Board review

​Complications of strabismus surgery

Diplopia

Iatrogenic Brown Syndrome: SO tightening procedures

Anti-Elevation Syndrome : IO weakening procedure (Anterior transposition and myectomy)

Lost and Slipped Muscles Pulled-in-Two Syndrome: especially with tight muscles and thyroid muscles

Perforation of the Sclera: large recessions, high myopes Postoperative Infections Pyogenic Granuloma and Foreign-Body Granuloma

Epithelial Cyst Conjunctival Scarring

Adherence Syndrome

Dellen

Change in Eyelid Position

​Anterior segment ischemia

Circulation to the anterior segment comes from the anterior ciliary arteries which are branches of muscular arteries which are in turn branches of ophthalmic arteries

The inferior and superior recti carry the bulk of the blood supply to the anterior segment

If operated on more than 2 recti muscles at the same sitting can cause anterior segment ischemia

Staged procedure Operate on oblique muscle if need to do a third muscle

Can do plication

Earliest sign is cell and flare Treatment with steroids

​Epiphora, photophobia and blepharospasm

Poll

Despite maximal medical management and prior surgery, a 5-year-old boy with Sturge-Weber syndrome presents for evaluation of progressive glaucoma OD. Anterior segment examination shows the corneas are clear with horizontal diameters 13 mm OD, 11 mm OS. Intraocular pressures measured 26 mmHg OD, 17 mmHg OS. Which treatment should be considered next?

• Drainage implant

• trabeculotomy

• Trabeculectomy

• Goniotomy

Glaucoma is the most common and serious complication in children with Sturge-Weber syndrome. Glaucoma develops in about half the cases. Therapy with topical drops can be effective, but when medical management fails, surgery is indicated. Setons or aqueous drainage devices have been shown to be useful for management of intractable glaucoma in patients with Surge-Weber syndrome. Goniotomy and trabeculotomy are not appropriate treatment methods in patients with Sturge-Weber syndrome who have failed previous surgical and medical management. Trabeculectomy in the absence of mitomycin-C is also unlikely to be successful in this patien

Multiple Choice

Under anesthesia, a 6-month-old boy is found to have corneal diameters of 13 mm OD and 12.5 mm OS. Significant bilateral corneal edema is also present. Intraocular pressures (IOPs) are 33 mmHg OD and 29 mmHg OS. What would be the preferred first-line treatment?

• goniotomy

• trabeculectomy with Mitomycin C

• cycloablation

• Trabeculotomy

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​•The primary treatment for most types of childhood glaucoma is surgery.

•PCG is usually effectively treated with angle surgery (goniotomy or trabeculotomy).

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•Medical treatment often has value prior to surgery and has long term benefit particularly in JOAG and some secondary childhood glaucomas.

TREATMENT OF PRIMARY CONGENITAL GLAUCOMA

•Clear cornea- Goniotomy or trabeculotomy

•

•Cornea compromised- Trabeculotomy or combined trabeculotomy and trabeculectomy.

​Sugical intervention is the treatment of choice fort primary congenital glaucoma. Trabeculotomy is preferable in cases of poor visualization of the angle secondary to corneal edema. Goniotomy involves incising the trabecular meshwork under direct visualization and is often preferred when the cornea is clear. Trabeculectomy with the use of mitomycin-C is often not successful in patients younger than one year. Cycloablation is reserved for extremely resistrent cases that are not responsive to other treatment modalities.

Poll

An 8-year-old boy presents for evaluation with a 3-day history of fever, lethargy, headache, eye pain, and eyelid edema. The child's past medical history is significant for sinusitis. On examination, the child appears uncomfortable. He is found to have 20/20 vision with his right eye and 20/40 vision with his left eye. Although the patient has full ocular motility with his right eye, there is proptosis and limitation of ocular motility with his left eye. The child also expresses pain in his left eye on ocular motility examination. Which of the following is the most appropriate initial step in treatment?

• Close monitoring with referral to a pediatric otolaryngologist

• Referral to radiology for orbital computed tomography

• Daily monitoring in the office and treatment with oral antibiotics

• Hospitalization and treatment with intravenous antibiotics

​The patient described above has a left orbital cellulitis. Orbital cellulitis is commonly associated with ethmoid or frontal sinusitis. Early signs and symptoms of orbital cellulitis include fever, lethargy, eyelid edema, rhinorrhea, headache, orbital pain, and tenderness on palpation. Unlike preseptal cellulitis, patients with orbital cellulitis also have proptosis and limited ocular motility on exam. Orbital cellulitis in children is a serious disease requiring hospitalization and treatment with intravenous antibiotics. Orbital computed tomography is important to perform, but it is not the most appropriate initial step in treatment. It is reasonable to consult an otolaryngologist due to the patient's history of sinusitis, especially if sinus disease is determined on computed tomography. However, the process of consulting an otolaryngologist should not delay the patient's hospitalization and treatment with intravenous antibiotics. Treatment of orbital cellulitis in a child in an outpatient setting is not appropriate.

Multiple Choice

A 13-year-old boy presents with a 6-month history of headaches, blurred vision, and intermittent crossed diplopia at near. His symptoms occur almost every day and are worse when he is tired. Your examination reveals an uncorrected acuity in each eye of 20/20. On a distant accommodative target, he is orthophoric. On a target at 1/3 m, he has a 15-prism-diopter exophoria. His near point of accommodation is 8 diopters in each eye. His fusional convergence amplitudes are 16 prism diopters to break and 12 to recover at 1/3 m, and 4 prism diopters to break and 2 to recover on a target at 6 m. Cycloplegic refraction reveals +0.75 sphere OD and +1.00 sphere OS. What would the best treatment option be?

• Resection of both medial rectus muscles

• Glasses with base-in prisms

• Exercises for convergence insufficiency

• Correction of the cycloplegic refractive error

The best treatment option for this patient would be exercises for convergence insufficiency. Many motivated patients with symptomatic convergence insufficiency will improve with exercises if their symptoms are related to near work. A base-in prism may be helpful in selected patients, although the patient may compensate for the prism and increase the size of the deviation. Prisms are probably best reserved for elderly patients whose accommodation cannot be used to aid convergence and for patients unwilling to do exercises. Correction of the hyperopia is likely to decrease convergence and aggravate the symptoms. Surgery can benefit patients with moderate-to-large deviations who have failed to respond to exercises and prisms. A persistent esodeviation with diplopia is common following strabismus surgery for convergence insufficiency.

Multiple Choice

In what condition are cyclopegic agents contraindicated during refraction?

• Young or uncooperative patients

• infantile glaucoma

• malignering

• Adverse side effects to anticholinergic drugs

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​The use of cycloplegic agents for cycloplegic refraction is an important part in the evaluation of patients with complaints pertaining to binocular vision and ocular motility. Adverse reactions to cycloplegic agents (anticholinergics) include allergic or hypersensitive reaction with conjunctivitis, eyelid edema, and dermatitis. Psychological effects have been observed in children receiving the drug. Adverse reactions occur more frequently with atropine compared to other agents. Systemic intoxication from atropine manifests as dry mouth, fever, flushing of the face, rapid pulse, nausea, dizziness, delirium, and erythema. Patients with previous adverse side effects are at risk for adverse reactions to further use of the offending cycloplegic agents.  In none of the other conditions are cycloplegic drops contraindicated.

Multiple Choice

Superior Oblique muscle palsy (fourth or trochlear nerve palsy) is the most common isolated cyclovertical muscle palsy encountered by ophthalmologists. Which of the following conditions is the most common cause of acquired superior oblique muscle palsy

• Cavernous sinus aneurysm

• direct trauma to tendon

• long standing hypertension

• Closed head trauma

Superior oblique palsy may be congenital or acquired. Congenital superior oblique palsy often results from a defect in the fourth nerve nucleus, or a defect in the motor portion of the fourth cranial nerve. Acquired superior oblique palsy most commonly occurs following closed head trauma. Rarely, acquired superior oblique palsy can result from central nervous system vascular problems, diabetes, or brain tumors. Direct trauma to the tendon or trochlea is an unusual cause of superior oblique palsy.

Poll

A 3-month-old infant undergoes lensectomy for a unilateral congenital cataract. Which of the following is most likely to develop in this patient?

• Secondary cataract

• vitreous hemorrhage

• amblyopia

• Hyphema

Children with unilateral cataracts are at particular risk for developing amblyopia, but children with bilateral cataracts are also at risk. Other disease-related complications associated with congenital cataracts include strabismus, glaucoma, and nystagmus. A primary posterior capsulotomy is usually created in young children undergoing cataract surgery. As a result, secondary cataracts (due to posterior capsule opacification) are not common.

Poll

A 29-year-old woman has a history of esotropia that was diagnosed at 4 years of age and treated with glasses and patching for a few months. She has had decreased vision in her right eye for as long as she can remember. She has noticed more crossing of her right eye in the past few years and would like it corrected. Her best-corrected visual acuity is 20/100 OD with a -0.50 sphere and 20/20 OS with a +0.50 sphere. Your examination reveals a 20-prism-diopter right esotropia in primary and side gaze. The esotropia decreases to 5 prism diopters in up gaze and increases to 30 prism diopters in down gaze. The remainder of her ocular examination is normal. What would be the best procedure to correct this deviation?

• R and R OD with infraplacement of the medial rectus muscle and supraplacement of the lateral rectus muscle

• Bilateral recessions of the medial rectus muscles with infraplacement

• Resection of the right lateral rectus muscle and recession of the right medial rectus muscle (R and R OD)

• Resection of the right lateral rectus, recession of the right medial rectus, and recession of the right inferior oblique

This patient demonstrates a V-pattern esotropia and decreased visual acuity in the right eye, presumably resulting from amblyopia. The esotropia could be corrected with a recession and resection procedure of either eye or bilateral medial rectus recession. Because the patient has significant visual impairment, it is reasonable to restrict surgery to the poorer eye if possible. Correction of the V pattern can best be achieved by vertical displacement of the horizontal rectus muscles. In this case, the medial rectus should be infraplaced and the lateral rectus supraplaced. An inferior oblique muscle recession is indicated only if the inferior oblique muscle is overacting and there is an associated incomitant vertical deviation.

Multiple Choice

A 4-week-old girl is referred for evaluation of an abnormal red reflex OS. Examination reveals a 6 mm dense, central posterior subcapsular lenticular opacity OS with a normal retinal examination. Cycloplegic retinoscopy reveals +2.00 sphere hyperopia in each eye. What step should be considered next?

• Spectacles

• daily pharmacological dilation

• lensectomy with anterior vitrectomy

• observation

Cataracts present at birth are serious because the visual system is not fully developed, putting the patient at risk for irreversible amblyopia if the visual axis is not cleared within 6 to 8 weeks of birth. Unilateral cataracts are more likely than bilateral opacities to cause permanent visual loss. Daily pharmacologic dilation is an inappropriate treatment for patients with visually significant cataracts (3 mm or greater). Because of its size and location, spectacles and observation are also inappropriate initial management options for this patient.

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Multiple Choice

Cytomegalovirus (CMV) is the most common intrauterine infection and has been isolated from the urine in up to 3% of newborns. A small percentage of these infants show clinical symptoms in the neonatal period and have widespread congenital anomalies. Which of the following is not a typical congenital anomaly associated with intrauterine CMV infection?

• Chorioretinitis

• microphthalmia

• limb abnormalities

• Hepatosplenomegaly

The predominant abnormalities associated with CMV infection are related to damage to the central nervous system. Among the abnormalities noted are mental retardation, seizures, spasticity, and deafness. Other manifestations include premature birth, small size for gestational age, microcephaly, jaundice, hepatosplenomegaly, thrombocytopenia, and anemia. Reported ocular findings include chorioretinitis, microphthalmia, cataracts, and optic disc anomalies. Limb anomalies are not generally associated with intrauterine CMV infection

Poll

A 1-year-old boy presents for evaluation following lensectomy for a unilateral cataract at 5 months of age. The parents report good compliance with daily patching and aphakic contact lens use for the last 6 months. Exam findings are consistent with severely decreased vision in the left eye. What is the most likely cause of the patient's poor vision?

• anisometric amblyopia

• strabismic amblyopua

• deprivation amblyopia

• ametropic amblyopia

Multiple Choice

A 3-month-old infant presents with a history of constant epiphora since birth. On examination the patient appears relatively comfortable and is found to have epiphora with mucopurulent discharge from both eyes. Fluorescein solution is placed into the tear film of each eye, and the patient is noted to have significant retention of the fluorescein dye with failure of the dye to appear in the nose after 15 minutes. The remainder of the exam is normal. Which of the following is the most likely diagnosis

• bilateral punctal atresia

• CNLDO

• Congenital glaucoma

• Bilateral cojunctivitis

Obstruction of drainage below the lacrimal sac tends to occur in 5% of newborns and is usually caused by a thin mucosal membrane at the distal end of the nasolacrimal duct. Symptoms consist of epiphora and mucoid or mucopurulent discharge. The impatency of the drainage system can be confirmed by placing fluorescein solution in the tear film and noting retention of the dye in the tear film after 5-10 minutes. The dye will also fail to appear in the nose or pharynx after 10-15 minutes. Conservative management involves nasolacrimal massage with topical broad spectrum antibiotics. Initial surgical management involves nasolacrimal duct probing. Conjunctivitis may have discharge that is serous, mucopurulent, or purulent. Patients with conjunctivitis tend to have burning, stinging, foreign body sensation, ocular discharge, and matting of the eyelids. Congenital glaucoma is associated with epiphora, photophobia, and blepharospasm. The cornea also tends to be enlarged with corneal clouding. Punctal atresia is usually ruled out by inspection.

Multiple Choice

What is a common ocular manifestation of herpes simplex complex infection in children?

• Unilateral giant papillary conjunctivitis

• Unilateral belpharoconjunctivitis

• Unilateral allergic conjunctivitis

• Unilateral vernal/atopic conjunctivitis

Herpes simplex complex results from infection with herpes simplex viruses 1 and 2 (HSV-1 and HSV-2). Close personal contact with infected individuals is the primary risk factor for herpes simplex. The diagnosis of herpes simplex is usually clinical, but virus can be cultured from vesicles. Unilateral blepharitis is considered to be a pertinent element in the history and manifestation of herpes simplex infection in children. Rarely the belpharitis can be bilateral. Patients may also present with watery discharge, decreased vision, vesicular lesions, and palpable preauricular lympadenopathy.  Allergic, giant papillary and vernal conjunctivitis are usually bilateral and not typical of herpetic disease

Multiple Choice

Which of the following statements best describes developmental dyslexia

• Dyslexia is not common in juvenile delinquents.

• Dyslexics often present to ophthalmologists with visual symptoms.

• Dyslexics often have below-normal intelligence.

• Dyslexics rarely have a positive family history for dyslexia.

Dyslexia is estimated to affect up to 8% of school-age children. As many as 75% of juvenile delinquents are thought to be dyslexic or to have learning disabilities. Recent evidence suggests that males and females may be affected nearly equally. A positive family history for learning disorders is not uncommon. If one parent is affected, a child has a five to tenfold greater risk of have a reading disorder than a child of unaffected parents. Most dyslexics are of normal intelligence or even gifted. Since almost all dyslexics are visually normal, they frequently pass unsuspected through ophthalmology offices with vague complaints such as headaches with reading, blurry blackboards, words running together, or reading difficulties. Parental requests for routine checkups are often initiated by disappointing performance rather than by a desire for screening or preventive care, as is usually presumed. The value of a careful history and early recognition cannot be overestimated.

Multiple Choice

A 6-year-old girl is diagnosed with anterior uveitis in her right eye. What is the preferred first-line therapy?

• Topical corticosteroids

• systemic immunosuppressants

• Prostaglandin inhibitors

• observation

The goal of uveitis treatment in children is to suppress inflammation to prevent complications such as glaucoma, cataracts, retinal detachment, and amblyopia. Mild anterior segment inflammation can be treated with topical cortical steroids and cycloplegic agents. Oral corticosteroids and immunosuppressants should be given in conjunction with the child's rheumatologist or pediatrician in severe cases in which the benefits outweigh the risks. Prostaglandin inhibitors are not currently considered preferred first-line therapy in children.

Multiple Choice

A 6-month-old girl presents for evaluation of esotropia, which has been present since birth. Examination reveals 40 prism diopters of esotropia. The patient is also noted to cross-fixate. Which one of the following is the most appropriate initial therapy?

• Surgical correction between 2 and 5 years of age

• alternate occulsion for treatment of amblyopia

• surgical correction before 1 year of age

• spectacle correction of 1 DS of hyperopia

Early surgery for infantile esotropia is believed to maximize binocular visual function. Gerth et al. determined that early surgery at or before 11 months of age promotes the development of cortical visual motion processing compared with standard surgery at age 11 to 18 months. The most commonly performed procedure for infantile esotropia is bilateral medial rectus muscle recession. Cycloplegic refraction tends to reveal +1 diopter of hyperopia, which is considered normal refractive error in young children. Thus, spectacles for correction of hyperopia are not the most appropriate initial therapy for patients with infantile esotropia. Although occlusion therapy is used to treat amblyopia, alternate occlusion therapy is not the most appropriate initial therapy for either infantile esotropia or amblyopia.

Multiple Choice

A 7-year-old boy presents with a 9-month history of frequent episodes of blinking. The episodes are short in duration and occur randomly. Visual acuity is normal. The child's refractive error is +0.50 sphere in each eye. The remainder of the ocular examination is normal. Which of the following statements best describes this situation?

• A tear secretion test with and without anesthetic is likely to be diagnostic.

• patient is likely to have a tic disorder

• blinking is more likely a habit

• A conjunctival scraping to look for eosinophils and mast cells is indicated.

This patient most likely has a tic disorder. Tic disorders represent a clinical spectrum from the mild, transient form seen in up to 15% of children to the potentially devastating Tourette's syndrome, for which prevalence estimates vary from 1:200 to 1:2000. Tic disorders are characterized by involuntary, sudden, rapid, brief, repetitive, stereotyped, purposeless movements or vocalizations. There is often a positive family history, and males are more likely to be affected than females. Other behavioral problems are frequently associated with tic disorders; obsessive-compulsive disorder and attention-deficit hyperactivity disorder are the most common. Dry eye syndromes are very rare in children. It is unlikely with an otherwise normal examination that this child would have decreased tear secretion. Allergic or vernal conjunctivitis is more common; however, it is often seasonal and will usually demonstrate abnormalities on anterior segment examination.

Multiple Choice

A 22-year-old patient with a compensatory head posture for V-pattern esotropia undergoes successful surgical realignment of the eyes. What is the patient most likely to report of the post-operative Worth 4-dot examination?

• 3 green lights – suppression of 1 eye

• 3 green lights, then 2 red lights – alternate suppression

• 5 lights – diplopia, but no suppression of either eye

• Sees all 4 lights – normal response/fusion

The Worth 4-dot test is used to evaluate suppression and anomalous retinal correspondence. During testing, glasses are worn with a red lens over 1 eye and a green over the other. A target is shown at distance (20 feet) and near (33 cm). The target consists of a light source that has 1 red light, 2 green lights, and 1 white light. The patient is then asked to describe the number and color of lights. If all 4 lights are appreciated, the patient is considered to have fusion or a normal response. Following successful surgical realignment of the eyes in a patient with V-pattern esotropia, the patient should have a normal response during Worth 4-dot testing

Poll

A 15-year-old boy has bilateral high myopia, a sensory exotropia, and a history of retinal detachment in the right eye requiring scleral buckling. He recently had a recession/resection muscle strabismus surgery in the right eye for his exotropia. On postoperative exam, his right eye has corneal edema and folds in Descemet's membrane, and anterior inflammation. What is the most likely diagnosis?

• Traumatic anterior uveitis

• anterior segment ischemia

• keratitis

• normal post-operative inflammation

Anterior segment ischemia is characterized by corneal epithelial edema, folds in Descemet's membrane, and additional signs of anterior uveitis. The risk for anterior segment ischemia increases following simultaneous surgery on three or more rectus muscles in the same eye or two rectus muscles in the same eye in patients with poor blood flow. Treatment involves the use of topical, subconjunctival, or systemic steroids. Normal postoperative inflammation does not result in corneal epithelial edema, folds in Descemet's membrane, or significant anterior uveitis. Keratitis is not seen following uncomplicated strabismus surgery

Multiple Choice

Three days following strabismus surgery, a 6-year-old child develops increasing conjunctival injection and eyelid edema in one eye. The child has vision of 20/25 OU and his ocular motility is full. What is the most likely diagnosis

• Preseptal/orbital cellulitis

• Allergic conjunctivitis

• anterior segment ischemia

• early post-op infalmmation

​Postoperative infections following strabismus surgery occur rarely, have typical onset 2 or 3 days postoperatively and can present as preseptal cellulitis, orbital cellulitis, or endophthalmitis. Early postoperative injection is not usually associated with increasing conjunctival injection or eyelid edema, which is described in this patient. The earliest signs of anterior segment ischemia are cells and flare in the anterior chamber. Corneal epithelial edema, folds in Descemet's membrane, and an irregular pupil may characterize more severe cases. Findings consistent with anterior segment ischemia are not described in this patient. Likewise allergic conjunctivitis is not a likely diagnosis in this patient.

Multiple Choice

A patient has strabismus surgery with adjustable sutures under using local anesthesia consisting of sub-Tenon's lidocaine injection. During postoperative adjustment, the patient experiences a vagal attack. Which of the following is the preferred management of this adverse event?

• Discontinue suture adjustment and ensure adequate airway and circulatio

• Discontinue suture adjustment and reassess patient in 24 hours.

• Continue suture adjustment after placing the patient in supine position.

• Continue suture adjustment after placing the patient in supine position.

Adjustable suture technique in strabismus surgery can be used in selected patients to adjust postoperative alignment. The technique is particularly useful in cases with unpredictable outcomes. Complications include movement during the critical part of the procedure in awake or inadequately anesthetized patients and lack of cooperation with postoperative suture adjustment. These complications can be minimized by ensuring adequate anesthesia and selecting patients carefully. If a patient experiences a vagal attack during postoperative suture adjustment, the procedure should be discontinued. In addition, the patient should be placed in a supine position, ensuring adequate airway and circulation.

Multiple Choice

An infant girl presents for evaluation with epiphora, blepharospasm, and photosensitivity. On examination, the infant is noted to have corneal clouding in the right eye, and the right cornea appears to be enlarged. Which of the following is the most likely cause of this patient's condition?

• CNLDO

• primary cogenital glaucoma

• conjunctivitis

• corneal abrasion

The clinical triad of primary congenital glaucoma includes epiphora, photophobia, and blepharospasm. Corneal clouding and enlargement of the cornea are other common findings. Corneal clouding is secondary to edema resulting from elevated intraocular pressure, and the presence of corneal clouding may be gradual or sudden in onset. Photophobia, epiphora, and blepharospasm result from the glare and epithelial abnormalities associated with corneal edema and opacification. Corneal enlargement results form gradual stretching of the cornea as a result of elevated intraocular pressure. Corneal enlargement tends to occur in older infants up to about 2-3 years of age. A corneal diameter of greater than 11.5 mm is suggestive of glaucoma in a newborn, and glaucoma should be suspected in any child with a corneal diameter greater than 13 mm.

Multiple Choice

A 16-year-old boy has a history of normal vision in both eyes. He presents complaining of a sudden decrease in vision in the right eye. His visual acuity is 20/200 OD and 20/15 OS. A relative afferent pupillary defect is present in the right eye, and visual field testing reveals a dense central scotoma OD. Fundus examination reveals a normal macula with a hyperemic-appearing disc OD. The result of MRI of the head and optic nerves is normal. If an abnormality in this patient's DNA related to visual loss were found, what would it most likely reveal?

• Chromosome 13 deletion

• A mutation on the X chromosome

• A mutation in the rhodopsin gene on chromosome 3

• A mutation of the mitochondrial DNA

This case is most consistent with a diagnosis of Leber's hereditary optic neuropathy. This condition is associated with mutations in the mitochondrial DNA in at least three loci: nucleotides 11778, 3460, and 14484. For reasons that are not well understood, males are affected more commonly than females. The disease is inherited from the maternal DNA, with a woman who harbors the mutation passing it to all of her offspring. Why only a fraction of the individuals who harbor the mutation will actually develop optic neuropathy is not currently understood. Molecular tests that reveal the presence of one of these three mutations are an extremely reliable way to make the diagnosis. The clinical presentation of Leber's hereditary optic neuropathy is not diagnostic of the condition. Neuroimaging should be considered in these patients at least once to rule out the possibility of a lesion of the optic nerve or brain. A mutation in the rhodopsin gene on chromosome 3 has been found in some types of retinitis pigmentosa. A mutation on the X chromosome has been associated with a number of ocular conditions, although not with Leber's hereditary optic neuropathy. Ocular manifestations of a chromosome 13 deletion include microphthalmia, colobomata, and retinoblastoma.

Multiple Choice

A 7-year-old boy presents with corneal pseudodendrites from herpes zoster ophthalmicus. What is the preferred management of this patient?

• Systemic corticosteroids and antibiotics

• Topical corticosteroids and antibiotics

• Systemic antiviral medication

• Topical antiviral medication

Herpes zoster ophthalmicus is rare in children. Pertinent clinical features include epiphora and vesicle formation on the head and eyelids. Uveitis may also be present. Immunocompromised children are at greater risk for developing the disease. Management includes systemic antivirals (eg, acyclovir, famciclovir, valacyclovir), moist compresses, topical antibiotics for cutaneous lesions, and topical lubricants. Topical corticosteroids and cycloplegics are used for stromal or disciform keratitis or uveitis, not features mentioned for this child.

Multiple Choice

A 3-year old girl is diagnosed with strabismic amblyopia. Following cycloplegic refraction, the child is also noted to have hyperopia equal to +5.00 sphere in each eye. Which of the following is the most appropriate next step in treatment?

• Full-time occlusion

• Full-time spectacles

• Strabismus surgery

• Cycloplegic agents

Treatment of amblyopia includes correcting refractive errors, forcing use of the poorer eye by limiting the use of the better eye, and eliminating obstacles to vision (such as a cataract). Patients with amblyopia and significant refractive errors are given full-time spectacles to correct the full refractive error as determined with cycloplegia. Correction of refractive errors alone with full-time spectacles will improve vision in the amblyopic eye in some children. Forcing use of the poorer eye by limiting use of the better eye is achieved with occlusion therapy and optical degradation (penalization). Strabismus surgery should be considered after treatment of amblyopia.

Multiple Choice

Which of the following statements does not accurately describe chlamydial conjunctivitis of the newborn?

• It is the most common infectious cause of neonatal conjunctivitis.

• It is commonly associated with pneumonitis.

• Silver nitrate 1% solution provides prophylaxis.

• Oral erythromycin should be prescribed.

The most common infectious cause of neonatal conjunctivitis is Chlamydia trachomatis. Up to 10% of asymptomatic pregnant women have been shown to be culture positive for this organism. Approximately 30% to 40% of children born to untreated affected mothers will be infected. Approximately 15% of newborns with conjunctivitis develop chlamydial pneumonitis. Because of possible systemic involvement, oral erythromycin is the treatment of choice. Either erythromycin or tetracycline, given topically within 1 hour after birth, significantly decreases the likelihood of developing chlamydial conjunctivitis. Silver nitrate has little or no effect in preventing this infection

Multiple Choice

Deafness has not been commonly associated with which of the following ocular findings

• Anterior lenticonus

• interstitial keratitis

• iris nevus

• retinitis pigmentosa

A number of ocular conditions, both congenital and acquired, have been associated with neurosensory deafness. Classically described syn­dromes associated with deafness and their ocular findings include Usher's (retinitis pigmentosa), Alport's (anterior lenticonus), and Co­gan's (interstitial keratitis) syndromes. Iris nevi are not commonly associated with neurosensory deafness