- Email: [email protected]
Eye strain associated with childhood-onset strabismus
e36 Methods: Retrospective case series of 7 patients evaluated at a single institution with abnormal vertical head position (chin-up or chindown). All patients underwent bilateral surgery on one vertical rectus muscle and the opposing oblique muscle with the same surgeon. Results: Seven children, ranging in age from 4 months to 5 years at presentation, underwent surgery to correct either a chin-down or chin-up head position. Two children had infantile nystagmus syndrome, four had albinism, and one had a cone-rod dystrophy. Six of the 7 patients had combined vertical recti and oblique muscle surgery. All but one demonstrated improvement in head position postoperatively. Specifically, 3 had complete resolution of abnormal head position, three had a reduction in head position, and one had no significant change. None of the children reported or had evidence of cyclotorsion postoperatively. Mean postoperative follow-up was 7.6 years (range, 5-9.5 years). Discussion: Combined vertical recti and oblique surgery to correct abnormal vertical head position is necessary to prevent cyclorotary disorders postoperatively, and provides long-term success. Conclusions: A modified Kestenbaum procedure is effective in improving a chin-up or chin-down position on a long-term basis. 131 Clinical characteristics of isolated foveal hypoplasia: a case series. Julie Y. Kwon, Maury Marmor, Sylvia R. Kodsi Introduction: Foveal hypoplasia (FH) is a rare entity consisting of decreased visual acuity (VA), nystagmus, blunted foveal reflex and poorly defined fovea. It is often associated with aniridia, albinism or other ocular abnormalities. Case reports of isolated foveal hypoplasia (IFH) usually describe patients with nystagmus and poor visual acuity. In our tertiary pediatric ophthalmology practice, we describe a case series of 9 patients who do not conform to the previously reported clinical characteristics of IFH. Methods:A retrospective chart review was conducted at two tertiary pediatric ophthalmology centers from 1990 to the present. Foveal hypoplasia diagnosis was made by ophthalmoscopy exam. When available, visual acuity was correlated with optical coherence tomography (OCT) findings and fundus photos. Results: Nine patients were identified with isolated foveal hypoplasia. All patients were Caucasian. VA ranged from 20/25 to 20/70. Six patients had some stereopsis, and 4 patients did not exhibit any nystagmus. OCT revealed decreased foveal depression and fundus photos showed abnormal maculofoveal vessels. Discussion: Contrary to previous reports of IFH with severely decreased visual function, this series describes a wide clinical spectrum of IFH, including excellent VA and stereopsis. As described by Thomas et al, visual acuity can be correlated with findings on OCT. Our case series may represent a spectrum of isolated foveal hypoplasia or foveal plana. Conclusions: Isolated foveal hypoplasia can present with good visual acuity and stereopsis. Nystagmus may not occur in some patients. 132 The red reflex test: can it detect anisometropia? Kara C. LaMattina, Leonard B. Nelson, Barry N. Wasserman, Kammi B. Gunton, Caroline N. DeBenedictis, Alex V. Levin, Bruce Schnall Introduction: The red reflex test has been theorized to be useful in the detection of anisometropia. To date, however, no study has looked at its specificity or sensitivity in screening for this important amblyogenic risk factor. Our study sought to define these, as well as the threshold of anisometropia needed to reliably detect asymmetry in the red reflex.
Volume 20 Number 4 / August 2016 Methods: This study was conducted in a single-masked, prospective manner with internal review board approval in the Pediatric Ophthalmology and Ocular Genetics Clinic at the Wills Eye Hospital. One hundred patients will be screened by a masked observer for asymmetry of the red reflex with their cycloplegic refraction documented by a senior physician. Results: To date, 26 patients with a median age of 7.5 years have been enrolled. Using univariate logistic regression on the absolute difference in spherical power, ROC analysis showed that the red reflex test has a sensitivity of 83.3% and a specificity of 80% in the detection of anisometropia equal to or greater than 0.5 diopters. Discussion: In the absence of concurrent strabismus, anisometropic amblyopia can be difficult to test in preverbal or developmentally delayed children who cannot participate in visual acuity testing. Technological advancements in refractive screening tools make for an appealing solution to this problem, but may not be readily available or financially reasonable for all practitioners. Conclusions: The red reflex test may be useful in detection of anisometropia, but further enrollment will increase the strength of our study. 133 Clinical features in children with posterior polymorphous corneal dystrophy. Young Chun Lee, Hae Ri Yum, Shin Hae Park Introduction: To describe clinical features in children detected with vesicle- or bandlike endothelial lesions characteristic of posterior polymorphous corneal dystrophy (PPCD) in their first or second decade of life. Methods: Seven unrelated Korean pediatric patients who were diagnosed by the presence of characteristic vesicular or band lesions at the level of Descemet's membrane were included. Thorough ocular examinations were performed, including best-corrected visual acuity, intraocular pressure, and refractive measurements, slit-lamp biomicroscopy, and specular microscopy. Results: Slit-lamp examinations revealed vesicular lesions in one patient and horizontally parallel band-like endothelial lesions in 6 patients. Four patients displayed unilateral corneal involvement, yielding 10 eyes with characteristic deep corneal lesions. Other corneal, iris, or fundus pathologic findings were not detected in all cases. Two children with amblyopia had improved visual acuity through appropriate refractive correction and occlusion therapy. A final visual acuity of more than 20/32 was achieved with appropriate refractive correction in all PPCD-affected eyes. Specular microscopic examinations revealed a reduced endothelial cell density composed of enlarged cell with no significant changes in the hexagonality and coefficient of variation in the PPCD-affected eyes. The endothelial assessments at 3 years did not demonstrate any statistically significant differences in ECD, HA, and CV compared with those at initial diagnosis. Discussion: The final visual acuity of more than 20/32 was achieved with appropriate refractive correction in all PPCD-affected eyes. Conclusions: Children with early-onset PPCD can gain good visual function by early appropriate refractive correction with occlusion therapy. Long-term monitoring of corneal endothelium should be required in pediatric patients with early-onset PPCD. 134 Eye strain associated with childhood-onset strabismus. David A. Leske, Sarah R. Hatt, Jonathan M. Holmes Introduction: We describe the association of the symptom of eye strain with childhood-onset strabismus and its association with clinical characteristics.
Journal of AAPOS
Volume 20 Number 4 / August 2016 Methods: 71 patients with childhood-onset strabismus (aged 13-82 years, median 39 years) prospectively rated frequency of eye strain on a Likert-type scale (never, rarely, sometimes, often, or always). Patients were required to have no previous surgery or surgery more than 10 years previously and not wearing prism. Patients were classified as having or not having, sensory fusion, motor fusion, microtropia (SPCT\10D at distance or near), and / or DVD. Strain ratings were converted to a score of 0 to 4 points (never to always) and mean scores were compared using t-tests for each characteristic using available data. Results: 46 (65%) patients with childhood-onset strabismus rated strain as more than rarely. More frequent strain was experienced by patients with microtropia versus larger deviations (2.5 1.3 points vs 1.8 1.1 points, P 5 0.02). More frequent strain (albeit nonsignificant) was experienced by patients with versus without motor fusion (2.4 1.2 points vs 2.0 1.2 points, P 5 0.2). Similar frequency of strain was reported for patients with and without sensory fusion (2.2 1.3 points vs 2.1 1.0 points, P 5 0.8) and with and without DVD (2.1 1.3 points vs 2.2 1.1 points, P 5 0.8). Discussion: The symptom of eye strain is commonly experienced by patients with childhood-onset strabismus. Conclusions: In childhood-onset strabismus, eye strain appears to be associated with microtropia and motor fusion. 135 Outcomes of nasolacrimal duct probing in older children. Katharine Liegel, Gregg T. Lueder Introduction: There is limited literature regarding the success rate of surgery for older children with nasolacrimal duct (NLD) obstruction. The current study investigated the outcomes of primary NLD probing in patients four years of age or older with simple membranous NLD obstruction. Methods:This was a retrospective chart review of children 4 years of age and older with uncomplicated NLDO obstruction who underwent surgery from 1997 to 2015. All patients had simple membranous obstruction that resolved with passage of probes, and normal irrigation following probing. Patients with trisomy-21, trauma and craniofacial anomalies were excluded. Outcome and need for additional surgeries were recorded. Results: Thirty-five patients with simple membranous NLD obstruction were treated. Surgery was successful in 30/35 (86%) of patients. Five patients had persistent symptoms that resolved following balloon catheter dilation or stent placement. Discussion: Previous reports have suggested that outcomes of NLD probing may be decreased in older children. This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that for younger patients. Conclusions: NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. 136 Clinical outcomes in children with orbital cellulitis and radiographic globe tenting. Rebecca A. Lindsay, John Kelly, Avery Weiss, Michelle T. Cabrera Introduction: Radiographically, a configurational, conical change of the posterior globe, previously termed globe tenting, is occasionally seen in severe cases of orbital cellulitis, and can be a predictor of profound ophthalmic sequela in adults. Little is known, however, about the visual consequences of such a finding in children with orbital cellulitis. Methods: A single site (Seattle Children's Hospital) retrospective chart review of 46 children with orbital cellulitis and orbital imaging
Journal of AAPOS
e37 was performed. Initial and final visual acuities (VA) were available for 34/46 patients. Tenting angles were measured on axial CT or orbital MRI based on prior published methods, with globe tenting defined as a posterior globe angle of less than or equal to 130 . Results: Six eyes with globe tenting were identified. The mean posterior globe angle was 125.2 degrees, compared to 145.1 in the affected eye of nontented (40) patients. The mean difference in posterior globe angle (unaffected contralateral globe angle affected globe angle) was 17.2 in tented vs. 1.4 in non-tented patients (P 5 0.008). The final mean logMAR VA following a treatment course (parenteral antibiotics and surgery where appropriate) was 0 in tented vs 0.02 in non-tented patients (P 5 0.7). Time to surgery was less in cases of globe tenting, although not statistically significant (mean, 1.5 days compared to 4 days; P 5 0.1). Discussion: Children with orbital cellulitis and globe tenting did not have poor visual outcomes in this small subset of patients. Conclusions: Rapid identification and intervention, including surgery when necessary, likely contributes to good outcomes. 137 A systematic guideline for treatment of common ocular emergencies in the pediatric population. Lea Ann Lope, Nisreen K. Mesiwala, Ellen Mitchell, Christin L. Sylvester, Kanwal Nischal Introduction: The creation of clinical treatment pathways enable evidence-based management steps to be employed systematically, and to highlight areas that need further study. Our goal was to create standardized, evidence-based guidelines for treatment of common ocular emergencies encountered in a pediatric setting. Methods: Residents researched common pediatric ocular diagnoses (hyphema, ruptured globe, preseptal/orbital cellulitis, corneal abrasions, chemical injuries, eyelid lacerations). Treatment algorithms were created using evidence from the medical literature. Treatment steps not proven in the literature were discussed among residents and faculty during a resident led department meeting. Upon consensus among the ophthalmology faculty, the guidelines were then shared with other hospital teams, who would be co-managing patients, for agreement. Results: Evidence-based guidelines of each ocular emergency were created as a tool for patient management in order to provide the most effective and efficient treatment in the emergency room setting. Discussion: This project enabled residents to become familiar with common pediatric ocular emergencies before taking call. Residents gained experience researching medical literature, best-practice guidelines and leading discussions on unproven treatment aspects in order to agree on a departmental-wide algorithm. Conclusions: Ultimately, the resident-derived protocols standardized the treatment of common pediatric ocular emergencies using evidence-based medicine at our hospital. This project also highlighted areas of treatment yet to be proven in the literature, and open for future resident research projects. 138 Small-angle, nonparalytic hypertropia in adults. Brian G. Mohney, Jennifer M. Martinez-Thompson, Nancy N. Diehl Introduction: The purpose of this study was to describe the clinical characteristics of nonparalytic, small-angle hypertropia in a population-based cohort of adults. Methods: The medical records of all adults (.18 years of age) diagnosed with non-paralytic hypertropia from January 1, 1985, through December 31, 2004, were retrospectively reviewed. Results: A total of 99 adults were diagnosed with an unspecified hypertropia during the 20-year period, constituting 14.3% of all forms of
Volume 20 Number 4 / August 2016 Methods: This study was conducted in a single-masked, prospective manner with internal review board approval in the Pediatric Ophthalmology and Ocular Genetics Clinic at the Wills Eye Hospital. One hundred patients will be screened by a masked observer for asymmetry of the red reflex with their cycloplegic refraction documented by a senior physician. Results: To date, 26 patients with a median age of 7.5 years have been enrolled. Using univariate logistic regression on the absolute difference in spherical power, ROC analysis showed that the red reflex test has a sensitivity of 83.3% and a specificity of 80% in the detection of anisometropia equal to or greater than 0.5 diopters. Discussion: In the absence of concurrent strabismus, anisometropic amblyopia can be difficult to test in preverbal or developmentally delayed children who cannot participate in visual acuity testing. Technological advancements in refractive screening tools make for an appealing solution to this problem, but may not be readily available or financially reasonable for all practitioners. Conclusions: The red reflex test may be useful in detection of anisometropia, but further enrollment will increase the strength of our study. 133 Clinical features in children with posterior polymorphous corneal dystrophy. Young Chun Lee, Hae Ri Yum, Shin Hae Park Introduction: To describe clinical features in children detected with vesicle- or bandlike endothelial lesions characteristic of posterior polymorphous corneal dystrophy (PPCD) in their first or second decade of life. Methods: Seven unrelated Korean pediatric patients who were diagnosed by the presence of characteristic vesicular or band lesions at the level of Descemet's membrane were included. Thorough ocular examinations were performed, including best-corrected visual acuity, intraocular pressure, and refractive measurements, slit-lamp biomicroscopy, and specular microscopy. Results: Slit-lamp examinations revealed vesicular lesions in one patient and horizontally parallel band-like endothelial lesions in 6 patients. Four patients displayed unilateral corneal involvement, yielding 10 eyes with characteristic deep corneal lesions. Other corneal, iris, or fundus pathologic findings were not detected in all cases. Two children with amblyopia had improved visual acuity through appropriate refractive correction and occlusion therapy. A final visual acuity of more than 20/32 was achieved with appropriate refractive correction in all PPCD-affected eyes. Specular microscopic examinations revealed a reduced endothelial cell density composed of enlarged cell with no significant changes in the hexagonality and coefficient of variation in the PPCD-affected eyes. The endothelial assessments at 3 years did not demonstrate any statistically significant differences in ECD, HA, and CV compared with those at initial diagnosis. Discussion: The final visual acuity of more than 20/32 was achieved with appropriate refractive correction in all PPCD-affected eyes. Conclusions: Children with early-onset PPCD can gain good visual function by early appropriate refractive correction with occlusion therapy. Long-term monitoring of corneal endothelium should be required in pediatric patients with early-onset PPCD. 134 Eye strain associated with childhood-onset strabismus. David A. Leske, Sarah R. Hatt, Jonathan M. Holmes Introduction: We describe the association of the symptom of eye strain with childhood-onset strabismus and its association with clinical characteristics.
Journal of AAPOS
Volume 20 Number 4 / August 2016 Methods: 71 patients with childhood-onset strabismus (aged 13-82 years, median 39 years) prospectively rated frequency of eye strain on a Likert-type scale (never, rarely, sometimes, often, or always). Patients were required to have no previous surgery or surgery more than 10 years previously and not wearing prism. Patients were classified as having or not having, sensory fusion, motor fusion, microtropia (SPCT\10D at distance or near), and / or DVD. Strain ratings were converted to a score of 0 to 4 points (never to always) and mean scores were compared using t-tests for each characteristic using available data. Results: 46 (65%) patients with childhood-onset strabismus rated strain as more than rarely. More frequent strain was experienced by patients with microtropia versus larger deviations (2.5 1.3 points vs 1.8 1.1 points, P 5 0.02). More frequent strain (albeit nonsignificant) was experienced by patients with versus without motor fusion (2.4 1.2 points vs 2.0 1.2 points, P 5 0.2). Similar frequency of strain was reported for patients with and without sensory fusion (2.2 1.3 points vs 2.1 1.0 points, P 5 0.8) and with and without DVD (2.1 1.3 points vs 2.2 1.1 points, P 5 0.8). Discussion: The symptom of eye strain is commonly experienced by patients with childhood-onset strabismus. Conclusions: In childhood-onset strabismus, eye strain appears to be associated with microtropia and motor fusion. 135 Outcomes of nasolacrimal duct probing in older children. Katharine Liegel, Gregg T. Lueder Introduction: There is limited literature regarding the success rate of surgery for older children with nasolacrimal duct (NLD) obstruction. The current study investigated the outcomes of primary NLD probing in patients four years of age or older with simple membranous NLD obstruction. Methods:This was a retrospective chart review of children 4 years of age and older with uncomplicated NLDO obstruction who underwent surgery from 1997 to 2015. All patients had simple membranous obstruction that resolved with passage of probes, and normal irrigation following probing. Patients with trisomy-21, trauma and craniofacial anomalies were excluded. Outcome and need for additional surgeries were recorded. Results: Thirty-five patients with simple membranous NLD obstruction were treated. Surgery was successful in 30/35 (86%) of patients. Five patients had persistent symptoms that resolved following balloon catheter dilation or stent placement. Discussion: Previous reports have suggested that outcomes of NLD probing may be decreased in older children. This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that for younger patients. Conclusions: NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. 136 Clinical outcomes in children with orbital cellulitis and radiographic globe tenting. Rebecca A. Lindsay, John Kelly, Avery Weiss, Michelle T. Cabrera Introduction: Radiographically, a configurational, conical change of the posterior globe, previously termed globe tenting, is occasionally seen in severe cases of orbital cellulitis, and can be a predictor of profound ophthalmic sequela in adults. Little is known, however, about the visual consequences of such a finding in children with orbital cellulitis. Methods: A single site (Seattle Children's Hospital) retrospective chart review of 46 children with orbital cellulitis and orbital imaging
Journal of AAPOS
e37 was performed. Initial and final visual acuities (VA) were available for 34/46 patients. Tenting angles were measured on axial CT or orbital MRI based on prior published methods, with globe tenting defined as a posterior globe angle of less than or equal to 130 . Results: Six eyes with globe tenting were identified. The mean posterior globe angle was 125.2 degrees, compared to 145.1 in the affected eye of nontented (40) patients. The mean difference in posterior globe angle (unaffected contralateral globe angle affected globe angle) was 17.2 in tented vs. 1.4 in non-tented patients (P 5 0.008). The final mean logMAR VA following a treatment course (parenteral antibiotics and surgery where appropriate) was 0 in tented vs 0.02 in non-tented patients (P 5 0.7). Time to surgery was less in cases of globe tenting, although not statistically significant (mean, 1.5 days compared to 4 days; P 5 0.1). Discussion: Children with orbital cellulitis and globe tenting did not have poor visual outcomes in this small subset of patients. Conclusions: Rapid identification and intervention, including surgery when necessary, likely contributes to good outcomes. 137 A systematic guideline for treatment of common ocular emergencies in the pediatric population. Lea Ann Lope, Nisreen K. Mesiwala, Ellen Mitchell, Christin L. Sylvester, Kanwal Nischal Introduction: The creation of clinical treatment pathways enable evidence-based management steps to be employed systematically, and to highlight areas that need further study. Our goal was to create standardized, evidence-based guidelines for treatment of common ocular emergencies encountered in a pediatric setting. Methods: Residents researched common pediatric ocular diagnoses (hyphema, ruptured globe, preseptal/orbital cellulitis, corneal abrasions, chemical injuries, eyelid lacerations). Treatment algorithms were created using evidence from the medical literature. Treatment steps not proven in the literature were discussed among residents and faculty during a resident led department meeting. Upon consensus among the ophthalmology faculty, the guidelines were then shared with other hospital teams, who would be co-managing patients, for agreement. Results: Evidence-based guidelines of each ocular emergency were created as a tool for patient management in order to provide the most effective and efficient treatment in the emergency room setting. Discussion: This project enabled residents to become familiar with common pediatric ocular emergencies before taking call. Residents gained experience researching medical literature, best-practice guidelines and leading discussions on unproven treatment aspects in order to agree on a departmental-wide algorithm. Conclusions: Ultimately, the resident-derived protocols standardized the treatment of common pediatric ocular emergencies using evidence-based medicine at our hospital. This project also highlighted areas of treatment yet to be proven in the literature, and open for future resident research projects. 138 Small-angle, nonparalytic hypertropia in adults. Brian G. Mohney, Jennifer M. Martinez-Thompson, Nancy N. Diehl Introduction: The purpose of this study was to describe the clinical characteristics of nonparalytic, small-angle hypertropia in a population-based cohort of adults. Methods: The medical records of all adults (.18 years of age) diagnosed with non-paralytic hypertropia from January 1, 1985, through December 31, 2004, were retrospectively reviewed. Results: A total of 99 adults were diagnosed with an unspecified hypertropia during the 20-year period, constituting 14.3% of all forms of