Volume 15 Number 1 / February 2011 e9

Methods: Clinical course and outcome data were collated prospec-tively in a group of 79 children and adolescents (116 eyes; mean age,11.1 yrs; range, 1-22 yrs) with neurobehavioral disorders exacerbatedby poor compliance with spectacles. Correction was achieved by im-plantation of an iris-enclaved (Verisyse myopic; Ophtec hyperopic ortoric) phakic IOL under general anesthesia. Mean follow-up was 2.4yrs (range, 4 mos to 5 yrs).Results: Myopia in 93 eyes ranged -10.0 to -22.75 D (mean -15.3 D)and hyperopia in 23 eyes +10.25 to +12.0 (mean +10.8 D). Goal refrac-tion was � 0 to +1 D. Myopia correction averaged 14.8 D and hyper-opia correction 9.5 D. Eighty-four percent of eyes were corrected towithin � 1 D of emmetropia and the remaining 16% to within � 2 D.Uncorrected visual acuity improved substantially in 97% of eyes (onaverage 20-fold; from a mean 20/1100 to a mean 20/46; mean Snellen-fraction gain 5 0.41). Ocular comorbidities accounted for residualsubnormal visual acuity (e.g. amblyopia, nystagmus, albinism, ROP).Visual functions improved (measured by validated survey) in 84%.Five eyes (4%) required IOL re-enclavation after trauma-relateddislocation.Conclusions: Phakic IOL implantation is effective for improving visualfunction in neurobehaviorally-impaired children who have ametropiabeyond the range of excimer laser correction.

032 Long-term outcome of medial rectus (MR) recession andpulley posterior fixation (PPF) in esotropia with high AC/A ratio.Geoffrey B. Wabulembo, Joseph L. DemerPurpose: Clark and colleagues showed that medial rectus (MR) re-cession with pulley posterior fixation (PF) treats esotropia witha high accommodative convergence to accommodation (AC/A) ratioas well in the short term as MR with scleral PF. This study examinedthe long term results.Methods:We reviewed 19 children who had undergone bilateral MRrecession and pulley PF for esotropia greater at near than distance(high AC/A). Mean follow-up was 3.2 � 3 (standard deviation, SD)years. Measurements were with cycloplegic correction andfollowing amblyopia treatment.Results: The mean age at presentation was 2.74 (SD 5 1.8) and atsurgery 4.3 (SD5 2.3) years. 9 (47.3%) children had amblyopia at ini-tial evaluation. Preoperative esotropia averaged 20.1� 11.2Δ for dis-tance and 35.4 �19.5Δ at near, with a mean near-distance disparity15.8� 13.3Δ. MR recession averaged 4.3� 1.4 mm. Early mean post-operative esotropia was 1.5 � 4Δ at distance and 1.6 � 3.3Δ at near.Additionally mean late postoperative esotropia was 1.3 � 2 atdistance and 2.1 � 3.2Δ at near, reducing the mean near-distancedisparity to 0.8 � 3.8Δ. At their last visit 19 (100%) had\ 10Δ nearand distance ET. Preoperatively, 17 (94%) required spectacles with+4.00 D average spherical equivalent, including 2 with bifocals. Post-operatively, 14 (78%) required spectacles, but none required bifocals.One reoperation (5.2%) was required for consecutive exotropia justover 6 years after surgery.Discussion: Kushner advocated MR recession without posterior fix-ation dosed for near esotropia in high AC/A. He reported long termoutcome of#10Δ deviation at near and distance in 19 (86%) of 22 pa-tients, with reduced spectacle power in most of them, elimination ofbifocals in 84%, and reoperation in 18%. In our series 19 (100%) of pa-tients had#10Δ deviation postoperatively, with only 1 (5.2%) reoper-ations. MR with PPF is simple and minimizes the perforation riskassociated with scleral PF.Conclusions: MR recession with PPF is a safe and highly effectivelong-term treatment for esotropia with high AC/A ratio that may besuperior to MR recession alone.

Journal of AAPOS

033 Monocanalicular versus bicanalicular intubation in thetreatment of congenital nasolacrimal duct obstruction. RickWhitehead, Daniel E. Neely, Derek T. Sprunger, Kathryn M. Haider,Gavin J. Roberts, David A. Plager, Drew B. Davis, Mark A. Prendes,Faruk OrgeIntroduction: Monocanalicular and bicanalicular silicone tube intu-bation have both been shown to effectively treat congenital nasola-crimal duct obstruction (NLDO). This study aims to compare thesuccess of each procedure and identify the likelihood of prematuretube extrusion.Methods: A retrospective chart review was performed on childrenwith congenital NLDO who were treated with primary bicanalicularor monocanalicular silicone tube intubation from 2001 to 2010. Chil-dren over 36 months or with other eyelid pathology were excluded.Success was defined as cessation of symptoms or minimal epiphoranot requiring further treatment.Results: 632 eyes are reported. Of those with bicanalicular intuba-tion, 366 of 421 (86.9%) had successful treatment. Successful mono-canalicular intubation occurred in 184 of 211 eyes (87.2%). There wasno statistically significant difference between the success rates.There were 68 eyes (16%) with bilateral intubation and 112 eyes(53%) with monocanalicular intubation that had premature tube ex-trusion. Of these eyes, 7 of the 68 (10.3%) bicanalicular tubes and10 of the 112 (8.9%) monocanalicular tubes were associated withtreatment failures.Conclusion: Monocanalicular and bicanalicular nasolacrimal ductintubation effectively treated congenital NLDO. Monocanalicular in-tubation resulted in more frequent tube extrusion but no increasedfailure rate.

034 A novel "upright-supine test" to differentiate skew deviationfrom trochlear nerve palsy and other causes of verticalstrabismus. Agnes Wong, Linda ColpaPurpose: Skew deviation is a vertical strabismus caused by a supra-nuclear lesion in the utriculo-ocular reflex pathway which normallydetects static head position. The magnitude of skew deviation ishead position dependent. We sought to determine the sensitivityand specificity of a new "upright-supine test" to differentiate skewdeviation from other causes of vertical strabismus.Methods: A total of 122 consecutive patients presented with a ver-tical strabismus were recruited: 22 skew deviation, 58 trochlearnerve palsy, and 42 other causes (eg restrictive causes, myastheniagravis, childhood strabismus). Twenty normal participants servedas control. The deviation was measured by the prism andalternate cover test using a near target at 1/3 meter in both theupright and supine positions. A vertical strabismus that decreasedby $ 50% from the upright to supine position constituted a positivetest.Results: The "upright-supine test" was positive in 18/22 patients withskew deviation, but negative in all patients with trochlear nerve palsyor other causes. The test's sensitivity was 82% and specificity was100%. All skew patients with a negative test exhibited other neuro-logic signs and three had a midbrain lesion, which may have causeda vertical strabismus from a combination of skew deviation andnuclear-fascicular trochlear nerve palsy.Discussion: The upright-supine test is highly specific fordifferentiating skew deviation from other causes of verticalstrabismus.Conclusions: The upright-supine test could be added as a fourth stepafter the "three-step" test. If the upright-supine test is positive, neuro-imaging should be considered to rule out skew deviation.