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AIM: To determine if a non-ophthalmologist can accurately screen for retinopathy of prematurity (ROP) by evaluating the posterior pole blood vessels of the retina. ROP is a common ocular disorder of premature infants and may require multiple screening examinations by an ophthalmologist to allow for timely intervention. Since there is a strong correlation between posterior pole vascular abnormalities and vision threatening ROP, screening examinations performed by non-ophthalmologist may yield useful clinical information in high risk infants. METHODS: Infants born at the Medical University of South Carolina who met screening criteria (n = 142) were examined by a single non-ophthalmologist using a direct ophthalmoscope to evaluate the posterior pole blood vessels for abnormalities of the venules and/or arterioles. To determine the accuracy of the non-ophthalmologist's clinical observations, infants were also examined by an ophthalmologist, using an indirect ophthalmoscope, who graded the posterior pole vessels as normal, dilated venules, or dilated and tortuous venules and arterioles (including "plus disease"). RESULTS: There was significant correlation (p <0.001) between the non-ophthalmologist's and ophthalmologist's diagnoses of posterior pole vascular abnormalities. 47 infants had normal posterior pole blood vessels by the non-ophthalmologist examination. Of these, 31 (66%) were considered to have normal vessels and 16 (34%) to have dilated venules by the ophthalmologist. The non-ophthalmologist correctly identified abnormal posterior pole vessels in all 21 infants diagnosed with abnormal arterioles and venules by the ophthalmologist. No infants with clinically important ROP ("prethreshold" or worse) would have failed detection by this screening method. CONCLUSION: Using a direct ophthalmoscope, a non-ophthalmologist can screen premature infants at risk for ROP by evaluating the posterior pole blood vessels of the retina. While not necessarily recommended for routine clinical practice, this technique may nevertheless be of value to those situations where ophthalmological consultation is unavailable or difficult to obtain.

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PURPOSE: Commonly recommended maximum lateral rectus muscle recession for exotropia ranges from as little as 7 mm to as much as 11 mm. Published studies on recessions of 8 mm or more are scarce. Many ophthalmic surgeons still avoid recessions larger than 7 mm because of the fear of creating abduction deficits and surgical overcorrections. Therefore, we sought to determine the incidence of clinically detectable abduction deficits and their correlation with early surgical overcorrection in exotropic patients who had undergone large 8 to 9 mm lateral rectus muscle recessions. SUBJECTS AND METHODS: A retrospective chart review identified 30 patients with exotropia ranging from 35delta to 65delta who were treated with 8 to 9 mm recessions of both lateral rectus muscles. Patients with concurrent oblique muscle surgery were included. Mean followup time was 15 months (range 3-30 mos). RESULTS: Twenty-four patients (80%) required only one operation. The remaining 6 patients (20%) required a second operation, four for overcorrection and two for undercorrection. Nine patients (30%) had mild but persistent abduction deficits postoperatively. However, abduction deficits were not predictive of poor outcome (p=0.959). Other variables that did not significantly affect outcome included age (p=0.894), systemic anomalies (p=0.127), size of preoperative exotropia (p=0.987) and amount of rectus muscle recession (p=0.480). However, concurrent oblique muscle surgery was associated with a higher risk of a poor result. CONCLUSIONS: 8-9 mm lateral rectus recessions are not associated with a poor outcome, except in association with concurrent oblique muscle surgery.

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BACKGROUND: Dilation and tortuosity of the posterior pole vessels ("plus disease") is a poor prognostic sign and may indicate the presence of threshold or pre-threshold retinopathy of prematurity (ROP). Because stage 3 ROP appears rarely in the absence of posterior pole vascular abnormalities, we prospectively evaluated the ability of non-ophthalmologists (4th-year medical students, pediatric residents, and nurse practitioners) to identify abnormalities in the retinal blood vessels of infants undergoing examinations for ROP. METHODS: Fifty infants weighting less than 1600 g at birth were examined between 32 and 40 weeks after conception. Prior to ophthalmological examination, non-ophthalmologist examiners graded posterior pole vessels as normal or abnormal based on ophthalmoscopic appearance. One hundred twenty-one ocular examinations were performed using the teaching mirror of the indirect ophthalmoscope, 179 using the direct ophthalmoscope. The indirect ophthalmoscopy was performed simultaneously by an ophthalmologist who evaluated the posterior pole vessels for abnormalities prior to conducting a peripheral fundus examination on either eye. RESULTS: Testing sensitivity for the non-ophthalmologist examiners using direct and indirect ophthalmoscopy was 96% and 92%, respectively. Combining the results from direct and indirect ophthalmoscopy, the Clopper-Pearson 95% sensitivity confidence interval for identifying abnormal arterioles and venules was 82% to 99%, with a point estimate of 95%. CONCLUSION: These data suggest that non-ophthalmologist examiners can detect posterior pole vascular abnormalities in premature infants. If properly trained, they could possibly play a role in screening or follow-up examinations for ROP.

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Dissociated strabismus includes movements in the vertical, horizontal, and torsional axes. Dissociated vertical deviation (DVD) is an oversimplified label because it implies a purely vertical deviation. When the abducting component of the dissociated strabismus complex is prominent, the term dissociated horizontal deviation (DHD) is used. We present six patients with accommodative esotropia who developed prominent DHD. Only two patients have a prior history of congenital esotropia. Latent nystagmus was observed in five of the patients. With the combination of DHD and esotropia, an esodeviation during active fixation may become an exodeviation when the patient is visually inattentive. Five patients required surgery for DHD. Four options are used and discussed. DHD can be treated alone with lateral rectus muscle recession. DHD can be treated as above, but combined with medial rectus muscle recessions or posterior fixation sutures to simultaneously treat the esotropia. The esotropia can be treated alone, possibly with a reduced surgical dosage. If the patient varies from an esodeviation to an exodeviation, but is straight much of the day, observation without surgical therapy may be advisable. Just as a hypotropia can have an overlying DVD, an esotropia can have an overlying DHD. This combination may masquerade as variable angle esotropia or may present as an esodeviation when the patient is visually attentive and an exodeviation when the patient is visually inattentive.

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Surgery on the extraocular muscles of the eye is generally consisted a safe procedure which is associated with low morbidity and mortality. While infrequent, intra-operative complications occasionally occur. Tenotomy of multiple rectus muscles can result in interruption of the vascular supply to the anterior segment of the eye. Anterior segment ischemia (ASI) may result. This article reviews the complication of anterior segment ischemia as a result of strabismus surgery and its potential for producing permanent visual loss.

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Two patients experienced hepatotoxicity associated with erythromycin estolate (Ilosone) usage, followed 13 and 15 years later by an hepatotoxic reaction with administration of erythromycin ethylsuccinate (E.E.S.). These cases provide further evidence for erythromycin ethylsuccinate-associated hepatotoxicity and demonstrate erythromycin cross-sensitivity after previous erythromycin estolate liver injury. Hepatotoxicity to both sensitivity after previous erythromycin estolate liver injury. Hepatotoxicity to both estolate and ethylsuccinate preparations of erythromycin stimulates speculation regarding the potentially hepatotoxic moiety of the erythromycin molecule. Furthermore, these cases suggest that all erythromycin preparations should be avoided or used only with careful monitoring in patients with previous erythromycin-associated liver injury.

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