Extraocular Muscle Repositioning and Diplopia: Associated with Ophthalmic Plaque Radiation Therapy for Choroidal Melanoma
OBJECTIVE: To evaluate extraocular muscle surgery associated with plaque brachytherapy for choroidal melanoma. DESIGN: Single-center retrospective cohort study. PARTICIPANTS: Three hundred twenty-nine eyes of 329 consecutive patients with clinically diagnosed choroidal melanoma. INTERVENTION: Palladium 103 plaque brachytherapy with or without extraocular muscle surgery. MAIN OUTCOME MEASURES: Type of muscle surgery required for each tumor location, timing, incidence, and duration of diplopia, as well as treatment. RESULTS: Two hundred fifty-four patients (n = 254/329; 77.2%) required muscle surgery. One hundred seven patients (n = 107/329; 32.5%) required surgery on 2 or more muscles. Of 373 muscles repositioned, the lateral rectus muscle (n = 115/373; 30.8%) and inferior oblique muscle (n = 70/373; 18.7%) were the most common, correlating to intraocular tumor location (P<0.001). Only 6 tumors (n = 6/61; 9.5%) originating from the iris and ciliary body required muscle surgery for plaque placement. Of the 312 patients with a preoperative visual acuity better than 20/400, diplopia was reported at the first postoperative visit by 41 patients (n = 41/312; 13.1%), 2 of whom had not undergone muscle surgery. Diplopia resolved spontaneously within 1 month in 18 patients (n = 18/41; 43.9%), between 1 and 6 months in 12 patients (n = 12/41; 29.3%), and at more than 6 months in 5 patients (n = 5/41; 12.2%). Among the 312 patients, persistent diplopia occurred in 6 patients (1.9%), including 1 who had not undergone muscle surgery. Treatment was declined in 1 patient, 3 patients (n = 3/41; 7.3%) were treated with prisms, and 2 patients (n = 2/41; 4.9%) required surgery. CONCLUSIONS: Extraocular muscle surgery frequently is required for plaque brachytherapy. Although transient diplopia occurred in 11.2% of patients, persistent diplopia occurred in only 1.9% of patients and was treatable.
Progression of traumatic lamellar macular hole to full-thickness macular hole and retinal detachment in a 3-year-old child
BACKGROUND:Traumatic macular holes in children are uncommon, and retinal detachment from a macular hole is even more uncommon because the vitreous is formed. METHODS:Interventional case report. RESULTS:A 3-year-old boy presented after trauma with a lamellar macular hole in his left eye. Over the next month, progression to a full-thickness macular hole with epiretinal membrane and then subsequent retinal detachment was documented with high-resolution optical coherence tomography. The patient underwent a pars plana vitrectomy, membrane peel, and perfluoropropane tamponade. Six months after surgery, the hole remained anatomically closed, and visual acuity was 20/20. CONCLUSION/CONCLUSIONS:Retinal detachment after a traumatic macular hole in this child was because of hyaloidal traction and epiretinal membrane contraction. Pars plana vitrectomy with surgical peeling of the epiretinal membrane and internal limiting membrane enabled the macular hole to close and the retina to reattach.
Comparison of eccentric fixation measurements using the streak target of an ophthalmoscope and a traditional visuoscopy target
PURPOSE/OBJECTIVE:To compare measurements of eccentric fixation using two different targets for fixation, a traditional visuoscope target and the streak target of an ophthalmoscope. PATIENTS AND METHODS/METHODS:Monocular fixation was evaluated using visuoscopy in 47 patients ranging in age from 4 months to 22 years. Visuoscopy measurements were compared using both the traditional visuoscope target and the streak target of a Welch Allyn ophthalmoscope. The streak light was rotated both horizontally and vertically to detect both horizontal and vertical eccentric fixation. RESULTS:The streak target improved testability of eccentric fixation in children younger than 3 years compared to the traditional visuoscope target (75% versus 30%). All of the patients older than 3 years were testable using both targets, with both methods yielding the same results. All of the patients with a visual acuity of at least 20/20 also demonstrated central fixation using both techniques. CONCLUSIONS:Using the streak of a Welch Allyn ophthalmoscope as a visuoscope target allows for testing of eccentric fixation in children younger than 3 years.