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The practicality of extended-wear contact lenses in the refractive correction of pediatric aphakia was assessed with 240 eyes in 184 patients. Patient ages at the time of contact lens fitting ranged from 18 days to 9.8 years. One hundred forty-one eyes were fit from 1 day to 55 months postoperatively and then followed for 6 months to 5.7 years (average, 29 months). Only five patients lost more than five lenses. The overall loss rate was less than one lens per year of follow-up. No patient had contact lens-related complications with permanent visual sequelae. Only 14% of patients had contact lens problems or factors related to parental inability to care for the lens which resulted in discontinuation of contact lens therapy. The authors were unable to identify any subset of patients who should be considered for primary surgical optical correction of their aphakia.

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The viruses of primary herpes simplex, herpes zoster, chicken pox, and vaccinia may produce inflammatory changes in the epithelial lining of the lacrimal canaliculi, resulting in varying degrees of obstruction. Five cases are described and compared with previously reported cases. A review of the literature suggests that the association of ocular viral infections and canalicular complications may be more prevalent than previously suspected. The possible important role of antiviral agents is considered. Early recognition and intubation can often prevent permanent canalicular obstruction, but late cases may require the Jones tube procedure, conjunctivodacryocystorhinostomy.

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To determine causative factors of persistent strabismus presenting after cataract surgery, the surgical techniques and subsequent motility findings of eight patients who had persistent postoperative strabismus were studied. In two of the eight patients, complications related to the placement of the bridle suture were believed causative based on subsequent surgical findings. A similar etiology could be speculated in an additional three patients. An isolated vascular accident coincident to the cataract operation could account for a sixth case. The final two patients were believed to have a decompensated congenital fourth nerve palsy. In no patients could the myotoxic effect of a local anesthetic or the hypoxic effect of an ocular pressure-reduction device plausibly account for the deviation.

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Ninety-seven patients with congenital esotropia with deviations of 50 prism dioptres or greater underwent large (6 and 7 mm) bimedial rectus recessions. The overall success rate with one operation was 83.5%. Judgment of final alignment was made at the last follow-up examination, six to 61 months (average 23.4 months) postoperatively. Large bimedial rectus recessions for congenital esotropia are an effective surgical treatment which does not significantly alter adduction.

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Congenital esotropia represents the most common type of strabismus. Its pathogenesis, however, remains uncertain. It is typically characterized as a large angle, constant esotropia with onset during the first six months of life. Associated clinical findings include normal refractive errors for age, amblyopia, dissociated vertical deviation, inferior oblique muscle overaction and nystagmus. It must be distinguished from Duane's retraction syndrome, Moebius syndrome, nystagmus blockage syndrome, and early onset accommodative esotropia, as well as other causes of esotropia in infancy. The surgical management may involve recession of both medial recti muscles, unilateral recession of a medial rectus muscle and a resection of a lateral rectus muscle or three or four muscle surgery.

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One hundred four consecutive patients (138 eyes) with congenital nasolacrimal duct obstruction were probed after the age of 13 months. One hundred twenty-nine eyes (93.5) were cured after the first probing. Based on this study and others showing the effectiveness of medical management, it is the current practice of the authors to delay probing until the patient is at least 13 months of age.

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Congenital ptosis and congenital heart disease are known to occur simultaneously in the presence of several well-recognized clinical syndromes. We report seven cases of documented, structural congenital heart defects found among 156 consecutive congenital ptosis patients operated at the Wills Eye Hospital. The possibility that the concurrence found in the patients was a manifestation of a dysmorphic syndrome was carefully excluded by observers skilled in the recognition of such anomalies. The observed rate of congenital heart disease, in otherwise normal congenital ptosis patients, was five times the expected rate in the pediatric population at large. This should alert ophthalmologists examining pediatric ptosis patients to the possibility of a coexisting structural heart defect.

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Five patients developed diplopia following cosmetic blepharoplasty. While temporary diplopia and visual disturbances are known to occur following this type of surgery, the persistence of diplopia with demonstrable muscle imbalance is not common. We encountered ocular motility complications involving the inferior or oblique muscle, inferior rectus muscle, and superior oblique tendon.

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Delayed initiation of proper therapy for infants with primary infantile glaucoma results in an unnecessarily poor outcome. In an effort to understand why some infants and children had more advanced disease than others, researchers reviewed the records of 24 consecutive infants and children with this problem. The presenting signs and symptoms were studied in particular. As noted by the parents, only 32% had the full classic symptom complex of epiphora and photophobia/blepharospasm. Twenty-one percent of infants and children presented with parents having noted signs of infantile glaucoma without ever noting symptoms. More than 90% of infants and children had signs of glaucoma at their initial presentation to a physician. Signs of glaucoma are apparently more difficult to appreciate in bilateral cases. In each of the three cases in which physicians repeatedly failed to make the diagnosis or refer the patient to an ophthalmologist bilateral disease was present. Recognition of the signs and symptoms of primary infantile glaucoma will allow physicians to refer infants and children at a time when good vision may be maintained in the majority of cases.

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We studied five patients with the unusual and insidious progression of congenital anterior polar cataracts during childhood. All five children ultimately required surgery. In two children the progressive opacification occurred in posterior portions of the lens and was inapparent to parents. We therefore recommend a regular and careful follow-up of all children with anterior polar cataracts.

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Fifty pediatric aphakic patients, ranging in age from 7 days to 11 years, were fitted with the Silsoft extended wear contact lens. Compared to other extended wear lenses, the Silsoft lens has several advantages. These include easier handling, a less traumatic fitting procedure for the child, the use of fluorescein for evaluation of the lens-cornea relationship and a low loss rate. This lens appears to be safe, with no permanent adverse effects on the cornea.

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Forty-two patients underwent strabismus surgery with a retrobulbar injection of 3% chloroprocaine hydrochloride. In the 18 patients who were followed up in the immediate postoperative period, the average duration of action of 3% chloroprocaine was found to be 2.13 hours. In addition to the advantages of local anesthesia, this short-acting anesthetic permits earlier modifications of adjustable sutures and the earlier discharge of patients on the same day as surgery.

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Patients with nystagmus and an eccentric null point in lateral gaze may assume an abnormal head position to maximise visual acuity. Surgical procedures for this condition can result in significant undercorrection of the head turn. A follow-up of 15 patients for an average of 33 months revealed a sustained improvement in head position with the use of the augmented modified Kestenbaum procedure.

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Forty-nine patients, ranging in age from 12 to 77 years, underwent strabismus surgery under local anesthesia. With standard preoperative medication and a retrobulbar injection of 2% mepivacaine hydrochloride (hyaluronidase added in 12 patients), effective anesthesia was obtained. Twenty-four patients were observed during the immediate postoperative period, and return of extraocular muscle function and visual acuity was found to be complete an average of 3.8 hours after the injection. The addition of hyaluronidase significantly altered the duration of the anesthetic. Local anesthesia may be a preferable technique in terms of decreased morbidity, especially in the older patient. The short duration of anesthesia and lack of side effects also enable the surgeon to use adjustable sutures and make the final adjustment relatively early in the postoperative period.

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Infants with capillary hemangiomas of the eyelid are at risk for amblyopia and strabismus. Several methods of treating these tumors have been associated with complications and limitations. The use of intralesional corticosteroid injections has been demonstrated to be a simple, safe, and effective method of treating capillary hemangiomas of the eyelid.

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One hundred forty-five consecutive frontalis suspension procedures performed during the years 1976 to 1982 at the Wills Eye Hospital for the repair of congenital ptosis were reviewed. Results with nylon polyfilament cable-type suture ( Supramid Extra) as the suspensory material were compared to results with allogenic fascia lata. Forty-nine of the 121 polyfilament cable-type suture procedures (40.5%) were considered failures either because of ptosis recurrence (28.1%) or granuloma formation (12.4%). Only two of 24 (8.3%) of the fascia lata cases failed. No granuloma was associated with the use of fascia lata. The clinical and pathologic characteristics of ptosis recurrence and suture-rejection granuloma formation are discussed. Available preparations of allogenic fascia lata are reviewed and suggested as alternatives to the use of nylon polyfilament cable-type sutures for the repair of congenital ptosis.

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