Prism placement. Measurements of horizontal and vertical deviations with the head tilted.

While performing prism and cover measurements for strabismus with the head tilted, prisms held before the eye should be positioned so that the base of the "horizontal" prism is parallel to the lateral wall of the orbit, and the base of the "vertical" prism is parallel to the floor of the orbit. This placement is required because with the head tilted, torsional compensation of the globe is minimal.

Ophthalmology. The resident's perspective.

To determine how and why current residents in ophthalmology chose their medical specialty, we formulated and distributed a questionnaire to all ophthalmology residents in accredited programs. The results of the survey gave insight into not only their decision-making processes in choosing ophthalmology, but also their backgrounds, the factors that were important in choosing their residency program, and their future plans in ophthalmology. A wide variety of factors was involved in the decision to pursue a career in ophthalmology. In addition, we found current residents to be well qualified academically and generally satisfied with their decision to enter ophthalmology.

Surgical practice kit. Ophthalmic suture simulator.

A practice surgery device used for training novice ophthalmic surgeons employs an inflatable bladder that supports a human bank scleral shell. The sclera is used for placement of sutures. A light source and universal joint to support a syringe are mounted on a 25 X 15-cm base. Glycerin-preserved sclera is available from many eye banks. Up to 100 practice sutures may be placed in each scleral shell. This device allows the beginning surgeon the opportunity to obtain a feel for needle passage through tissue. Technique for the use of loupe or microscope magnification can also be developed. In addition, a deflation of the scleral "globe" occurs when a needle is placed too deeply. This emphasizes the need of superficial suture placement.

A suture-reinforced scleral sling. Technique for suspension of the ptotic upper lid.

A frontalis sling procedure for ptosis repair, employing preserved human bank sclera and polyfilament, cable-type, ophthalmic (Supramid Extra) suture in combination has been devised and tried. Results indicate that these two readily available materials that are now used separately may be combined for lid suspension. They are easy to work with and produce lasting results.

Aphakic cystoid macular edema in children.

Twenty-five eyes of 18 pediatric patients (aged 7 1/2 months to 14 years 8 months) who had had cataract extractions were examined for evidence of cystoid macular edema (CME) with fluorescein angiography. No patient showed CME when studied from five weeks to four years after surgery. One patient with Peter's anomaly, glaucoma, and chronic iridocyclitis had intense fluorescence of the aqueous and vitreous that precluded evaluation of the macula. Even if this patient is assumed to have had CME, its incidence in our population of aphakic pediatric patients was no more than 4%.

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.

Treatment of acquired nystagmus with botulinum A toxin.

We injected botulinum A toxin into the retrobulbar space of one eye each in two patients who had acquired nystagmus with oscillopsia and decreased vision. After injection of 25 units of botulinum A toxin, visual acuity improved from 20/80 to 20/30 in one patient, and both patients were able to read and watch television. Improved vision lasted from five to 13 weeks. No adverse side effects were observed after a total of five injections in each patient.

A long-term follow-up study of scleral grafting for exposed or extruded orbital implants.

We conducted a long-term follow-study of 20 patients whose exposed or extruded orbital implants had been replaced or salvaged with scleral grafts. We judged 11 cases to be successes and six failures. Three patients were lost to follow-up. Among the failures were three orbits that had received radiation therapy for retinoblastoma. They could not retain an orbital implant despite several scleral grafts.

Extraocular muscle lacerations.

Five cases of laceration of an extraocular muscle without involvement of the globe or significant involvement of the adnexa occurred after injury with a pencil, mower blade, screen door, and building nail, and at surgery when the surgeon operated on the wrong muscle. The inferior rectus muscle was involved in three cases, the lateral rectus muscle in one, and the medial rectus muscle in one, Traumatic muscle laceration involves the inferior or medial rectus muscles more often than the other muscles. This may occur for two reasons: these muscles are closer to the corneoscleral limbus, and they are more visible during the protective blink with associated upward and usually outward movement of the globe (Bell's phenomenon). When the lacerated muscle could be found, it was repaired either by reinsertion to the sclera or reunion of the severed muscle segments. When the muscle could not be found, a muscle transfer procedure was carried out. Patients with fusion before injury regained fusion in part of the visual field after muscle repair.

Synthetic absorbable suture for strabismus surgery.

Polyglactin 910 (Vicryl), a synthetic absorbable braided suture in 5-0 or 6-0 size, was satisfactory for recession and resection of extraocular muscles. It produced an acute allergic reaction in only one of 89 cases (1.5%) as compared to a 19% reaction when collagen suture of like size was used. Polyglactin 910 suture, when left partially exposed, may be irritating and can cause excessive reaction when used at the conjunctival limbus.

Extraocular muscle-tendon transfer with scleral augmentation.

Two patients with 90 prism diopters of exotropia and an absent medial rectus muscle each had the nasal half of the superior and inferior rectus muscles joined with a thin strip of preserved sclera. The center of the scleral strip was first anchored to host sclera at the usual site of the medial rectus insertion. Alignment was improved in the primary position with a residual exodeviation of 25 prism diopters and 20 prism diopters, respectively. Each patient required secondary conjunctival recession because of a delle.

Photo-induced convulsion after using the translid binocular interactor.

A 12-year-old boy with small-angle secondary exotropia and minimal amblyopia experienced photo-induced epilepsy after using the Translid Binocular Interactor, a device designed to treat several of the motor and sensory abnormalities of the eyes alternately with a bright flash at 10 cps. Whether or not the device is effective, it is potentially dangerous to susceptible individuals.

Persistent binocular diplopia after cataract surgery.

We reviewed the records of 38 consecutive patients who had persistent binocular diplopia after cataract surgery. The patients were divided into ten categories based on the suspected conditions underlying the diplopia. Of 16 patients who underwent strabismus surgery, five achieved the therapeutic goal of single binocular vision in the primary and reading position, and four attained this with prismatic or botulinum toxin therapy in addition to surgery. Seven patients continued to have diplopia despite strabismus surgery and adjunctive therapy. Even small residual deviations were often intolerable, because of highly diminished fusional amplitudes.

Linear subcutaneous fat atrophy after corticosteroid injection of periocular hemangiomas.

Two children developed evidence of subcutaneous fat atrophy after corticosteroid injection of periocular hemangiomas. The atrophy appeared at the site of injection and followed the expected course of lymphatic channels to the vicinity of regional lymph nodes.

Depth of strabismic amblyopia determined with neutral density filters.

We used a neutral density filter to assess motor responses in the fixation patterns of 25 patients, ranging in age from 5 to 54 years, with strabismic amblyopia. Shifts of fixation back to the preferred eye occurred when the visual acuity of the preferred eye through the filter was marginally better than that of the amblyopic eye. Thus, we were able to correlate the level of the filter at which this shift occurred with the level of amblyopia. This technique may be particularly helpful in the examination of preliterate children and in monitoring the progress in the treatment of amblyopia.

Congenital blepharoptosis, anisometropia, and amblyopia.

A review of the records of 65 patients who had surgery for congenital blepharoptosis of the upper eyelid during a three-year period revealed the preoperative presence of anisometropia, strabismus, or amblyopia in 19 patients. Postoperatively, ten of the 65 patients developed or increased their astigmatism in the operated eye. In four of these patients amblyopia attributed to this postoperative astigmatism developed. The results of our study suggest that blepharoptosis surgery done in the first few years of life may contribute to the development of astigmatism and amblyopia in some patients.

Treatment of congenital glaucoma.

We reviewed 37 consecutive patients who had undergone at least one goniotomy, filtering surgery, and patching for amblyopia because of congenital glaucoma between 1969 and 1979. Of 32 eyes treated for uncomplicated congenital glaucoma, 25 (78%) achieved satisfactory control of intraocular pressure. Seven of the 12 eyes (58%) for which Snellen visual acuities could be obtained had visual acuities of 6/15 (20/50) or better. Of eight eyes treated for complicated congenital glaucoma, four (50%) achieved satisfactory control of intraocular pressure, but the visual acuities of these patients could not be tested.

Unilateral esotropia after enucleation in infancy.

Five patients developed esotropia in the remaining eye after unilateral enucleation in the first few weeks to months of life. Esotropia was associated with a face turn toward the opposite side and abduction nystagmus with a null point in extreme adduction. Our experience with these patients supports the reflexogenic theory for the development of a type of congenital-infantile esotropia. An intact globe-ocular muscle relationship, even in a blind eye, may have a stabilizing effect on the fellow eye in the first few weeks to months of life, and this should be considered before enucleation is done.

Hibiclens keratitis.

Presumed accidental corneal exposure to Hibiclens (chlorhexidine 4% and detergent) in two patients resulted in severe and permanent corneal opacification. We investigated the corneal toxicity of Hibiclens by gross, biomicroscopic, and histopathologic studies of rabbit eyes exposed to Hibiclens for varying time intervals ranging from five to 15 minutes. Severe, irreversible, and progressive corneal damage resulted in all eyes studied.

Incidence of strabismus in neonates.

In an attempt to learn whether esotropia is present at birth or develops later in infancy, we observed 1,219 alert infants in a normal newborn nursery at a city hospital. Of these, 593 (48.6%) had orthotropic findings; 398 (32.7%) had exotropia, 40 (3.2%) had esotropia (intermittent in 17 with 14 varying between esotropia and exotropia and nine with a variable esotropia), and 188 (15.4%) were not sufficiently alert to permit classification. No infant displayed typical signs of congenital esotropia. We concluded that congenital-infantile esotropia is not connatal but rather develops in the first few weeks or months after birth.