Biomedical subjects
M R Ing
Publications and source records attributed to M R Ing.
Physicians' greatest enemy--complacency!
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Botulinum toxin therapy in exotropia.
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Needle sterility during strabismus surgery.
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Outcome study of bilateral lateral rectus recession for intermittent exotropia in children.
BACKGROUND AND OBJECTIVE: The purpose of this paper is to report a statistical analysis of the surgical results in a consecutive series of 52 children treated by bilateral lateral rectus recession for intermittent exotropia when the operating surgeon was confronted by an increase in manifestation of the strabismus. PATIENTS AND METHODS: The charts were abstracted for age at initial surgery, quantity of initial deviation, initial refraction, motor alignment at one week, six months, and at the end of the study. The incidence and result of secondary surgery and the incidence of the monofixation syndrome result was also determined. RESULTS: Thirty-two (62%) of the patients were successfully aligned at six months by the initial surgery performed for a mean of 25 prism diopters (PD) of preoperative deviation at a mean age of 4 years 8 months. Eleven patients (21%) were undercorrected and 9 patients (17%) were overcorrected at the six month exam. The patients were followed for a mean of 4 years, 4 months. Alignment at 6 months postoperatively was predictive of success by the end of the study, but the age at initial surgery, the size of the deviation, esotropia at 1 week, and initial refraction were not predictive of success. Secondary surgery was performed in 11 patients and the monofixation syndrome result was found in 5 patients. CONCLUSION: Successful alignment was achieved in the majority of children treated by an initial bilateral lateral rectus recession utilizing a currently popular surgical dosage table. Long term alignment success was not predicted by esotropia during the first postoperative week or the age at initial surgery but was correlated with the 6-month data. Secondary surgery was performed in 20% and the incidence of the monofixation syndrome was approximately 10% at the end of the study.
Intermittent exotropia: far distance target for surgical dosage.
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Botulinum toxin treatment of infantile esotropia in children.
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Pediatric ophthalmology and strabismus management in Hawaii.
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Outcome study of bilateral lateral rectus recession for intermittent exotropia in children.
PURPOSE: This paper reports an outcome study of 52 consecutive children treated by bilateral lateral rectus recession for intermittent exotropia over a 9 year period (1981-90) with a minimum follow up of 6 months. METHODS: Successful alignment was defined as the absence of any postoperative intermittent or constant tropia in any position of gaze. The study examined the variables that might be predictive of successful alignment. The charts were abstracted for age at initial surgery, quantity of initial deviation, initial refraction, motor alignment at 1 week and 6 months, final alignment, secondary surgery results and the incidence of a monofixation syndrome result. RESULTS: Motor tests demonstrated that 32 (62%) of the patients were successfully aligned by the initial procedure performed for a mean of 25 prism diopters of preoperative deviation while viewing distant targets at a mean age of 4 years 8 months, followed for a mean of 4 years, 4 months. The incidence of undercorrections and overcorrections were approximately equal in quantity suggesting that the current surgical dosage was adequate, but the age at initial surgery, initial deviation, initial refraction and 1 week postoperative alignment results were not predictive of success. Alignment at 6 months, however, was highly correlated with successful alignment by the end of the study (p = 0.002). Secondary surgery was performed for 11 patients and 5 patients were found to have a monofixation syndrome result. CONCLUSION: Successful alignment was achieved in the majority of children treated for intermittent exotropia by an initial bilateral lateral rectus recession. However, 20% of the patients received secondary surgery for a residual deviation, and the study confirmed a previously reported 10% incidence of monofixation syndrome result in children surgically treated for this type of strabismus.
Progressive increase in the quantity of deviation in congenital esotropia.
BACKGROUND AND OBJECTIVE: It was the author's clinical impression that many individuals with congenital esotropia demonstrated an increase in the quantity of deviation measured over time. The present study statistically examines the prevalence and quantity of increase in the amount of deviation measured for a consecutive series of patients with congenital esotropia prior to surgical alignment. PATIENTS AND METHODS: A retrospective chart review was conducted for patients treated during a 5-year period. Data were recorded for the initial and final measurements of the strabismus and the initial and final surgical plans prior to surgery. Also recorded were the age at surgery, length of observation before surgery, refraction, use of patching, and initial motor alignment outcome. RESULTS: Approximately 50% of 41 patients showed an average increase of 20 prism diopters (PD) in the quantity of the deviation when they were observed for an average of 3 months. The age at initial measurement, age at surgery, length of observation prior to surgery, refraction, or use of patching could not be used to identify patients with the increase in the amount of strabismus. However, in cases where the final surgical plan was based on the measurements made the day before surgery, 90% of the patients showed an initial surgical alignment to within 10 PD or orthotropia by 6 weeks postoperatively. CONCLUSIONS: These data indicate that a significant increase in the amount of preoperative deviation is very prevalent in patients being observed for congenital esotropia. This finding suggests that the timing of preoperative measurements is very important, and that the data collected close to the date of surgery are the most important with which to plan surgery.
Surgical alignment prior to six months of age for congenital esotropia.
PURPOSE: To complete the first independent and largest multicenter outcome investigation to analyze the motor and functional results of a series of patients surgically aligned prior to age 6 months and followed for a minimum of 4 years. METHODS: Sixteen patients, surgically aligned at an average age of 4.2 months, were examined at an average of 7.1 years to assess their motor and functional outcomes. RESULTS: Motor and sensory tests showed 11 patients to have a small or negligible motor misalignment at near point with both binocular fusion and gross stereopsis ability. A single patient aligned by 3 months of age demonstrated reproducible refined stereoacuity on sensory testing. However, the patients who achieved alignment by 4 or 5 months did not demonstrate any better quality of binocularity than that found in a previously studied group of patients aligned at 6 months. CONCLUSION: Binocularity that includes refined stereoacuity remains an elusive target and a rare outcome for an ophthalmologist treating congenital esotropia, despite very early surgical alignment.
Outcome study of surgical alignment before six months of age for congenital esotropia.
BACKGROUND: Recently, several ophthalmic surgeons have reported surgical alignment with congenital esotropia in patients younger than 6 months of age to improve the quality of the binocular result. METHODS: The author performed a multicenter independent study of the motor and sensory results obtained in a group of patients younger than 6 months of age. These patients underwent surgical alignment by other investigators to within 10 prism diopters for a minimum of 6 months. The patients had been followed for a minimum of 4 years and were required to have sufficient maturity and normal neurologic status to reliably respond to tests for fusion and stereopsis. The patients were examined and analyzed by the author before any knowledge of the clinical record. RESULTS: Sixteen patients underwent surgical alignment at an average age of 4.2 months. Follow-up examination took place at an average age of 7.1 years. Motor and sensory tests showed 11 patients to have a small or negligible motor misalignment at near point with both binocular fusion and gross stereopsis ability. One patient, aligned by 3 months of age, demonstrated reproducible refined stereoacuity on sensory testing. The author observed, however, that alignment by 4 or 5 months of age did not result in better quality of binocularity than a previously studied group of patients who underwent alignment at 6 months of age. CONCLUSION: Binocularity that includes refined stereoacuity remains an elusive target and rare outcome for the ophthalmologist treating congenital esotropia, despite the use of very early surgical alignment.
Intraocular gas and low-altitude air flight.
BACKGROUND: Air travel has been contraindicated for patients with intraocular gas on the basis of experimental studies, because of the risk of elevated intraocular pressure during atmospheric depressurization. METHODS: A clinical study of gas bubble volume and intraocular pressure rise during a low-altitude air flight was performed on a patient with a gas bubble volume of 65% after retinal detachment surgery. RESULTS: The flight was well tolerated, and the patient did not experience pain or decreased vision. The maximum altitude of the flight was 3,000. Maximum intraocular pressure was 49 mmHg, with a baseline of 16 mmHg. Increases in intraocular pressure and bubble volume were instantaneous with changes in altitude. Implications for pressurized flight situations are discussed. CONCLUSION: Low-altitude air flight can be well tolerated by patients with intraocular gas, even with a relatively large vitreous cavity gas fill. Decisions about when to let patients with intraocular gas fly should be made on an case-to-case basis, depending on ocular factors and the planned flight characteristics.
Progressive increase in the angle of deviation in congenital esotropia.
The majority of patients with congenital esotropia in this consecutive series of 41 patients showed an increase in the angle of deviation when followed over an average of 3 months. The ages at the initial measurement and surgery, the cycloplegic refraction, and the clinical response to patching could not be used to identify those patients with a progressive increase in the quantity of the deviation. It was found, however, that if the preliminary surgical plan was adjusted (as it was in the majority of the patients in this series) to reflect the latest measurements obtained the day before surgery, a relatively high percentage of patients (90%) could be found to have achieved satisfactory alignment by the 6-week postoperative visit.
Botulinum alignment for congenital esotropia.
BACKGROUND: Botulinum toxin injection into the medial rectus has been recommended by several investigators as an alternative to incisional surgery for treatment of patients with congenital (essential infantile) esotropia. Currently, there are no published studies demonstrating both the motor and sensory results of congenital esotropic patients aligned by botulinum toxin. METHODS: The author traveled to two medical centers to personally and objectively examine, with standardized testing methods, 12 patients with congenital esotropia who had been aligned for a minimum of 6 months by the age of 2 years by other investigators. The selected patients had been followed for a minimum of 3 years and were of sufficient maturity to reliably respond to sensory testing. A comparison was made between the author's conclusions about the binocularity results of these patients and the assessment of the treating ophthalmologists. RESULTS: Only 6 of the 12 patients demonstrated optimum motor alignment to within 10 prism diopters (PD) of orthophoria at the time of the study. A minimum of 1-month (average, 5 months) post-botulinum injection was found to be necessary to establish this alignment. Only three of these six aligned patients could both fuse and demonstrate gross stereopsis without the assistance of compensatory prisms. These results can be contrasted to a previously reported group of surgically aligned cases in which 66 of 90 patients aligned by 2 years of age could both fuse and demonstrate stereopsis, without any use of compensatory prisms. CONCLUSION: These results must be considered preliminary. However, alignment by botulinum appears to be less effective in establishing evidence for binocularity than incisional surgery in the treatment of congenital esotropia (P < 0.001).
Botulinum alignment for congenital esotropia.
This is the first report of a group of patients with congenital esotropia examined for motor and sensory evidence of binocularity a minimum of 3 years after alignment by botulinum. Evidence for binocularity was clearly present in approximately one half of the patients. Lag time to satisfactory alignment was at least 1 month (average, 5 months) following the initial botulinum injection. The results must be considered preliminary. However, when these results are compared with those of patients with congenital esotropia aligned by incisional surgery by age 2 years and examined with the same testing devices by this same investigator, botulinum alignment appears to be less effective than surgical alignment in establishing evidence for binocularity (P < 0.005).
Infection following strabismus surgery.
Sixty-three strabismus surgeons were surveyed regarding the incidence of infection they found following strabismus surgery and their use of preoperative and postoperative antibiotics to prevent or treat such infections. Cellulitis was rare (1 per 1900 cases) and endophthalmitis was even rarer (1 per 30,000 cases). Infection was not entirely prevented by either preoperative or postoperative topical antibiotics. Twelve surgeons reported using no antibiotics but did not report higher rates of infection than those who did use them.
Potential acuity meter to predict postoperative visual acuity.
Thirty-three eyes were examined with the potential acuity meter (PAM) to determine preoperatively the expected visual acuity for patients undergoing cataract surgery. The preoperative visual acuity was compared to the best postoperative visual acuity. Although several patients had moderate macular degeneration as well as cataracts, there was an overall accuracy to within two lines of the best visual acuity in 96% of patients. There was a tendency to underestimate rather than overestimate postoperative visual acuity when these readings were in error. The instrument was only used if the cataract examined had some clarity. Older patients who were unsteady had difficulty performing the test.