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Biomedical subjects

R A Saunders

Publications and source records attributed to R A Saunders.

102 records · Page 6Linked to original sources
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Congenital absence of the superior rectus muscle: a case report.

We report a case of bilaterally absent superior rectus muscles presenting clinically as a double elevator palsy. This patient is unique due to paradoxical ocular movements on attempted upgaze and the absence of other major craniofacial anomalies. Successful surgical correction was accomplished using a modified Jensen procedure where the superior halves of the horizontal rectus muscles were united using synthetic absorbable sutures. Congenital absence of the superior rectus muscles should be suspected in patients with severe elevation deficiency associated with paradoxical ocular movements.

Adolescent↗
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Early correction of severe congenital ptosis.

Twelve infants with severe unilateral or bilateral congenital ptosis were surgically repaired before 1 year of age in an attempt to achieve early functional and cosmetic improvement. In all cases, a frontalis suspension using polyfilament nylon suture (Supramid Extra) was performed. Postoperatively, 10 patients achieved near normal eyelid position and all had resolution of their chin-up head posture. Two slings eventually failed, requiring repeat procedures for recurrent ptosis. Two developed signs of cellulitis that were successfully treated with oral antibiotics.

Blepharoptosis↗
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Surgery on the normal eye in Duane retraction syndrome.

Duane retraction syndrome is a well-described congenital eye movement disorder whose management is still controversial. Various surgical strategies have been advocated, usually limited to the involved (restricted) eye to eliminate a face turn or a manifest deviation in the primary position. However, surgery on the normal eye has the potential to expand the field of single binocular vision as well as restore primary position alignment. In patients with mild-to-moderate duction deficiencies in the restricted eye, we have used very large recessions or posterior fixation sutures on the normal eye to create matching duction limitations, which in some cases produce a wider range of fusion postoperatively.

Adult↗
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Downgaze restriction after placement of superior oblique tendon spacer for Brown syndrome.

Diplopia in the reading position developed in two patients with unilateral Brown syndrome after a 7-millimeter section of #240 silicone retinal band was sewn between the cut ends of the superior oblique tendon at tenotomy. In both cases, forced ductions were positive, indicating a restrictive downgaze deficit. Surgical exploration revealed adhesions that prevented the normal sliding of the superior oblique tendon beneath the superior rectus muscle. Forced ductions became normal and downgaze improved after removal of the silicone band. Secondary superior oblique muscle paresis was also evident at the time of reoperation, requiring recession of the contralateral inferior rectus muscle (cases 1 and 2) and recession of the ipsilateral inferior oblique muscle (case 1). A restrictive downgaze deficit and a paretic overcorrection must be recognized as possible complications of the superior oblique tendon silicone "expander" operation.

Adult↗
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The predictive value of posterior pole vessels in retinopathy of prematurity.

Dilation and tortuosity of the posterior pole vessels "(plus disease)" is a sign of poor prognosis and may be associated with threshold or prethreshold retinopathy of prematurity (ROP). We have found that normal posterior pole vessels are a reliable marker for the absence of stage 3 ROP. One hundred thirty-two consecutive premature infants weighing less than 1600 g at birth underwent ROP examinations between 32 and 40 weeks' postconceptional age. The status of the posterior pole vessels was compared to peripheral retinal pathology. Vascular findings in the posterior pole were graded 0, 1, 2, or 3, with 0 representing normal arterioles and venules and 3 representing plus disease. The remainder of the fundus examination was recorded using the international Classification of ROP, then converted to a severity scale based on zone and stage of ROP. For each infant, only one examination representing the most severe stage of ROP reached prior to treatment or spontaneous regression was used for data analysis. There was a highly significant Spearman's rank correlation (rs = 0.65) between the posterior pole vascular abnormalities and the severity of ROP in the retinal periphery. Clinically important ROP was not found in any patient with normal posterior pole vessels (grade 0) and stage 3 disease was usually associated with both venous and arterial vascular abnormalities (grades 2 or 3). When ocular examination of premature infants is difficult because of poor dilation of the pupil, hazy media, or medical instability, normal appearance of the posterior pole vessels can be a reassuring finding if it is necessary to postpone complete fundus examination in infants at risk for ROP.

Fundus Oculi↗
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Dissociated horizontal deviation and accommodative esotropia: treatment options when an eso- and an exodeviation co-exist.

Dissociated strabismus includes movements in the vertical, horizontal, and torsional axes. Dissociated vertical deviation (DVD) is an oversimplified label because it implies a purely vertical deviation. When the abducting component of the dissociated strabismus complex is prominent, the term dissociated horizontal deviation (DHD) is used. We present six patients with accommodative esotropia who developed prominent DHD. Only two patients have a prior history of congenital esotropia. Latent nystagmus was observed in five of the patients. With the combination of DHD and esotropia, an esodeviation during active fixation may become an exodeviation when the patient is visually inattentive. Five patients required surgery for DHD. Four options are used and discussed. DHD can be treated alone with lateral rectus muscle recession. DHD can be treated as above, but combined with medial rectus muscle recessions or posterior fixation sutures to simultaneously treat the esotropia. The esotropia can be treated alone, possibly with a reduced surgical dosage. If the patient varies from an esodeviation to an exodeviation, but is straight much of the day, observation without surgical therapy may be advisable. Just as a hypotropia can have an overlying DVD, an esotropia can have an overlying DHD. This combination may masquerade as variable angle esotropia or may present as an esodeviation when the patient is visually attentive and an exodeviation when the patient is visually inattentive.

Accommodation, Ocular↗
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Can non-ophthalmologists screen for retinopathy of prematurity?

BACKGROUND: Dilation and tortuosity of the posterior pole vessels ("plus disease") is a poor prognostic sign and may indicate the presence of threshold or pre-threshold retinopathy of prematurity (ROP). Because stage 3 ROP appears rarely in the absence of posterior pole vascular abnormalities, we prospectively evaluated the ability of non-ophthalmologists (4th-year medical students, pediatric residents, and nurse practitioners) to identify abnormalities in the retinal blood vessels of infants undergoing examinations for ROP. METHODS: Fifty infants weighting less than 1600 g at birth were examined between 32 and 40 weeks after conception. Prior to ophthalmological examination, non-ophthalmologist examiners graded posterior pole vessels as normal or abnormal based on ophthalmoscopic appearance. One hundred twenty-one ocular examinations were performed using the teaching mirror of the indirect ophthalmoscope, 179 using the direct ophthalmoscope. The indirect ophthalmoscopy was performed simultaneously by an ophthalmologist who evaluated the posterior pole vessels for abnormalities prior to conducting a peripheral fundus examination on either eye. RESULTS: Testing sensitivity for the non-ophthalmologist examiners using direct and indirect ophthalmoscopy was 96% and 92%, respectively. Combining the results from direct and indirect ophthalmoscopy, the Clopper-Pearson 95% sensitivity confidence interval for identifying abnormal arterioles and venules was 82% to 99%, with a point estimate of 95%. CONCLUSION: These data suggest that non-ophthalmologist examiners can detect posterior pole vascular abnormalities in premature infants. If properly trained, they could possibly play a role in screening or follow-up examinations for ROP.

Humans↗
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Surgery for vertical head position in null point nystagmus.

PURPOSE: We applied the general concepts of Anderson and Kestenbaum to the management of patients with chin up or chin down head posture caused by vertical or horizontal nystagmus. METHODS: We reviewed retrospective charts of seven patients with vertical plane torticollis who had surgical management of null point nystagmus. RESULTS: Three patients with chin down head posture underwent successful treatment using large recessions of the superior rectus muscles combined with inferior oblique muscle anterior transposition. The four patients with chin up head posture were more resistant to surgical treatment. Two of the four required multiple surgical procedures for adequate correction, but had residual torticollis. CONCLUSION: Bilateral superior rectus muscle recession combined with inferior oblique muscle anterior transposition is effective surgical management of vertical plane torticollis with chin down head posture caused by null point nystagmus. Although the treatment of patients with chin up head posture was less successful, surgically induced down-gaze deficits may be necessary to improve outcome.

Adolescent↗
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Mechanized anterior capsulectomy as an alternative to manual capsulorhexis in children undergoing intraocular lens implantation.

BACKGROUND: Although manual capsulorhexis is an ideal anterior capsulectomy technique for adults, it is more difficult to perform in very young eyes because the capsular bag is more elastic. Our mechanized anterior capsulectomy technique has compared favorably with manual capsulorhexis in the laboratory using autopsy eyes. We now report the results of circular mechanized anterior capsulectomy in consecutive pediatric patients receiving a posterior chamber intraocular lens (IOL) after cataract extraction. METHODS: Twenty eyes of 17 consecutive patients between 6 months and 13 years of age underwent a mechanized anterior capsulectomy followed by IOL implantation into the capsular bag. The integrity of the anterior capsular edge was evaluated at the completion of capsulectomy, prior to IOL insertion, and at the end of surgery. RESULTS: A single radial tear developed in three eyes (15%) of two patients (12%). In the remaining 17 eyes (85%), an intact circular capsulectomy edge was verified at the completion of the mechanized capsulectomy, at the end of IOL insertion, and at the completion of surgery. Complete in-the-bag capsular fixation of the IOL was accomplished in all 20 eyes. Both patients who sustained radial tears were older children (age 11 years). All IOLs remain well centered behind a smooth circular anterior capsular edge after a minimum follow up of 6 months. CONCLUSION: A mechanized anterior capsulectomy technique can produce a circular capsular opening that resists tearing during lens aspiration and IOL insertion. The vitrector-cut capsulectomy performed well even in the youngest patients in whom manual capsulorhexis would have been difficult to control.

Adolescent↗
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Retinal examinations in infants after extracorporeal membrane oxygenation.

BACKGROUND: Ophthalmic examinations performed in infants undergoing extracorporeal membrane oxygenation (ECMO) are recommended because ocular abnormalities have been known to occur after this procedure. METHODS: We reviewed medical records of infants treated with ECMO was subsequently underwent routine ophthalmic examination prior to or immediately after hospital discharge. Examinations were performed in a fashion similar to that for retinopathy of prematurity screening. RESULTS: Eye examinations were recorded for 171 patients (342 eyes). Fundus examination was normal in 302 eyes (88%). Abnormal retinovascular findings such as venous dilation or intraretinal hemorrhages, when present, were not considered vision threatening and required no treatment. CONCLUSION: Clinically important retinal findings were not identified in our patients undergoing postECMO screening. Routine dilated fundus examination is probably not cost effective and places additional and potentially unnecessary stress on these infants.

Extracorporeal Membrane Oxygenation↗
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Predictive value of regression and theoretical IOL formulas in pediatric intraocular lens implantation.

PURPOSE: Intraocular lenses (IOLs) are being implanted in children with greater frequency and in a wider age range. The accuracy of available regression and theoretical formulas in predicting correct IOL power for pediatric eyes, however, has not been reported. METHODS: We reviewed medical records of 47 consecutive pediatric IOL implantations after cataract extraction that met inclusion criteria. Age at surgery ranged from 2 months to 10 years, with measured axial lengths of the eye between 18.6 and 26.7 mm. For the purpose of this study, the 2-month postoperative refraction was considered the post-IOL refractive outcome. Using preoperative globe axial length, corneal curvature, IOL power, and the A constant for the lens provided by the manufacturer, we employed the four common IOL power formulas (one regression formula [SRK-II] and three theoretical formulas [SRK-T, Holladay, and Hoffer Q]) to predict refractive outcome. RESULTS: The average difference between predicted and actual postoperative refractive error ranged from 1.2 to 1.4 diopters (D) for all formulas. Predicted postoperative refraction was less than the actual in 89 calculations and greater in 99. No significant differences in predictive accuracy were found in any of the axial length groups (group 1 P = 0.79, group 2 P = 0.42, and group 3 P = 0.86). All formulas were slightly less accurate in group 3 patients (shortest eyes). In this group, the Hoffer Q formula had the lowest error (1.4 D) and the SRK-II had the highest error (1.8 D). The difference was not statistically significant (P = .86). CONCLUSIONS: In our pediatric study eyes, all four IOL power calculation formulas predicted mean refractive outcome within 1.4 D. Theoretical formulas did not outperform the regression formula.

Adolescent↗