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April 2006


• Review of a Difficult Subject
• Refining the Target Pressure Concept
• Your Call Is Important
• Correction

Review of a Difficult Subject

I read with interest “How to Assess and Treat Infantile Nystagmus” (Ophthalmic Pearls, November/ December) and found it an interesting and informative review of a difficult subject.

As the authors pointed out, treatment options include the use of the Kestenbaum-Anderson procedure. But in their description of a nystagmus patient with a left face turn and a null point in dextroversion, the left lateral and right medial rectus muscles would need to be resected, not recessed as indicated in the article. This would need to be combined with corresponding recessions of the right lateral and left medial rectus muscles in order to achieve the desired effect of moving the eyes to the left, thereby decreasing or eliminating the face turn to the left. Movement of the vertical rectus muscles can also achieve improvement in vertical torticollis, but this again usually involves both recession and resection of the appropriate muscles.

The last paragraph was perhaps the most important in advising parents and educators that adoption of unconventional reading positions must be allowed and encouraged in these children. Fifteen years of experience in pediatric ophthalmology has taught me that most of these children, fortunately, do not need surgical correction in order to achieve their educational goals.

Daniel T. Weaver, MD
Billings, Mont.

EyeNet is grateful to Dr. Weaver and others who offered that correction. The Academy’s Basic and Clinical Science Course (BCSC) explains in detail the Kestenbaum-Anderson procedure in Section 6: Pediatric Ophthalmology and Strabismus (2005–2006, pages 162–163).


Refining the Target Pressure Concept

Regarding “The Search for True Pressure Amid Daily and Seasonal Fluctuations” (Clinical Update, January): While it would be nice to know more about diurnal IOP fluctuations in our patients, the clinical trials—Advanced Glaucoma Intervention Study (AGIS) and Collaborative Initial Glaucoma Treatment Study (CIGTS)—showed us that we already can achieve long-term visual field stability in patients, consistently reaching appropriate target pressures that are based upon the degree of optic nerve damage and the IOP that caused the damage.

AGIS taught us that patients with advanced damage (mean deviation –10 decibels) do best with an IOP in the low-normal range, while CIGTS showed us that patients with mild, initial damage (–5 dB) do perfectly well at somewhat higher pressures (mean reduced from 25 to 17 mmHg) as long as the IOP is lowered at least 35 percent.

The Collaborative Normal Tension Glaucoma Study showed that lowering the IOP by 30 percent (mean 16 to 11 mmHg) reduced the risk of progression by two-thirds. On the other hand, far worse outcomes occurred in the Early Manifest Glaucoma Study, in which target pressures were not adopted.

Contrary to some of the comments in the article, the target pressure concept is not diminished—but might be refined—by being able to follow fluctuations.

Paul Palmberg, MD, PhD


Your Call Is Important

I really enjoyed your recent EyeNet Opinion, “Is This the Party to Whom I Am Speaking?” (January). I have gone through the same thought process hundreds of times and am glad you wrote the article for me. Don’t you love to hear, “your call is really important to us . . .”?

As long as I am in my office, an intelligent human will answer the phone!

Kenneth H. Musson, MD
Traverse City, Mich.



The drug doses of two experimental ocular implants described in the January EyeNet (“Get Drugs Straight to the Eye,” pages 37–40) were incorrect. Posurdex and Surodex contain, respectively, 700 micrograms and 60 micrograms—not milligrams—of dexamethasone. EyeNet regrets the error.


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