Absence of spontaneous venous pulsations in children with pseudopapilledema

Volume 15 Number 1 / February 2011 Methods: Retrospective chart review of pediatric patients with orbital trauma from 2006-2010 who underwent CT. Imaging findings of orbital fracture were compared to motility exam. Results: We identified 96 patients with orbital fractures including 30 roof fractures (23%), 49 medial fractures (37%), 46 floor fractures (35%) and 7 lateral fractures (5%). 1 roof, 14 medial, and 17 floor fractures showed entrapment on CT but full rotations clinically, whereas 1 roof, 7 medial, and 10 floor fractures showed entrapment on both CT imaging and motility exam. There was no entrapment of lateral wall fractures. When there was evidence of entrapment on CT but no restriction on exam, 72% had entrapment of fat only on imaging. When there was both evidence of entrapment on CT scan and restricted motility, 61% showed entrapment of muscle and fat. Only 36% of patients with entrapment on imaging had motility restriction. Lastly, there were 9 patients with restriction on motility testing but no entrapment on imaging. Discussion: The most commonly fractured orbital bone in our series was the lamina papyracea, however floor fractures are more likely to be entrapped on imaging and show restriction on exam. Radiologic evidence of entrapment did not correlate well with evidence of restriction on exam. We continue to evaluate other imaging features that may better correlate with clinical entrapment. Conclusions: Motility testing is an essential part of the evaluation of pediatric orbital fracture patients. 060 Does amount of immediate postoperative esotropia predict later alignment after surgery for intermittent exotropia? Luke W. Deitz, Stacy L. Pineles, Federico G. Velez Introduction: It is well accepted that esotropic (ET) over-correction on post-operative-day 1 (POD1) is a desired outcome for long-term stability after surgery for intermittent exotropia (XT). It is unclear why some patients who are appropriately over-corrected eventually demonstrate recurrent XT while others maintain a stable deviation. Methods: The records of all patients who underwent primary correction of XT were reviewed, and those with any ET on POD1 were included. The status at the last visit was categorized as orthotropic \ 8Δ XT, recurrent XT . 8Δ, monofixation ET \ 10Δ, or consecutive ET . 10Δ. Results: Seventy-two subjects met the study inclusion criteria. The mean POD1 alignment was 6  3Δ ET and 5  3Δ ET at distance and near. At the last visit, 36 (50%) of the subjects were orthotropic \ 8Δ XT, 27 (37%) had recurrence of XT . 8Δ, 9 (13%) had monofixation ET \ 10Δ, and none had consecutive ET . 10Δ. There was no significant difference between groups in terms of onset age, age at surgery, stereopsis, distance or near deviation (pre-operative or on POD1), or follow-up. Risk factor analysis did not reveal a significant association between XT type, surgical approach, or POD1 alignment and risk of recurrent XT or monofixation ET. Conclusions: The results of appropriate esotropic over-correction for XT are variable and unpredictable. In a large population, we were unable to determine associations with recurrent XT or secondary ET. 061 Does the 3-step test or any other clinical feature predict superior oblique (SO) atrophy? Joseph L. Demer, Robert A. Clark, Jennifer Kung Purpose: SO palsy is a pathophysiologic diagnosis implying trochlear neuropathy with secondary denervation atrophy. Can clinical features, including the 3-step test, accurately predict SO atrophy? Methods: Orbital MRI in 90 head tilts was performed in 22 patients with positive 3-step tests and other clinical features of chronic SO palsy and 16 orthotropic subjects. All underwent detailed histories and clinical evaluations.

Journal of AAPOS

e17 Results: Ten patients had normal and 12 unilaterally small SO muscles consistent with denervation (p \ 0.00001). No clinical feature differed between patients with vs. without SO atrophy (p . 0.13). Two patients with SO atrophy had traumatic or congenital origin; all other patients had uncertain onset and etiology. Normal subjects exhibited 3-7 extorsion of all rectus pulleys in orbit up vs. down tilts. In orbits with SO atrophy, the lateral (LR) and inferior rectus pulleys paradoxically intorted. Patients with normal SO size exhibited reduced or reversed extorsion of the hypertropic medial, superior, and LR pulleys, with normal fellow orbit behavior. In normal subjects and in SO atrophy, the inferior oblique (IO) contracted in orbit up tilt, but paradoxically relaxed in patients without SO atrophy. Discussion: No clinical features predict SO atrophy, including the 3step test. Most cases with positive 3-step tests lack definable strabismus onset and etiology. Rectus pulleys and the IO behave differently during head tilt when the SO is atrophic vs. normal. Conclusions: Abnormal rectus pulley shift and IO relaxation can "masquerade" as SO palsy, giving a positive 3-step test that does not reflect trochlear neuropathy in half the cases. 062 Absence of spontaneous venous pulsations in children with pseudopapilledema. Noha S. Ekdawi, Michael C. Brodsky Purpose: To evaluate the presence or absence of spontaneous venous pulsations in children. Methods: Prospective examination of children with pseudopapilledema and controls for spontaneous venous pulsations. Results: Our study group consisted of 16 children diagnosed with pseudopapilledema. The average age of these children was 9.8 (range, 6-17) years. Only 4 (25%) of the 16 had spontaneous venous pulsations on exam. One child was diagnosed with drusen. Our control group consisted of 16 normal children. The average age of these children was 9 (range, 5-14) which was not significantly different from our study group (p 5 0.15). 12 (75%) had spontaneous venous pulsations on exam which is significantly difference from the children with pseudopapilledema (p 5 0.0055). Discussion: The absence of spontaneous venous pulsations may reflect the underlying pathophysiology of pseudopapilledema, which is attributable to local axonal stasis (arising from a tight scleral canal) producing a local compression effect which is similar to that produced by increased perioptic CSF pressure in papilledema. Conclusions: The majority of children with pseudopapilledema do not have spontaneous venous pulsations. Therefore, the absence of spontaneous venous pulsations in children should not suggest elevated intracranial pressure in children with unexplained optic disc elevation. 063 Positive Bielschowsky head tilt test in cases of comitant exotropia. Ayman M. Elghonemy, Fadia S. Attia Purpose: We aimed to study the incidence and factors influencing positive Bielschowsky head tilt test (BHTT) in cases of comitant exotropia. Methods: We prospectively studied 85 consecutive patients of comitant exotropia including patients associated with primary inferior or superior oblique muscles overactions, or hypertropia. We excluded patients with incomitancy, extraocular muscles palsy, and dissociated vertical deviation (DVD). Results: Positive BHTT was detected in 84 (98.82%) patients; 57 (67.06%) bilaterally and 27 (31.76%) unilaterally. Forty four (51.8%) patients did not show hypertropia in primary position. Obliques overactions were not detected in 52 (61.2%) patients. Mean difference in vertical deviation between right and left tilts was 11.54Δ, its