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Treatment of pediatric ocular surface pyogenic granuloma with topical timolol
Volume 21 Number 4 / August 2017 Conclusions: Based upon our study and literature review, while screening could begin at age 5 years for NP-SCR, screening of children without ophthalmologic symptoms to identify treatmentrequiring P-SCR could begin later, at age 9 years for SC and age 13 years for SS. 077 Accuracy of preoperative iol master lens power calculations for artisan aphakia lenses in children. Christine E. Martinez, Richard P. Golden Introduction: The purpose of this study is to assess the accuracy of lens power calculations in the implantation of Artisan Aphakia lenses in pediatric eyes. Methods: Retrospective comparative analysis was performed for 36 eyes of 19 pediatric patients undergoing Artisan lens implantation. Ocular biometry was performed with IOLMaster. Predicted refractive outcomes were compared to actual refractive outcomes. Mean absolute prediction errors (APE) and prediction errors (PE) were calculated. Results: Mean patient age was 11.4 years old. 7/36 (19.4%) eyes were phakic and 29/36 (80.6%) eyes were aphakic at the time of surgery. Mean axial length was 24.17 1.33 mm. The APE was lowest using Hoffer Q (0.41 0.24 D), followed by Holladay 1 (0.45 0.30 D), SRK/T (0.47 0.33 D), SRK II (0.53 0.35 D), and Haigis (1.72 0.59 D). The PE was closest to plano using SRK/T ( 0.12 0.57 D), followed by Hoffer Q (0.23 0.42 D), Holladay 1 (0.27 0.47D), SRK II ( 0.33 0.55), and Haigis (1.72 0.62 D). In phakic eyes, APE was lowest for Holladay 1 (0.18 0.30 D) and Hoffer Q (0.29 0.27 D). In aphakic eyes, APE was similar (range 0.43-0.52 D) for all formulae except Haigis. Discussion: Good results were obtained using Hoffer Q, Holladay 1, SRK II, and SRK/T formulae. Haigis was the least accurate formula. Holladay 1 and Hoffer Q were the most accurate in phakic eyes. Conclusions: This study helps establish the reliability of various formulae in lens power calculations for implantation of Artisan Aphakia lenses in pediatric patients. 078 Risk of retinal detachment in children with ocular coloboma. Monte D. Mills, Sila Bal, Lauren A. Tomlinson, Gui-shuang Ying, Gil Binenbaum Introduction: Optic nerve (ONC) and chorioretinal (CRC) coloboma are associated with retinal detachment (RD). The risk during early childhood is unclear. We determined the prevalence and age at onset of acquired RD in children with coloboma. Methods: Retrospective cohort study of children with ONC and/or CRC, examined over 4-years at a childrens-hospital-based clinic. Eyes with presumed congenital RD or retinal dysplasia were excluded. Primary outcomes were prevalence and age at diagnosis of acquired RD. Results: A total of 208 eyes (120 children) were studied. Median age at latest examination was 5.2 years (Q1,2 years; Q3,10 years; range, 0.1-19.9 years). Thirty-five children (29%) had genetic/syndromic associations; 69 (58%) had bilateral involvement. A total of 143 eyes (69%) had ONC; 141 (68%), CRC; 76 (37%), both. ONC size was small-medium-large in 9%-57%-34% eyes; CRC was small-mediumlarge in 10%-57%-33% eyes. CRC involved macula and periphery, 59%; periphery only, 41%. Two eyes (2 children) had acquired RD (0.96%; 95% CI, 0.3%-3.4%): 1 chronic-appearing RD, diagnosed 7 years; 1 acute RD, diagnosed 13 years. Discussion: Reported prevalence of RD with ONC/CRC varies with age and referral bias: .40%, adults, high bias; 24%, children, high
Journal of AAPOS
e25 bias; 7% children, low bias; 0%-4%, children, no bias (populationbased). Our findings confirm a low incidence early in life, though onset has been reported during infancy. Conclusions: RD associated with coloboma is uncommon in early childhood but does occur, so screening examinations are indicated. Prior referral-based and population-based reports have suggested a wide range of incidence, varying from 1% to 40%. A more complete understanding of secondary retinal detachment, including incidence, risk factors, and ocular associations, is needed before considering possible prophylactic treatments. 079 Primary intraocular lens implantation in infants less than 6 months: a long term outcome. Ramesh Kekunnaya, Mithila Negalur, Virender Sachdeva Introduction: Intraocular lens (IOL) implantation in infants still remains challenging despite advances in pediatric cataract surgery. We aimed to study the long-term safety profile and visual outcomes of primary IOL implantation in infants less than 6 months of age. Methods: Retrospective, observational study of a selected few infants who underwent cataract surgery (lens aspiration, primary posterior capsulorhexis and anterior vitrectomy) with primary IOL implantation between January 2008 and December 2011, with a minimum 3-year follow-up. Results: A total of 71 eyes of 40 infants (31 bilateral, 9 unilateral; mean age, 4.6 months) satisfying the inclusion criteria were reviewed. Mean follow-up was 51 months (range, 36-84 months). Median corrected visual acuity at final visit was 0.74 logMAR (interquartile range, 0.501-1.000 logMAR), with an average myopic shift of 6.7 D over 4.2 years. Most common postoperative complication was visual axis opacification (VAO), seen in 13 eyes (18%), mandating membranectomy within 1 year of primary surgery. Other complications included pigmentary IOL deposits in 11 eyes (15%), IOL decentration and glaucoma in 4 eyes each (5.6%). Analysis using a mixed linear effect model found no significant association of laterality of cataract and postoperative complications with final visual acuity (P $ 0.12 for all observations). Discussion: Our study suggests that primary IOL implantation provides early and optimal visual rehabilitation even in younger infants. VAO was the commonest postoperative complication to develop, however the overall complication rate was significantly lower compared to other studies. Conclusions: Primary implantation of IOL in appropriately selected infants, even under 6 months is safe with favourable visual outcome.
080 Treatment of pediatric ocular surface pyogenic granuloma with topical timolol. Isdin Oke, Maan Alkharashi, Robert A. Petersen, Alena Ashenberg, Ankoor S. Shah Introduction: Pyogenic granulomas (PGs), acquired vascular lesions, form on the ocular or palpebral surface from inflammation related to chalazia, trauma, or surgery. They are unsightly, spontaneously bleed, and cause irritation. Traditional treatment with topical steroids and surgery has side effects. We queried whether beta-blockers might resolve these lesions given that the dermatologic literature suggests response. Methods: We reviewed the case records of children with acquired, ocular surface PGs treated at Boston Childrens Hospital from 2014 to 2016. We identified treatment with timolol, and we abstracted the cause, duration, and symptoms of the PG in these cases as well as the treatment duration and response.
e26 Results: Four cases of PG treated with timolol 0.5% were identified during this time frame. Each was treated twice daily for 30 days, and each showed complete resolution with no recurrence and with no adverse effects. Discussion: This pilot case series suggests that ocular surface PGs respond to topical timolol treatment similar to dermatologic PGs. Conclusions: Topical timolol has a lower side-effect profile than conventional topical steroid or surgical therapies for ocular surface PGs. If these results are confirmed in a larger series of patients, this may become the desired treatment modality. 081 Impact of medical trainees on clinical efficiency in a pediatric ophthalmology practice. Leah G. Reznick, Michelle R. Hribar, Sarah Read-Brown, Issac Goldstein, Michael F. Chiang, Thomas R. Yackel Introduction: In an academic clinical practice, little information exists to describe how medical trainees affect the flow of an ophthalmology practice. Using data obtained through electronic health records (EHR) analysis, we can understand how training physicians influences the examination and wait times for patients. Methods: Clinical workflow was mapped through time-stamp data obtained through the EHR. EHR analysis identified the appointment, examination, and wait times via activity by staff, medical trainees, and the pediatric ophthalmologist within the patient chart. Results: EHR time stamps were evaluated for one pediatric ophthalmologist (LR) during each half-day session. A total of 8,013 patient encounters were identified: 853 with a trainee and 7160 without. The mean exam time with a trainee was 27% longer (37 mins with and 25 mins without a trainee, P \ 0.001). Mean wait time was 26% longer for clinic sessions with a trainee (40 mins with and 32 mins without trainees, P \ 0.001). Mean clinic length increased by 5.0% for a half-day session (237 mins with and 226 mins without a trainee, P value 5 0.001). Discussion: Future studies are needed to investigate why medical trainees worsen wait times and clinical session lengths for all patients. Residents increase examination and wait times the most followed by fellows and students. Further analysis can help create schedules that maximize clinical efficiency with trainee involvement. Conclusions: Inclusion of medical trainees within a single pediatric ophthalmology practice lengthens appointment times and worsens wait times for both the patients seen by a trainee and those who do not see a trainee. 082 Cataract incidence and severity after therapeutic radiation for brain tumors. Cody Richardson, Casey Smith, Thomas Merchant, Amar Gajjar, Mary E. Hoehn Introduction: To determine the incidence of cataract formation and requirement for cataract surgery in a pediatric population receiving therapeutic radiation for brain tumors (SJMB03). A lower risk group (LR), without known metastasis, received 23.4 Gy and a higher risk (HR), with known metastatic disease, received 36-39.6 Gy. Methods: Chart review of patients enrolled in SJMB03 study who received an ophthalmic exam. Results: 162 patients met inclusion criteria (104 LR and 58 HR). Sixtyfour patients developed cataracts (39.5%). Forty-four (42.3%) developed cataracts in LR versus 20 (34.5%) in HR. Median time to cataract formation was 92.75 months (range 22-146) in LR and 44.75 months (range 22-118) in HR. Twenty-seven patients required cataract surgery (16.7% of the total patients and 42.2% of those that developed cataracts). 35.5% of LR cataracts required extraction while 60% of HR cataracts required extraction (P 5 0.05). Median length of follow up for patients without cataracts was 18.5 months in LR and 6 months
Volume 21 Number 4 / August 2017 in HR. 11 patients in HR died during the follow up period, while 4 in LR expired (P \ 0.001). Discussion: Cataract formation is common in patients receiving radiation therapy for brain tumors. There was no statistically significant difference in cataract formation between HR and LR. More patients in HR expired during follow-up, which likely led to a lower detection rate. Patients in HR were more likely to need cataract surgery. Conclusions: Long term ophthalmic follow-up is needed for these patients as cataracts can appear years later and almost half of these patients will require cataract surgery. 083 Making the modified Nishida transposition surgery adjustable. Pradeep I. Sharma, Anin Sethi, Rohit Saxena, Swati Phuljhele Introduction: The modified Nishida procedure is an effective surgical procedure for the management of nonresolving abducens nerve palsy. We compared the predictability of postoperative results with this procedure when combined with an adjustable or a nonadjustable MR recession. Methods: A total of 21 consecutive patients of nonresolving abducens nerve palsy which underwent modified Nishidas procedure were randomized into two groups: AMR, with adjustable MR recession and NMR, with non-adjustable MR recession. These patients were evaluated to compare the preoperative and postoperative deviation in primary gaze by PBCT, abduction amplitude, field of binocular single vision (FBSV) and any signs of anterior segment ischemia on slit-lamp biomicroscopy. Results: Mean preoperative deviation was 57.64D 24.36D in the NMR group and 56D 23.66D in AMR group while the postoperative deviation was 8.36D 23.46D and 4.6D 3.13D, respectively. While there was no significant difference in correction between the two groups, 6 months postoperatively, the AMR group had a significantly higher number of orthophoric (+8D to 8D) patients(10/10) compared to the NMR group (6/11) (P 5 0.035). In AMR group 6/10 patients were adjusted, 5 for overcorrection, 1 for undercorrection. Improvement in abduction and FBSV was not significantly different in the two groups. Discussion: 60% of the patients in the adjustable MR recession group required postoperative adjustment indicating the role of adjustable MR recession in the originally non-adjustable transposition procedure. Conclusions: Adjustable MR recession along with Modified Nishida procedure in abducens palsy provides a more acceptable and predictable surgical outcome. 084 Strabismus following glaucoma drainage device implantation for refractory childhood glaucoma: incidence and risk factors. Sonali D. Talsania, Andrew Lee, Sharon F. Freedman Introduction: The reported incidence of strabismus following glaucoma drainage device (GDD) implantation in adults and children ranges from 1.4% to 77%, with most studies retrospective, and with few risk factors identified. PurposeTo determine incidence and risk factors for strabismus in children following GDD implantation. Methods: Ongoing retrospective review of sequential GDDs implanted for refractory pediatric glaucoma (ages 0-21 years) under one attending surgeon from 1999 to 2015. Clinical features gathered included glaucoma type/details, pre-/post-GDD vision and sensorimotor findings (binocularity/motility/alignment [primary gaze]), and surgical details (# GDDs/eye, GDD type/location). Significant alignment change included: new-onset post-GDD strabismus and $10D increase (horizontal and/or vertical).
Journal of AAPOS
Journal of AAPOS
e25 bias; 7% children, low bias; 0%-4%, children, no bias (populationbased). Our findings confirm a low incidence early in life, though onset has been reported during infancy. Conclusions: RD associated with coloboma is uncommon in early childhood but does occur, so screening examinations are indicated. Prior referral-based and population-based reports have suggested a wide range of incidence, varying from 1% to 40%. A more complete understanding of secondary retinal detachment, including incidence, risk factors, and ocular associations, is needed before considering possible prophylactic treatments. 079 Primary intraocular lens implantation in infants less than 6 months: a long term outcome. Ramesh Kekunnaya, Mithila Negalur, Virender Sachdeva Introduction: Intraocular lens (IOL) implantation in infants still remains challenging despite advances in pediatric cataract surgery. We aimed to study the long-term safety profile and visual outcomes of primary IOL implantation in infants less than 6 months of age. Methods: Retrospective, observational study of a selected few infants who underwent cataract surgery (lens aspiration, primary posterior capsulorhexis and anterior vitrectomy) with primary IOL implantation between January 2008 and December 2011, with a minimum 3-year follow-up. Results: A total of 71 eyes of 40 infants (31 bilateral, 9 unilateral; mean age, 4.6 months) satisfying the inclusion criteria were reviewed. Mean follow-up was 51 months (range, 36-84 months). Median corrected visual acuity at final visit was 0.74 logMAR (interquartile range, 0.501-1.000 logMAR), with an average myopic shift of 6.7 D over 4.2 years. Most common postoperative complication was visual axis opacification (VAO), seen in 13 eyes (18%), mandating membranectomy within 1 year of primary surgery. Other complications included pigmentary IOL deposits in 11 eyes (15%), IOL decentration and glaucoma in 4 eyes each (5.6%). Analysis using a mixed linear effect model found no significant association of laterality of cataract and postoperative complications with final visual acuity (P $ 0.12 for all observations). Discussion: Our study suggests that primary IOL implantation provides early and optimal visual rehabilitation even in younger infants. VAO was the commonest postoperative complication to develop, however the overall complication rate was significantly lower compared to other studies. Conclusions: Primary implantation of IOL in appropriately selected infants, even under 6 months is safe with favourable visual outcome.
080 Treatment of pediatric ocular surface pyogenic granuloma with topical timolol. Isdin Oke, Maan Alkharashi, Robert A. Petersen, Alena Ashenberg, Ankoor S. Shah Introduction: Pyogenic granulomas (PGs), acquired vascular lesions, form on the ocular or palpebral surface from inflammation related to chalazia, trauma, or surgery. They are unsightly, spontaneously bleed, and cause irritation. Traditional treatment with topical steroids and surgery has side effects. We queried whether beta-blockers might resolve these lesions given that the dermatologic literature suggests response. Methods: We reviewed the case records of children with acquired, ocular surface PGs treated at Boston Childrens Hospital from 2014 to 2016. We identified treatment with timolol, and we abstracted the cause, duration, and symptoms of the PG in these cases as well as the treatment duration and response.
e26 Results: Four cases of PG treated with timolol 0.5% were identified during this time frame. Each was treated twice daily for 30 days, and each showed complete resolution with no recurrence and with no adverse effects. Discussion: This pilot case series suggests that ocular surface PGs respond to topical timolol treatment similar to dermatologic PGs. Conclusions: Topical timolol has a lower side-effect profile than conventional topical steroid or surgical therapies for ocular surface PGs. If these results are confirmed in a larger series of patients, this may become the desired treatment modality. 081 Impact of medical trainees on clinical efficiency in a pediatric ophthalmology practice. Leah G. Reznick, Michelle R. Hribar, Sarah Read-Brown, Issac Goldstein, Michael F. Chiang, Thomas R. Yackel Introduction: In an academic clinical practice, little information exists to describe how medical trainees affect the flow of an ophthalmology practice. Using data obtained through electronic health records (EHR) analysis, we can understand how training physicians influences the examination and wait times for patients. Methods: Clinical workflow was mapped through time-stamp data obtained through the EHR. EHR analysis identified the appointment, examination, and wait times via activity by staff, medical trainees, and the pediatric ophthalmologist within the patient chart. Results: EHR time stamps were evaluated for one pediatric ophthalmologist (LR) during each half-day session. A total of 8,013 patient encounters were identified: 853 with a trainee and 7160 without. The mean exam time with a trainee was 27% longer (37 mins with and 25 mins without a trainee, P \ 0.001). Mean wait time was 26% longer for clinic sessions with a trainee (40 mins with and 32 mins without trainees, P \ 0.001). Mean clinic length increased by 5.0% for a half-day session (237 mins with and 226 mins without a trainee, P value 5 0.001). Discussion: Future studies are needed to investigate why medical trainees worsen wait times and clinical session lengths for all patients. Residents increase examination and wait times the most followed by fellows and students. Further analysis can help create schedules that maximize clinical efficiency with trainee involvement. Conclusions: Inclusion of medical trainees within a single pediatric ophthalmology practice lengthens appointment times and worsens wait times for both the patients seen by a trainee and those who do not see a trainee. 082 Cataract incidence and severity after therapeutic radiation for brain tumors. Cody Richardson, Casey Smith, Thomas Merchant, Amar Gajjar, Mary E. Hoehn Introduction: To determine the incidence of cataract formation and requirement for cataract surgery in a pediatric population receiving therapeutic radiation for brain tumors (SJMB03). A lower risk group (LR), without known metastasis, received 23.4 Gy and a higher risk (HR), with known metastatic disease, received 36-39.6 Gy. Methods: Chart review of patients enrolled in SJMB03 study who received an ophthalmic exam. Results: 162 patients met inclusion criteria (104 LR and 58 HR). Sixtyfour patients developed cataracts (39.5%). Forty-four (42.3%) developed cataracts in LR versus 20 (34.5%) in HR. Median time to cataract formation was 92.75 months (range 22-146) in LR and 44.75 months (range 22-118) in HR. Twenty-seven patients required cataract surgery (16.7% of the total patients and 42.2% of those that developed cataracts). 35.5% of LR cataracts required extraction while 60% of HR cataracts required extraction (P 5 0.05). Median length of follow up for patients without cataracts was 18.5 months in LR and 6 months
Volume 21 Number 4 / August 2017 in HR. 11 patients in HR died during the follow up period, while 4 in LR expired (P \ 0.001). Discussion: Cataract formation is common in patients receiving radiation therapy for brain tumors. There was no statistically significant difference in cataract formation between HR and LR. More patients in HR expired during follow-up, which likely led to a lower detection rate. Patients in HR were more likely to need cataract surgery. Conclusions: Long term ophthalmic follow-up is needed for these patients as cataracts can appear years later and almost half of these patients will require cataract surgery. 083 Making the modified Nishida transposition surgery adjustable. Pradeep I. Sharma, Anin Sethi, Rohit Saxena, Swati Phuljhele Introduction: The modified Nishida procedure is an effective surgical procedure for the management of nonresolving abducens nerve palsy. We compared the predictability of postoperative results with this procedure when combined with an adjustable or a nonadjustable MR recession. Methods: A total of 21 consecutive patients of nonresolving abducens nerve palsy which underwent modified Nishidas procedure were randomized into two groups: AMR, with adjustable MR recession and NMR, with non-adjustable MR recession. These patients were evaluated to compare the preoperative and postoperative deviation in primary gaze by PBCT, abduction amplitude, field of binocular single vision (FBSV) and any signs of anterior segment ischemia on slit-lamp biomicroscopy. Results: Mean preoperative deviation was 57.64D 24.36D in the NMR group and 56D 23.66D in AMR group while the postoperative deviation was 8.36D 23.46D and 4.6D 3.13D, respectively. While there was no significant difference in correction between the two groups, 6 months postoperatively, the AMR group had a significantly higher number of orthophoric (+8D to 8D) patients(10/10) compared to the NMR group (6/11) (P 5 0.035). In AMR group 6/10 patients were adjusted, 5 for overcorrection, 1 for undercorrection. Improvement in abduction and FBSV was not significantly different in the two groups. Discussion: 60% of the patients in the adjustable MR recession group required postoperative adjustment indicating the role of adjustable MR recession in the originally non-adjustable transposition procedure. Conclusions: Adjustable MR recession along with Modified Nishida procedure in abducens palsy provides a more acceptable and predictable surgical outcome. 084 Strabismus following glaucoma drainage device implantation for refractory childhood glaucoma: incidence and risk factors. Sonali D. Talsania, Andrew Lee, Sharon F. Freedman Introduction: The reported incidence of strabismus following glaucoma drainage device (GDD) implantation in adults and children ranges from 1.4% to 77%, with most studies retrospective, and with few risk factors identified. PurposeTo determine incidence and risk factors for strabismus in children following GDD implantation. Methods: Ongoing retrospective review of sequential GDDs implanted for refractory pediatric glaucoma (ages 0-21 years) under one attending surgeon from 1999 to 2015. Clinical features gathered included glaucoma type/details, pre-/post-GDD vision and sensorimotor findings (binocularity/motility/alignment [primary gaze]), and surgical details (# GDDs/eye, GDD type/location). Significant alignment change included: new-onset post-GDD strabismus and $10D increase (horizontal and/or vertical).
Journal of AAPOS