- Email: [email protected]
Surgical outcomes in adult sixth nerve palsy
Volume 17 Number 1 / February 2013 Conclusions: PRK is an effective and stable surgical alternative in children with refractive errors who are unable to tolerate traditional therapy. 088 Surgical outcomes in adult sixth nerve palsy. Jason H. Peragallo, Beau B. Bruce, Nancy J. Newman, Amy K. Hutchinson, Valerie Biousse, Scott R. Lambert Introduction: Sixth nerve palsy (6NP) is the most common adult ocular motor nerve palsy. Our goal was to identify factors associated with surgical outcomes in 6NP. Methods: Medical records of all adult patients from 1988-2012 with 6NP who underwent strabismus surgery or botulinum toxin injections were retrospectively reviewed. Success was defined as absence of diplopia without prisms, vertical deviation #2D, and horizontal deviation #10D. Results: 83 patients from four surgeons were included [50 (60%) women; mean age 52 (range, 20-86)]. 66 (80%) had unilateral sixth nerve palsies. Palsies were complete in 34 (41%). 21 (25%) had .1 surgery. Underlying etiology was idiopathic/microvascular in 23 (28%), traumatic in 23 (28%), neoplastic in 19 (23%), and miscellaneous causes in 18 (22%). Success frequency was similar across etiologies. 16/42 patients (38%) with trauma or neoplasm required repeat surgery vs 5/41 (12%) with other etiologies (P\0.05). Success was more frequent with Hummelsheim-type procedures than vertical rectus transposition (VRT) among patients with complete palsies (7/9 5 78% vs 8/23 5 35%; P \ 0.05). Success was more frequent among all surgically-treated 6NP patients who had adjustable vs nonadjustable sutures (21/29 5 73% vs 22/44 5 52%; P 5 0.06). Discussion: Etiology of 6NP does not appear to affect surgical success in adults, but patients with traumatic and neoplastic causes were more likely to require repeat procedures. Despite a small number of patients, success was more frequent using the Hummelshiemtype procedure and with adjustable sutures. Conclusions: Surgical success in adults does not correlate with the etiology of the sixth nerve palsy, but may vary based on the type of procedures in this patient population. 089 Prospective evaluation of the spot (Pediavision) vision screener as autorefractor and in the detection of amblyogenic risk factors compared to Plusoptix and a comprehensive pediatric ophthalmology examination. Mae Millicent Peterseim, Rupal H. Trivedi, Vera A. Ball, Maria E. Shtessel, M. Edward Wilson, Jennifer D. Davidson Introduction: The Pediavision Spot photorefractor screener has been marketed over the last year (1) without published validation. We report a prospective study of the Spot compared to the more validated Plusoptix screener and to a comprehensive examination. We also report these evaluations utilizing modifications to photorefractor referral criteria that have been proposed to improve specificity while maintaining sensitivity. (2) Methods: After informed consent, patients underwent screening with the Spot and with the Plusoptix prior to their comprehensive examination by a pediatric ophthalmologist masked to the results. Data including refractions, pass/refer, strabismus and any ocular pathology, were entered into a Redcap database for statistical analysis. Results: Currently, 161 patients have been enrolled (average age, 6 years). The sensitivity and specifity of the Spot for detection of proposed AAPOS amblyopia risk factors (3) are 0.98 and 0.49. With proposed modifications to the manufacturers criteria the Spot sensitivity is 0.87 and specificity 0.72 and with the Plusoptix, sensitivity 0.91 and specificity 0.61. Compared to cycloplegic retinoscopy (right eyes), the Spot showed a mean difference of -0.99D 1.15 for SE and
Journal of AAPOS
e25 0.36 D 0.63 for cylinder. Corresponding numbers for the Plusoptix were 0.37D 1.20 for SE and 0.31D 0.63 cylinder. Discussion: In this ongoing study, sensitivity for the Spot with manufacturers guidelines is excellent and is comparable to the more established Plusoptix. Proposed modifications to manufacturers referral criteria improve specificity with acceptable sensitivity for both the Spot and the Plusoptix. The Spot underestimates hyperopia more than does the Plusoptix. Conclusions: The Spot is an effective pediatric vision screener comparable to the Plusoptix. Proposed modifications to the manufacturers criteria may be useful for the Spot and for the Plusoptix. 090 Hypertropia in unilateral, isolated abducens nerve palsy. Matthew S. Pihlblad, Joseph L. Demer Introduction: If hypertropia is observed with 6NP, multiple cranial neuropathies or a skew deviation are often considered. Understanding of the association of hypertropia with 6NP would facilitate etiologic evaluation. Methods: We retrospectively reviewed binocular alignment in a consecutive series of 43 cases of unilateral, isolated, previously unoperated 6NP. Complete 6NP was defined as inability to abduct past midline, and incomplete palsy as lesser limitation. Results: Etiologies of 6NP included: microvascular-15, trauma-5, meningioma-4, idiopathic-3, nasopharyngeal carcinoma-2, meningitis-2, aneurysm-2, migraine-2, arteriovenous malformation-1, neovascular compression-1, retrobulbar block-1, abducens schwanomma-1, sarcoma-1, stroke-1, carotid-cavernous fistula-1, and Arnold-Chiari malformation-1. Hypertropia in any gaze position was found on objective alternate cover or Krimsky testing in 30% (13/43), and on subjective Hess screen testing in 63% (22/35) of 6NP cases. Hypertropia on objective or subjective testing were found in 50% (7/14) of patients with complete and 62% (18/29) with partial 6NP. Mean (SD) hypertropia was 5.3D 2.2D, range, 2D -10D on clinical examination, and 4.72.1D, range, 2D -10D on Hess screen testing. The ipsilesional eye was hypertropic in 64% (14/22), and hypotropic in 36% (8/22) of cases. Discussion: Small angle hypertropia is frequently associated with 6NP, not necessarily implying another neurological lesion. Recent anatomical and physiological studies have demonstrated that the lateral rectus muscle has separately-innervated superior and inferior compartments. Some hypertropias associated with 6NP may result from pathology weakening one lateral rectus compartment more than the other, thus inducing a vertical imbalance. Conclusions: Measurable hypertropia is commonly seen in unilateral, isolated 6NP, whether complete, or partial. 091 The association of prematurity and nonglaucomatous optic disk cupping in children. Alexander E. Pogrebniak Purpose: To examine the association of premature birth and nonglaucomatous optic disc cupping in children and the neurologic correlates in premature and nonpremature cohorts with nonglaucomatous optic disc cupping. Methods: Within a comprehensive pediatric ophthalmology practice associated with a childrens hospital, a computerized database search was conducted of all patients seen over a four year period with nonglaucomatous optic disc cupping. Optic disc parameters measured with digital photographs and history with regard to prematurity were evaluated and compared to control groups from the same practice. Data regarding associated systemic or neurologic disease was tabulated and existing neuroimaging reviewed. Results: Forty-five eyes (mean horizontal cup/disc 0.704 SD 0.021) with nonglaucomatous cupping had clinically larger discs than 31 eyes (mean horizontal cup/disc 0.407 0.095) without large cups
Journal of AAPOS
e25 0.36 D 0.63 for cylinder. Corresponding numbers for the Plusoptix were 0.37D 1.20 for SE and 0.31D 0.63 cylinder. Discussion: In this ongoing study, sensitivity for the Spot with manufacturers guidelines is excellent and is comparable to the more established Plusoptix. Proposed modifications to manufacturers referral criteria improve specificity with acceptable sensitivity for both the Spot and the Plusoptix. The Spot underestimates hyperopia more than does the Plusoptix. Conclusions: The Spot is an effective pediatric vision screener comparable to the Plusoptix. Proposed modifications to the manufacturers criteria may be useful for the Spot and for the Plusoptix. 090 Hypertropia in unilateral, isolated abducens nerve palsy. Matthew S. Pihlblad, Joseph L. Demer Introduction: If hypertropia is observed with 6NP, multiple cranial neuropathies or a skew deviation are often considered. Understanding of the association of hypertropia with 6NP would facilitate etiologic evaluation. Methods: We retrospectively reviewed binocular alignment in a consecutive series of 43 cases of unilateral, isolated, previously unoperated 6NP. Complete 6NP was defined as inability to abduct past midline, and incomplete palsy as lesser limitation. Results: Etiologies of 6NP included: microvascular-15, trauma-5, meningioma-4, idiopathic-3, nasopharyngeal carcinoma-2, meningitis-2, aneurysm-2, migraine-2, arteriovenous malformation-1, neovascular compression-1, retrobulbar block-1, abducens schwanomma-1, sarcoma-1, stroke-1, carotid-cavernous fistula-1, and Arnold-Chiari malformation-1. Hypertropia in any gaze position was found on objective alternate cover or Krimsky testing in 30% (13/43), and on subjective Hess screen testing in 63% (22/35) of 6NP cases. Hypertropia on objective or subjective testing were found in 50% (7/14) of patients with complete and 62% (18/29) with partial 6NP. Mean (SD) hypertropia was 5.3D 2.2D, range, 2D -10D on clinical examination, and 4.72.1D, range, 2D -10D on Hess screen testing. The ipsilesional eye was hypertropic in 64% (14/22), and hypotropic in 36% (8/22) of cases. Discussion: Small angle hypertropia is frequently associated with 6NP, not necessarily implying another neurological lesion. Recent anatomical and physiological studies have demonstrated that the lateral rectus muscle has separately-innervated superior and inferior compartments. Some hypertropias associated with 6NP may result from pathology weakening one lateral rectus compartment more than the other, thus inducing a vertical imbalance. Conclusions: Measurable hypertropia is commonly seen in unilateral, isolated 6NP, whether complete, or partial. 091 The association of prematurity and nonglaucomatous optic disk cupping in children. Alexander E. Pogrebniak Purpose: To examine the association of premature birth and nonglaucomatous optic disc cupping in children and the neurologic correlates in premature and nonpremature cohorts with nonglaucomatous optic disc cupping. Methods: Within a comprehensive pediatric ophthalmology practice associated with a childrens hospital, a computerized database search was conducted of all patients seen over a four year period with nonglaucomatous optic disc cupping. Optic disc parameters measured with digital photographs and history with regard to prematurity were evaluated and compared to control groups from the same practice. Data regarding associated systemic or neurologic disease was tabulated and existing neuroimaging reviewed. Results: Forty-five eyes (mean horizontal cup/disc 0.704 SD 0.021) with nonglaucomatous cupping had clinically larger discs than 31 eyes (mean horizontal cup/disc 0.407 0.095) without large cups