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Elkamshoushy A, Awadein A, Elhilali H, Hassanein DH. Overcorrection after vertical muscle transposition with augmentation sutures in sixth nerve palsy. Eye (Lond) 2023; 37:127-131. [PMID: 35031706 PMCID: PMC9829669 DOI: 10.1038/s41433-021-01660-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 06/01/2021] [Accepted: 06/21/2021] [Indexed: 01/17/2023] Open
Abstract
PURPOSE To report a series of cases, who developed consecutive exodeviation after vertical muscle transposition (VRT) performed for sixth nerve palsy, describe their management and analyse their outcome. DESIGN Retrospective case series. METHODS This is an institutional study on patients who developed consecutive exotropia following VRT for sixth nerve palsy in two different centres. The age, gender, cause, and time to surgery were reviewed. Ductions, versions and angles of misalignment were analysed. In those who developed an exotropia >10 PD after surgery, a second surgery was performed. The time to the second surgery, intra-operative findings, surgical procedure and outcome were studied. RESULTS A total of 164 cases of VRT for sixth nerve palsy were identified. Nine patients developed consecutive exotropia >10 PD (5.5%). There were no significant differences in the characteristics of those who developed overcorrection compared to those who did not. Five patients had full-tendon muscle transposition, three patients had Hummelsheim procedure and one patient had Jensen procedure. The average angle of consecutive exotropia was 26 ± 9 Δ (range 10-40 Δ). After the second surgery, angle of exotropia decreased to 21 ± 15 PD. Seven patients still had residual exotropia ≥10Δ and the exotropia was corrected in the remaining two patients. The time to second surgery in those two patients was much shorter than the other seven patients. CONCLUSIONS Patients who undergo VRT should be followed up in the early post-operative period and revisiting the transposition should be done immediately in case of consecutive exotropia to avoid permanent overcorrection.
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Affiliation(s)
- Amr Elkamshoushy
- Ophthalmology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Awadein
- Ophthalmology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hala Elhilali
- Ophthalmology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Dina H Hassanein
- Ophthalmology Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
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Muralidhar R, Churawan L, Sekar M, Chidambaram AP, Mugdha P, Ramamurthy D. Outcome of delayed adjustable strabismus surgery in children using a bow-tie optional adjustable technique. Indian J Ophthalmol 2019; 67:258-262. [PMID: 30672482 PMCID: PMC6376808 DOI: 10.4103/ijo.ijo_398_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose: The aim of this article is to study the feasibility of a delayed adjustable technique of strabismus surgery in children using an optional adjustable suture technique. Methods: The retrospective study included patients <12 years of age. Recessions were done using an optional adjustable bow-tie technique and resections were done by the conventional technique. Patients were evaluated on the third postoperative day and adjustments done when needed. Statistical analysis was done using Microsoft Excel 2010®. Results: The study included 11 patients with exotropia and 16 patients with esotropia. The mean age of the patients was 5.2 years (range 1–11 years). The mean preoperative distance deviation was 46.7 ± 10.4 prism diopters (PD) for exotropic patients and 47.1 ± 16.9 PD for esotropic patients. The mean preoperative near deviation was 46.6 ± 11 PD for exotropic patients and 52.4 ± 17.1 PD for esotropia. Two patients with exotropia (18.2%) and four patients with esotropia (25%) were adjusted under intravenous ketamine in the operating room under anesthetist supervision. No difficulty was encountered in advancing/recessing the muscles. The success rate at 1 month was 100% for exotropia and 87.5% for esotropia. The success rate at the final follow-up was 81.8% for patients with exotropia and 68.7% for patients with esotropia. Conclusions: This delayed optional adjustable strabismus surgery technique provides good short-term results and lower adjustment rates.
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Affiliation(s)
- R Muralidhar
- The Eye Foundation, 582A DB Road, R.S. Puram, Coimbatore, India
| | - Lal Churawan
- The Eye Foundation, 582A DB Road, R.S. Puram, Coimbatore, India
| | - M Sekar
- The Eye Foundation, 582A DB Road, R.S. Puram, Coimbatore, India
| | - A P Chidambaram
- The Eye Foundation, 582A DB Road, R.S. Puram, Coimbatore, India
| | - P Mugdha
- The Eye Foundation, Coonoor Road, ELK Hill Road Junction, Ooty, India
| | - D Ramamurthy
- The Eye Foundation, 582A DB Road, R.S. Puram, Coimbatore, India
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Modabber M, Dan AF, Coussa RG, Flanders M. Retrobulbar anaesthesia for adjustable strabismus surgery in adults: a prospective observational study. Can J Ophthalmol 2018; 53:621-626. [PMID: 30502988 DOI: 10.1016/j.jcjo.2018.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 02/22/2018] [Accepted: 02/27/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To characterize the ocular response to retrobulbar anaesthesia and to evaluate the efficacy of retrobulbar anaesthesia for adjustable strabismus surgery in adults. DESIGN Prospective observational study. PARTICIPANTS Adult patients undergoing adjustable strabismus surgery under retrobulbar anaesthesia. METHODS Surgical success was defined by ocular alignment within 10 prism diopters (PD) of orthotropia for horizontal rectus surgery and within 5 PD for vertical rectus surgery. After retrobulbar injection of Xylocaine with epinephrine, the onset time and the degree of visual impairment, ocular akinesia, and analgesia were evaluated. Postoperative parameters included the restoration of vision, onset of pain, resolution of ptosis, normalization of pupil, resolution of extraocular motility deficits, and the timing of postoperative adjustment. Perioperative complications were also documented. RESULTS A total of 33 patients were initially included in this study. Two patients experienced complications (perioperative retrobulbar hemorrhage, postoperative suprachoroidal hemorrhage) and were excluded from data analysis. Of the remaining 31 patients (mean age, 50.2 ± 14.8 years), surgical outcome was satisfactory in 30/31 (96.8%) patients at the first postoperative visit and in 15/19 (78.9%) cases at last follow-up (mean, 6.1 ± 1.6 months). Excellent intraoperative ocular akinesia and analgesia was achieved with retrobulbar anaesthesia. After retrobulbar injection, visual impairment was the first to resolve to preoperative levels within (mean ± SD) 3.7 ± 1.9 hours postinjection, followed by onset of pain at 4.1 ± 1.0 hours, resolution of ptosis at 4.3 ± 1.9 hours, and normalization of pupil reactivity at 6.1 ± 1.0 hours. The resolution of anaesthesia upon extraocular motility occurred within 5.7 ± 1.0 hours postinjection (range, 4.5-8.0 hours), allowing for subsequent same-day postoperative adjustment. CONCLUSIONS Retrobulbar anaesthesia in the context of adult, adjustable strabismus surgery is a relatively safe and effective technique. It provides excellent intraoperative analgesia and akinesia. Retrobulbar anaesthesia enables for same-day suture adjustments to be reliably performed.
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Affiliation(s)
- Milad Modabber
- Department of Ophthalmology, McGill University, Montréal, Qué..
| | - Andrei F Dan
- The School of Medicine, McGill University, Montréal, Qué
| | - Razek G Coussa
- Department of Ophthalmology, McGill University, Montréal, Qué
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Chalifoux E, Alkharashi M, Superstein R, Louis M, Blais C, Sabzevari S, Flanders M. Adjustable surgical treatment of adult exotropia: postoperative target angles and surgical success. CANADIAN JOURNAL OF OPHTHALMOLOGY 2016; 51:254-257. [PMID: 27521663 DOI: 10.1016/j.jcjo.2016.02.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 02/25/2016] [Accepted: 02/28/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study had 3 objectives: (i) to characterize clinical profiles of adults with consecutive exotropia (CXT), intermittent exotropia (IXT), and sensory exotropia (SXT); (ii) to correlate immediate postoperative target angles with successful long-term ocular alignment; and (iii) to compare the efficacy of adjustable versus nonadjustable medial rectus resection ± advancement. STUDY DESIGN Retrospective, observational, and interventional cohort study. PARTICIPANTS A total of 133 adult exotropic patients treated surgically at 3 different hospitals between July 2012 and June 2013. METHODS The patients were divided according to clinical profiles (CXT, IXT, and SXT) based on ophthalmic and orthoptic assessments. Two treatment groups were established: group I-adjustable medial rectus resection ± advancement and adjustable lateral rectus recession; group II-nonadjustable medial resection ± advancement and adjustable lateral rectus recession. Measurements of immediate postadjustment alignment (target angle) and 4-6 months of follow-up alignment were performed and compared between groups. Surgical success was defined as distance primary position alignment within 10 prism diopters (PD) of orthotropia 4-6 months postoperatively. RESULTS Comparison of clinical profile groups showed that CXT patients had more hyperopia and amblyopia and smaller preoperative deviations; IXT patients had more diplopia and larger preoperative deviations (near > distance); and SXT patients had poor vision in the deviating eye and larger preoperative deviations. Immediate postoperative alignment was 5.2 PD of esodeviation in group I and 3.2 PD of esodeviation in group II. Overall success rates for ocular alignment at 4-6 months postoperatively were comparable with both surgical techniques (74.6% for group I and 74.3% for group II). Patients with a preoperative deviation ≥40 PD had a lower surgical success rate (63.8%) than patients with a deviation <40 PD (80%). Patients presenting with a significant (-1 or worse) abduction deficit in the operated eye at their first visit after surgery had a better success rate at 4-6 months' follow-up (83.3% vs 67.8%). CONCLUSIONS Adjustable and nonadjustable medial rectus surgeries seem equally successful. Creation of an abduction deficit in the early postoperative period seems predictive of a better outcome. Larger preoperative angles (≥40 PD) were associated with more exotropic drift and a lower percentage of surgical success. Future studies will continue to search for surgical strategies and the ideal target angle that will produce the best long-term alignment stability.
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Affiliation(s)
- Emmanuelle Chalifoux
- Department of Ophthalmology, McGill University, MUHC, Montreal, Quebec, Canada; Département d'Ophtalmologie, Université de Montréal, Montreal, Quebec, Canada
| | - Maan Alkharashi
- Department of Ophthalmology, McGill University, MUHC, Montreal, Quebec, Canada
| | - Rosanne Superstein
- Department of Ophthalmology, McGill University, MUHC, Montreal, Quebec, Canada; Département d'Ophtalmologie, Université de Montréal, Montreal, Quebec, Canada
| | - Melissa Louis
- Département d'Ophtalmologie, Université de Montréal, Montreal, Quebec, Canada
| | - Claire Blais
- Département d'Ophtalmologie, Université de Montréal, Montreal, Quebec, Canada
| | - Shamim Sabzevari
- Département d'Ophtalmologie, Université de Montréal, Montreal, Quebec, Canada
| | - Michael Flanders
- Department of Ophthalmology, McGill University, MUHC, Montreal, Quebec, Canada; Département d'Ophtalmologie, Université de Montréal, Montreal, Quebec, Canada.
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Peragallo JH, Bruce BB, Hutchinson AK, Lenhart PD, Biousse V, Newman NJ, Lambert SR. Predictors of Good Motor and Sensory Outcomes Following Strabismus Surgery for Patients with Third Nerve Palsies. Neuroophthalmology 2014; 39:12-16. [PMID: 27928324 DOI: 10.3109/01658107.2014.956228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 08/16/2014] [Accepted: 08/16/2014] [Indexed: 11/13/2022] Open
Abstract
Strabismus from third nerve palsy (3NP) is difficult to treat. Our goal was to explore factors associated with successful surgical outcomes in 3NP. Institutional records of all adult patients (>18 years) from 1988 to 2012 with 3NP who underwent strabismus surgery or botulinum toxin injections were retrospectively reviewed. Success was defined as absence of diplopia, vertical deviation ≤2 prism dioptres (PD), and horizontal deviation ≤10 PD. Fifty-six patients from four surgeons were included. Thirty (54%) were female; mean age was 48 (range: 20-80). Forty-four (79%) had unilateral 3NP; 9 (16%) had other ocular motor nerve palsies. 3NP were complete in 24 (43%). Underlying aetiology was idiopathic/microvascular in 5 (9%), traumatic in 13 (23%), neoplastic in 12 (21%), aneurysmal in 10 (18%), and other central nervous system related in 16 (29%). Trauma was associated more frequently with aberrant regeneration than other aetiologies: 9/13 (69%) versus 4/43 (9%) (p < 0.01). Ten patients (18%) had >1 surgery. Surgical success was achieved in 28/56 (50%). Success rate was unaffected by aetiology, degree of palsy, pupillary involvement, presence of aberrant regeneration, or number of other cranial nerves involved. However, adjustable sutures were used in 27 patients (48%), and there was a trend toward higher success rates when adjustable versus nonadjustable sutures were used (63% versus 38%; p = 0.06). Unlike with sixth nerve palsies, the aetiology and degree of 3NP does not appear to affect the success rates or number of procedures performed. Strabismus surgeries for 3NP with adjustable sutures may be associated with better outcomes.
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Affiliation(s)
| | - Beau B Bruce
- Departments of Ophthalmology; Departments of Neurology; Department of Epidemiology, Rollins School of Public Health and Laney Graduate School, Emory University Atlanta, GeorgiaUSA
| | | | | | | | - Nancy J Newman
- Departments of Ophthalmology; Departments of Neurology; Departments of Neurological Surgery, Emory University School of MedicineAtlanta, GeorgiaUSA and
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Peragallo JH, Bruce BB, Hutchinson AK, Lenhart PD, Biousse V, Newman NJ, Lambert SR. Functional and Motor Outcomes of Strabismus Surgery for Chronic Isolated Adult Sixth Nerve Palsy. Neuroophthalmology 2014; 38:320-325. [PMID: 27928319 DOI: 10.3109/01658107.2014.957780] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 08/20/2014] [Accepted: 08/20/2014] [Indexed: 11/13/2022] Open
Abstract
Abducens nerve palsy is the most common acquired ocular motor nerve palsy in adults. Chronic cases of abducens palsy often require surgical intervention to relieve disabling diplopia. The goal of this study was to identify factors associated with surgical outcomes in isolated abducens palsy. Medical records of all adult patients from 1988 to 2012 with abducens palsies who underwent strabismus procedures were retrospectively reviewed. Motor alignment, extraocular motility, and sensory outcomes were recorded. Success was defined as absence of diplopia without prisms or face turn, vertical deviation ≤2 prism dioptres (PD), and horizontal deviation ≤10 PD. Eighty-one patients (age range: 20-86 years) met inclusion criteria. Success was achieved in 58% of patients. Final success rates for abducens palsy were 50% for neoplastic, 59% traumatic, 57% for microvascular/unknown, and 67% for other central nervous system causes (p > 0.05). Patients with an underlying neoplastic or traumatic aetiology required more than one strabismus procedure more often than those with microvascular/idiopathic or other central nervous system causes (48% vs. 24%; p = 0.03). For complete abducens palsies, patients who underwent Hummelsheim-type procedures had a higher success rate than those who underwent a full-tendon vertical rectus muscle transposition. (78% versus 35%; p = 0.049). Success rates for strabismus procedures in patients with abducens palsies are similar across all aetiologies. Frequency of re-operation is higher among those patients with neoplastic or traumatic aetiologies for their abducens palsies. Hummelsheim-type procedures have a higher success rate for complete abducens palsies than full-tendon vertical rectus transpositions.
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Affiliation(s)
| | - Beau B Bruce
- Departments of Ophthalmology; Neurology; Department of Epidemiology, Rollins School of Public Health and Laney Graduate SchoolEmory University, Atlanta, GeorgiaUSA
| | | | | | | | - Nancy J Newman
- Departments of Ophthalmology; Neurology; Neurological Surgery, Emory University School of MedicineAtlanta, GeorgiaUSA
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Razmjoo H, Attarzadeh H, Karbasi N, Najarzadegan MR, Salam H, Jamshidi A. A survey of outcome of adjustable suture as first operation in patients with strabismus. Adv Biomed Res 2014; 3:179. [PMID: 25250293 PMCID: PMC4166057 DOI: 10.4103/2277-9175.139529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 08/07/2013] [Indexed: 11/05/2022] Open
Abstract
Background: Adjustable suture used for years to improve the outcome of strabismus surgery. We surveyed outcome of our patients with strabismus who underwent adjustable suture. Materials and Methods: This retrospective study was performed at Ophthalmology Centre of Feiz Hospital in Isfahan on 95 participants that candidate for adjustable suture strabismus surgery. Patients were divided into three age groups: Under 10 years, 10-19 years, and 20 years and over. Outcome of adjustable suture surgery consequence of residual postoperative deviation was divided into four groups: Excellent, good, acceptable, and unacceptable. Results: Out of 95 patients studied, 51 (53.7%) were males and 44 (46.3%) were females. The mean of deviation angles were 53.8 ± 17.9 PD (Prism dioptres) in alt XT, 44.5 ± 12 PD in alt ET and 52 ± 13.5 PD in const ET, 47.1 ± 13.1PD in cons XT, respectively. There was no significant difference between the groups (P = 0.051). Results of surgery were in 38 patients (40%) excellent, in 31 patients (32.6%) good, in 19 patients (20%) acceptable, and in 7 patients (7.4%) unacceptable. Seven (7.4%) patients required reoperation. Conclusions: In the present study, the frequency of re-operation was much lower than other similar studies (7.4% vs. 30-50%). This suggests that the adjustable technique that used in our study can be associated with lower reoperation than other adjustable techniques used in the other similar studies.
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Affiliation(s)
- Hasan Razmjoo
- Department of Ophtalmology, Isfahan University of Medical Science, Isfahan, Iran
| | - Hosein Attarzadeh
- Department of Ophtalmology, Isfahan University of Medical Science, Isfahan, Iran
| | - Najmeh Karbasi
- Department of Ophtalmology, Isfahan University of Medical Science, Isfahan, Iran
| | | | - Hasan Salam
- Department of Ophtalmology, Isfahan University of Medical Science, Isfahan, Iran
| | - Aliraza Jamshidi
- Department of Ophtalmology, Isfahan University of Medical Science, Isfahan, Iran
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Abstract
Although adjustable sutures are considered a standard technique in adult strabismus surgery, most surgeons are hesitant to attempt the technique in children, who are believed to be unlikely to cooperate for postoperative assessment and adjustment. Interest in using adjustable sutures in pediatric patients has increased with the development of surgical techniques specific to infants and children. This workshop briefly reviews the literature supporting the use of adjustable sutures in children and presents the approaches currently used by three experienced strabismus surgeons.
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Affiliation(s)
- J Mark Engel
- Division of Pediatric Ophthalmology, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - David L Guyton
- The Krieger Children's Eye Center at The Wilmer Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David G Hunter
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston.
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Peragallo JH, Velez FG, Demer JL, Pineles SL. Postoperative drift in patients with thyroid ophthalmopathy undergoing unilateral inferior rectus muscle recession. Strabismus 2013; 21:23-8. [PMID: 23477773 DOI: 10.3109/09273972.2012.762533] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Extraocular muscles of patients with thyroid ophthalmopathy (TO) may respond differently to strabismus surgery than those of other strabismic patients. This study reports postoperative alignment changes in patients with TO compared with patients with non-restrictive strabismus following unilateral inferior rectus muscle recession (IRR). METHODS We reviewed records of patients with and without TO who underwent unilateral IRR. Group A had adjustable muscle sutures, while Group B had permanent or semi-adjustable sutures. Controls were patients undergoing adjustable unilateral IRR for other indications. RESULTS Mean preoperative hypotropias were 17 ± 9, 21 ± 7, and 11 ± 4 PD for groups A (n=13), B (n=14), and controls (n=19), respectively. Postoperative day one (POD1) measurements after adjustment were 1.2 ± 2.5, 3.7 ± 4.9, and 0.3 ± 2.4 PD, respectively, representing overall undercorrections in all cases (the preoperative deviation was given a positive (+) value and overcorrections were deemed negative (-) deviations). Dose response from linear regression analysis of thyroid patients compared with control patients for IRR was 3.26 PD/mm (SE 0.18) vs 2.38 PD/mm (SE 0.18) (p=0.001). Mean final measurements were -0.7 ± 5.6 (overcorrection), 2.7 ± 5.7, and 1.7 ± 5.7 PD of hypotropia, respectively. Final overcorrections occurred in 23%, 14%, and 16% of patients, for adjustables, permanent sutures, and control subjects, respectively. Drifts from POD1 measurements after adjustment to final measurements were -1.9 ± 4.3, -1.0 ± 4.6, and 1.4 ± 5.9 PD respectively (p=0.05 for comparison between Group A and controls). CONCLUSIONS TO patients with adjustable sutures drift toward postoperative overcorrection.
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Affiliation(s)
- Jason H Peragallo
- Jules Stein Eye Institute and Department of Ophthalmology, University of California, Los Angeles, California, USA
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