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Ocular Motility Problems Following Episcleral Plaque Brachytherapy
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Abstracts
Can the Need for Bifocals be Predicted During Initial Examination of the Child with Suspected Accommodative Esotropia? David K. Coats, Chirag Parghi; Baylor College of Medicine, Houston, TX Purpose: Some ophthalmologists prescribe bifocals at initial examination of children with suspected accommodative esotropia when a large near/distance disparity is present. The purpose of this study was to determine if the need for bifocals can accurately be predicted. Methods: Retrospective analysis of presenting features including size of near/distance disparity, refractive error (SEQ), and time to treatment. A bifocal was recommended at follow-up if a residual esotropia was present at near only. Results: Near/distance disparity: Twenty-five (64%) of 39 patients without disparity, 10 (63%) of 16 with disparity 20 PD responded favorably to single-vision lenses (P ⫽ 0.405). Of those not responding favorably to single-vision lenses, favorable response to bifocal use was found in 2 (14%) of 14 without disparity, 2(33%) of 6 with, and 0 (0%) of 1 with more than 20 PD disparity. Hyperopic refractive error: four (66%) of six patients with a SEQ of ⫹0.25 D to ⫹2.00 D, 15 (68%) of 22 with a SEQ of ⫹2.25 D to ⫹4.00 D, and 23 (66%) of 35 with a SEQ of ⬎ ⫹4.00 D responded favorably to single-vision lenses (P ⫽ 0.982). Time to treatment: nine (75%) of 12 patients seen within 1 month of onset, 16 (84%) of 19 seen 1 and 4 months after onset, and 17 (53%) of 32 seen 4 or greater months after onset responded favorably to single-vision lenses (P ⫽ 0.059). Conclusions: Single-vision glasses are the appropriate treatment for the initial management of the patient with suspected accommodative esotropia. High hyperopia and the presence of a large near/distance disparity are not predictive of the need for bifocals. Ocular Motility Problems Following Episcleral Plaque Brachytherapy Emma L.M. Dawson, DBO, Richard M. Comer, MD, FRCOph, John P. Lee, FRCOph; Moorfields Eye Hospital, London, UK Purpose: To ascertain the incidence of diplopia and strabismus in patients treated with plaque brachytherapy and its subsequent treatment. Method: A single-center retrospective case note review of all patients undergoing plaque brachytherapy for all types of intraocular tumors between 1996 and 2004. Results: There were 215 consecutive, 54% male, with an average age of treatment of 61.5 years and a range of 22 to 91 years, undergoing plaque brachytherapy. Twenty (9%) developed diplopia or strabismus; in four cases the symptoms were transient. Fourteen patients required treatment, and two declined treatment. Seven were treated with prisms only; three underwent Botulinum Toxin injections; four were treated with extraocular eye muscle surgery; three required one operation, and one required two procedures. Conclusion: The incidence of ocular motility disorders following plaque brachytherapy (9%) is significant enough to warrant inclusion in the consent process for conservative treatment of intraocular tumors. Treatment for the troublesome diplopia can be either prisms, Botulinum Toxin, or surgery.
Journal of AAPOS Volume 10 Number 1 February 2006 Field Evaluation of the Welch–Allyn SureSight Vision Screener: Incorporating the VIP Study Recommendations Sean P. Donahue, MD, PhD, Alissa C. Hudson, MD; Tennessee Lions Eye Center, Vanderbilt University Medical Center, Nashville, TN Introduction: The prospective VIP study evaluated 11 methods of screening. Their Phase I analysis suggested two sets of referral criteria for the Welch–Allyn SureSight (WASS) that produce 90 and 94% specificity, respectively. With these criteria, the WASS had higher sensitivity than most other methodologies. We evaluated the usefulness of the new criteria in a field study of healthy preschool children. Methods: Lay volunteers screened 2165 children, aged 2 to 5 years, at day-care centers, preschools, and mother’s day out programs. The WASS software was altered by the manufacturer to recommend referral using the VIP criteria with 90% specificity. Referred children were seen by local ophthalmologists and optometrists, who performed comprehensive eye examinations with cycloplegic refraction. Gold standard criteria for exam failure were based upon published AAPOS vision screening committee standards. Outcome measures were screening success and positive-predictive value. Results: Screening was successful in 99% of children. The referral rate using the 90% specificity criteria was 11.5%. Most children (72%) were referred for suggested astigmatism. Overall positive-predictive value was 30% (70% of referrals were false positives). The 94% specificity criteria from VIP Phase I decreased the referral rate to 7.4% and substantially decreased overreferrals for suspected astigmatism, but caused several anisometropes to go undetected. Higher specificity was achieved by raising astigmatism referral criteria but leaving anisometropic criteria unchanged. Conclusion: The WASS can be used successfully for preschool screening provided criteria with high specificity are incorporated into the instrument’s software program. Higher PPV can be achieved without jeopardizing sensitivity by refining astigmatism criteria. Inferior Oblique Orbital Fixation: A Profound Weakening Procedure Noa Ela-Dalman, MD, Federico G. Velez, MD, David R. Stager Sr, MD, Joost Felius, PhD, Arthur L. Rosenbaum, MD; Jules Stein Eye Institute, UCLA, Los Angeles, CA and Dallas, TX Introduction: Recurrent or persistent inferior oblique overaction is common following inferior oblique recession or anterior transposition. Inferior oblique nasal and temporal myectomy and anteriornasal transposition may result in undesirable inferior oblique palsy, exotropia, incyclotorsion, or limitation of elevation. Previous studies have shown that a rectus extraocular muscle may be profoundly weakened if the muscle insertion is reattached to adjacent orbital periosteum. Aim: Describe a reversible inactivation of the inferior oblique muscle. Methods: Eight subjects with V-pattern exotropia and/or inferior oblique overaction underwent inferior oblique orbital fixation procedure by attaching its insertion to the periosteum of the lateral orbital wall. Four subjects with persistent inferior oblique overaction following inferior oblique anterior transposition underwent bilateral inferior oblique orbital wall fixation. Four subjects with no previous inferior oblique surgery underwent unilateral inferior oblique orbital wall fixation; three of these four subjects had superior oblique palsy with a large vertical deviation in primary position and one had a V-pattern with asymmetric inferior oblique overaction. Results: V-pattern significantly improved from 22.2 ⫾ 11.8 PD to 5.6 ⫾ 7 PD postoperatively (P ⫽ 0.005). Inferior oblique overaction improved from 2.6 ⫾ 0.9 (range ⫹1.5 to ⫹4) to ⫺0.3 ⫾ 0.6 (range ⫺1 to ⫹1) postoperatively (P ⬍ 0.001). Seven of eight subjects had no residual overelevation in adduction postoperatively. Unilateral inferior oblique orbital fixation corrected 8 PD of vertical deviation in the primary position and 25 PD in adduction. Mean postoperative follow-up was 4 months. Conclusion: Inferior oblique orbital fixation has a profound weakening effect on the inferior oblique muscle. Advantages of this procedure include reversibility and the ability to be converted into another form of weakening procedure, if required.
Abstracts
Can the Need for Bifocals be Predicted During Initial Examination of the Child with Suspected Accommodative Esotropia? David K. Coats, Chirag Parghi; Baylor College of Medicine, Houston, TX Purpose: Some ophthalmologists prescribe bifocals at initial examination of children with suspected accommodative esotropia when a large near/distance disparity is present. The purpose of this study was to determine if the need for bifocals can accurately be predicted. Methods: Retrospective analysis of presenting features including size of near/distance disparity, refractive error (SEQ), and time to treatment. A bifocal was recommended at follow-up if a residual esotropia was present at near only. Results: Near/distance disparity: Twenty-five (64%) of 39 patients without disparity, 10 (63%) of 16 with disparity 20 PD responded favorably to single-vision lenses (P ⫽ 0.405). Of those not responding favorably to single-vision lenses, favorable response to bifocal use was found in 2 (14%) of 14 without disparity, 2(33%) of 6 with, and 0 (0%) of 1 with more than 20 PD disparity. Hyperopic refractive error: four (66%) of six patients with a SEQ of ⫹0.25 D to ⫹2.00 D, 15 (68%) of 22 with a SEQ of ⫹2.25 D to ⫹4.00 D, and 23 (66%) of 35 with a SEQ of ⬎ ⫹4.00 D responded favorably to single-vision lenses (P ⫽ 0.982). Time to treatment: nine (75%) of 12 patients seen within 1 month of onset, 16 (84%) of 19 seen 1 and 4 months after onset, and 17 (53%) of 32 seen 4 or greater months after onset responded favorably to single-vision lenses (P ⫽ 0.059). Conclusions: Single-vision glasses are the appropriate treatment for the initial management of the patient with suspected accommodative esotropia. High hyperopia and the presence of a large near/distance disparity are not predictive of the need for bifocals. Ocular Motility Problems Following Episcleral Plaque Brachytherapy Emma L.M. Dawson, DBO, Richard M. Comer, MD, FRCOph, John P. Lee, FRCOph; Moorfields Eye Hospital, London, UK Purpose: To ascertain the incidence of diplopia and strabismus in patients treated with plaque brachytherapy and its subsequent treatment. Method: A single-center retrospective case note review of all patients undergoing plaque brachytherapy for all types of intraocular tumors between 1996 and 2004. Results: There were 215 consecutive, 54% male, with an average age of treatment of 61.5 years and a range of 22 to 91 years, undergoing plaque brachytherapy. Twenty (9%) developed diplopia or strabismus; in four cases the symptoms were transient. Fourteen patients required treatment, and two declined treatment. Seven were treated with prisms only; three underwent Botulinum Toxin injections; four were treated with extraocular eye muscle surgery; three required one operation, and one required two procedures. Conclusion: The incidence of ocular motility disorders following plaque brachytherapy (9%) is significant enough to warrant inclusion in the consent process for conservative treatment of intraocular tumors. Treatment for the troublesome diplopia can be either prisms, Botulinum Toxin, or surgery.
Journal of AAPOS Volume 10 Number 1 February 2006 Field Evaluation of the Welch–Allyn SureSight Vision Screener: Incorporating the VIP Study Recommendations Sean P. Donahue, MD, PhD, Alissa C. Hudson, MD; Tennessee Lions Eye Center, Vanderbilt University Medical Center, Nashville, TN Introduction: The prospective VIP study evaluated 11 methods of screening. Their Phase I analysis suggested two sets of referral criteria for the Welch–Allyn SureSight (WASS) that produce 90 and 94% specificity, respectively. With these criteria, the WASS had higher sensitivity than most other methodologies. We evaluated the usefulness of the new criteria in a field study of healthy preschool children. Methods: Lay volunteers screened 2165 children, aged 2 to 5 years, at day-care centers, preschools, and mother’s day out programs. The WASS software was altered by the manufacturer to recommend referral using the VIP criteria with 90% specificity. Referred children were seen by local ophthalmologists and optometrists, who performed comprehensive eye examinations with cycloplegic refraction. Gold standard criteria for exam failure were based upon published AAPOS vision screening committee standards. Outcome measures were screening success and positive-predictive value. Results: Screening was successful in 99% of children. The referral rate using the 90% specificity criteria was 11.5%. Most children (72%) were referred for suggested astigmatism. Overall positive-predictive value was 30% (70% of referrals were false positives). The 94% specificity criteria from VIP Phase I decreased the referral rate to 7.4% and substantially decreased overreferrals for suspected astigmatism, but caused several anisometropes to go undetected. Higher specificity was achieved by raising astigmatism referral criteria but leaving anisometropic criteria unchanged. Conclusion: The WASS can be used successfully for preschool screening provided criteria with high specificity are incorporated into the instrument’s software program. Higher PPV can be achieved without jeopardizing sensitivity by refining astigmatism criteria. Inferior Oblique Orbital Fixation: A Profound Weakening Procedure Noa Ela-Dalman, MD, Federico G. Velez, MD, David R. Stager Sr, MD, Joost Felius, PhD, Arthur L. Rosenbaum, MD; Jules Stein Eye Institute, UCLA, Los Angeles, CA and Dallas, TX Introduction: Recurrent or persistent inferior oblique overaction is common following inferior oblique recession or anterior transposition. Inferior oblique nasal and temporal myectomy and anteriornasal transposition may result in undesirable inferior oblique palsy, exotropia, incyclotorsion, or limitation of elevation. Previous studies have shown that a rectus extraocular muscle may be profoundly weakened if the muscle insertion is reattached to adjacent orbital periosteum. Aim: Describe a reversible inactivation of the inferior oblique muscle. Methods: Eight subjects with V-pattern exotropia and/or inferior oblique overaction underwent inferior oblique orbital fixation procedure by attaching its insertion to the periosteum of the lateral orbital wall. Four subjects with persistent inferior oblique overaction following inferior oblique anterior transposition underwent bilateral inferior oblique orbital wall fixation. Four subjects with no previous inferior oblique surgery underwent unilateral inferior oblique orbital wall fixation; three of these four subjects had superior oblique palsy with a large vertical deviation in primary position and one had a V-pattern with asymmetric inferior oblique overaction. Results: V-pattern significantly improved from 22.2 ⫾ 11.8 PD to 5.6 ⫾ 7 PD postoperatively (P ⫽ 0.005). Inferior oblique overaction improved from 2.6 ⫾ 0.9 (range ⫹1.5 to ⫹4) to ⫺0.3 ⫾ 0.6 (range ⫺1 to ⫹1) postoperatively (P ⬍ 0.001). Seven of eight subjects had no residual overelevation in adduction postoperatively. Unilateral inferior oblique orbital fixation corrected 8 PD of vertical deviation in the primary position and 25 PD in adduction. Mean postoperative follow-up was 4 months. Conclusion: Inferior oblique orbital fixation has a profound weakening effect on the inferior oblique muscle. Advantages of this procedure include reversibility and the ability to be converted into another form of weakening procedure, if required.