferative therapy with intraoperative sponge 5-fluorouracil appears as effective as, and is possibly safer than, mitomycin C. It may be a useful adjunct in recurrent strabismus surgery or in other situations where a risk of excessive postoperative scarring exists.

Predictive value of temporal retinal disease in retinopathy of prematurity.

PURPOSE: Screening examinations for retinopathy of prematurity (ROP) can be stressful to the premature infant. The temporal retina is the most easily visualized area of the peripheral retina. This study was undertaken to determine whether evaluation of the temporal peripheral retina provides a reliable indicator of the ROP status of the entire retina. METHODS: A total of 690 ROP eye examinations were performed on 156 premature infants. Eye examinations of 95 patients were reviewed retrospectively and of 61 patients prospectively. All patients were born at less than 34 weeks estimated gestational age (EGA) and had a birth weight less than 1600 g. No examinations were performed prior to 4 weeks of age. Each eye examination was considered independently. The fundus examination was recorded using the International Classification of Retinopathy of Prematurity. The temporal four clock hours of retina were classified as the "temporal" retina. The remainder of the peripheral retina was classified as "nontemporal." RESULTS: A highly significant correlation (Pearson correlation coefficient = 0.88) between the severity (ie, stage) of temporal ROP and the severity of nontemporal ROP was noted. The status of temporal ROP was found to be more advanced or the same as nontemporal retina in 91.2% of the examinations. Nontemporal disease was found to be more severe than temporal disease in 8.8% of the examinations, but only 0.4% of examinations indicated nontemporal disease that was worse than temporal disease by more than one stage. CONCLUSIONS: The temporal retinal disease status in ROP is strongly predictive of the disease status of the entire retina. An abbreviated retinal examination of the temporal clock hours provides a reliable indicator of the highest stage of ROP present in the entire retina. Such a screening examination, although not recommended for routine screening, may be useful when a complete ROP examination cannot be performed because of physiologic instability or poor visibility.

Capsular management and refractive error in pediatric intraocular lenses.

BACKGROUND: Guidelines for intraocular lens (IOL) implantation in children regarding patient selection, age limitations, operative techniques, including management of the posterior capsule, and refractive goals are not universally agreed on. METHODS: The authors placed posterior chamber IOLs in the capsular bag of 79 eyes in 57 children. Patient age ranged from 10 months to 17 years. Follow-up averaged 2 years. Patients were selected on the basis of age, cataract morphology, laterality, and lack of potential complicating factors. In general, postoperative refractions were intended to be mildly hyperopic with the magnitude dependent on patient age. RESULTS: Seventy-nine percent of patients able to report a postoperative visual acuity showed 20/40 or better visual acuity. Vision was limited by amblyopia in the remaining patients. There were no significant complications. The posterior capsule opacified on average 2 years after surgery regardless of patient age. CONCLUSIONS: Implantation of posterior chamber IOLs in carefully selected children appears to be effective and safe. Consideration should be given to primary posterior capsulectomy-anterior vitrectomy at the time of lens implant in children who are not expected to be candidates for yttrium aluminum garnet (YAG) capsulotomy within 18 months of surgery.

Surgical management of strabismus associated with chronic progressive external ophthalmoplegia.

PURPOSE: The purpose of the study is to describe the clinical characteristics and surgical management of strabismus associated with chronic progressive external ophthalmoplegia. METHODS: The authors present four patients with chronic progressive external ophthalmoplegia and strabismus requiring extraocular muscle surgery, with attention to presenting symptoms, patterns of misalignment, results of surgical and nonsurgical therapies, and associated ocular or systemic conditions or both. RESULTS: Three patients reported diplopia before surgery. One patient presented with an esotropia, one with an exotropia, and two with hypertropia. Three patients required only one strabismus surgery, and one patient required multiple surgeries. CONCLUSIONS: Chronic progressive external ophthalmoplegia may have clinical characteristics similar to those of myasthenia gravis or thyroid ophthalmopathy. Patients with chronic progressive external ophthalmoplegia and strabismus frequently have diplopia in primary position and may benefit from extraocular muscle surgery to improve alignment. In addition, because these patients typically have poor motor fusion, prisms often are useful adjuncts to surgery.

Recession of both horizontal rectus muscles in Duane syndrome with globe retraction in primary position.

INTRODUCTION: Duane syndrome is characterized by abduction deficiency, narrowing of the palpebral fissure on adduction, and globe retraction,which can be the most prominent aspect of the motility disorder. Recession of both horizontal rectus muscles was investigated for treatment of severe globe retraction. METHODS: Three patients with Duane syndrome were operated on for severe globe retraction. The medial rectus muscles were recessed from between 5.5 to 6.5 mm and the lateral rectus muscles 7.0 to 9.0 mm simultaneously. The recessions were asymmetric, as evidenced by amount of esotropia and face turn. Preoperative Hertel measurements were made in primary gaze, 30-degree left gaze, and 30-degree right gaze. The measurements were repeated at 6 months and 1 year after the operation. RESULTS: All three patients had improvement in globe retraction. The 6-month Hertel readings in primary position were improved by a mean of 3.0 mm (range 2.5 to 3.5 mm) measured in primary gaze. Hertel measurements were stable at 1 year after the operation. No complications were encountered. CONCLUSIONS: Recession of both horizontal rectus muscles is effective in the treatment of significant globe retraction in Duane syndrome.

Comitant strabismus.

Comitant strabismus has been investigated and treated for centuries. Advances in understanding the etiology of this disorder have improved our ability to successfully treat it. This article addresses recent insights into the causes and treatments of comitant strabismus, with a focus on congenital esotropia, intermittent exotropia, and adult strabismus.

Management of experimental globe perforation during strabismus surgery.

BACKGROUND: The incidence of potentially vision-threatening globe perforation during strabismus surgery is reportedly between less than 1% and 12% of cases. Optimal treatment of globe perforation is not known; however, traditionally it has been treated with cryotherapy at the time of surgery or observation without treatment. The indirect-ophthalmoscope-directed diode laser may provide a safe and effective alternative treatment. METHODS: We perforated the globes of six adult Dutch rabbits (12 eyes) and treated four eyes with cryotherapy and four with diode laser; the remaining four were not treated. RESULTS: Histologic examination of the untreated eyes revealed a cellular reaction around the polyglactin suture that formed a non-uniform chorioretinal adhesion. The cryotherapy eyes had a tenuous chorioretinal adhesion and retinal pigment epithelium (RPE) cells in the vitreous on several sections. The laser-treated eyes had a firm, wide chorioretinal adhesion, with minimal tissue disruption and no release of RPE cells. No complications occurred. CONCLUSION: We conclude that indirect-ophthalmoscope-directed diode laser retinopexy was safe and efficacious for globe perforation during strabismus surgery on rabbits and could be expected to be useful in humans.

Surgical treatment of superior oblique palsy.

Reports of several large series of patients with superior oblique palsy (SOP) published in 1986 or before set forth important guidelines for both diagnosis and treatment of this condition. Newer information about the anatomy, physiology, and pathophysiology of the superior oblique has accrued over the past decade. This paper reviews our experience with diagnosis and treatment of SOP over the past 5 years in light of this new information. Charts of patients treated for SOP over 5 year (1990 to 1995) were reviewed for male or female sex, age, symptoms, refraction, vision, stereo acuity, head posture, facial asymmetry, intraoperative superior oblique traction test, diagnostic position prism and cover test, torsion, surgery performed, and results of treatment. The charts of 190 patients were reviewed. In 181, postoperative examinations were performed by us. The etiology of the SOP was congenital in 137 and acquired in 53. Twenty-nine acquired cases were due to trauma and 24 arose from other causes. Fifty-six patients had facial asymmetry, 51 of whom had congenital SOP. Ninety-five had a lax tendon, 83 (87%) of whom had congenital SOP. Sixty-six had a normal tendon, 29 (44%) of whom had acquired SOP. Seventy-seven percent of patients had Knapp class I, III, or IV palsy. An average of 1.26 surgeries was performed per patient. Inferior oblique weakening was performed in 177 (93%), while 68 vertical rectus recessions were done. Thirty-five patients had superior oblique tuck or resection, all on lax tendons, and 15 had Harada Ito procedures for torsion. Six patients had mild Brown syndrome postoperatively, none of which required a takedown. A cure, defined as relief of symptoms or elimination of strabismus and head tilt, was achieved in 166 of 181 (92%) of patients. Successful treatment of SOP can be accomplished in the majority of cases by selective surgery usually beginning with inferior oblique weakening plus additional vertical rectus and horizontal surgery as needed, with superior oblique strengthening used only for lax tendons or when torsion is the main problem.

Progressive overcorrection after inferior rectus recession.

We reviewed 67 cases of inferior rectus muscle recession. In 14 cases, the hypotropia was corrected to a satisfactory alignment in the immediate postoperative period followed by a progressive overcorrection (hypertropia). Patients with thyroid eye disease were at highest risk for progressive overcorrection, as 9 of 18 (50%) developed the problem. Patients undergoing adjustable suture were at a higher risk for development of the overcorrection, as 1 of 35 (3%) surgeries done with standard techniques had the overcorrection while 13 of 32 (41%) done on an adjustable suture had the problem. However, the actual act of adjustment was found not to be a predisposing factor. Also, operating upon multiple muscles was found not to be a risk factor for the complication. Once progressive overcorrection occurred, it was more difficult to correct when the patient had thyroid eye disease. We also reviewed 77 consecutive cases of superior, lateral, and medial rectus muscle recessions and found no cases of progressive overcorrection.

Surgical results in Brown syndrome.

Surgical treatment for Brown superior oblique tendon sheath syndrome, now called Brown syndrome, has been advocated for patients with abnormal head posture or manifest hypotropia in primary gaze. Several surgical procedures with variable results and complications have been reported without consensus. Techniques and results of treatment for Brown syndrome at two institutions were reviewed. Charts of all patients who had undergone surgical treatment at Texas Children's Hospital, Houston, Tex, and Riley Hospital for Children, Indianapolis, Ind, between 1965 and 1989 were reviewed. The review yielded 38 patients. Superior oblique tenectomy was the most efficacious initial procedure. Surgery was successful in the treatment of anomalous head posture associated with Brown syndrome. There was no loss of sensory function as a result of surgery, but surgery did not inevitably lead to improved sensory function. We do not advocate superior oblique weakening combined with simultaneous surgery for iatrogenic superior oblique palsy as an initial procedure for Brown syndrome, since nearly one-half of our patients did not develop superior oblique palsy when followed for more than 1 year.