Biomedical subjects
Publications and source records attributed to D A Hiles.
Prolapse of the conjunctiva from the superior cul-de-sac is an infrequent complication following external levator resection. In uncooperative patients or children, repositioning of the prolapsed fold of tissue may be difficult and result in a fused conjunctival fold. This complication occurred in 4 of 102 children of the authors' series; its management is outlined.
Rapid recognition and appropriate therapy will prevent or remediate most of the complications occurring in children after cataract aspiration and IOL implantation. Some of the complications of pediatric IOL implantations are related to the increased scleral pliability and decreased rigidity which predispose scleral collapse, vitreous loss, flat anterior chamber and corneal endothelial damage. A second group of complications is associated with the enhanced inflammatory and fibrotic responses peculiar to a child's eye. This group includes operative striate keratitis and iridocyclitis, late IOL precipitates, secondary and postpseudophakos membranes, iris erosion and synechiae formation, and IOL tilt and displacement. Although the intraocular lens is a possible means of visual rehabilitation for children with traumatic cataracts or unilateral infantile cataracts, its long-term risk/benefit ratio must still stand the test of time.
Our data indicate that corneal endothelial cell density in a normal eye remains essentially unchanged from ages five to 20. Changes in cell density and morphology during the first five years of life need further investigation. In this study, the mean endothelial cell count of a normal population of children was 2696 cells/mm2. Children undergoing cataract aspiration had a mean cell loss from the normal of 7.2%. The cell loss rates for push-pull aspiration-irrigation or phacoemulsification cataract extraction were not statistically different. The implantation of an intraocular lens was associated with a 33.3% endothelial cell loss when compared to the control or normal population of eyes. A mean loss of 38.0% was noted when the IOL eyes were compared to their normal fellow eyes.
Eight children in whom 2-loop iridocapsular lenses or 2-loop iris suture lenses were implanted have exhibited peripheral iris erosion adjacent to the IOL haptic, through the iris stroma, and eventually through the iris pigment epithelium. The process appears to be very gradual and these patients have exhibited no signs of iris irritation of hyphema. No treatment has been instituted.
The authors treated 38 patients with exodeviations by occlusion of the preferred eye for three to six hours daily for an average of 15 months. This treatment resulted in a significant improvement in the latency of the deviation as well as a decrease in the size of the strabismic angle. The majority of those patients responding to this method of therapy initially had good central and maintained fixation in each eye, an exodeviation of 20 prism diopters or less at both 6 and 1/3 m, and the presence of fusional vergence amplitudes.
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Three patients had four lid distichiasis and signs and symptoms of allergic rhinoconjunctivitis. The findings consisted of ocular irritation with tearing, photophobia, periodic lid swelling, rhinorrhea, and boggy nasal mucosa. Treatment of the allergic rhinoconjunctivitis was unsuccessful until the distichiasis was relieved. Exacerbations of signs and symptoms recurred when lashes regrew. A neural reflex relationship exists to explain most of the symptom complex resulting from ocular irritation. In the evaluation of patients with rhinoconjunctivitis, trichiasis should be looked for, especially if there is noticeable photophobia present.
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The intraocular lens offers an additional experimental parameter to be considered for the visual rehabilitation of children with traumatic or unilateral infantile cataracts. The disadvantages of aphakic spectacles or contact lens and amblyopia have committed many of these eyes to the status of visual cripples. In this series of 41 patients, with a maximum of 24 months follow-up, it has been concluded that the IOL may be successfully implanted.
The intraocular lens offers an additional parameter to be considered for the visual rehabilitation of children with traumatic or infantile cataracts. The disadvantages of aphakic spectacles or contact lens have committed many of these eyes to the status of visual cripples. Bearing in mind all of the complications and the lack of long-term follow-up, the IOL warrants careful consideration for use in this group of cataract patients. In this series of 27 patients with a maximum of 18 months' follow-up, it is concluded that the IOL may be successfully implanted and that, thus far, no eye has been made worse than the patients preinsertion status.
Ninety eyes undergoing surgery for the removal of traumatic cataracts were evaluated. In the total group, the visual results fell generally into the 2 categories of satisfactory or poor. Most commonly, the latter patients sustained extensive preoperative trauma or were visually immature at the time of the injury. Forty-eight eyes, or 54% of this series, achieved an acuity of 20/80 or better, with 38, or 42%, achieving a corrected acuity of 20/20 to 20/30. There were 20 eyes in the patients 6 years of age and under, and a visual result of 20/60 or better was obtained in 7 of those eyes.
An improved understanding of the role of the vitreous in ocular pathology has led to a more rational approach to the prevention and management of vitreous loss during infantile cataract extractions. Infantile cataract surgery, properly performed by modifications of the Scheie aspiration and Kelman phacoemulsification techniques, should be associated with an incidence of vitreous loss no greater than that for adult extractions by current intracapsular or extracapsular techniques. Preexisting ocular lesions, faulty technique, and an inexperienced operator all contribute to the occurrence of vitreous loss. Improved techniques, surgical expertise, and an understanding of the factors that predispose to vitreous loss can reduce its incidence. Proper management of vitreous loss will decrease or eliminate its untoward sequelae; eyes so managed can be visually rehabilitated with the same ease or difficulty as similar eyes in which vitreous was not lost. The authors do not, however, advocate either the accidental or intentional disturbance of the intact vitreous body.
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The intraocular lens offers an experimental alternative to be considered for the visual rehabilitation of children with traumatic or unilateral infantile cataracts. The disadvantages of aphakic spectacles or contact lenses and amblyopia have committed many of these eyes to the status of visual cripples. In this series of 41 patients with a maximum of 24 months follow-up, it has been concluded that an IOL may be successfully implanted. I wish to reemphasize that vitreous involvement does not preclude IOL implantation providing all the vitreous is removed from the anterior chamber by the conclusion of the operation. Discissions of secondary membranes should be performed if there is any doubt as to the clarity of the membrane. All patients should be repeatedly refracted and the over-refraction prescribed to assure that the child is obtaining the best possible form vision to the aphakic eye. Bifocals are encouraged for near work. Vigorous occlusion therapy is undertaken in all patients exhibiting signs of amblyopia.