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ROP—the movie—2
78
Abstracts
ROP. They required 813 examinations (3.7 per infant) and 13.6% received laser treatment. The cost model included laser photocoagulation (CPT 67228) at $982.14, initial hospital consultation (CPT 99254) at $144.89, and inpatient follow-up consultation (CPT 99233) at $80.68. Our average total costs of screening and treatment came to $2471.70 per infant. The present value for Quality Adjusted Life Years (QALY ) added is 2.38. The cost effectiveness of screening and laser treatment of ROP in 2006 is $1038.53/QALY. Discussion: Utility, measured in Price/QALY, is generally considered cost effective when it is below $100,000/QALY. Our utility value of $1038.53/QALY supports current practices as not only beneficial but also cost effective. Mechanism of action of the inferior oblique following anterior transposition. Forrest J. Ellis, David L. Guyton Introduction: Following inferior oblique anterior transposition (IOAT ), some believe contraction of the distal inferior oblique has an antielevation effect. IOAT is associated with persistent extorsion, especially in abduction. Extorsion can deflect the paths of the rectus muscles and cause relative contralateral inferior oblique overaction (IOOA). To understand this effect, the action of the inferior oblique muscle following three surgical procedures (IOAT, recession, and myectomy) was studied. Methods: A retrospective chart review of unilateral superior oblique palsy patients who underwent inferior oblique surgery alone or combined with contralateral inferior rectus recession. Results: Forty-five patients were identified. Twenty had isolated inferior oblique surgery; 19 were combined with contralateral IR recession, and 6 had contralateral IR recession alone. All three types of inferior oblique surgery resulted in similar reductions in IOOA and hypertropia in straight-ahead gaze. Overcorrections were greater following myectomy (3/12 alone, 2/11 combined with IR) than with IOAT (0/4, 3/5), or with recession (0/4, 2/3). The induced reduction in upgaze was similar among the groups: myectomy (2.8⌬); recession (0.1⌬); IOAT (1.7⌬). Side-gaze incomitance, contralateral IOOA, and persistent extorsion were greater following IOAT. Discussion: Contraction of the distal inferior oblique segment following IOAT does not appear to limit primary vertical gaze any more than inferior oblique myectomy or recession. However, IOAT results in persistent extorsion, altering the paths of the rectus muscles, causing less elevation in abduction. Conclusions: The vertical action of the inferior oblique is equally limited following all three inferior oblique weakening procedures. Antielevation in abduction following IOAT can be caused by extorsion. ROP—the movie—2. Anna L. Ells, Leslie MacKeen Introduction: Serial digital photographic examinations have been combined into a movie format, which demonstrates development and evolution of the disease over time. This dynamic format has revolutionized the teaching of retinopathy of prematurity (ROP), by illustrating the subtle changes in the temporal arcade angle and choroidal vascular pattern, which can be observed over time in these movies. Method: Consecutive weekly or biweekly images were obtained on the same infant and were captured using digital retinal photography (RetCam-120®) and then archived on compact discs. Those infants most photographic and demonstrative of the evolution of ROP were selected for animation. The optic nerve vessels were aligned and image border blended into the previous image using a layer mask, thus creating an animation of con-
Volume 11 Number 1 February 2007
secutive images. Discussion: The animated movies highlight the evolving features of ROP, such as development of arborized retinal vessels posterior to the ridge; development of stage 3 lesions; progression and regression of plus disease; choroidal vascular changes accompanying the progression of ROP; dynamic changes in the temporal arcade angle; and regression of disease following laser photocoagulation. Conclusions: The documentation of this disease as it is evolving and then presented in a “movie format,” using digital retinal photographic technology, has allowed subtle anatomical changes to be visualized and potentially studied, allowing a new dimension to our understanding of ROP. Retinal hemorrhages in patients with epidural hematomas. Brian J. Forbes, Cindy W. Christian, Matthew Cox Purpose: This article presents a series of infants found to have epidural hematomas (EDHs) from accidental etiologies with associated retinal hemorrhages (RH). Methods: From January 1998 to December 2002, 15 children under 3 years of age with radiographic evidence of a traumatic epidural hematoma were found to be eligible for this study, 9 of which had eye examinations. Results: Five patients, all children less than 8 months of age and requiring surgical evacuation of the EDH, had evidence of RHs. Of the five patients with RHs, four were unilateral and one was bilateral, all confined to the posterior pole. Three of the five patients with RHs and one of the four patients without RHs had a depressed Glasgow Coma Scale score. All five infants with RHs had soft-tissue swelling of the scalp and three had skull fractures. Of the four patients with normal eye exams, two had skull fractures and three required surgical evacuation. The institutional child protection team evaluated all five patients with RHs and each case was felt to be consistent with the history provided. Conclusions: The pathophysiology of RHs in patients with both accidental and nonaccidental head injury is uncertain and likely multifactorial. We found RHs in five of nine patients who presented to our hospital with isolated EDHs and all were evaluated by the institutional child protection team and found not to have been victims of abuse. Given the pathophysiology of EDHs in young children, raised intracranial pressure may be a contributing factor to the presence of RHs in our patients. Long-term use of botulinum toxin for strabismus. Richard W. Gardner, Emma L. M. Dawson, Gill G.W. Adams, John P. Lee Introduction: In the UK healthcare system, patients can choose between surgery and Botulinum Toxin treatment for strabismus. Since 1982, 17,345 injections have been given to 6692 patients. Some patients have benefited from long-term toxin management. Methods: A retrospective review using the toxin clinic database was used to identify patients who underwent 25 or more injections. Results: Sixty-three patients (0.94%) fulfilled our criteria. There were 42 females and 21 males, with an average age at first injection of 41 years (range 15 to 80). The number of injections per patient ranged from 25 to 68 (mean of 34). The length of time patients attended was between 3 and 22 years. The time interval between injections tended to increase in most patients and the angle tended to reduce. The largest diagnostic group was consecutive exotropia (38.1%), followed by secondary exotropia (12.7%). Thirteen patients had no previous strabismus surgery. Twenty patients had one operation, 13 had two operations, and 17 had three or more operations. Seventy-eight percent had no demonstrable binocular function, 18% had binocular function,
Journal of AAPOS
Abstracts
ROP. They required 813 examinations (3.7 per infant) and 13.6% received laser treatment. The cost model included laser photocoagulation (CPT 67228) at $982.14, initial hospital consultation (CPT 99254) at $144.89, and inpatient follow-up consultation (CPT 99233) at $80.68. Our average total costs of screening and treatment came to $2471.70 per infant. The present value for Quality Adjusted Life Years (QALY ) added is 2.38. The cost effectiveness of screening and laser treatment of ROP in 2006 is $1038.53/QALY. Discussion: Utility, measured in Price/QALY, is generally considered cost effective when it is below $100,000/QALY. Our utility value of $1038.53/QALY supports current practices as not only beneficial but also cost effective. Mechanism of action of the inferior oblique following anterior transposition. Forrest J. Ellis, David L. Guyton Introduction: Following inferior oblique anterior transposition (IOAT ), some believe contraction of the distal inferior oblique has an antielevation effect. IOAT is associated with persistent extorsion, especially in abduction. Extorsion can deflect the paths of the rectus muscles and cause relative contralateral inferior oblique overaction (IOOA). To understand this effect, the action of the inferior oblique muscle following three surgical procedures (IOAT, recession, and myectomy) was studied. Methods: A retrospective chart review of unilateral superior oblique palsy patients who underwent inferior oblique surgery alone or combined with contralateral inferior rectus recession. Results: Forty-five patients were identified. Twenty had isolated inferior oblique surgery; 19 were combined with contralateral IR recession, and 6 had contralateral IR recession alone. All three types of inferior oblique surgery resulted in similar reductions in IOOA and hypertropia in straight-ahead gaze. Overcorrections were greater following myectomy (3/12 alone, 2/11 combined with IR) than with IOAT (0/4, 3/5), or with recession (0/4, 2/3). The induced reduction in upgaze was similar among the groups: myectomy (2.8⌬); recession (0.1⌬); IOAT (1.7⌬). Side-gaze incomitance, contralateral IOOA, and persistent extorsion were greater following IOAT. Discussion: Contraction of the distal inferior oblique segment following IOAT does not appear to limit primary vertical gaze any more than inferior oblique myectomy or recession. However, IOAT results in persistent extorsion, altering the paths of the rectus muscles, causing less elevation in abduction. Conclusions: The vertical action of the inferior oblique is equally limited following all three inferior oblique weakening procedures. Antielevation in abduction following IOAT can be caused by extorsion. ROP—the movie—2. Anna L. Ells, Leslie MacKeen Introduction: Serial digital photographic examinations have been combined into a movie format, which demonstrates development and evolution of the disease over time. This dynamic format has revolutionized the teaching of retinopathy of prematurity (ROP), by illustrating the subtle changes in the temporal arcade angle and choroidal vascular pattern, which can be observed over time in these movies. Method: Consecutive weekly or biweekly images were obtained on the same infant and were captured using digital retinal photography (RetCam-120®) and then archived on compact discs. Those infants most photographic and demonstrative of the evolution of ROP were selected for animation. The optic nerve vessels were aligned and image border blended into the previous image using a layer mask, thus creating an animation of con-
Volume 11 Number 1 February 2007
secutive images. Discussion: The animated movies highlight the evolving features of ROP, such as development of arborized retinal vessels posterior to the ridge; development of stage 3 lesions; progression and regression of plus disease; choroidal vascular changes accompanying the progression of ROP; dynamic changes in the temporal arcade angle; and regression of disease following laser photocoagulation. Conclusions: The documentation of this disease as it is evolving and then presented in a “movie format,” using digital retinal photographic technology, has allowed subtle anatomical changes to be visualized and potentially studied, allowing a new dimension to our understanding of ROP. Retinal hemorrhages in patients with epidural hematomas. Brian J. Forbes, Cindy W. Christian, Matthew Cox Purpose: This article presents a series of infants found to have epidural hematomas (EDHs) from accidental etiologies with associated retinal hemorrhages (RH). Methods: From January 1998 to December 2002, 15 children under 3 years of age with radiographic evidence of a traumatic epidural hematoma were found to be eligible for this study, 9 of which had eye examinations. Results: Five patients, all children less than 8 months of age and requiring surgical evacuation of the EDH, had evidence of RHs. Of the five patients with RHs, four were unilateral and one was bilateral, all confined to the posterior pole. Three of the five patients with RHs and one of the four patients without RHs had a depressed Glasgow Coma Scale score. All five infants with RHs had soft-tissue swelling of the scalp and three had skull fractures. Of the four patients with normal eye exams, two had skull fractures and three required surgical evacuation. The institutional child protection team evaluated all five patients with RHs and each case was felt to be consistent with the history provided. Conclusions: The pathophysiology of RHs in patients with both accidental and nonaccidental head injury is uncertain and likely multifactorial. We found RHs in five of nine patients who presented to our hospital with isolated EDHs and all were evaluated by the institutional child protection team and found not to have been victims of abuse. Given the pathophysiology of EDHs in young children, raised intracranial pressure may be a contributing factor to the presence of RHs in our patients. Long-term use of botulinum toxin for strabismus. Richard W. Gardner, Emma L. M. Dawson, Gill G.W. Adams, John P. Lee Introduction: In the UK healthcare system, patients can choose between surgery and Botulinum Toxin treatment for strabismus. Since 1982, 17,345 injections have been given to 6692 patients. Some patients have benefited from long-term toxin management. Methods: A retrospective review using the toxin clinic database was used to identify patients who underwent 25 or more injections. Results: Sixty-three patients (0.94%) fulfilled our criteria. There were 42 females and 21 males, with an average age at first injection of 41 years (range 15 to 80). The number of injections per patient ranged from 25 to 68 (mean of 34). The length of time patients attended was between 3 and 22 years. The time interval between injections tended to increase in most patients and the angle tended to reduce. The largest diagnostic group was consecutive exotropia (38.1%), followed by secondary exotropia (12.7%). Thirteen patients had no previous strabismus surgery. Twenty patients had one operation, 13 had two operations, and 17 had three or more operations. Seventy-eight percent had no demonstrable binocular function, 18% had binocular function,
Journal of AAPOS