Timolol. A new drug for management of chronic simple glaucoma.

Timolol maleate, a potent beta-adrenergic antagonist, reduces intraocular pressure in rabbits. With topical application in one eye, a significant reduction in pressure is seen in the contralateral, untreated eye also. When used in conjunction with timolol, other adrenergic amines, such as norepinephrine and epinephrine, produce an additional hypotensive response. On the other hand, pretreatment with timolol does inhibit the ocular hypotensive response to topically applied albuterol. No further reduction in pressure is seen after application of this beta-adrenergic agonist to eyes pretreated with timolol. In a double-blind study with patients who had previously been receiving various medications for control of elevated intraocular pressures, timolol was as effective as pilocarpine in reducing intraocular tension. Many common complaints associated with pilocarpine therapy, including miosis, ocular irritation, and blurred vision, were not encountered with timolol therapy.

Ocular and adnexal complications of unilateral orbital advancement for plagiocephaly.

Strabismus, ptosis, lateral canthal dystopia, nasolacrimal obstruction, and cranial nerve palsy were noted preoperatively in 32%, 21%, 14%, 12%, and 9% of 34 patients, respectively, undergoing ophthalmologic evaluation prior to unilateral orbital advancement for plagiocephaly. Thirty-two percent of the patients had normal preoperative ocular and adnexal examination results. Ptosis, strabismus, and amblyopia were frequently acquired postoperative abnormalities in 29%, 18%, and 18% of the patients, respectively. Forty-four percent of the patients had no new abnormalities following craniofacial surgery.

Ocular alignment after craniofacial reconstruction.

We undertook a retrospective study of 160 patients to ascertain if craniofacial reconstruction affected ocular alignment. In most patientspre-existing alignment and binocularity were unaffected by craniofacial surgery; thus, correction of any strabismus can be performed on a child without concern for disruption of muscle tissue by later craniofacial surgery.

Variations in extraocular muscle number and structure in craniofacial dysostosis.

Five of 12 patients with craniofacial dysostosis who needed strabismus surgery had anomalies of extraocular muscle structure and number. Two cul-de-sac incisions per eye are sufficient to investigate all muscles for anomalies and add little time or risk to the planned strabismus procedure. The origin of these anomalies and their frequency in craniofacial stenosis are unknown.

Ocular motility in craniofacial reconstruction.

Of 140 children undergoing major craniofacial reconstruction at The Children's Hospital of Philadelphia and examined preoperatively and postoperatively by the Ophthalmology Division, only 10 had surgically induced alteration in primary position horizontal alignment, 4 greater than 10 prism diopters. Only 2 patients had a new strabismus in primary position created by craniofacial surgery, both cranial nerve palsies. We believe early strabismus surgery is advantageous for attainment of binocularity and ease of tissue manipulation. Of 44 patients with craniofacial dysostosis (Crouzon), 20 had preoperative strabismus, and 12 required extraocular muscle surgery. Five of 12 had anomalies of extraocular muscle number and structure, usually involving the superior rectus muscle.

Ophthalmologic injuries.

The types of eye injuries that occur in various sports are discussed, with an emphasis on racquet sports and ice hockey. Both field management and treatment by a specialist are considered. Physicians should encourage players to wear polycarbonate or industrial safety-thickness lenses or protective face cages.

Topical anesthesia for strabismus surgery.

Twenty-two adults underwent strabismus surgery under topical anesthesia over the past 4 years. Benefits of this technique include avoidance of certain hazards of general and retrobulbar anesthesia, the ability to adjust eye position to the patient's satisfaction on the operative table, and expanded options for patients unwilling to undergo general anesthesia. The major disadvantages are the possibility of increased patient discomfort. Patient selection is important.

True transposition procedures.

Three patients with large-angle strabismus and irreversible amblyopia in a previously-operated eye underwent a true transposition procedure in which a segment of resected extraocular muscle was used to lengthen its antagonist. Postoperative results were satisfactory and stable during follow-up of 9 to 14 months. Four prism diopters of deviation were corrected per millimeter of "alteration" (mm resection plus mm lengthening plus mm recession minus mm advancement). True transposition procedures can permit surgeons to capture large strabismus deviations with two-muscle surgery on one eye, appear safe and predictable, and offer an option in those patients who refuse adjustable suture techniques.

Overacting oblique muscles in exotropia: a mechanical explanation.

Patients with exotropia often show apparent overaction of the inferior and superior oblique muscles. Are the oblique muscles contracted, are they truly overacting overacting, or does the eye flip up or down in adduction from the leash effect of a contracted lateral rectus muscle? Theoretically, if the mechanical limits of ocular rotations were circular or elliptical, rather than square or rectangular, we would expect a patient with exotropia to develop a vertical deviation in extreme gaze into the oblique quadrants, for the abducting eye would reach the mechanical limit, while the adducting eye would still be free to move up or down, giving the appearance of both inferior and superior oblique overaction. The circular or elliptical limits of ocular rotations were documented with tracings from slow-motion video recordings. Also, reduction of pseudo-overation of the obliques in both eyes following unilateral surgery for exotropia was observed in three patients. The strabismus surgeon should be aware of this possible mechanism for pseudo-overaction of the obliques and should avoid muscle surgery in this clinical setting.

Ophthalmologic injuries.

Increasing numbers of young people are being attracted to organized sports. Racquet sports, as they are individual sports, will give a lifetime of continual pleasure. Increasing numbers of eye injuries are being seen, however. Now that adequate eye protection is available, it behooves all physicians who are interested in prevention of eye injury to encourage players to wear polycarbonate or industrial safety thickness lenses, or protective face cages in suitable sports frames, to prevent any of the catastrophic, serious, and blinding eye injuries seen in the past.

Ocular manifestations of genetic and development diseases.

Significant advances were reported this year in the identification of the chromosomal location of mutated genes on the 13 and 6 chromosomes which cause forms of autosomal dominant Stargardt's macular dystrophy. Observations in monozygotic twins with age-related macular dystrophy were described. Mitochondrial DNA mutations in Cubans with optic and peripheral neuropathy were reported. A new autosomal dominant proximal myotonic myopathy was described. Persistence of the tunica vasculosa lentis was suggested as a helpful sign of congenital myotonic dystrophy. The panoply of ocular findings in acromesomelic dysplasia were presented. Genetic characterization of the ocular findings in Duchenne type and Becker's muscular dystrophy was reported. Finally, a new syndrome of autosomal dominant cerebellar ataxia with retinal degeneration was described.

Survey of management strategies for nystagmus patients with vertical or torsional head posture.

Surgery for a horizontal face turn or tilt in patients with congenital nystagmus began in 1953 and has been modified frequently since then. There are few published reports stating the frequency of or surgical guidelines for the treatment of a vertical or torsional head position due to congenital nystagmus and associated null point. To address this issue a questionnaire was sent to all members of the American Association for Pediatric Ophthalmology and Strabismus. Most respondents see one or two cases of vertical head posture yearly and use observation as their primary therapy. When surgery is indicated, a graded bilateral vertical rectus recession or combined vertical rectus recession-resection procedure are usually done. Most respondents see no cases of torsional head posture yearly, and an overwhelming majority observe these patients. No one surgical procedure was advocated by most of the responding surgeons.

Pseudotumor cerebri and childhood systemic lupus erythematosus.

Pseudotumor cerebri is a clinical syndrome characterized by elevated intracranial pressure with normal biochemical and cellular characteristics of the cerebrospinal fluid and normal radiologic studies of the skull. This syndrome has been reported infrequently as a primary feature of central nervous system involvement by systemic lupus erythematosus (SLE). We report clinical features in 3 adolescent black females with pseudotumor cerebri as a presenting manifestation of SLE.

A controlled trial of early versus late treatment with zidovudine in symptomatic human immunodeficiency virus infection. Results of the Veterans Affairs Cooperative Study.

BACKGROUND: Zidovudine is recommended for asymptomatic and early symptomatic human immunodeficiency virus (HIV) infection. The best time to initiate zidovudine treatment remains uncertain, however, and whether early treatment improves survival has not been established. METHODS: We conducted a multicenter, randomized, double-blind trial that compared early zidovudine therapy (beginning at 1500 mg per day) with late therapy in HIV-infected patients who were symptomatic and had CD4+ counts between 0.2 x 10(9) and 0.5 x 10(9) cells per liter (200 to 500 per cubic millimeter) at entry. Those assigned to late therapy initially received placebo and began zidovudine when their CD4+ counts fell below 0.2 x 10(9) per liter (200 per cubic millimeter) or when the acquired immunodeficiency syndrome (AIDS) developed. RESULTS: During a mean follow-up period of more than two years, there were 23 deaths in the early-therapy group (n = 170) and 20 deaths in the late-therapy group (n = 168) (P = 0.48; relative risk [late vs. early], 0.81; 95 percent confidence interval, 0.44 to 1.59). In the early-therapy group, 28 patients progressed to AIDS, as compared with 48 in the late-therapy group (P = 0.02; relative risk, 1.76; 95 percent confidence interval, 1.1 to 2.8). Early therapy increased the time until CD4+ counts fell below 0.2 x 10(9) per liter (200 per cubic millimeter), and it produced more conversions from positive to negative for serum p24 antigen. Early therapy was associated with more anemia, leukopenia, nausea, vomiting, and diarrhea, whereas late therapy was associated with more skin rash. CONCLUSIONS: In symptomatic patients with HIV infection, early treatment with zidovudine delays progression to AIDS, but in this controlled study it did not improve survival, and it was associated with more side effects.

Long-term follow-up of symptomatic HIV-infected patients originally randomized to early versus later zidovudine treatment; report of a Veterans Affairs Cooperative Study. VA Cooperative Study Group on AIDS Treatment.

Following a 4-year controlled trial comparing early and later zidovudine treatment, we conducted an additional 3-year follow-up. Of the original 338 patients, 275 participated. Clinical outcome measures were AIDS and death. In the early therapy group (n = 170), 67 patients progressed to AIDS compared with 85 in the later therapy group (n = 168); the relative risk (RR) comparing early with later therapy was 0.72% (95% confidence interval [CI] 0.52-0.99; p = 0.044). The early therapy group had 74 deaths compared with 73 in the later therapy (RR = 0.98; 95% CI, 0.71-1.36; p = 0.91). The early group had a peak CD4+ count increase at 1-2 months and a delay of 1 year before CD4+ counts fell below baseline. For patients who received zidovudine for more than the median duration (20.3 months) before their first AIDS diagnosis, the RR for death was 2.08 (95% CI, 1.36-3.19, p = 0.001). Additional factors independently associated with poor prognosis following AIDS were a CD4+ count of < 100 cells/mm3 and increased severity of the first AIDS diagnosis, whereas use of another antiretroviral agent was associated with improved survival. We conclude that early zidovudine therapy delays progression to AIDS but does not affect survival. Patients who progress to AIDS while on prolonged zidovudine monotherapy many benefit from a change to other antiretroviral therapy(ies).