Journal of Pediatric Ophthalmology and Strabismus

Management Issues in Adult Strabismus

Maureen E. Lloyd; Frederick M. Wang; Barry N. Wasserman; Leonard B. Nelson.

Nelson: Today we will discuss management issues in adult strabismus. The first patient is a 60-year-old man with increasing exotropia since childhood who has had no previous surgery. His visual acuity is 20/20 in the right eye and 20/25 in the left eye. He has an exotropia that measured 70 prism diopters (PD) that was comitant in all fields of gaze and the same at near. How would you determine the amount of deviation that the patient actually will have to be operated upon?

Wasserman: This is a great patient to operate on. He will finally be able to make eye contact with his peers. Measuring these patients can be challenging when they get past your prisms. I will generally have an assistant hold a 50 base-in prism in front of the dominant eye and then I will add increasing prisms to the nondominant eye and can clear an alternate prism cover test until they are neutralized, adding up the amount of prism to determine their deviation.

Nelson: Once you measure and he is 70 PD, would you operate on the 70?

Wasserman: How I would proceed with the patient has more to do with the history than the measurements. If this was a patient who had a history of intermittent exotropia who was decompensating, I would be less worried if that happened. If he was having only intermittent diplopia with this, I would assume it was a long-term chronic problem that was decompensating. If it was more acute, I would be more concerned about a neurological event and would want a medical and neurological evaluation first.

Wang: I agree with everything Dr. Wasserman said. I would also want to know why this patient waited until he was 60 years old. If his goals are psychosocial, then he may not be happy with the result. You may not be able to straighten out that part of his life, even if his eyes become relatively straight. There have been a lot of articles written on why people wait. Once I decided to proceed with surgery, I would do a forced traction test and then I would leave some room for a second procedure. I would do large recessions (up to 12 mm) on both lateral recti and see where the patient ended up in terms of being happy.

The Spot Vision Screener: A Major Impact in Pediatric Ophthalmology Practices

Leonard B. Nelson

During the past several years, the number of pediatricians performing visual screening with the Spot Vision Screener (Welch Allyn, Skaneateles Falls, NY) has increased substantially. How do I know that has occurred? Almost daily I have been examining more children referred by pediatricians for abnormal Spot test findings. I have been impressed by how many preverbal children were prescribed glasses as a result. In many cases, the prescription has been for significant anisometropia. I hope the early prescribing of glasses for anisometropia will reduce the incidence of amblyopia treatment.

In this issue, Peterseim et al.’s study supports my own Spot test observations. There are pediatric referrals in which glasses prescriptions are not necessary at that time. It is important that we as pediatric ophthalmologists educate the pediatricians and school nurses who are using the Spot Vision Screener extensively about the specific criteria for prescribing for the different refraction errors detected.

The specificity of the Spot Vision Screener also allows for use by pediatric ophthalmology practices, especially in cases where it becomes extremely difficult to dilate and provide adequate refractions in developmentally challenged children. It may also provide appropriate refractive data in young children who are wearing glasses and may need a change but are not able to cooperate for a manifest refraction. Usually this scenario requires a repeat cycloplegic refraction.

Insurance reimbursement for the Spot test varies widely and depends on the family’s specific insurance guidelines. Perhaps pediatric ophthalmology and pediatric organizations should work together to provide guidelines for insurance companies about the importance of the Spot test in detecting early refractive errors that significantly affect the visual development of young children.

Pediatric Sympathetic Ophthalmia: 20 Years of Data From a Tertiary Eye Center in India

Parthopratim Dutta Majumder; Saurabh Mistry; Sudharshan Sridharan. Et all

PURPOSE:

To examine the clinical profile of sympathetic ophthalmia among the pediatric age group.

METHODS:

Retrospective review of patients 18 years and younger with sympathetic ophthalmia seen in a tertiary eye care center between 1997 and 2017.

RESULTS:

Of 20 patients included in the study, 70% were male. The most common inciting event for sympathetic ophthalmia was trauma (85%), followed by vitreoretinal surgery (15%). All patients were treated with systemic steroids. Seventeen patients received additional corticosteroid-sparing immunosuppressive agents, and 4 patients (20%) required more than one immunosuppressive agent. Azathioprine was the most commonly used corticosteroid-sparing immunosuppressive agent. The most common complications were cataract (50%) and ocular hypertension (30%). The mean presenting best corrected visual acuity in the sympathizing eye was 1.15 ± 0.99 logarithm of the minimum angle of resolution (logMAR), which improved to 0.54 ± 1.00 logMAR following treatment. Visual outcome was good (6/12 or better) in 70% of the sympathizing eyes, and 3 of the exciting eyes in the current study had good visual outcomes after the treatment.

CONCLUSIONS:

Prompt and effective management with corticosteroid-sparing immunosuppressive therapy in children with sympathetic ophthalmia allows favorable control of the disease and retention of good visual acuity.

Practice Patterns in the Surgical Management of Pediatric Traumatic Cataracts

Angela Y. Zhu; Courtney L. Kraus.

PURPOSE:

To facilitate the development of standardized guidelines for the surgical management of patients with pediatric traumatic cataracts by assessing current ophthalmologists’ practice patterns.

METHODS:

This was a cross-sectional, observational, and retrospective study. A 24-question electronic survey of current practices pertaining to the surgical management of pediatric traumatic cataracts was sent to pediatric ophthalmologists worldwide. Preferences for pre-operative evaluation, surgical timing and techniques, and postoperative management were analyzed.

RESULTS:

Of the 56 respondents, 62.5% practiced in academic settings. Of the 49 respondents (87.5%) who performed pediatric ruptured globe repair, 41.7% would perform simultaneous cataract extraction if anterior capsular violation existed, whereas 4.1% would do so without capsular violation (P < .001). Most respondents (50.9%) would remove visually significant cataracts within 4 weeks in patients within the amblyogenic age range (P = .02), whereas 63.6% would wait longer outside the amblyogenic range. Preferences for intraocular lens selection, primary posterior capsulotomy, and timing of amblyopia therapy differed.

CONCLUSIONS:

Individual management practices regarding pediatric traumatic cataracts vary depending on associated globe injuries and patient age. Trends exist in surgical planning, intraoperative techniques, and visual rehabilitation methods, but no single approach has achieved complete unanimity. Therefore, further investigation into optimal timing and the extent of surgical intervention, refractive correction, and postoperative care is necessary prior to developing evidence-based guidelines for enhancing visual outcomes in this population.

Painful Proptosis in a 12-Year-Old Boy

Jamie H. Choi; Wasim A. Samara; Adam E. Pflugrath; William H. Benson.

A previously healthy 12-year-old boy presented 6 days after suffering blunt trauma to the right periorbital region. He initially complained of only mild pain but later developed right periorbital swelling and headaches. On examination, his uncorrected visual acuity at near was 20/50 and 20/25 in the right and left eyes, respectively. His extraocular motility was limited to −3 in all directions on the right, but full on the left. The right eye was proptotic in addition to severe upper eyelid edema, erythema, and 360 degrees of nonhemorrhagic chemosis with prolapsed conjunctiva. A computed tomography (CT) scan of the orbit with contrast showed a dilated right superior ophthalmic vein (Figure 1A) with right-sided proptosis, orbital fat stranding, and ethmoid sinusitis (Figure 1B). Nasal aspirate cultures revealed scant growth of Staphylococcus aureus. Blood analysis showed an elevated white blood cell count of 13,600/µL (82.2% neutrophils, 10.5% lymphocytes, and 7.1% monocytes). He was discharged with a 12-week supply of oral amoxicillin-clavulanate and enoxaparin. At his 3-week follow-up visit, extraocular motility was full with a corrected visual acuity of 20/20 in both eyes. Repeat imaging showed resolution of the orbital cellulitis and significant reduction in the size of the right superior ophthalmic vein. Although rare, the diagnosis of superior ophthalmic vein thrombosis (SOVT) should be considered in patients who present with painful proptosis, chemosis, periorbital edema, and ophthalmoplegia.1 SOVT is assessed by imaging, preferably via contrast-enhanced CT scan or magnetic resonance imaging.2 The most common cause of septic SOVT is paranasal sinusitis.2 Aseptic causes include anatomic constraints, inflammation, hematologic abnormalities, and, rarely, trauma.2,3 Although this patient did have a history of blunt ocular trauma, it is unclear whether or not his sinusitis was either exacerbated or precipitated by this event. The goal of treatment is to prevent SOVT progression to cavernous sinus thrombosis, which can lead to rapid neurologic deterioration, permanent blindness, or death. Patients should begin an empiric treatment with broad-spectrum antibiotics while awaiting final culture results. Systemic anticoagulation therapy is recommended for all patients.2,4…