Ahmed Awadein

PURPOSE: To compare suture spacers with silicone band expanders in superior oblique-weakening surgery.

METHODS: We retrospectively reviewed the charts of consecutive patients who had superior oblique weakening with either suture spacers or silicone expanders and had been followed for a minimum follow-up of 6 months. The ductions, versions, and the degree of fundus torsion were analyzed in all patients before and after surgery. In addition, surgery time and postoperative complications were analyzed.

RESULTS: The record review identified 25 patients, of whom 13 had been treated with superior oblique muscle suture spacers and 12 with superior oblique muscle silicone expanders. Both groups showed improved ductions and versions. In patients with Brown syndrome, complete normalization of superior oblique muscle overaction occurred in 67% of patients who had suture spacers and 67% of patients who had silicone expanders. In patients with A-pattern strabismus, normal function of the superior oblique muscle occurred in 75% of patients with suture spacers and 67% of patients with silicone expanders. Surgery time was significantly less in patients who had suture spacers. Severe orbital inflammation occurred in 1 patient around the silicone band and was managed by removal of the implant.

CONCLUSIONS: Both suture spacers and silicone expanders improved the comitance of versions and normalized superior oblique muscle function. Longer surgery time and more severe inflammatory reaction are possible drawbacks of silicone expanders.

PURPOSE: To identify factors that influence binocular function in anisometropic, nonstrabismic children before and after optical correction and amblyopia therapy.

METHODS: This was a prospective observational study of consecutive patients with nonstrabismic anisometropia. Visual acuity and responses to the 4(Δ) base-out prism test, the Worth 4-dot test, and the TNO test were recorded after spectacle correction and every 3 months for 1 year. Factors affecting visual acuity and binocular function were analyzed using univariate and multiple stepwise regression analysis.

RESULTS: A total of 118 subjects were enrolled. At the end of the first year, the mean improvement in visual acuity was 2.6 ± 2.3 lines. The percentage of patients showing a positive response to the 4(Δ) base-out prism test increased from 47% to 79%; fusion in the Worth 4-dot test, from 37% to 66%; and measurable stereopsis on TNO testing, from 59% to 80%. Better initial visual acuity and better final visual acuity were associated with better binocular function. Interocular refractive error difference was a predictor of poor binocular function in multiple regression analysis if the difference in spherical error exceeded 4 D. Patients with amblyopia showed significantly worse binocular function compared to those with no amblyopia.

CONCLUSIONS: Binocular function of anisometropic children can be improved with refractive correction and amblyopia therapy.

BACKGROUND: The purpose of this study was to evaluate the use of intralesional propranolol injection in the management of periocular capillary hemangioma.

METHODS: A prospective study was performed in 22 consecutive patients with periocular hemangioma. Twelve patients underwent intralesional propranolol injection and ten patients underwent intralesional triamcinolone injection. The size of the lesion was measured serially every week during the first month, every 2 weeks for the second month, and then monthly for another 2 months. The refractive error and degree of ptosis if present were measured before injection and at the end of the study.

RESULTS: There was reduction in the size of hemangioma, astigmatic error, and degree of ptosis in both groups. The difference in outcome between both groups was not statistically significant. Rebound growth occurred in 25% of the propranolol group and 30% of the steroid group but responded to reinjection. No adverse effects were reported during or after intralesional propranolol injection.

CONCLUSION: Intralesional propranolol injection is an alternative and effective method for treatment of infantile periocular hemangioma.

PURPOSE: To evaluate the success rate of adjustable suture techniques in horizontal eye muscle surgery in children aged 10 years and younger.

METHODS: A retrospective review of children who had horizontal eye muscle surgery at or before the age of 10 years. Patients were divided into 1 of 2 groups according to whether a nonadjustable or an adjustable technique was used. The preoperative measurements, type of strabismus, and postoperative results were analyzed.

RESULTS: A total of 98 cases in the nonadjustable group and 298 cases in the adjustable group were identified. Early success rate, defined as alignment within 8(Delta) of straight at the end of 3 months, was notably greater in the adjustable group (79%) than in the nonadjustable group (64.5%). The difference was statistically significant (p < 0.01). In the adjustable group, adjustment was performed in 64% of the cases, either because of an undercorrection or overcorrection. The adjustment procedure was performed under topical proparacaine in 20% of cases and under intravenous propofol in 80%. No complications were reported during the adjustment procedure.

CONCLUSIONS: The use of adjustable sutures can provide an improved success rate over nonadjustable sutures in eye muscle surgery in children aged 10 years or younger.

PURPOSE: To evaluate the success rate of adjustable suture techniques in horizontal eye muscle surgery in children aged 10 years and younger.

METHODS: A retrospective review of children who had horizontal eye muscle surgery at or before the age of 10 years. Patients were divided into 1 of 2 groups according to whether a nonadjustable or an adjustable technique was used. The preoperative measurements, type of strabismus, and postoperative results were analyzed.

RESULTS: A total of 98 cases in the nonadjustable group and 298 cases in the adjustable group were identified. Early success rate, defined as alignment within 8(Delta) of straight at the end of 3 months, was notably greater in the adjustable group (79%) than in the nonadjustable group (64.5%). The difference was statistically significant (p < 0.01). In the adjustable group, adjustment was performed in 64% of the cases, either because of an undercorrection or overcorrection. The adjustment procedure was performed under topical proparacaine in 20% of cases and under intravenous propofol in 80%. No complications were reported during the adjustment procedure.

CONCLUSIONS: The use of adjustable sutures can provide an improved success rate over nonadjustable sutures in eye muscle surgery in children aged 10 years or younger.

While the functions of many of the proteins located in or associated with the photoreceptor cilia are poorly understood, disruption of the function of these proteins may result in a wide variety of phenotypes ranging from isolated retinal degeneration to more pleiotropic phenotypes. Systemic findings include neurosensory hearing loss, developmental delay, situs-inversus, infertility, disorders of limb and digit development, obesity, kidney disease, liver disease, and respiratory disease. The concept of "retinal ciliopathies" brings to attention the importance of further molecular analysis of this organelle as well as provides a potential common target for therapies for these disorders. The retinal ciliopathies include retinitis pigmentosa, macular degeneration, cone-dystrophy, cone-rod dystrophy, Leber congenital amaurosis, as well as retinal degenerations associated with Usher syndrome, primary ciliary dyskinesia, Senior-Loken syndrome, Joubert syndrome, Bardet-Biedl syndrome, Laurence-Moon syndrome, McKusick-Kaufman syndrome, and Biemond syndrome. Mutations for these disorders have been found in retinitis pigmentosa-1 (RP1), retinitis pigmentosa GTPase regulator (RPGR), retinitis pigmentosa GTPase regulator interacting protein (RPGR-IP), as well as the Usher, Bardet-Biedl, and nephronophthisis genes. Other systemic disorders associated with retinal degenerations that may also involve ciliary abnormalities include: Alstrom, Edwards-Sethi, Ellis-van Creveld, Jeune, Meckel-Gruber, Orofaciodigital Type 9, and Gurrieri syndromes. Understanding these conditions as ciliopathies may help the ophthalmologist to recognize associations between seemingly unrelated diseases and have a high degree of suspicion that a systemic finding may be present.

We describe 3 patients who experienced corneal neovascularization following keratoplasty and were treated with a single subconjunctival injection of 2.5 mg bevacizumab. Although there was immediate regression of the corneal vascularization and haze, as well as improvement in the anterior chamber reaction, the effects were short-lived and starting from the second week, the corneal vessels began to progress. All 3 cases ended in permanent graft failure. The series suggests a possible role for bevacizumab in the management of graft rejection with vascularization.

PURPOSE: To characterize, and evaluate the surgical management of, patients with unilateral deficiency of depression in adduction, suggesting superior oblique muscle underaction, without significant ipsilateral inferior oblique muscle overaction.

METHODS: Such patients were identified who also had received either ipsilateral inferior oblique (IO) muscle weakening or contralateral inferior rectus muscle recession. Their histories, motility patterns, intraoperative findings, types of strabismus surgery, and postoperative results were analyzed.

RESULTS: Twelve patients were identified with unilateral deficiency of depression in adduction, with no or minimal ipsilateral IO muscle overaction. Three of these patients (25%) had previously had surgery for Brown syndrome. Four (33%) had prior orbital floor trauma. On exaggerated forced duction testing recorded for nine patients, a tight IO muscle was recorded in 78%, with no laxity of the superior oblique tendon. Four patients (33%) underwent contralateral inferior rectus muscle recession, but in all four the deficiency of depression in adduction recurred. The other eight (67%) had an IO muscle weakening procedure and achieved overall improvement of ocular alignment. Nine subsequent patients with a similar pattern of misalignment were each managed with an IO weakening procedure, with good results.

CONCLUSIONS: This motility pattern, which we are calling an "inverted Brown pattern," is caused by a tight or inelastic IO muscle. In such cases, IO muscle weakening yields better results than contralateral inferior rectus muscle recession, even though there is no significant IO muscle overaction preoperatively.

Title: Vitrectomy guided by staining of the internal limiting membrane with indocyanine green Aim: To study the value of staining of ILM with ICG in macular hole surgery and to study the possible complications related to both peeling of ILM and to ICG Subject and Methods: The study was performed on 10 patients with idiopathic macular hole (group A) and 10 patients with traumatic macular hole (group B). All patients were subjected to pars plana vitrectomy followed by ICG-assisted peeling of the ILM. Anatomical success was assessed based on clinical examination and OCT. Visual improvement was measured in both groups. Possible complications related to ICG were studied by fluorescein angiography, visual field analysis and ERG. The removed ILM was examined by transmission electron microscopy Results: Closure of the macular hole was achieved in 80% of patients of group A and in 90% of patients of group B. Statistically significant improvement in visual acuity was obtained in patients of group A. Visual improvement in group B was nil. Fluorescein angiography showed perimacular hyperfluorescence in only 2 patients. Visual field showed improvement in macular sensitivity which correlated with both the anatomical success rate and the visual improvement. ERG showed improvement in 30-Hz flicker amplitude. The removed ILM showed proliferation of glial cells on the inner surface with no histopathological evidence of other retinal elements. Conclusion: ICG-assisted peeling of the ILM has given encouraging results in macular hole surgery, particularly in idiopathic macular hole.