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Purpose To examine the characteristics of blepharoptosis and the success of surgical intervention in a large group of children presenting to a specialist at paediatric ophthalmology center. Methods Ten-year retrospective case notes review of patients presenting to the Birmingham Children's Hospital for blepharoptosis surgery. Resultant database was interrogated for aetiology of ptosis; severity; surgical correction; outcome; complications and need for reoperation. Results One hundred and fifty five children (186 eyes) underwent blepharoptosis surgery. Hundred and ten patients (71%) were treated with a levator resection procedure, 28 (18%) underwent a brow suspension using Mersilene mesh, 15 (10%) with Fasanella Servat procedure and 2 (1%) with La Mange procedure. The mean post-operative follow-up was 30.82 months with 84 children completing a minimum of 12 months follow-up. Overall, 70.97% lids were successfully corrected with a single operation. In 9.14% lids, the results were fair but no further surgery was carried out. Reoperation was required in 19.89% of lids with the mean time to second surgery being 32.69 months. Amblyopia was found in 26.45% (41 children); in 3 patients, their amblyopia became manifest after the ptosis surgery. A concomitant squint was present in 14.19%, and 18.70% had a significant refractive error requiring spectacles prescription, with anisometropia present in more than 72% of these patients. Conclusions Early referral to an ophthalmologist is necessary even though surgical correction may be delayed. Children with congenital ptosis need to be monitored for amblyopia both pre-and post-operatively, as the incidence of strabismus and refractive errors is much higher than the general population and these may develop even after ptosis surgery.

Background: Septo-optic dysplasia (SOD) is a disorder with postulated environmental and genetic aetiology. This study delineates clinical features and potential perinatal environmental factors along with epidemiology in SOD children. Methods: Assessment of patients with SOD triad features in the UK West Midlands region. Results: Of 227 patients identified between 1998 and 2009 with 1 or more feature of the triad, 55 had midline defects, 149 had optic nerve hypoplasia and 132 had hypopituitarism. Eighty-eight children (52% males; incidence 8.3/100,000 live births) had SOD defined as 2 out of 3 features and 21 (24%) had all 3. Sixty-one percent had anterior pituitary deficiency and 21.5% had diabetes insipidus. Median maternal/paternal ages in SOD were 21 and 23.5 years, compared to UK means of 29.3 and 32.4 years (p < 0.001). First trimester bleeding was markedly increased at 12/48 (25%) compared to 0.07% in the UK (p < 0.001). Ethnicity showed a non-significant higher prevalence in Afro-Caribbean and mixed race groups, and significantly lower prevalence (p = 0.004) in South Asian groups compared to West Midland and Birmingham city data: 8% versus 2.5 and 6.7%, 9% versus 1.8 and 3.2% and 3% versus 8.4 and 21%, respectively. Conclusions: SOD is associated with younger maternal and paternal age, primigravida births and ethnic differences. Increased first trimester bleeding may indicate that SOD is a vascular disruption sequence.

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SUMMARYThe results of squint surgery in 42 children with primary, non-paralytic, childhood exotropia are analysed. A 'favourable outcome', defined as a final alignment for near and distance within ±10 dioptres of straight, or within ±20 dioptres of straight with evidence of bi nocular single vision, was achieved in 39 (93%) children.The factors affecting the final outcome are discussed, including age of onset, age at the time of surgery, pre operative and post-operative amblyopia, refractive error, anisometropia, the surgical procedures used, and post operative ocular alignment.Exotropia in childhood may be primary, secondary, con secutive or paralytic. 1 Primary childhood exotropia may be constant, when the exotropia is manifest for both near and distance, or intermittent, when the exotropia is mani fest for either near or distance. Intermittent distance exo tropia may be either true or simulated depending on the amount of exophoria controlled for near by accommo dation and fusional forces.2We reviewed children who underwent strabismus sur gery for primary childhood exotropia at the Birmingham Children's Hospital, in order to determine the results achieved, to identify the factors associated with favour able and less favourable outcomes, and to consider this information in the planning of future surgery for this condition. PATIENTS AND METHODSThe case notes of consecutive patients undergoing surgery for childhood exotropia at the Birmingham Children's Hospital in the 5 year period between January 1982 and December 1986 were reviewed. Any child with paralytic or consecutive exotropia, neurological disorder, ocular pathology, or a post-operative follow-up period of less than 24 months, was excluded. Information was obtained from the pre-operative examination, and from examin- Eye (1994) 8, 632-637 © 1994 Royal College of Ophthalmologists ations at 2 weeks, at 3-6 months, and at yearly intervals thereafter until discharge.True distance exotropia was defined as an exotropia at distance which exceeded the exophoria at near by more than 10 dioptres; simulated distance exotropia was con sidered present when the difference was 10 dioptres or less.3Amblyopia was defined as a difference of two lines or more between the monocular visual acuities. Anisometro pia was defined as a spherical or cylindrical difference of greater than 1.0 dioptre between the two eyes.4 All refrac tions were undertaken under cycloplegia using either cyclopentolate or atropine. Binocular single vision was assessed using tests of motor and sensory fusion as described in a previous publication, and one or more of these tests of motor or sensory fusion were used at each pre-operative or post -operative examination.5 A 'favourable outcome' was defined as a final align ment for near and distance within ± 10 dioptres of straight, or within ±20 dioptres of straight with evidence of bi nocular single vision.Statistical analysis was performed using medians and the non-parametric Mann-Whitney test for comparing continuous variables, and the chi-squared tes...

Since its first description optic nerve hypoplasia has been identified with increasing frequency, and a range of associated problems have been described. The major neurological and endocrine associations are well established, but those factors that predispose to the development of optic nerve hypoplasia remain unclear. To understand the aetiology of these problems better, and to formulate a management regime, we studied a consecutive series of 40 patients who were divided into three groups. Group 1 (n=24) had severe bilateral optic nerve hypoplasia; group 2 (n= 10) had mild, bilateral optic nerve hypoplasia; and group 3 (n=6) had unilateral optic nerve hypoplasia. Previously described aetiological factors (for example, low maternal age or maternal alcohol or drug ingestion) were not present in any of the groups; this removes the need to screen a specific population. It is important that careful neurological and developmental assessments are carried out in children with optic nerve hypoplasia to identify potential disease. The role of imaging is discussed.Patients and methods A diagnosis of optic nerve hypoplasia was made or confirmed by one of us (HEW) based on the appearance of a combination of features, the most important of which were (a) a small optic nerve head, (b) a second pigmented ring around the disc, and (c) tortuosity or abnormal origin of the vessels arising from the disc.'0 Rarely were all features present in any one eye. A detailed history was obtained from the mother in every case, specifically including the obstetric history, a history of smoking, alcohol consumption, or drug ingestion during pregnancy, and a history of problems in the neonatal period. The child's development and growth pattern were recorded and in all bilateral cases, and three unilateral, examination by a paediatric neurologist (SHG) was performed. In addition, most children had computed tomography performed, and, where it was considered appropriate, their endocrine state was investigated and any deficiency treated. Serial visual acuity measurements were taken using tests appropriate for age, and included preferred looking acuities in very young or retarded children.The diagnosis of optic nerve hypoplasia has been made with increasing frequency since its early descriptions,1 2 and it is no longer considered a rarity. A number of predisposing factors have been described, including maternal anticonvulsant ingestion,3 low maternal age,4 maternal alcohol or drug abuse,5 6 prenatal intracranial pathology,7 etc. In addition a wide range of neurological8 and endocrine9 associations have been recorded.In view of this array of associations it is difficult to identify a practical and appropriate management regime for each child with optic nerve hypoplasia. In particular, certain clinically important questions have not been directly addressed. Do only those children with severe optic nerve hypoplasia have neurological and endocrine problems? Do all children require some form of central nervous system imaging? Do positive resul...

Nasolacrimal intubation has been advocated to obviate the need for dacryocystorhinostomy (DCR) for childhood epiphora which fails to resolve despite apparently successful probings. Twenty-eight intubations were attempted on children falling into this category. Of these, 25 were anatomically successful intubations (3 having had to be abandoned because of difficulties in retrieving the silicone tubes from the nose). Twenty patients (80%) had complete resolution of symptoms, 2 (8%) had improvement of symptoms such that no further intervention was necessary and 3 (12%) proceeded to DCR. A greater likelihood of a good outcome was seen if the tubes were left in situ for 6 months or more. We suggest that primary nasolacrimal intubation (that is nasolacrimal intubation without DCR) should be the next step in the management of childhood epiphora which fails to resolve after two probings. This approach may avoid a DCR in over 80% of children.

Aims-To evaluate the incidence of retinal haemorrhages after convulsions in children. Patients and methods-All children who required hospital admission after an episode of convulsions were included in the study. Complete neurological and ocular examinations, including ophthalmoscopy, were undertaken within 48 hours of hospital admission. Results-Thirty three children were examined according to the protocol and their seizures were classified by a paediatric neurologist. Despite the fact that some of the children also vomited or underwent cardiopulmonary resuscitation, none of the 33 children developed retinal haemorrhages. Conclusions-Convulsions rarely (if ever)give rise to retinal haemorrhages. The finding of retinal haemorrhages should stimulate a detailed assessment to exclude non-accidental injury, whatever the nature of the associated or antecedent events.