<h4>EXCERPT</h4> <p><b>Wagner:</b> A 9-year-old boy with tyrosinase-positive oculocutaneous albinism presents with best spectacle-corrected visual acuity of 20/80 in both eyes and a +2, -250 at 180° refraction that is symmetric in both eyes. He has a horizontal pendular nystagmus typical of oculocutaneous albinism, with no face turn or demonstrable null point or null zone. The parents want to know whether anything can be done surgically to reduce the nystagmus, and if so, whether it will improve his visual acuity. They have been told that he will never be able to drive, and they are hoping there may be a possible solution for this problem with surgery. Dr. Del Monte, how would you handle talking to the parents about this, and what can you offer the family?</p> <p><b>Del Monte:</b> Certainly, you have to maximize the potential with standard means first. You have to make sure they have the correct refraction and double-check it with a repeat cycloplegic if you need to. Just because he has a poor macular formation and abnormal innervation of the optic nerve does not mean that he cannot have maximal potential, so you want to maximize that.</p> <p>Assuming that you have done that, then of course you look for head positions. You mentioned there are not any, and that is another thing that is easy to work on and fix. Anyone older than 4 or 5 years is certainly a good candidate for those kinds of procedures, but this particular patient does fall into a group. I am not a big advocate of the large four-muscle recessions, and I have had no experience with the tenotomies. However, patients who have visual acuity near the driving vision range, from 20/70 to 20/100, are potentially candidates for large muscle recessions, and I have done it in a few of these patients.</p> <p>Typically, the literature supports that you do not get more than a line or so of vision improvement. You do get cosmetic improvement in the amplitude of the nystagmus, so they do appreciate that, but you get only a line or so of improvement. A patient who has a 20/80 visual acuity potentially is one who could improve to 20/70 or 20/60 and get a driver’s license. That to me is one of the indications for that procedure, so I certainly would discuss that with the patient. However, there is a significant risk with that procedure of creating a strabismus, and I would have to warn them about that as well.</p>