Ординатура / Офтальмология / Английские материалы / Pediatric Ophthalmology Current Thought and A Practical Guide_Wilson, Saunders, Trivedi_2008

17.4Postoperative Infections and Inflammation

Signs of mild conjunctivitis may develop within the postoperative period. The etiology may be bacterial, viral, or allergic. Sensitivity to topical medications or suture material may produce conjunctival vascular injection and a serous or mucoid discharge. Appropriate topical medications will help to alleviate the signs and symptoms in these cases. In 1991 Ing surveyed 63 strabismus surgeons regarding the incidence of infection they found following strabismus surgery and their use of preoperative and postoperative antibiotics to prevent or treat infections. Cellulitis was reported in 1 of 1900 cases and endophthalmitis at a rate of 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 [24].

17.4.1 Orbital Cellulitis

Infections following strabismus surgery occur infrequently. Orbital cellulitis may develop on the second or third postoperative day and may be preseptal or postseptal. Clinical signs include proptosis, edema of the eyelids, chemosis, and restriction of ocular motility in a febrile patient. The infection usually responds well to systemic antibiotics [25, 26]. Signs of postseptal involvement necessitate parenteral antibiotic therapy. Indirect ophthalmoscopy should be performed to rule out endophthalmitis. A single case of visual loss from orbital cellulitis in a 56-year-old patient following strabismus surgery has been reported. Loss of vision occurred despite orbital surgery including orbital decompression [27].

17.4.2 Myositis

Orbital myositis is an idiopathic inflammatory condition that rarely occurs following strabismus surgery.

Clinical findings include orbital pain, eyelid swell-

ing, focal hyperemia, and chemosis over the affected muscle. There is a limitation of extraocular motility in the field of action of the affected muscle or in the opposite field. Computed tomography scanning demonstrates enlargement of the involved muscle. Symptoms of myositis may develop from 4 days to 4 weeks following strabismus surgery, and are more likely in a previously operated muscle. A rapid resolution after treatment with systemic corticosteroids can be considered pathognomonic for this condition. In their series of 4 cases, Wolf et al. postulated that painful postoperative inflammation involving a quadrant following muscle surgery may be falsely attributed to a “suture reaction” when it is indeed myositis in many cases [28].

17.4.3 Necrotizing Scleritis

Necrotizing scleritis belongs to the same spectrum of idiopathic orbital inflammatory disease as extraocular muscle myositis. This may occasionally occur after strabismus surgery and presents with diffuse conjunctival injection, ocular or orbital pain, headache, and acute change in refractive error. Absence of muscle thickening on CT scanning differentiates necrotizing scleritis from myositis. Bilateral anterior necrotizing scleritis has been recently reported in a

19-month-old girl following a postoperative infection after strabismus surgery (Fig. 17.3) [29].

A granulomatous inflammation of the sclera following strabismus surgery may occur months or even years later. This condition has been termed primary surgically induced necrotizing scleritis (SINS) and is often associated with autoimmunity in adults [30].

17.4.4 Endophthalmitis

Endophthalmitis following strabismus surgery is a very unlikely occurrence but is associated with loss of vision in most reported cases. The incidence is estimated to be between 1:30,000 and 1:185,000 [10, 24]. The typical findings include lethargy, asymmetric conjunctival injection, eyelid swelling, and possibly fever within 4 days of surgery [30]. The diagnosis

Fig. 17.3  a Child 1 week after bilateral superior rectus muscle recession for dissociated vertical deviation with cellulitis of her left upper eyelid. b Subsequent examination under anesthesia revealed scleral necrosis with large retinocele behind the original superior rectus muscle insertion (arrow). The globe is positioned in down gaze with a forceps, and the corneal limbus is visible near the lower eyelid. c Same patient 3 months after scleral patch graft. She retained good vision in the operated eye. (Courtesy of R. Saunders)

is made when leukocoria secondary to vitritis is recognized. Hypopyon may be present. The importance of viewing a normal red reflex sometime during the

7-day period following strabismus surgery in a child

with fever, lethargy, and excessive postoperative ocular inflammation cannot be overemphasized.

The issue arises whether scleral perforation precedes endophthalmitis following strabismus surgery.

Recchia and co-authors reported six cases of endophthalmitis after pediatric strabismus surgery. The ages of the patients ranged from 8 months to 6 years. The authors state that in none of their cases were scleral perforations reported. They conclude that “the development of endophthalmitis neither requires nor implies that perforation of the globe occurred” [30].

Cases have been reported where endophthalmitis occurred in association with both recognized and suspected scleral perforation [31]. Various organisms have been implicated as causing endophthalmitis following strabismus surgery. Reported organisms include Staphylococcus epidermidis, Streptococcus pneumoniae, and Hemophilus aegyptius [32−34].

Regardless of the etiology, the outcomes pertaining to vision following endophthalmitis are generally poor in spite of heroic efforts to save these eyes. Most eyes that undergo vitrectomy are lost. There are case reports where eyes were saved following intravitreal antibiotic and steroid injections. The author has treated a case of delayed endophthalmitis (presentation 10 days following strabismus surgery) with peribulbar injections of antibiotics and corticosteroids coupled with systemic antibiotic therapy. Useful vision was maintained in this patient.

Risk factors for endophthalmitis might include surgery on small eyes with thin sclera as in very young children. In spite of its infrequency, this remains the most serious complication following strabismus surgery since it usually results in loss of vision.

17.5 Anterior Segment Ischemia

Anterior segment ischemia may occur following strabismus surgery on three, or at times two, rectus muscles. The seven anterior ciliary arteries traversing within the rectus muscles and the two long posterior ciliary arteries provide the blood supply to the anterior segment. Two anterior ciliary arteries run forward within each rectus muscle, except in the lateral rectus muscle where there is only one, although anatomic variations are common. It is important to note that the vessels do not always lie along the muscle borders,

particularly when performing surgery to split a rectus muscle for transposition [35].

The relative contributions of these vessels have been elucidated by the iris fluorescein angiography studies by Hayreh and Scott [36]. Tenotomy of one or both of the horizontal rectus muscles produced no appreciable circulatory disturbance in the iris, but tenotomy of the superior or inferior rectus muscle produced circulatory delay in the superotemporal or inferotemporal sectors. Tenotomies of a horizontal and one or two vertical rectus muscles combined produced a delay in filling in the iris in the vertical rectus muscle region only. Blood supply of the nasal half of the iris was usually not disturbed by tenotomy of the vertical and/or medial rectus muscle. Their findings indicate that the blood supply of the iris is segmental and suggest that operating on the two vertical rectus muscles along with the lateral rectus muscle increase the risk of developing anterior segment ischemia. The implication is that the long posterior ciliary arteries provide most of the blood supply to the medial and nasal areas of the iris, while the vertical rectus muscles assume the major role in supplying the superior temporal and inferior temporal regions of the iris.

The clinical findings of anterior segment ischemia may vary but usually include postoperative pain developing a few days after strabismus surgery. The pain may be moderate but can be severe in cases of impending necrosis. The affected eye may develop microcystic edema and corneal stromal thickening and corectopia (Fig. 17.4). Aqueous flare and cell and nonpigmented keratic precipitates are seen on slit lamp examination. The early changes may resolve spontaneously or rarely, progress to sector iris atrophy, corneal neovascularization, cataracts, or phthisis bulbi. There is do definitive treatment for anterior segment ischemia. The finding of anterior chamber flare and cell often results in the clinician administering systemic and topical corticosteroids, and topical atropine 1% drops. deSmet and co-workers successfully used oxygen administered in a hyperbaric chamber to treat ischemia in a 62-year-old dysthroid patient following a two vertical rectus muscle procedure [37].

Patients have been reported to develop anterior segment ischemia following full tendon transposition of the superior and inferior rectus muscles 9 and 20 years after they underwent horizontal rectus muscle surgery. Ipsilateral carotid artery ligation and hyperlipoproteinemia may have been contribu-

Fig. 17.4  a Striate keratopathy, corectopia, and anterior chamber cell and flare following full tendon transposition of the vertical recti and medial rectus muscle recession in 30-year-old man with Duane’s syndrome. b Iris fluorescein angiography 10 days postoperatively shows delayed iris filling with leakage inferiorly. (Courtesy of R. Saunders)

tory factors [38]. A 62-year-old woman with thyroid ophthalmopathy after simultaneous surgery on both vertical rectus muscles was reported to develop anterior segment ischemia [39]. Simon and colleagues reviewed the records of 34 eyes in 26 patients who underwent surgery on three or four rectus muscles. Only one patient, with thyroid disease, developed mild signs of anterior segment ischemia. They concluded that surgery on three or four rectus muscles in healthy patients is probably safe when performed in a staged fashion [40]. Full tendon transfer procedures combined with recession of another rectus muscle have been reported to produce anterior segment ischemia [43].

An attempt may be made to preserve the anterior ciliary arteries by dissecting them from the muscle and tendon. The muscle and tendon are recessed or resected while the vessels are left undisturbed. This meticulous surgery, usually performed using a microscope, may help to avoid the development of anterior segment ischemia [41, 42].

17.6 Delayed Postoperative Reactions

Chronic inflammation and delayed healing following strabismus surgery may compromise an otherwise satisfactory result in alignment. Recognition of the etiology and appropriate treatment produces an optimal final surgical result in most cases.

17.6.1 Foreign Body Granuloma

A foreign body granuloma may develop on the surface of the conjunctiva or sclera near the site where the sutures were placed to attach the muscle to the sclera. These probably represent a granulomatous reaction to suture material, retained eyelashes, cotton fiber or glove powder. A hyperemic pedunculated tender mass may become evident within a few weeks following strabismus surgery (Fig. 17.5); these may respond to topical steroids but often require surgical excision.

The mass can be removed by placing a small scissor below the granuloma which is usually attached by a thin single strand to the conjunctiva or sclera. A single snip, following topical anesthesia, will usually suffice in a cooperative patient. Local pressure on a closed eyelid for 2 min is often necessary for hemostasis.

17.6.2 Prolapse of Tenon’s Capsule

Leaving Tenon’s capsule exposed near the limbus may produce an inflammatory reaction and ultimately a granuloma. It can also serve as a nidus for infection. Upon completion of conjunctival closure, irrigation of the operative field with balanced salt solution will cause any exposed Tenon’s capsule to “fluff up.” This can easily be distinguished from conjunctival tissue and can be resected or reposited.

17.6.3 Allergic Reactions

Suture material may produce an acute allergic reaction within 24 h of surgery. The patient may complain of ocular discomfort and itching and signs include conjunctival hyperemia, chemosis, and eyelid edema. Treatment of an acute allergic reaction consists of

Fig. 17.5  A hyperemic, pedunculated granuloma has formed 2 weeks following strabismus surgery

topical corticosteroids and cold compresses. Such reactions were far more common when cat-gut sutures were used. The near exclusive use of synthetic absorbable sutures has greatly decreased the likelihood of this occurrence. Topical medications that contain neomycin are associated with a high rate of sensitivity and may prolong the healing period.

17.6.4 Conjunctival Inclusion Cysts

Inadvertent enclosure of conjunctival epithelium into the wound may result in the production of a conjunctival inclusion cyst. These cysts appear as noninflamed translucent masses several days to weeks after surgery (Fig. 17.6). Attempts to drain these cysts with a needle puncture are usually unsuccessful as they refill with serous fluid. Cure usually requires surgical excision of the entire cyst down to bare sclera.

17.6.5 Subconjunctival Cysts

Kushner reported six patients operated on for large subconjunctival cysts that developed up to 35 years after strabismus surgery. In four of these patients the cyst was located between the anterior edge of the muscle and the site to which the muscle had been sutured during previous surgery. The muscle was found to be attached to the posterior wall of the cyst and not to the sclera. In two patients a sudoriferous cyst was found that had originally been mistaken for an abscess when excision was attempted [44].

Fig. 17.6  A conjunctival inclusion cyst at the inferior temporal fornix incision site, 10 days following inferior oblique muscle recession

17.6.6 Dellen Formation

Dellen are small areas of corneal thinning with a shallow depression near the limbus. They result from perilimbal elevated tissue, such as heaped-up bulbar conjunctiva, which prevents the eyelid from resurfacing the cornea with tears during blinking. Fluorescein dye may pool in the corneal depression. This painful complication is more likely to occur following a limbal approach and when excessive tissue is advanced during a resection of a muscle.Artificial tears or other ocular lubricants may help to control the signs and symptoms. Patching may be necessary during the postoperative period. Once the conjunctival elevation lessens, the dellen will resolve. Rarely, surgery will be required to reduce the amount of perilimbal tissue.

17.6.7Adipose Tissue Adherence Syndrome

Surgical penetration of Tenon’s capsule near the fat pad where the extraocular muscles penetrate may result in the anterior prolapse of orbital adipose tissue.

This can result in a scar composed of fat and fibrous tissue which becomes evident in the postoperative period. The resulting adherence syndrome will limit motility and produce incomitance. Future attempts to remove the scar may produce further restriction of motility. Recognized rents in Tenon’s capsule should be closed with an absorbable suture after the orbital fat is reposited during initial strabismus surgery. This

complication is more likely to occur during surgery on the inferior oblique muscle, because of its posterior location and proximity to Tenon’s capsule. Isolation of the inferior oblique muscle under direct visualization helps to avoid this complication.

17.7 Restrictive Strabismus

A major problem following strabismus surgery, particularly in reoperations, is the development of postoperative adhesions. Scar tissue may involve the conjunctiva, Tenon’s capsule, intermuscular membrane, orbital fat, sclera, and extraocular muscles. The scar tissue may result in a restrictive strabismus which can negate the effects of the strabismus procedure. Various materials and therapeutics have been used in an attempt to prevent the development of surgical adhesions. Sodium hyaluronate [45], and antimetabolites including mitomycin C [46] and 5-fluorouracil [47], have been used with mixed results. A bioabsorbable membrane composed of sodium hyaluronate and carboxymethylcellulose has been used experimentally as a sleeve or barrier to prevent surgical adhesions in strabismus surgery [48]. This material holds promise when placed between the muscle and conjunctiva in preventing scar formation.

17.7.1 Eyelid Position Changes

Surgery on the vertical rectus muscles may produce an unacceptable narrowing or widening of the palpebral fissure. Eyelid displacement occurs in the same direction as the shift in the insertion of the muscle. This results from inadequate dissection of the fascial connections between the inferior rectus muscle and the lower eyelid retractors, or between the superior rectus muscle and levator muscle complex. Eyelid changes are most likely to occur following recession of the inferior rectus muscle, because posterior dissection is limited by the attachment of the inferior oblique to the inferior rectus muscle (Lockwood’s ligament; Fig. 17.7) [10]. As little as 4−5 mm of surgery can alter the lid position unless the inelastic cords that extend between the muscle capsule, lower eyelid tarsal skin, and inferior orbital septum are completely severed. As a general rule, all inter-

muscular and fascial connections should be severed back to at least 12 mm when operating on the vertical rectus muscles. Retractor lysis and advancement and reattachment of the capsulopalpebral head may prevent eyelid retraction after inferior rectus muscle recession. Patients with thyroid ophthalmopathy are particularly prone to lower eyelid retraction following inferior rectus muscle surgery (Fig. 17.8) [49].

Proptosis may become more pronounced following extraocular muscle recessions particularly in patients with thyroid ophthalmopathy [9].

17.7.2Advancement of the Plica Semilunaris and Conjunctiva

The plica semilunaris may be advanced inadvertently during strabismus surgery. The edge of the semilunar fold may be mistaken for the edge of the conjunctiva and may be advanced and sutured to the sclera. Advancement may also occur following a large me-

dial rectus resection. This will produce protuberant chronically inflamed tissue and sometimes corneal dellen formation (Fig. 17.9). Additional surgery may be necessary to recess the plica and conjunctiva.

17.7.3 Adjustable Suture Issues

Complications can occur during or following an adjustable suture strabismus procedure. The sutures may detach from the sclera during postoperative adjustment. If recognized, the patient may need to be brought back to the operating room for reattachment.

A common problem following adjustable suture procedures is exposure of a large suture knot

(Fig. 17.10). Every attempt should be made to cover the knot with the conjunctiva. An exposed knot may produce a painful foreign body sensation and interfere with postoperative healing. Topical corticosteroids may be useful, although excision of the knot may be necessary once the muscle has attached to the

Fig. 17.9  Protuberant chronically inflamed conjunctiva following resection and advancement of the left medial rectus muscle in a patient who underwent a reoperation

Fig. 17.10  Visible knot and sutures following an adjustable recession of the superior rectus muscle

sclera. Occasionally a patient may not tolerate the adjustment and experience syncope from a vaso-vagal nerve response. The administration of an intravenous nonsteroidal anti-inflammatory agent, such as ketorolac tromethamine, prior to adjustment works well in most cases.

17.7.4 Changes in Refractive Error

Surgery on two horizontal rectus muscles in one eye may produce a temporary change in the refractive error. Newly induced with-the-rule astigmatism following strabismus surgery usually resolves in a few months [50].

17.7.5Complications Related to Anesthesia

During strabismus surgery, hooking and traction on an extraocular muscle may cause bradycardia. This oculocardiac reflex can produce asystole. Frequently, the anesthesiologist will ask the surgeon to release the traction on the muscle as he monitors the heart rate. Intravenous atropine may need to be administered during the procedure. This reflex is unpredictable and can occur following traction on any rectus muscle.

Malignant hyperthermia is a disease characterized by extreme heat production which may be triggered by inhalational anesthetic agents, muscle relaxants, and some local amide anesthetics. A hypermetabolic state occurs as intracellular calcium stimulates muscle contracture. A shift toward anaerobic metabolism results in lactate production and acidosis.

The earliest signs of malignant hyperthermia include tachycardia and elevated carbon dioxide. Temperature rise and respiratory and metabolic acidosis follow. This condition can be fatal due to cardiac arrest if diagnosis and treatment are delayed. Early treatment includes hyperventilation with oxygen and intravenous dantrolene which prevents the release of calcium from the muscle cells. The surgical procedure should be terminated as the anesthetic agent is discontinued.

The incidence of malignant hyperthermia is greater in children with strabismus, ptosis, and other musculoskeletal abnormalities. This extremely rare condition can occur as an isolated case or as a dominantly inherited condition with incomplete penetrance. The mortality rate from this condition is about 10%. Malignant hyperthermia susceptibility testing is available to screen for this condition [51].

Take Home Pearls

•The S-24 needle is more frequently involved in the penetrations and perforations than other needles [5].Asmaller S-14 or S-29 spatula needle might be a better choice.

•Instillation of 2.5% phenylephrine in each eye at the beginning of surgery will

provide hemostasis and dilate the pupil well enough to allow indirect ophthalmoscopy, if necessary, upon completion of surgery.

•In cases of restricted strabismus a second hook under the insertion can help to create sufficient space to pass the sutures in the tendon.

•Preoperative MRI may be helpful in planning surgery to retrieve a lost rectus muscle.

•Review the patient’s chart in the operating room prior to the first incision to confirm the correct muscle and planned procedure.

•Avoid penetrating Tenon’s capsule and advancing the conjunctiva too anteriorly in resection procedures.

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Contents

18.3Clinical Features  . . . . . . . . . . .   245

18.5Fusion Maldevelopment Nystagmus

Syndrome  . . . . . . . . . . . . .   247

18.7Clinical Evaluation  . . . . . . . . . .   249

Core Messages

•The three most common forms of nystagmus in childhood begin early in infancy and are not congenital, and include infantile nystagmus syndrome (old “congenital nystagmus”),

fusion maldevelopment nystagmus syndrome (old “latent” nystagmus), and spasmus nutans syndrome.

•Nystagmus associated with neurological or vestibular disease can usually

be suspected due to associated neurological signs and symptoms.

•Eye movement recordings now provide the clinician with a way to diagnose, classify, and understand the pathophysiology of nystagmus in infancy and childhood.

•Medical and surgical treatments aimed directly at decreasing or improving the ocular oscillation of nystagmus is now available.