- Email: [email protected]
Effectiveness of lateral rectus resection for residual esotropia in dysthyroid ophthalmopathy
Volume 20 Number 4 / August 2016 used to identify time required for all clinical documentation during 1 year (2558 patient visits), using software developed by the authors. Results: Mean SD time spent by the ophthalmologist was 14.0 7.5 minutes/patient (3.7 2.3 minutes (26%) examining, 6.4 4.6 minutes (46%) talking, 3.5 3.4 (25%) documenting). EHR documentation required a total of 5.4 2.4 minutes/patient (2.5 1.4 minutes [47%] during patient exams, 2.0 1.9 minutes [38%] during business hours but outside patient exams, and 0.8 1.2 minutes [16%] outside business hours). Discussion: Based on study findings, EHR documentation would require 162 minutes/day, in a typical 30-patient day. Time requirements for the pediatric ophthalmologist in this study were comparable to that of 4 ophthalmologists from other sub-specialties (n 5 291 patients observed, n 5 10,522 patients in audit logs). Time demands for EHRs in this study are longer than previously-published paper documentation times. Conclusions: EHR documentation time requirements are significant, and occupy a large proportion of the overall pediatric ophthalmology patient encounter. Studies toward improving EHR interfaces and integrating EHRs into the patient encounter are warranted. 009 Effectiveness of lateral rectus resection for residual esotropia in dysthyroid ophthalmopathy. Oscar A. Cruz, Gillian Roper-Hall, Eric Y. Kim Introduction: Strabismus occurs in 17%-51% of patients with dysthyroid ophthalmopathy and is most commonly restrictive in nature. Strabismus surgery has traditionally focused on recession to minimize duction limitations and alleviate restriction. Methods:Twenty-seven patients underwent a bimedial rectus recession in a three-year period from June 2012 to June 2015. Nine patients had a residual esotropia. We performed bilateral lateral rectus resection on nine patients with residual esotropia following initial bimedial rectus recession. No vertical muscle surgery was performed on any patients in this study. Results: Seven of 9 patients had successful outcome with fusion in primary and reading gaze without prism. Discussion: The resections generally had predictable results with more effect at distance than near (as expected). The procedure did not create any exodeviations at near. Both failures had initial deviations of .60D prior to medial rectus recession and persistent limitation of ductions prior to lateral rectus resection. Conclusions: Bimedial rectus recession may successfully correct esotropia in most patients with dysthyroid ophthalmopathy. Bilateral lateral rectus resection can be effective for residual esotropia. 010 Characteristics of retinal hemorrhage in premature infants in the telemedicine system for the evaluation of acute-phase retinopathy of prematurity (e-ROP) Study. Ebenezer Daniel, Gui-shuang Ying, Graham E. Quinn Introduction: Retinal hemorrhage is not an uncommon feature in premature infants at risk for ROP, the morphology of which has not been adequately characterized. Methods: All image sets from eyes in the e-ROP study that were ever noted for retinal hemorrhage on either eye examination or image grading were selected for hemorrhage grading. Trained readers graded presence, location, type (dot, blot, flame, preretinal and vitreous), number, total area, and location of hemorrhage to ROP. Results: Hemorrhages occurred in 267 (22%) of 1,239 infants (\1251 g birth weight) and included, dot 8.2%, blot 12.3%, flame 3.4%, preretinal 12.3% and vitreous 1.6%. 56% of the hemorrhages were
Journal of AAPOS
e3 observed at first visit at a median postmenstrual age of 34 weeks (Q1 33, Q3 36). Most hemorrhages were unilateral (83%) with only one type of hemorrhage (78%). Hemorrhage was located in zone I only (40%), zone II only (35%) or in both zones (23%). When preretinal hemorrhages were associated with ROP, 63% were anterior, 52% posterior and 37% were atop the retinopathy. Hemorrhage resolved 38% by week 2, 56% by week 4 and 76% by week 8, with preretinal resolving rapidly (57% by week 2, 98% by week 6). Lower birth weight (P \0.001) and gestational age (P \ 0.001) were associated with retinal hemorrhage in a dose–response manner. Discussion: Retinal hemorrhage in premature infants, typically resolve within a short time period. In eyes with ROP, preretinal hemorrhages are generally posterior to the retinopathy. Conclusions: Intraocular hemorrhages, common in premature infants, are more likely to be seen in smaller, less mature infants. 011 Bupivacaine injection treatment of comitant strabismus. Iara Debert, Joel M. Miller, Kenneth K. Danh, Alan B. Scott Introduction: Bupivacaine injection of extraocular muscles, initially an accidental event causing unwanted strabismus following retrobulbar anesthesia, has been used since 2006 to treat over 100 cases of strabismus. We report here the magnitude and stability of alignment corrections achieved by injecting bupivacaine (BPX) and botulinum toxin into extraocular muscles using EMG guidance in 55 adult patients with comitant horizontal strabismus. Methods: In this prospective observational clinical series, BPX was injected into the lateral rectus of 31 patients with esodeviations, and into the medial rectus of 24 patients with exodeviations. A second BPX injection was given to 24 patients who had residual strabismus, and a third BPX injection was given to 1 patient. Epinephrine was added to the BPX in 30% of injections; botulinum toxin was injected into the antagonist in 68% of injections. Alignment was measured at 6 months and at 1, 2, 3, 4, and 5 years after treatment. Average follow-up was 28 months. Results: Average initial misalignments of 24D were reduced at 28 months by 16D, with residual deviations #10D in 56% of patients. For patients with initial misalignment larger than 25D, treatment correction averaged 21D. Alignments were stable over follow-ups as long as 5 years. Discussion: Stability of outcomes was the striking feature in this series. Large alignment corrections were achieved by large BPX and botulinum toxin doses. Epinephrine may have increased BPX effectiveness. Conclusions: Bupivacaine injection treatment effects stable, clinically significant corrections in comitant horizontal strabismus, providing an alternative to conventional strabismus surgery. 012 Sizes and pulley locations of rectus extraocular muscles in concomitant and pattern exotropia. Joseph L. Demer, Rui Hao Introduction: We used magnetic resonance imaging (MRI) to measure rectus extraocular muscle (EOM) size, contractility, and pulley locations in normal control subjects and subjects with concomitant and pattern exotropia to determine whether these factors contribute to exotropia. Methods: High-resolution, quasicoronal plane MRI was performed in 9 subjects with concomitant exotropia, 6 with pattern exotropia, and 21 normal volunteers. Rectus pulley locations were determined in central gaze in oculocentric coordinates. Cross sections in multiple contiguous image planes were summed and multiplied by the 2 mm slice thickness as indicators of EOM volumes.
Journal of AAPOS
e3 observed at first visit at a median postmenstrual age of 34 weeks (Q1 33, Q3 36). Most hemorrhages were unilateral (83%) with only one type of hemorrhage (78%). Hemorrhage was located in zone I only (40%), zone II only (35%) or in both zones (23%). When preretinal hemorrhages were associated with ROP, 63% were anterior, 52% posterior and 37% were atop the retinopathy. Hemorrhage resolved 38% by week 2, 56% by week 4 and 76% by week 8, with preretinal resolving rapidly (57% by week 2, 98% by week 6). Lower birth weight (P \0.001) and gestational age (P \ 0.001) were associated with retinal hemorrhage in a dose–response manner. Discussion: Retinal hemorrhage in premature infants, typically resolve within a short time period. In eyes with ROP, preretinal hemorrhages are generally posterior to the retinopathy. Conclusions: Intraocular hemorrhages, common in premature infants, are more likely to be seen in smaller, less mature infants. 011 Bupivacaine injection treatment of comitant strabismus. Iara Debert, Joel M. Miller, Kenneth K. Danh, Alan B. Scott Introduction: Bupivacaine injection of extraocular muscles, initially an accidental event causing unwanted strabismus following retrobulbar anesthesia, has been used since 2006 to treat over 100 cases of strabismus. We report here the magnitude and stability of alignment corrections achieved by injecting bupivacaine (BPX) and botulinum toxin into extraocular muscles using EMG guidance in 55 adult patients with comitant horizontal strabismus. Methods: In this prospective observational clinical series, BPX was injected into the lateral rectus of 31 patients with esodeviations, and into the medial rectus of 24 patients with exodeviations. A second BPX injection was given to 24 patients who had residual strabismus, and a third BPX injection was given to 1 patient. Epinephrine was added to the BPX in 30% of injections; botulinum toxin was injected into the antagonist in 68% of injections. Alignment was measured at 6 months and at 1, 2, 3, 4, and 5 years after treatment. Average follow-up was 28 months. Results: Average initial misalignments of 24D were reduced at 28 months by 16D, with residual deviations #10D in 56% of patients. For patients with initial misalignment larger than 25D, treatment correction averaged 21D. Alignments were stable over follow-ups as long as 5 years. Discussion: Stability of outcomes was the striking feature in this series. Large alignment corrections were achieved by large BPX and botulinum toxin doses. Epinephrine may have increased BPX effectiveness. Conclusions: Bupivacaine injection treatment effects stable, clinically significant corrections in comitant horizontal strabismus, providing an alternative to conventional strabismus surgery. 012 Sizes and pulley locations of rectus extraocular muscles in concomitant and pattern exotropia. Joseph L. Demer, Rui Hao Introduction: We used magnetic resonance imaging (MRI) to measure rectus extraocular muscle (EOM) size, contractility, and pulley locations in normal control subjects and subjects with concomitant and pattern exotropia to determine whether these factors contribute to exotropia. Methods: High-resolution, quasicoronal plane MRI was performed in 9 subjects with concomitant exotropia, 6 with pattern exotropia, and 21 normal volunteers. Rectus pulley locations were determined in central gaze in oculocentric coordinates. Cross sections in multiple contiguous image planes were summed and multiplied by the 2 mm slice thickness as indicators of EOM volumes.