Journal of Pediatric Ophthalmology and Strabismus

Management of Divergence Insufficiency Esotropia

Dawn N. Duss, MD; Suqin Guo, MD; Frederick M. Wang, MD; Rudolph S. Wagner, MD

Journal of Pediatric Ophthalmology and Strabismus. 2020;57(1):4-6

Abstract

Wagner: Today’s topic is management of divergence insufficiency esotropia, which is often called age-related distance esotropia. I want to distinguish that from true divergence insufficiency, which often implies a neurologic cause. It still can in older individuals, but this is more specifically about a patient who developed the condition over time. An active and healthy 74-year-old woman presented with double vision at distance. This started intermittently, but became constant at distance after a few weeks and she still was only bothered slightly at near. It was particularly bothersome while driving and watching television. She had cataract surgery with intraocular lenses implanted in both eyes approximately 1 year before experiencing any double vision, so it didn’t seem to be proximal to the surgery. On examination, she had a comitant deviation of 15 prism diopters at distance and a slight esophoria of 2 prism diopters at near, which did not seem to bother her as much as the distance diplopia. How would you treat this patient with an acquired comitant esotropia with a greater distance deviation?

Wang: Although your presentation indicates that this is a primary age-related phenomenon, I would first make sure that I’m not dealing with a sixth nerve palsy or some variant of a paretic lateral rectus muscle. I would make sure that in addition to the fact that she’s comitant, she doesn’t have any abduction deficiency or endpoint nystagmus. She has nothing in her history that would indicate something else is going on, such as headaches or any neurologic history that would indicate increased intracranial pressure. If all of those things were in place, I would continue to follow her. I probably wouldn’t do neuroimaging, but I would if I had any suspicions. I would treat her distance diplopia with prisms.

Wagner: In this particular case, she didn’t have an abduction deficit. Nerves were normal, but I think everyone would agree that this is the proper approach to this type of presentation. You’re not really sure if it was isolated or not.

Guo: I agree. I would definitely want to make sure that the patient had a full eye examination and there were no other neurological issues. I would also make sure that the patient had no thyroid issues or myasthenia. If there were any suspicious findings, I would do neuroimaging to rule out incomitant esotropia. If all of the neurological and systemic work-ups are negative and the typical presentation was as you have mentioned, I would observe the patient. If she is symptomatic at distance, I would give her base-out prisms first.

Duss: I would also check for a sedimentation rate if she’s in that age group and make sure she has no symptoms of giant cell. I’m seeing more of this type of patient in my own practice. Although we’re apt to go straight to prisms, I’ve had a few patients who wanted to be spectacle free. I’m not opposed to the idea of surgery even with such a small angle deviation. This is a new presentation for this patient, so I agree that prisms are probably the first step. However, more of these patients who have specialty intraocular lenses or have refractive procedures along with their cataract surgeries want to be spectacle free. I have operated on several small-angle divergence insufficiency esotropias with good success.

Wagner: To follow-up on what you said about the frequency, the Rochester Epidemiology Project estimated divergence insufficiency esotropia to be present in approximately 10% of all adult strabismus cases. It’s more common than you might think, and the median age at presentation was 74 years in the study that they…

Influence of Axial Length on Intraocular Pressure Measurement With Three Tonometers in Childhood Glaucoma

Carmen Mendez-Hernandez, MD, PhD; Paula Arribas-Pardo, MD, PhD; Ruben Sanchez Jean, GOO, MSc; Julian Garcia-Feljoo, MD, PhD

Journal of Pediatric Ophthalmology and Strabismus. 2020;57(1):27-32

Abstract

PURPOSE:

To determine the agreement between intraocular pressure (IOP) measurements obtained using the handheld version of the Goldmann applanation (Perkins; Clement-Clarke, Haag-Streit, Harlow, United Kingdom), rebound Icare-Pro (Icare, Tiolat Oy, Helsinki, Finland), and Tonopen XL (Reichert Inc., Depew, NY) tonometers in children with childhood glaucoma and to identify factors that may affect those measurements.

METHODS:

Ninety-one eyes of 46 children with early-onset childhood glaucoma were included in this cross-sectional study in which IOP, ocular axial length, anterior chamber depth, lens thickness, vitreous length, and central corneal thickness measurements were obtained under general anesthesia. Agreement between tonometers was evaluated using intraclass correlation coefficients (ICCs) and the Bland–Altman method. The influence of ocular biometric parameters and central corneal thickness on IOP measurements was analyzed using multiple linear regression analysis.

RESULTS:

The mean age of the children in the current study was 29.1 months (range: 13 to 31 months). The Icare-Pro and Tonopen XL overestimated IOP measurements compared to the Perkins tonometer (Icare-Pro–Perkins mean IOP difference: 2.2 ± 3.4 mm Hg, P < .0001, 95% confidence interval [CI]: 1.5 to 2.9 vs Tonopen XL–Perkins mean IOP difference: 6.7 ± 7.1 mm Hg, P < .0001, 95% CI: 5.2 to 8.2). The Icare-Pro showed greater agreement with the Perkins tonometer than the Tonopen XL (ICC: 0.789, 95% CI: 0.697 to 0.856, P < .0001 vs 0.453, 95% CI: 0.272 to 0.603, P < .0001). Ocular axial length affected IOP measurements the most, finding increased impact on Tonopen XL (slope: 0.086, 95% CI: 0.013 to 0.16, P = .022 vs 0.997, 95% CI: 0.369 to 1.625, P = .002 vs 1.571, 95% CI: 0.541 to 2.602, P < .0001 for Perkins, Icare-Pro, and Tonopen XL IOP measurements, respectively).

CONCLUSIONS:

Ocular axial length affects IOP measured by the Perkins, Icare-Pro, and Tonopen XL devices in patients with childhood glaucoma. The Icare-Pro shows more agreement with the Perkins tonometer than the Tonopen XL; therefore, it seems to be a more suitable option for these patients.

Amblyopia Risk Factors in Newborns With Congenital Nasolacrimal Duct Obstruction

Aldo Vagge, MD, PhD; Claudia Tulumello, MD; Marco Pellegrini, MD; Marco Di Maita, MD; Michele Iester, MD, PhD; Carlo Enrico Traverso, MD

Journal of Pediatric Ophthalmology and Strabismus. 2020;57(1):39-43

Abstract

PURPOSE:

To investigate the presence of amblyopia risk factors in newborns with congenital nasolacrimal duct obstruction (CNLDO) and age-matched healthy control subjects.

METHODS:

This retrospective case-control study involved newborns aged 30 to 60 days with CNLDO and age-matched healthy control subjects. Amblyopia risk factors were identified in accordance with the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee recommendations. The prevalence of amblyopia risk factors was compared in newborns with CNLDO and age-matched healthy control subjects, newborns with unilateral and bilateral CNLDO, and the affected eye and fellow eye of newborns with unilateral CNLDO.

RESULTS:

Amblyopia risk factors were found in 18 patients (11.9%) with CNLDO and 19 control subjects (8.7%) (P = .314). Eyes with CNLDO showed a significantly lower spherical equivalent compared to control eyes (2.01 ± 1.21 vs 2.79 ± 1.14 diopters, P < .001). No difference in amblyopia risk factors was found in eyes with unilateral and bilateral CNLDO (11.5% vs 12.1%; P = .908) or in eyes with unilateral CNLDO and fellow eyes (9.8% vs 12.3%; P = .540).

CONCLUSIONS:

CNLDO does not seem to be associated with amblyopia risk factors in newborns. Because anisometropia might develop later on, all patients with CNLDO should be monitored for amblyopia.

Outcome of Primary Probing for Simple Membraneous Congenital Nasolacrimal Duct Obstruction in Children Older Than 4 Years

Margaret Reynolds, MD; Gregg Lueder, MD

Journal of Pediatric Ophthalmology and Strabismus. 2020;57(1):44-47

Abstract

PURPOSE:

To report outcomes of nasolacrimal duct (NLD) probing in children 4 years and older with simple membranous NLD obstruction.

METHODS:

The records of all patients 4 years and older with congenital NLD obstruction who underwent surgery from 1997 to 2015 at Washington University School of Medicine were retrospectively reviewed. Of 47 patients reviewed, 18 (38.3%) were found to have simple membranous obstructions and were included in this study. Simple membranous obstruction was present at the distal duct and was relieved with passage of the probes in all patients. Children with canalicular or diffuse distal NLD stenosis (as defined by a tight, gritty feeling or multiple obstructions when passing the probe through the bony portion of the NLD), trisomy 21, lacrimal trauma, or craniofacial abnormalities were excluded. A successful outcome was determined by resolution of epiphora and periocular crusting.

RESULTS:

Eighteen patients with ages ranging from 4.1 to 10.6 years with simple membranous NLD obstruction were treated. Sixteen of 18 (88.9%) patients had good outcomes following NLD probing. Two patients had persistent symptoms that resolved following balloon dilation and stent placement.

CONCLUSIONS:

This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that of younger patients. NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. Additional procedures such as balloon catheter dilation or stent placement may not be necessary at the time of initial probing.

Comparison of Retinal Vascular Structure in Eyes With and Without Amblyopia by Optical Coherence Tomography Angiography

Esat Cinar, MD; Berna Yuce, MD; Fatih Aslan, MD; Gökhan Erbakan, MD

Journal of Pediatric Ophthalmology and Strabismus. 2020;57(1):48-53

Abstract

PURPOSE:

To evaluate the retinal vascular structure in amblyopic eyes by optical coherence tomography angiography (OCTA).

METHODS:

Thirty-seven eyes of 37 patients with anisometric amblyopia were compared with 37 eyes of 37 age- and gender-matched control subjects by OCTA in terms of superficial capillary plexus vessel density, deep capillary plexus vessel density, and foveal avascular zone.

RESULTS:

The mean age was 12 ± 4.2 years in patients with amblyopia and 13 ± 6.1 years in individuals without amblyopia. Foveal superficial capillary plexus vessel densities were 20.49% ± 3.27%, 19.70% ± 3.82%, and 19.96% ± 3.84%, and parafoveal superficial capillary plexus vessel densities were 48.50% ± 3.64%, 49.01% ± 3.33%, and 48.9% ± 2.98% in amblyopic, fellow, and control eyes, respectively. The foveal deep capillary plexus vessel densities were 18.95% ± 3.76%, 18.6% ± 4.50%, and 19.29% ± 4.01%, and parafoveal deep capillary plexus vessel densities were 51.0% ± 4.21%, 51.85% ± 4.12%, and 52.03% ± 3.57% in amblyopic, fellow, and control eyes, respectively. Superficial and deep capillary plexus vessel densities in the foveal and parafoveal areas were not significantly different between the groups (P > .05). The parafoveal area was evaluated in quadrants. In the superior quadrant, superficial and deep capillary plexus parafoveal densities were significantly lower in amblyopic eyes (P < .05). No significant difference was observed in the foveal avascular zone between the groups (P > .05).

CONCLUSIONS:

Although no significant vascular damage was demonstrated by OCTA in amblyopic eyes, localized defects may be specific for it. Additional studies are needed to evaluate any specific localization of vascular damage related to amblyopia.

Combined Vitrectomy and Anti-VEGF Treatment for Stage 4 Retinopathy of Prematurity With Extensive Neovascular Proliferation

Parijat Chandra, MD; Devesh Kumawat, MD, FICO; Divya Agarwal, MD; Rohan Chawla, MD, FRCS

Journal of Pediatric Ophthalmology and Strabismus. 2020;57(1):61-66

Abstract

PURPOSE:

To study the role of combined vitrectomy and intravitreal anti-vascular endothelial growth factor (VEGF) injection for stage 4 retinopathy of prematurity (ROP) with extensive neovascular proliferation.

METHODS:

In a retrospective interventional study at a tertiary eye care center, 15 eyes (9 infants) with advanced stage 4 ROP underwent 25-gauge vitrectomy combined with intravitreal 0.625 mg of bevacizumab (n = 12) or 0.25 mg of ranibizumab (n = 3) injection and were followed up until 65 weeks’ postconceptional age (PCA). The perinatal history, tractional retinal detachment (TRD) characteristics (zone, stage, and presence of “plus” disease), treatment details, and anatomical outcomes were reviewed. The main outcome measures were fibrovascular tissue and TRD regression and final macular status.

RESULTS:

Mean gestational age and birth weight were 28.5 ± 1.2 weeks and 1,167 ± 185 g, respectively. Thirteen eyes had zone I disease and 2 eyes had zone II disease. Thirteen eyes were stage 4A and 2 eyes were stage 4B ROP. The morphology was aggressive posterior ROP in 10 eyes. The mean PCA at surgery was 37.8 ± 2.3 weeks. Lensectomy was also performed in 2 eyes. Rapid fibrovascular tissue regression was seen in 14 eyes within 2 weeks, followed by TRD regression and macular vascularization, although 2 eyes had macular pucker formation. Persistent vitreous bleeding was present in 1 eye, which needed lavage, and eventually the TRD regressed. Disease reactivation was noted in 1 eye at 5 weeks and was managed with repeat intravitreal anti-VEGF injection.

CONCLUSIONS:

Anti-VEGF treatment combined with vitrectomy leads to rapid disease regression in advanced stage 4 ROP with extensive neovascular proliferation.