Practice-Changing News in Pediatric Ophthalmology

American Association for Pediatric Ophthalmology and Strabismus 2013

Monte D. Mills, MD


April 23, 2013

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Hello. I am Monte Mills from the Children's Hospital of Philadelphia in the division of ophthalmology. I have just returned from the 2013 meeting of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) and I would like to recap some of the highlights of that meeting for Medscape.

Strabismus: Not Just in the Young

The 2013 Leonard Apt lecture, which memorialized Dr. Apt, a father of pediatric ophthalmology who just passed away this year, was delivered by Joseph Demer.[1] Dr. Demer discussed a new syndrome, for which he has coined the term "sagging eye syndrome." He described this syndrome in aging individuals, who have a combination of upper eyelid ptosis, superior sulcus deformity, and variable divergent paralysis esotropia and cyclovertical strabismus. He showed, in a very elegant series of MRI scans, how the erectus muscle pulleys are damaged in aging. He discussed treatment for the syndrome, which includes a combination of horizontal surgery and vertical muscle partial tenotomies.

Pediatric Cataract Surgery

The other major main lecture was the 2013 Costenbader lecture, delivered by Dr. Edward Wilson[2] from the University of South Carolina, who discussed the role of vitrectomy in the evolution of pediatric cataract surgery. Through his vast experience in pediatric cataract surgery, he explained how vitrectomy is safe, necessary, and unlike adult cataract surgeries, very effective in the treatment of children with a very low rate of retinal detachment and endophthalmitis.

In a related presentation from the same group, Trivedi and colleagues[3] discussed new guidelines and a new model for prescribing contact lens powers based on preoperative biometry of pediatric cataract eyes for aphakic contact lens fitting. This new model is much more effective than our previous empirical, age-based model and was quite accurate within the parameters that are available in aphakic contact lenses for infants.

Exercises for Convergence Insufficiency

An interesting article on strabismus in a recent publication[4] described the use of exercises for convergence insufficiency. A convergence insufficiency treatment trial was presented by Horwood, Toor, and Riddell,[5] titled "The Effect of Effort and Exercise on Convergence and Accommodation." A group of normal adult volunteers were randomly assigned to placebo treatment, no treatment, and various forms of convergence and accommodative treatment. With some of the exercises, the investigators measured small improvements in convergence and accommodation, but a much larger effect on accommodative and convergence measurements was produced from tester encouragement and volunteer effort. The investigators concluded that effort and encouragement play much larger roles than previously thought in convergence and accommodative measurements. These effects have to be taken into consideration when interpreting the outcomes of exercise therapy for convergence insufficiency.

New Treatment for Superior Oblique Palsy

With respect to strabismus surgery, Whitman and colleagues[6] presented a new concept for the treatment of superior oblique palsy. They reported 32 consecutive cases of superior oblique palsy treated with a single type of surgery: superior oblique tuck associated with contralateral yoke recessions. They demonstrated excellent outcomes, and this will change the previous paradigm of using different types of procedures for palsies with different preoperative measurements and/or different intraoperative traction testing. Whitman and colleagues' article on superior oblique tuck will be a landmark paper on the treatment of superior oblique palsy going forward.

Outcomes of Pediatric Keratoplasty in Infants

Finally, from our own institution, Areaux and colleagues[7] presented the anatomic and visual outcomes of pediatric keratoplasty during infancy, looking at 79 eyes with pediatric keratoplasty during the first year of life. When comparing the eyes done early during infancy vs those done later in infancy, they discovered that the outcomes of graft survival and time to failure were very similar. There were also very similar visual outcomes, which, although this was a nonrandom consecutive case series, tells us that early transplants are not more risky in terms of graft survival, and that it might be reasonable to postpone transplant and still achieve good visual outcomes.

These were some of the most interesting papers presented at the 2013 AAPOS meeting in Boston, Massachusetts. This is Monte Mills from the Children's Hospital of Philadelphia, for Medscape. Thank you.