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Outcomes of esotropia surgery in children born prematurely
e18 065 Macular homonymous hemianopsia in children with optic tract lesions. Mark S. Hansen, Fatema Ghasia, Tariq Bhatti, Mays El-Dairi Background/Purpose: Optic tract lesions resulting in homonymous hemianopsia are associated with bow-tie optic atrophy. Optical Coherence Tomography (OCT) has been proven to be a useful clinical tool in the diagnosis and follow-up of optic neuropathies. We hypothesized that a homonymous hemianopsia due to an optic tract lesion can also be seen by OCT. Methods: Eight patients (age, 5-21; mean, 11 years) with an optic tract lesion and eight age-matched controls were enrolled in an IRB-approved observational case series. They had a complete neuro-ophthalmic examination, including visual field testing confirming a homonymous hemianopsia. All patients then underwent OCT of the macula and retinal nerve fiber layer (RNFL). Results: The macular thickness map displayed temporal thinning of the macula in the eye ipsilateral to the lesion, and nasal thinning in the eye contralateral to the lesion (ipsilateral temporal retinal thickness 5 39 5 mm vs 81 12 mm [P 5 0.0046]; contralateral nasal retinal thickness 5 32 5 mm vs 73 10 mm [P 5 0.01]). The pattern of the thinning respected the vertical midline by qualitative assessment. RNFL values were decreased compared to normals (P \ 0.05 for all). Discussion: Due to Wallerian degeneration, lesions at the optic chiasm or at the optic tract result in partial optic atrophy that can be visualized with macular OCT. Conclusions: OCT confirms previous clinical and pathological studies by demonstrating thinning of the macula in a pattern that respects the vertical midline in cases of homonymous hemianopsia due to an optic tract lesion. OCT is a useful diagnostic tool in the pediatric population that may be too young to cooperate with formal visual field testing. 066 Does inferior oblique recession cause overcorrections in laterally incomitant small hypertropias due to presumed superior oblique palsy? Karen Hendler, Federico G. Velez, Arthur L. Rosenbaum, Joseph L. Demer, Guillermo Velez, Stacy L. Pineles Background/Purpose: Inferior oblique recession (IOR) may be indicated in patients with incomitant vertical deviations, but some are concerned that this fixed procedure may cause overcorrections when the central gaze hypertropia is small. This study evaluated effects of IOR in cases of laterally incomitant hypertropias \10D in central gaze, clinically consistent with superior oblique palsy (SOP) based upon the three-step test. Methods: We retrospectively reviewed patients with hypertropias \10 PD in central gaze and positive three-step tests who underwent graded IOR. A control group was comprised of patients undergoing adjustable contralateral inferior rectus recession (IRR). Primary outcomes were reduction of lateral incomitance and number of overcorrections. Results: Mean follow up was 9.4 months (range, 0.03-56.1) and 8.2 months (range, 0.03-32.2) for the IOR (n 5 25) and IRR (n 5 21) groups, respectively. Mean central gaze hypertropia decreased from 5.6D 2.1D to 0.1D 1.2D and 7.1D 2.0D to 2.3D 5.3D for the IOR and IRR groups, respectively. Incomitance (deviation in central vs contralateral gaze) was 10.3D 6.9D preoperatively for the IOR group, and 2.2D 3.3D postoperatively (P \ 0.001). There were 8% overcorrections in central gaze in the IOR group and 14.3% in the IRR group (P 5 0.6). No patient undergoing IOR was overcorrected in deorsumversion, but 19% after IRR (P 5 0.03).
Volume 16 Number 1 / February 2012 Discussion: Although small deviation hypertropias can be treated with prisms or small, adjustable IRRs, IOR collapses incomitance without causing more overcorrections in central gaze than IRR. Conclusions: IOR is a reasonable treatment for small, laterally incomitant hypertropias clinically consistent with SOP. 067 Head oscillations as part of infantile nystagmus syndrome. Richard W. Hertle, Dongsheng Yang, Frank Carusone, Stephanie Knox, Nancy Hanna Background/Purpose: Infantile nystagmus syndrome (INS) may be accompanied by headshaking which is more prominent during periods of intense emotion, concentration and visual fixation. This association has been poorly studied but is reported to occur in 10 to 28% of patients. The purpose of this study was to characterize these head oscillations in a large cohort of patients with INS. Methods: From 1999 to 2010, 1,650 patients with INS who had information collected as part of a prospective database had statistical analysis of their clinical, electrophysiological, and demographic data reviewed for the presence of head oscillation and its associations. In 20 patients, simultaneous head and eye oscillations were electrophysiologically recorded and analyzed. In addition, the suboccipital triangle musculature was dissected and studied in cadavers. Results: Of the all the patients, 29% had an associated head oscillation. There was no association with sex, waveform, eye or systemic conditions. Head recordings averaged, small amplitude (2 -7 ), multiplanar, 1 to 4 Hz, variable but similar, waveforms to the ongoing eye oscillation that were not compensatory to the eye oscillations. Cadaveric analysis showed a pathophysiological role of the subocciptal musculature in the genesis of the oscillation. Discussion: Head oscillations promote socially confusing cues in these patients. Almost uniformly, the head oscillations represent an associated involuntary movement of pathological origin and not an adaptive strategy to improve vision. Conclusions: The neck musculature responsible for these small amplitude, multiplanar movements are most likely those of the suboccipital triangle. As a result of this knowledge, we are now proposing and investigating pharmacological therapy aimed at this musculature. 068 Outcomes of esotropia surgery in children born prematurely. Lani Hoang, Carolyn Wu, Deborah VanderVeen Background: There is a higher rate of strabismus in premature infants compared to full-term infants, but their strabismus surgery outcomes are poorly understood. We reviewed results after primary esotropia surgery in children born prematurely. Methods: Retrospective review of patients born\34 weeks undergoing esotropia surgery in 2005-2010 by two surgeons using standard surgical doses. Strabismus and vision measures, ocular history, comorbidities and surgical procedure were collected within 6 months postoperatively and at last visit. Failure was defined as residual esotropia of .10 prism diopters or any exotropia not associated with an esodeviation. Results: Twenty-four patients were identified. Mean age at surgery was 4.5 years; mean follow up was 38 months. Nine cases (36%) were failures in the early postoperative period and 11 (44%) at last follow up. Of the 9 failures, 5 underwent additional surgery for consecutive exotropia. Two cases improved to successful outcome by the last visit. Mean gestational age(GA)/birthweight of the success group was 29 weeks/1037 g vs 26 weeks/805 g in the failure group. Vision deficits were present in 5 children in the failure group and 3 in the success group. Only two children demonstrated binocularity, both in the success group.
Journal of AAPOS
Volume 16 Number 1 / February 2012 Conclusions: Good results were obtained with standard surgical doses for esotropia for many children (64%) with history of prematurity. Not surprisingly, children born at lower GAs had more variable responses and overcorrection, though subnormal vision did not contribute significantly to surgical failure. Even with good vision and successful alignment, demonstration of binocularity was rare. 069 Do we adjust ourselves out of a good result? Jonathan M. Holmes, Laura Liebermann, David A. Leske, Sarah R. Hatt Background: Adjustable sutures are used by some strabismus surgeons to achieve what they believe to be an optimum immediate postoperative alignment that enhances outcome. Critics of adjustable sutures sometimes suggest that "we can adjust ourselves out of a good result" and that we would do better to "leave alone." We studied whether patients who were adjusted had inferior outcomes to those who were simply tied off. Methods: To study a uniform patient cohort, we retrospectively identified 149 consecutive patients who underwent an adjustable reoperation for horizontal strabismus and also had a 6-week outcome exam. In every case, the intent of the surgeon was to tie off, and only to adjust if the patient was not within the intended immediate postoperative range. Eighty-six (58%) were adjusted and 63 (42%) were simply tied off. Success 6-weeks postoperatively was predefined based on angle and diplopia at distance and near. Results: A similar proportion of patients who underwent adjustment were successful at 6-weeks, compared with those who were simply tied off (78% vs 71%, P 5 0.4). Discussion: We speculate that without adjustment in the immediate postoperative period, outcomes in those patients would have been less successful, since preadjustment angles were as large as 30 XT and 35 ET. Conclusions: There is no evidence that adjustment per se yields inferior outcomes. Without adjustment, some patients would almost certainly have had poor outcomes; therefore, the success rate of an entire cohort would be worse without adjustable sutures. 070 Comparison of surgical success rates in one muscle recession vs. recession-resection procedures for correction of sensory strabismus in children. Luisa M. Hopker, David R. Weakley Purpose: Few reports address the effectiveness of surgery for sensory strabismus in children. We reviewed patients undergoing primary horizontal surgery from 2004-2010 to compare surgical success rates in one muscle recession versus recession-resection procedures for sensory strabismus. Methods: Eighty-three patients were included, 42 underwent onemuscle recession, 41 underwent recession-resection. Mean age at surgery was 65 months (range, 6 months to 18 years) and mean follow-up was 35 months (range, 6 months to 7.5 years). Age at surgery (P 5 0.54) and follow-up (P 5 0.65) were comparable in the two groups. Results: Successful postoperative alignment (within 10D) was achieved in 74% of one-muscle procedures versus 54% of recession-resection procedures (P 5 0.06). Mean preoperative deviation in the one-muscle group was 28D versus 43D in the recession-resection group. Overcorrection was seen in 17% of the recession-resection vs. 10% of the one-muscle recessions (P 5 0.35). One muscle recession resulted in a mean correction of 3.4 PD/mm of surgery versus 3.7D /mm for recession-resection (P 5 0.30). In patients with deviations of 30PD or less, success rates were similar (82% one muscle recession vs 78% recession-resection) (P 5 0.99).
Journal of AAPOS
e19 Discussion: Both recession-resection and one muscle recession are effective for the correction of sensory strabismus. Though there was a trend for better results with one muscle recession, patients undergoing recession-resection had a larger mean preoperative deviation. Conclusions: Advantages of one muscle recession include fewer overcorrections, shorter operative time, and a remaining fresh muscle when reoperation is indicated. 071 Visually evoked potential detection of amblyopia in the clinic. Casey M. Howards, Sina S. Omran, Sean P. Donahue Background/Purpose: Preverbal children with amblyopia risk factors can be challenging to manage, as they may have a fixation preference but may or may not have amblyopia. We developed a user and patient friendly test using visually evoked potentials (VEPs) to aide in management of such children. Methods: We tested 33 normal children and 43 amblyopic children aged 3-12 years using the Diopsys NOVA-TR system. A checkerboard pattern reversal VEP was produced at 2 Hz for each of 5 spatial frequencies. Stimuli were presented for 10 seconds (20 reversals) and the entire test typically took less than five minutes. The relative diminution of P100 amplitude between the eyes, and the absolute prolongation of P100 latency were compared for each spatial frequency. Results: A 9 millisecond difference in P100 latency for at least 2 spatial frequencies, or a twenty-five percent diminution in P100 amplitude between eyes for at least 3 spatial frequencies correctly identified 94% of normal subjects as being normal, and 81% of amblyopic subjects as being abnormal, including 72% of subjects with mild amblyopia (2-3 lines of intraocular difference), and 88% of subjects with moderate or severe amblyopia (.4 lines difference). Discussion: A pattern reversal VEP at 5 spatial frequencies can be used to correctly identify children with amblyopia, without misclassifying many normal individuals. This is important since fixation preference testing can be unreliable in detecting amblyopia in preverbal children. Conclusions: The development of a clinically useful evoked potential test will help pediatric ophthalmologists manage amblyopia in preverbal children. 072 Efficacy of hang-back recessions in comparison to conventional recessions. Magdalene D. Israel, Ranojit Basu, Mitalee Choudhury Background/Purpose: Hang-back technique was introduced by Repka and Guyton in 1987 to circumvent various problems encountered with conventional scleral suturing. The aim of our study was to compare the efficacy of hang back recessions and conventional recessions in commitant horizontal strabismus. Methods: The surgical outcome in 35 patients who had undergone conventional recession was compared with 35 patients who had undergone recession by hang back technique. Commitant esotropia and exotropia were included in the study for both the groups. The patients were under 18 years of age without any ocular or systemic pathology. The surgery was done under General anesthesia and was followed for one year. Results: The mean age of conventional recession and hang back recession was 9.5 and 8.5, respectively. The mean preoperative deviation was 44.65D in the conventional group and 42.08D in the hangback group. The success rate (ortho to \10D) in both the groups was 88.57%. Discussion: According to literature hang-back recessions are associated with overcorrections, but in our study we did not find any
Volume 16 Number 1 / February 2012 Discussion: Although small deviation hypertropias can be treated with prisms or small, adjustable IRRs, IOR collapses incomitance without causing more overcorrections in central gaze than IRR. Conclusions: IOR is a reasonable treatment for small, laterally incomitant hypertropias clinically consistent with SOP. 067 Head oscillations as part of infantile nystagmus syndrome. Richard W. Hertle, Dongsheng Yang, Frank Carusone, Stephanie Knox, Nancy Hanna Background/Purpose: Infantile nystagmus syndrome (INS) may be accompanied by headshaking which is more prominent during periods of intense emotion, concentration and visual fixation. This association has been poorly studied but is reported to occur in 10 to 28% of patients. The purpose of this study was to characterize these head oscillations in a large cohort of patients with INS. Methods: From 1999 to 2010, 1,650 patients with INS who had information collected as part of a prospective database had statistical analysis of their clinical, electrophysiological, and demographic data reviewed for the presence of head oscillation and its associations. In 20 patients, simultaneous head and eye oscillations were electrophysiologically recorded and analyzed. In addition, the suboccipital triangle musculature was dissected and studied in cadavers. Results: Of the all the patients, 29% had an associated head oscillation. There was no association with sex, waveform, eye or systemic conditions. Head recordings averaged, small amplitude (2 -7 ), multiplanar, 1 to 4 Hz, variable but similar, waveforms to the ongoing eye oscillation that were not compensatory to the eye oscillations. Cadaveric analysis showed a pathophysiological role of the subocciptal musculature in the genesis of the oscillation. Discussion: Head oscillations promote socially confusing cues in these patients. Almost uniformly, the head oscillations represent an associated involuntary movement of pathological origin and not an adaptive strategy to improve vision. Conclusions: The neck musculature responsible for these small amplitude, multiplanar movements are most likely those of the suboccipital triangle. As a result of this knowledge, we are now proposing and investigating pharmacological therapy aimed at this musculature. 068 Outcomes of esotropia surgery in children born prematurely. Lani Hoang, Carolyn Wu, Deborah VanderVeen Background: There is a higher rate of strabismus in premature infants compared to full-term infants, but their strabismus surgery outcomes are poorly understood. We reviewed results after primary esotropia surgery in children born prematurely. Methods: Retrospective review of patients born\34 weeks undergoing esotropia surgery in 2005-2010 by two surgeons using standard surgical doses. Strabismus and vision measures, ocular history, comorbidities and surgical procedure were collected within 6 months postoperatively and at last visit. Failure was defined as residual esotropia of .10 prism diopters or any exotropia not associated with an esodeviation. Results: Twenty-four patients were identified. Mean age at surgery was 4.5 years; mean follow up was 38 months. Nine cases (36%) were failures in the early postoperative period and 11 (44%) at last follow up. Of the 9 failures, 5 underwent additional surgery for consecutive exotropia. Two cases improved to successful outcome by the last visit. Mean gestational age(GA)/birthweight of the success group was 29 weeks/1037 g vs 26 weeks/805 g in the failure group. Vision deficits were present in 5 children in the failure group and 3 in the success group. Only two children demonstrated binocularity, both in the success group.
Journal of AAPOS
Volume 16 Number 1 / February 2012 Conclusions: Good results were obtained with standard surgical doses for esotropia for many children (64%) with history of prematurity. Not surprisingly, children born at lower GAs had more variable responses and overcorrection, though subnormal vision did not contribute significantly to surgical failure. Even with good vision and successful alignment, demonstration of binocularity was rare. 069 Do we adjust ourselves out of a good result? Jonathan M. Holmes, Laura Liebermann, David A. Leske, Sarah R. Hatt Background: Adjustable sutures are used by some strabismus surgeons to achieve what they believe to be an optimum immediate postoperative alignment that enhances outcome. Critics of adjustable sutures sometimes suggest that "we can adjust ourselves out of a good result" and that we would do better to "leave alone." We studied whether patients who were adjusted had inferior outcomes to those who were simply tied off. Methods: To study a uniform patient cohort, we retrospectively identified 149 consecutive patients who underwent an adjustable reoperation for horizontal strabismus and also had a 6-week outcome exam. In every case, the intent of the surgeon was to tie off, and only to adjust if the patient was not within the intended immediate postoperative range. Eighty-six (58%) were adjusted and 63 (42%) were simply tied off. Success 6-weeks postoperatively was predefined based on angle and diplopia at distance and near. Results: A similar proportion of patients who underwent adjustment were successful at 6-weeks, compared with those who were simply tied off (78% vs 71%, P 5 0.4). Discussion: We speculate that without adjustment in the immediate postoperative period, outcomes in those patients would have been less successful, since preadjustment angles were as large as 30 XT and 35 ET. Conclusions: There is no evidence that adjustment per se yields inferior outcomes. Without adjustment, some patients would almost certainly have had poor outcomes; therefore, the success rate of an entire cohort would be worse without adjustable sutures. 070 Comparison of surgical success rates in one muscle recession vs. recession-resection procedures for correction of sensory strabismus in children. Luisa M. Hopker, David R. Weakley Purpose: Few reports address the effectiveness of surgery for sensory strabismus in children. We reviewed patients undergoing primary horizontal surgery from 2004-2010 to compare surgical success rates in one muscle recession versus recession-resection procedures for sensory strabismus. Methods: Eighty-three patients were included, 42 underwent onemuscle recession, 41 underwent recession-resection. Mean age at surgery was 65 months (range, 6 months to 18 years) and mean follow-up was 35 months (range, 6 months to 7.5 years). Age at surgery (P 5 0.54) and follow-up (P 5 0.65) were comparable in the two groups. Results: Successful postoperative alignment (within 10D) was achieved in 74% of one-muscle procedures versus 54% of recession-resection procedures (P 5 0.06). Mean preoperative deviation in the one-muscle group was 28D versus 43D in the recession-resection group. Overcorrection was seen in 17% of the recession-resection vs. 10% of the one-muscle recessions (P 5 0.35). One muscle recession resulted in a mean correction of 3.4 PD/mm of surgery versus 3.7D /mm for recession-resection (P 5 0.30). In patients with deviations of 30PD or less, success rates were similar (82% one muscle recession vs 78% recession-resection) (P 5 0.99).
Journal of AAPOS
e19 Discussion: Both recession-resection and one muscle recession are effective for the correction of sensory strabismus. Though there was a trend for better results with one muscle recession, patients undergoing recession-resection had a larger mean preoperative deviation. Conclusions: Advantages of one muscle recession include fewer overcorrections, shorter operative time, and a remaining fresh muscle when reoperation is indicated. 071 Visually evoked potential detection of amblyopia in the clinic. Casey M. Howards, Sina S. Omran, Sean P. Donahue Background/Purpose: Preverbal children with amblyopia risk factors can be challenging to manage, as they may have a fixation preference but may or may not have amblyopia. We developed a user and patient friendly test using visually evoked potentials (VEPs) to aide in management of such children. Methods: We tested 33 normal children and 43 amblyopic children aged 3-12 years using the Diopsys NOVA-TR system. A checkerboard pattern reversal VEP was produced at 2 Hz for each of 5 spatial frequencies. Stimuli were presented for 10 seconds (20 reversals) and the entire test typically took less than five minutes. The relative diminution of P100 amplitude between the eyes, and the absolute prolongation of P100 latency were compared for each spatial frequency. Results: A 9 millisecond difference in P100 latency for at least 2 spatial frequencies, or a twenty-five percent diminution in P100 amplitude between eyes for at least 3 spatial frequencies correctly identified 94% of normal subjects as being normal, and 81% of amblyopic subjects as being abnormal, including 72% of subjects with mild amblyopia (2-3 lines of intraocular difference), and 88% of subjects with moderate or severe amblyopia (.4 lines difference). Discussion: A pattern reversal VEP at 5 spatial frequencies can be used to correctly identify children with amblyopia, without misclassifying many normal individuals. This is important since fixation preference testing can be unreliable in detecting amblyopia in preverbal children. Conclusions: The development of a clinically useful evoked potential test will help pediatric ophthalmologists manage amblyopia in preverbal children. 072 Efficacy of hang-back recessions in comparison to conventional recessions. Magdalene D. Israel, Ranojit Basu, Mitalee Choudhury Background/Purpose: Hang-back technique was introduced by Repka and Guyton in 1987 to circumvent various problems encountered with conventional scleral suturing. The aim of our study was to compare the efficacy of hang back recessions and conventional recessions in commitant horizontal strabismus. Methods: The surgical outcome in 35 patients who had undergone conventional recession was compared with 35 patients who had undergone recession by hang back technique. Commitant esotropia and exotropia were included in the study for both the groups. The patients were under 18 years of age without any ocular or systemic pathology. The surgery was done under General anesthesia and was followed for one year. Results: The mean age of conventional recession and hang back recession was 9.5 and 8.5, respectively. The mean preoperative deviation was 44.65D in the conventional group and 42.08D in the hangback group. The success rate (ortho to \10D) in both the groups was 88.57%. Discussion: According to literature hang-back recessions are associated with overcorrections, but in our study we did not find any