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Analysis of clinical misdiagnoses in children treated with enucleation
Volume 14 Number 1 / February 2010 consisted of 2 hours of daily patching plus randomization to either 0.51 mg/kg/tid levodopa with carbidopa 0.17 mg/kg/tid OR 0.76 mg/ kg/tid levodopa with carbidopa 0.17 mg/kg/tid for 8 to 10 weeks. Visual acuity was measured with E-ETDRS testing after stopping the medication and again 8-12 weeks later after a period of patching alone. Adverse events were elicited at each contact. Results: The mean improvement after 8-10 weeks of treatment was 4 letters in the 16 subjects in the low-dose group and 6 letters in the 17 subjects in the high dose group. Ten or more letters of improvement was noted in 2 (13%) of the low-dose group and 5 (29%) in the highdose group. No subject stopped the study medication. Headaches were reported by 6 subjects. After discontinuing levodopa, the mean change 8-12 weeks later was 2 letters in the low-dose group and 3 letters in the high-dose group. Conclusions: Improvement in amblyopic eye acuity was observed in both groups. Levodopa/carbidopa was well tolerated. A placebo controlled trial is necessary to determine whether levodopa can augment occlusion therapy. 026 Analysis of clinical misdiagnoses in children treated with enucleation. Tina Rutar, Susan Hung, Michele Bloomer, J. Brooks Crawford Introduction: The purpose of the retrospective case series was to evaluate discordant clinical and pathological diagnoses that have led to pediatric enucleations over time. Methods: All pathology reports of pediatric enucleation specimens (subject ages 0 to 18 years) from one ocular pathology laboratory from 1960 to 2008 were reviewed. Specimens with discordant clinical and pathologic diagnoses were further analyzed. Formalin-fixed, paraffin-embedded sections of enucleated eyes of any misdiagnoses were reevaluated. Results: Out of 729 pediatric patients (746 eyes) who underwent enucleation during the study period, there were 29 patients (4.0%) and 30 eyes (4.0%) with discordant clinical and pathological diagnoses. Of the 362 patients enucleated for clinically-suspected malignancies, 21 (5.8%) were misdiagnosed in that no evidence of malignancy was found on histopathological examination. Of the 367 patients enucleated for suspected benign clinical indications, 7 (1.9%) had intraocular malignancies by histopathology. The misdiagnosis enucleation rate decreased with each respective decade studied, with the highest rate of 6.5% (18/276 eyes) in the 1960s and no misdiagnoses occurring from 1990 to 2008. Conclusions: In children, benign and malignant intraocular conditions can simulate each other, especially retinoblastoma, Coats disease, nematode, and bacterial endophthalmitis, panuveitis, and persistent hyperplastic primary vitreous. Clinical misdiagnoses in pediatric enucleation specimens have decreased throughout the past five decades, likely due to improved diagnostic techniques. However, we recommend that in uncertain situations, the ophthalmologist discuss the remote possibility of clinical misdiagnosis during the pediatric enucleation consent process. 027 Incidence of pediatric Horner syndrome and the risk of neuroblastoma: A population-based study. Stephen J. Smith, Nancy N. Diehl, Jacqueline A. Leavitt, Brian G. Mohney Purpose: There are no known population-based studies on the incidence of pediatric Horner syndrome, and the current recommended work-up is based on the frequency of underlying etiologies, including neuroblastoma, reported at major referral centers. The purpose of this study is to describe the incidence of pediatric Horner syndrome and the risk of occult malignancy in a population-based cohort.
Journal of AAPOS
e7 Methods: The medical records of all pediatric patients (\19 years) residing in a defined population who were diagnosed with Horner syndrome from January 1, 1969, through December 31, 2008, were retrospectively reviewed. Results: Twenty pediatric patients were diagnosed with Horner Syndrome during the 40-year period, yielding an age- and gender-adjusted incidence of 1.42 (95% CI, 0.80-2.04) per 100,000 patients \ 19 years of age. Eleven (55%) of the 20 had a congenital onset, for a birth prevalence of 1 in 6250 (95% CI, 3333-10000), while the remaining 9 (45%) were acquired. Seven (63.6%) of the 11 congenital cases had a history of birth trauma while the remaining 4 (36.4%) had no identifiable cause for their syndrome. Six (66%) of the 9 acquired cases occurred following surgery or trauma while the remaining 3 (33%) had no known etiology. None (95% CI, 0.0%-16.8%) of the 20 patients were found to have a neuroblastoma or other malignancy during a mean following of 56.5 months (range, 0.0-256.9 months). Conclusions: The incidence of pediatric Horner syndrome in this population was 1.42 per 100,000 patients\19 years, with a birth prevalence of 1 in 6,250 for those with congenital onset. Birth, surgical or other trauma accounted for 13 (65%) of the patients while none of the 20 patients were found to have an underlying mass lesion. 028 Trabeculotomy without scleral flap for the treatment of pediatric glaucoma. Erin D. Stahl, Scott E. Olitsky Introduction: The purpose of this report is to describe a modification of the conventional trabeculotomy procedure. This retrospective, case series review examines 14 cases of trabeculotomy surgery performed without a scleral flap. In these cases, the radial scleral incision was initiated into full-thickness sclera and dissected posteriorly until Schlemm's canal was located. The scleral incision was then secured with 10-0 vicryl suture. Methods: Our patient database was searched for trabeculotomy surgeries performed since September 2006. The operative reports were reviewed and surgical data was collected on those cases done without a scleral flap. Data on age, gender, etiology of elevated intraocular pressure, corneal diameter, pre-op intraocular pressure, location of trabeculotomy site, evidence of canal, ability to cannulate in both directions, and 1 day postoperative examination of wound and anterior chamber were recorded. Results: Of the 14 cases there was no incidence of postoperative wound leak or flat anterior chamber. In all cases, Schlemm's canal was located and cannulated with the trabeculotome in both directions. Etiology of glaucoma treated in this study included infantile glaucoma, juvenile glaucoma, and aphakic glaucoma. Conslusions: This case series shows that trabeculotomy can be successfully completed without the use of a scleral flap. Abandoning the need for the scleral flap in trabeculotomy surgery may be beneficial in cases of advanced glaucoma in which the sclera has become stretched and thinned. Primary cases have also been found to be satisfactorily completed without the creation of a scleral flap. 029 Anterior transposition of the inferior oblique for unilateral superior oblique palsy. Mitchell B. Strominger, Nikhil N. Batra, Noopur N. Batra Purpose: Anterior transposition of the inferior oblique muscle for the treatment of unilateral superior oblique palsy remains controversial due to reports of surgical overcorrection resulting in postoperative hypotropia. This study was to determine our incidence of postoperative hypotropia in primary position and the effectiveness of anterior transposition of the inferior oblique muscle in the treatment of unilateral superior oblique palsy with inferior oblique overaction.
Journal of AAPOS
e7 Methods: The medical records of all pediatric patients (\19 years) residing in a defined population who were diagnosed with Horner syndrome from January 1, 1969, through December 31, 2008, were retrospectively reviewed. Results: Twenty pediatric patients were diagnosed with Horner Syndrome during the 40-year period, yielding an age- and gender-adjusted incidence of 1.42 (95% CI, 0.80-2.04) per 100,000 patients \ 19 years of age. Eleven (55%) of the 20 had a congenital onset, for a birth prevalence of 1 in 6250 (95% CI, 3333-10000), while the remaining 9 (45%) were acquired. Seven (63.6%) of the 11 congenital cases had a history of birth trauma while the remaining 4 (36.4%) had no identifiable cause for their syndrome. Six (66%) of the 9 acquired cases occurred following surgery or trauma while the remaining 3 (33%) had no known etiology. None (95% CI, 0.0%-16.8%) of the 20 patients were found to have a neuroblastoma or other malignancy during a mean following of 56.5 months (range, 0.0-256.9 months). Conclusions: The incidence of pediatric Horner syndrome in this population was 1.42 per 100,000 patients\19 years, with a birth prevalence of 1 in 6,250 for those with congenital onset. Birth, surgical or other trauma accounted for 13 (65%) of the patients while none of the 20 patients were found to have an underlying mass lesion. 028 Trabeculotomy without scleral flap for the treatment of pediatric glaucoma. Erin D. Stahl, Scott E. Olitsky Introduction: The purpose of this report is to describe a modification of the conventional trabeculotomy procedure. This retrospective, case series review examines 14 cases of trabeculotomy surgery performed without a scleral flap. In these cases, the radial scleral incision was initiated into full-thickness sclera and dissected posteriorly until Schlemm's canal was located. The scleral incision was then secured with 10-0 vicryl suture. Methods: Our patient database was searched for trabeculotomy surgeries performed since September 2006. The operative reports were reviewed and surgical data was collected on those cases done without a scleral flap. Data on age, gender, etiology of elevated intraocular pressure, corneal diameter, pre-op intraocular pressure, location of trabeculotomy site, evidence of canal, ability to cannulate in both directions, and 1 day postoperative examination of wound and anterior chamber were recorded. Results: Of the 14 cases there was no incidence of postoperative wound leak or flat anterior chamber. In all cases, Schlemm's canal was located and cannulated with the trabeculotome in both directions. Etiology of glaucoma treated in this study included infantile glaucoma, juvenile glaucoma, and aphakic glaucoma. Conslusions: This case series shows that trabeculotomy can be successfully completed without the use of a scleral flap. Abandoning the need for the scleral flap in trabeculotomy surgery may be beneficial in cases of advanced glaucoma in which the sclera has become stretched and thinned. Primary cases have also been found to be satisfactorily completed without the creation of a scleral flap. 029 Anterior transposition of the inferior oblique for unilateral superior oblique palsy. Mitchell B. Strominger, Nikhil N. Batra, Noopur N. Batra Purpose: Anterior transposition of the inferior oblique muscle for the treatment of unilateral superior oblique palsy remains controversial due to reports of surgical overcorrection resulting in postoperative hypotropia. This study was to determine our incidence of postoperative hypotropia in primary position and the effectiveness of anterior transposition of the inferior oblique muscle in the treatment of unilateral superior oblique palsy with inferior oblique overaction.