What’s New and Important in Pediatric Ophthalmology and Strabismus

Aim: To study postoperative residual vertical deviation and abnormal head posture (AHP) after surgical treatment for congenital superior oblique palsy (SOP). Method: Children with both SOP and AHP who underwent extraocular muscle surgery for correction of AHP were recruited. The patients received complete ophthalmic and orthopaedic examinations. Residual AHP was classified according to severity of face turn, head tilt and chin elevation. Results: Thirty-two children with mean age at operation of 82.6 months were recruited, with mean follow-up of 37.9 months. Of these children, 65.6% had a postoperative vertical deviation of less than three prism dioptres. In addition, 34.4% patients had resolved (0°), 34.4% had mild (1°–10°), and 31.3% had significant residual torticollis (>10°). Of the patients with significant residual torticollis, 33.3% had ocular causes. The mean age at operation for the patients with residual torticollis (95.9 months) was older than those without torticollis (79.9 months) (p = 0.018). Residual torticollis was found to be related to sternocleidomastoid muscle tightness (p = 0.013). Conclusion: The success rate for eliminating significant AHP after strabismus surgery for patients with congenital SOP was 68.8%. Early surgery was associated with a better outcome. Association was also found between sternocleidomastoid tightness and AHP. A multidisciplinary approach is recommended in the management of torticollis as ophthalmic and orthopaedic comorbidities can coexist. Comment: Nice article reporting their results in a series of 32 patients with SOP. Anomalous head position was only relieved in 68% in this series. Residual anomalous head position was associated with tight sternocleidomastoid muscle, therefore these pts should have orthopedic consultation prior to further ophthalmic intervention. Intraoperative adjustable suture surgery for excyclotorsion: a modification of the Harada-Ito procedure. Ameri A et al. JPOS Nov-Dec 2009; 46: 368-371. Tucking of the anterior one-third of the superior oblique tendon was performed with nonabsorbable suture in two patients. The amount of tuck was adjusted until the fovea was at the level of the superior one-third of the disc through indirect ophthalmoscopy. In the patient with local anesthesia, a double Maddox rod test was used to evaluate subjective cyclotorsion intraoperatively. No regression was noted in 18 months of follow-up. This introduces a new therapeutic option for patients with BSO paresis and symptomatic excyclotorsion without vertical deviation in primary position. Evaluation of Refraction in a Statistically Significant Sample: changes according to age and strabismus. Chiesi C et al. JPOS Sept-Oct 2009; 46:266-272. A population-based sample of 12,534 subjects 6 months to 20 years of age were examined between 2004 and 2006. Patients were divided into those with orthophoria and those with strabismus and the latter group divided into esodeviation and exodeviation. Patients with esodeviation tend to share a higher initial degree of hyperopia than the general population. The myopic shift in these patients occurring in later years appears to be lower than the general population. Patients with exodeviation have similar refractive errors to those with orthophoria. Astigmatism often plays an important role in anisometropic amblyopia.