Biomedical subjects
B J Kushner
Publications and source records attributed to B J Kushner.
The management of nasolacrimal duct obstruction in children between 18 months and 4 years old.
PURPOSE: Success with nasolacrimal duct probing has been shown to be inversely correlated with age. Consequently, several authors have suggested that the older child with a previously untreated nasolacrimal duct obstruction should undergo silicone intubation or a balloon catheterization as the primary surgical procedure because older children are more likely to have complicated obstructions that will not respond to simple probing. The purpose of this study was to investigate the hypothesis that older children with uncomplicated nasolacrimal duct obstruction can be successfully managed with simple probing. METHODS: A 14-year prospective study was conducted of consecutive patients older than age 18 months with nasolacrimal duct obstruction. All were treated (subject to certain exclusion criteria) with a simple nasolacrimal duct probing. Careful attention was paid to the type of obstruction encountered at surgery. Outcome evaluation included a standard ophthalmologic examination plus a dye disappearance test at 6 weeks after surgery. A follow-up examination or telephone interview was conducted 1 year after surgery. RESULTS: Of 378 children undergoing nasolacrimal duct probing, 23 met the inclusion criteria of being older than age 18 months (18 to 48 months). Seventy percent of the 23 children had a good outcome from the probing procedure. When analyzed by the type of obstruction, 12 of the 12 children (100%) with a simple membrane at the valve of Hasner had a good outcome. This contrasted with a success rate of 4 of 11 children (36%) who had complicated obstructions (p < 0.01). Complicated nasolacrimal duct obstructions were more prevalent in older children. CONCLUSION: A simple probing of the nasolacrimal duct has an excellent success rate in children up to 4 years old if an uncomplicated obstruction is found at the valve of Hasner.
Grand rounds #51: a case of consecutive exotropia after medial rectus recession for Duane syndrome.
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Grand rounds #49: A case of bilateral asymmetric Duane syndrome with fixation with the more affected eye.
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Grand rounds #50: A case of a lost medial rectus muscle in an eye in which the inferior rectus muscle "pulled in two".
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Grand rounds #52: a case of a residual left exotropia and hypertropia after previous surgery for a third nerve palsy.
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Botulinum toxin management of essential infantile esotropia in children.
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Restriction of elevation in abduction after inferior oblique anteriorization.
PURPOSE: Inferior oblique anteriorization is gaining popularity for the treatment of dissociated vertical divergence associated with inferior oblique overaction. This procedure is based on the theory that moving the insertion of the inferior oblique muscle anterior to the equator changes its vector of force from one of elevation to one that opposes elevation. The purpose of this investigation is to describe, investigate the cause, and outline treatment for a complication I observed after inferior oblique anteriorization. This postoperative syndrome consists of a motility pattern that resembles marked residual inferior oblique overaction associated with a Y or V pattern. It is probably caused by a restriction of elevation of the abducting eye causing fixation duress, with a resultant upshoot of the contralateral adducting eye. METHODS: A retrospective chart review was conducted for all patients on whom I performed bilateral inferior oblique anteriorization for inferior oblique overaction associated with dissociated vertical divergence. Patients in whom this postoperative syndrome developed were compared with those in whom it did not with respect to type and extent of surgery. In addition, cases of patients I treated or examined for this complication but whose inferior oblique anteriorization had been performed by other ophthalmologists were also analyzed. RESULTS: I performed bilateral inferior oblique anteriorization in 77 patients. In 29 patients the inferior oblique muscles were placed level with the insertions of the inferior rectus muscles, in 31 patients they were placed 1 mm anterior to the insertions of the inferior rectus muscles, and in 17 patients they were placed 2 mm anterior. The postoperative syndrome described here developed in two of the 77 patients; both had the inferior oblique muscles placed 2 mm anterior to the insertions of the inferior rectus muscle. These were also the only two patients in this series in whom the new insertion of the inferior oblique muscle was spread out laterally at the time of anteriorization. I have seen an additional six patients in whom this syndrome developed after undergoing operations by other ophthalmologists. In four, the inferior oblique muscles were placed 2 mm anterior to the insertions of the inferior rectus muscles, and in two they were placed 3 mm anterior. Of the eight patients I have observed with this complication, I reoperated on six. The surgical procedure consisted of denervation or extirpation of both inferior oblique muscles in four patients and conversion to standard recessions of the inferior oblique muscles in two patients. In all six patients,the versions were markedly improved and the Y orV pattern was eliminated after reoperation. CONCLUSIONS: Anteriorization of the inferior oblique muscles more than 1 mm anterior to the insertions of the inferior rectus muscle may cause a limitation of elevation in abduction, resulting in a Y or V pattern that mimics inferior oblique overaction. This may be more likely to occur if the new insertions of the inferior oblique muscles are spread out laterally at the time of anteriorization.
Is alignment within 8 prism diopters of orthotropia a successful outcome for infantile esotropia surgery?
OBJECTIVE: To determine if there is better long-term motor alignment or sensory outcome 5 years after surgery for infantile esotropia for patients who exhibit any of three categories of alignment 6 months after surgery: orthotropia, up to 8 prism diopters (delta) of esotropia, or up to 8 delta of exotropia. DESIGN: A 15-year prospective study with 5-year outcome determination was conducted in surgically treated esotropic infants. RESULTS: Of 118 patients in the study group, 24 had orthotropia, 84 had up to 8 delta of esotropia, and 10 had up to 8 delta of exotropia 6 months after surgery. The patients who were orthotropic 6 months after surgery were more likely to show good alignment and better binocularity 5 years after surgery than were patients with small-angle esotropia or small-angle exotropia. Patients who were esotropic 6 months after surgery were more likely to have good alignment and binocularity 5 years after surgery than were patients who were exotropic 6 months after surgery. CONCLUSION: Small-angle esotropia, small-angle exotropia, and orthotropia are not equally desirable outcomes after surgery for infantile esotropia. Orthotropia is a decidedly better outcome than a small-angle esotropia, which is preferable to a small-angle exotropia.
Balloon catheter dilatation for treatment of congenital nasolacrimal duct obstruction.
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Grating visual acuity with Teller cards compared with Snellen visual acuity in literate patients.
OBJECTIVE: To determine the usefulness of Teller Acuity Cards for detecting three levels of vision deficit, the cutoff for amblyopia (20/40 or poorer), vision impairment (20/70), or legal blindness (20/200). DESIGN: We compared grating visual acuity with the Teller cards with Snellen visual acuity (our gold standard) in 69 literate patients with amblyopia or other cause of vision loss in a prospective masked study. RESULTS: Teller card visual acuity and distance Snellen visual acuity correlated significantly (r = .508, P < .001); however, Teller card visual acuity explained only 26% of the variation in distance Snellen visual acuity. Teller card visual acuity had a low sensitivity for detecting vision deficit of 20/40 or poorer (58%), vision deficit of 20/70 or poorer (39%), or legal blindness (24%), but somewhat more accurately reflected near Snellen visual acuity than distance visual Snellen acuity. Teller cards had a higher positive predictive value--80% for 20/70 visual acuity and 43% for legal blindness, as determined by near Snellen visual acuity. Specificity of Teller cards was 88% for detecting visual acuity loss of 20/70 and 98% for legal blindness. Negative predictive value of Teller cards for detecting visual acuity loss of 20/70 was 50% and for legal blindness was 71%. CONCLUSIONS: Teller Acuity Cards may underestimate the presence of amblyopia of all types, legal blindness, and a specified level of vision impairment (20/70). Even in the presence of normal visual acuity measurements with Teller cards, significant visual loss as assessed by standard Snellen optotypes may be anticipated in many patients.
Fixation switch diplopia.
OBJECTIVE: To present guidelines for the diagnosis and management of fixation switch diplopia. BACKGROUND: Adults with a history of strabismus since childhood may experience acquired diplopia if a change in their refractive error or use of spectacles encourages fixation with their nondominant eye. This is referred to as "fixation switch diplopia." If correctly diagnosed, this seldom-recognized cause of acquired diplopia in adults can almost always be successfully treated with the proper optical management. PATIENTS: A retrospective review was carried out for all patients with the diagnosis of fixation switch diplopia who were seen in my private practice. RESULTS: A review of patient records identified 16 patients with fixation switch diplopia. In four patients, the switch in fixation was spontaneous owing to the development of myopia in the previously preferred eye in patients with mild contralateral amblyopia. Six patients developed diplopia owing to their "monovision" (one eye optically corrected for distance and the other eye presbyopic). In six patients, fixation switch diplopia occurred because a noncycloplegic subjective refraction was performed in the presence of amblyopia, resulting in an unbalanced refractive correction. In all 16 patients, symptoms were eliminated when proper optical correction was instituted to encourage fixation with the dominant eye. CONCLUSIONS: Fixation switch diplopia is a cause of acquired diplopia in adults with a history of strabismus since childhood. It can usually be successfully treated with proper optical management.
Early office-based vs late hospital-based nasolacrimal duct probing.
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Infantile uniocular blindness with bilateral nystagmus. A syndrome.
BACKGROUND: A syndrome has been described in which some patients with uniocular infantile blindness have a horizontal nystagmus in their contralateral, structurally sound eye. This nystagmus has the characteristics of latent nystagmus. This study investigated the hypothesis that this syndrome is present when infantile monocular blindness occurs in patients who are genetically predisposed to congenital strabismus. In these patients, nystagmus, which would be latent, is made manifest by media opacity or suppression acting as an occluder. PATIENTS: 1 prospectively studied all patients with this syndrome whom I examined between 1982 and 1994. Evaluation included a careful investigation of whether there was a family history of congenital strabismus. Three patients underwent electro-oculography. RESULTS: The series consisted of 24 patients with the syndrome of infantile uniocular blindness with bilateral nystagmus, of whom 14 (58%) had a family history of congenital strabismus. In a consecutive series of 50 patients with monocular congenital blindness caused by opacity of the ocular media but not manifesting nystagmus of the contralateral eye, only three patients (6%) had a family history of congenital strabismus. This difference was statistically significant (P < .01). CONCLUSIONS: It appears likely that the syndrome of monocular infantile blindness with bilateral nystagmus represents a manifest nystagmus of the latent type in patients who have inherited a genetic predisposition for congenital strabismus. In these patients, the monocular blindness (opacity of the media or suppression) acts as an occluder, making manifest what would have been latent nystagmus.
Management of diplopia limited to down gaze.
OBJECTIVE: To evaluate the usefulness of various optical and surgical treatment modalities in the treatment of patients who were symptom free in the primary position of gaze yet had symptomatic diplopia in the reading position (down gaze at near). PATIENTS AND METHODS: A retrospective chart review was conducted to identify all patients with presbyopia I have treated who were symptom free in the primary position but had diplopia in down gaze associated with vertically incomitant strabismus. Of 51 patients identified, 32 were symptomatic in down gaze due to a hypertropia associated with a unilateral inferior rectus muscle underaction. Twenty-two of these patients had previously undergone recession of the affected inferior rectus muscle for treatment of thyroid eye disease; four patients, for correction of entrapment secondary to blow-out orbital fracture; and four patients, for treatment of superior oblique muscle palsy. Two patients had undergone prior surgery for superior oblique myokymia. Eight patients had horizontal diplopia associated with an A pattern, and eight patients had horizontal diplopia associated with a V pattern. Three patients had vertical and horizontal diplopia after partial recovery from third-nerve palsy. RESULTS: The treatment modalities were varied and individualized. Treatment consisted of optical management (20 patients), surgical management (21 patients), or a combination of both (10 patients). These treatment modalities resulted in comfortable single binocular vision for reading in 41 of the 51 patients. Successful optical treatment consisted of Fresnel prisms (four patients), slab-off prisms (two patients), single-vision readers (seven patients), switch to nonprogressive bifocal lenses (three patients), and a high bifocal segment (16 patients). Successful surgical modalities included posterior fixation of the contralateral inferior rectus muscle (10 patients), surgery for A- or V- pattern strabismus (five patients), or bilateral inferior rectus muscle recession (six patients). CONCLUSION: Diplopia in the reading position frequently can be alleviated with a systematic approach that includes both optical and surgical modalities.
Partly accommodative esotropia. Should you overcorrect and cut the plus?
OBJECTIVES: To investigate the long-term motor stability and sensory outcome of patients with partly accommodative esotropia who were overcorrected surgically and in whom the hyperopic correction was reduced postoperatively, and to determine if those results depended on the amount of hyperopia present. DESIGN: A 15-year prospective study that analyzed 5-year outcome. Patients whose esotropia was not initially overcorrected were used as controls. PATIENTS: Of 382 patients who underwent surgery for partly accommodative esotropia, 22 were surgically overcorrected and were followed up for 5 years. RESULTS: Of the eight patients in the study group with 2.5 diopters or less of hyperopia in their fixing eye, seven had good motor alignment compared with four of 14 patients who had more than 2.5 diopters of hyperopia. Ninety-one percent (148/163) of the control patients who had greater than 2.5 diopters of hyperopia maintained good motor alignment 5 years after surgery compared with 29% of the study group patients. This difference was statistically significant. Of the eight study patients with less than 2.5 diopters of hyperopia, five developed good stereopsis compared with one of 14 patients with greater hyperopia. CONCLUSIONS: Surgical overcorrection in patients with partly accommodative esotropia with greater than 2.5 diopters of hyperopia may not be reversible by postoperative reduction in the hyperopic correction. It often is reversible, however, in patients with 2.5 diopters or less of hyperopia.
Binocular field expansion in adults after surgery for esotropia.
OBJECTIVES: To determine how frequently adults with long-standing esotropia will experience an expansion of their binocular visual field after surgical correction of their strabismus and to determine if the postoperative expansion of binocular fields in esotropic adults correlates with the type of esotropia (infantile vs acquired), duration of the deviation, visual acuity in the deviating eye, or a history of satisfactory alignment in early childhood. DESIGN: Preoperative and postoperative binocular visual fields were measured in a consecutive series of 37 adults undergoing surgery for esotropia. The fields were obtained and graded by masked observers. RESULTS: Before surgery, all patients had a constricted binocular field on the side of the deviating eye. In 35 of the 37 patients, the visual fields met predetermined criteria for accuracy and were included in data analysis. After surgery, 34 of those 35 patients experienced an expansion of their binocular field consistent with the degree to which the eye was surgically straightened. There was no correlation with binocular field expansion after surgery and the type of esotropia (infantile vs acquired), duration of the deviation, visual acuity in the deviating eye, or a history of satisfactory alignment in early childhood. CONCLUSIONS: Binocular field expansion occurs in the vast majority of esotropic patients after strabismus surgery if the surgery is successful in correcting esotropia. The developmental gains that are reported in infants undergoing surgery for infantile esotropia may be due to an expansion of their binocular field after surgery.
Grating acuity tests should not be used for social service purposes in preliterate children.
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