Are isolated ocular motor nerve palsies in the elderly truly 'low risk' for abnormal neuro-imaging outcomes?

BACKGROUND

Neurologically isolated ocular motor nerve palsies often present a management dilemma. Neuroimaging is more likely to be offered to patients <50 years without coexisting ischaemic risk factors as their risk of sinister underlying causes is thought to be higher. However, populations are rapidly ageing and advanced neuroimaging is now more widely available. We thus investigated the incidence of abnormal neuroimaging outcomes in the traditionally low-risk older patient group.

METHODS

This is a retrospective cohort study of 353 patients presenting with isolated ocular motor nerve palsies to a tertiary neuro-ophthalmology service in Singapore over a four-year (2015 to 2019) period. Clinical data was obtained through manual review of case records. Common aetiologies, age-based differences in prevalence of causes and abnormal neuroimaging outcomes were statistically analysed.

RESULTS

Abnormal neuroimaging outcomes were significantly greater in the younger cohort only when age segregation was performed at 60 years of age. In a multivariate analysis, acute onset rather than ischaemic risk factors were independently predictive of normal neuroimaging outcomes. After adjusting for prior cancer risk and clinical bias from presumed ischaemic palsies, abnormal neuroimaging outcomes were seen in 14.1% ≥ 50 yrs, 10.9% ≥ 60 yrs and 15.1% ≥ 70 yrs.

CONCLUSIONS

In patients presenting with isolated ocular motor nerve palsies, acute onset may be a more reliable indicator of an ischaemic palsy rather than advanced age or presence of ischaemic risk factors. If onset is not acute, neuroimaging should be considered irrespective of age and coexisting ischaemic risk factors.

The incidence, clinical features, and management of essential infantile esotropia in the United Kingdom. A British Ophthalmology Surveillance Unit (BOSU) study

BACKGROUND/OBJECTIVES

A national study was undertaken through the British ophthalmology surveillance unit (BOSU) to determine the incidence, presenting features and management of essential infantile esotropia (EIE) in the UK.

METHODS

Data from a prospective national observational study of newly diagnosed EIE presenting to clinicians in the United Kingdom over a 12-month period were collected. Cases with a confirmed diagnosis by a clinician of a constant, non-accommodative esotropia ≥20 prism dioptres (PD), presenting at ≤12 months, with no neurological or ocular abnormalities were identified through BOSU. Follow-up data were collected at 12 months.

RESULTS

A total of 57 cases were reported giving an incidence of EIE of 1 in 12,828 live births. The mean age of diagnosis and intervention were 7.05 ± 2.6 months (range 2-12) and 14.7 ± 4.9 months (range 6.5-28.1), respectively. Management was surgical in 59.6%, botulinum toxin alone in 22.8%, and 17.5% were observed. The preoperative angle of esotropia was smaller in the observation group (P = 0.04). The postoperative angle of esotropia was not statistically significant between botulinum toxin or surgery (P = 0.3), although the age of intervention was earlier in the botulinum group (P = 0.007). Early intervention (before 12 months of age) did not influence the post-intervention motor outcomes between 0 and 10 prism dioptres of esotropia (P = 0.78).

CONCLUSIONS

The incidence of EIE in the UK is considerably lower than reported in other population-based studies. The preferred method of treatment was surgical with earlier intervention in those treated with botulinum toxin. An early age of intervention (<12 months) did not influence motor outcomes.

Factors associated with changes in horizontal deviation after inferior oblique weakening surgery

BACKGROUND/AIMS

To identify the factors affecting postoperative horizontal deviation following isolated inferior oblique (IO) weakening surgery.

METHODS

The medical records of patients who had undergone isolated IO weakening surgery between February 2010 and September 2021, with a minimum follow-up period of 6 months, were retrospectively reviewed. Patients were divided into two groups, eso-shift, and non-eso-shift, based on the change in horizontal deviation at postoperative 6 months. Eso-shift or exo-shift was defined as a change of 2Δ or more.

RESULTS

A total of 77 patients were included. Among them, 49 patients (63.6%) showed changes in horizontal deviation: 37 (48.0%) eso-shift, 12 (15.6%) exo-shift. Twenty-eight patients (36.4%) showed no change in alignment. The eso-shift group showed the following characteristics compared to the non-eso-shift group: older age (P < 0.001), higher proportion of patients with preoperative exo-deviation (P < 0.001), and greater preoperative hypertropia in primary gaze (P < 0.001), down gaze (P = 0.031), ipsilateral gaze (P < 0.001), and ipsilateral head tilt (P = 0.002). Regarding the postoperative changes in horizontal deviation based on prior horizontal strabismus, patients with preoperative exo-deviation showed a statistically significant eso-shift. The patients with prior eso-deviation tended toward exo-shift, while those without prior horizontal deviation rarely changed.

CONCLUSION

Changes in postoperative horizontal deviation are associated with preoperative horizontal and vertical deviation, which might result from changes in the rectus muscle due to oblique muscle dysfunction. Also, this study suggests that isolated IO weakening surgery could effectively correct small-angle horizontal deviation in patients with inferior oblique overaction (IOOA) and horizontal strabismus.

Eyetracking-enhanced VEP for nystagmus

Visual evoked potentials (VEPs) are an important prognostic indicator of visual ability in patients with nystagmus. However, VEP testing requires stable fixation, which is impossible with nystagmus. Fixation instability reduces VEP amplitude, and VEP reliability is therefore low in this important patient group. We investigated whether VEP amplitude can be increased using an eye tracker by triggering acquisition only during slow periods of the waveform. Data were collected from 10 individuals with early-onset nystagmus. VEP was obtained under continuous (standard) acquisition, or triggered during periods of low eye velocity, as detected by an eye tracker. VEP amplitude was compared using Bonferroni corrected paired samples t-tests. VEP amplitude is significantly increased when triggered during low eye velocity (95% CI 1.42-6.83 µV, t(15) = 3.25, p = 0.0053). This study provides proof-of-concept that VEP amplitude (and therefore prognostic reliability) can be increased in patients with early onset nystagmus by connecting an eye tracker and triggering acquisition during periods of lower eye velocity.

Feasibility study of an automated Strabismus screening Test using Augmented Reality and Eye-tracking (STARE)

BACKGROUND

New digital technologies (augmented reality headsets, eye-tracking) may potentially allow for automated assessments of ocular misalignment. Here, we evaluate the feasibility of a novel, open-source strabismus test ("STARE") as an automated screening tool.

METHODS

Work progressed in 2 phases. In phase 1 ("development"), we used Fresnel prisms to elicit horizontal misalignments of known magnitude (1-40 prism dioptres) in orthotropic controls. In phase 2 ("validation"), we applied the system to adults with an established diagnosis of strabismus, and quantified the ability of the test to distinguish between those with horizontal misalignment and those without. Agreement between the alternate prism cover test measurements and STARE measurements was computed using Bland-Altman plots and product-moment correlation coefficients.

RESULTS

Seven orthotropic controls and nineteen patients with strabismus were recruited (mean age 58.7 ± 22.4 years). STARE was able to identify the presence of horizontal strabismus with an area under the curve of 1.00 (100% sensitivity and 100% specificity). The mean difference (bias) {95% CI} was 2.1 {-1.8, 9.9} prism dioptres, and the 95% coefficient of repeatability {95% CI} was ±27.9 {14.8, 50.8} prism dioptres. The Pearson correlation between APCT and STARE was r24 = 0.62, P < 0.001.

CONCLUSIONS

STARE shows promise as a simple, automated tool for performing a screening assessment of strabismus. It is a rapid (60 s) test that can be performed using a consumer augmented reality headset with integrated eye-tracking, and might conceivably be used remotely by non-specialists in future as a means of highlighting individuals needing face-to-face specialist care.

Acute acquired concomitant esotropia: May COVID-19 lockdowns have changed its presentation?

PURPOSE

To evaluate the effects of COVID-19 lockdown in Italy on the features of Acute Acquired Concomitant Esotropia (AACE).

SUBJECTS

Patients of the Polyclinic Hospital of Bari diagnosed with AACE between January 2018 and December 2021, subdivided in pre-lockdown group - diagnosed before March 2020 - and post-lockdown group.

METHODS

Medical records were reviewed, and statistical analysis performed. Deviation size was assessed in the 9 cardinal positions of gaze with refractive correction. Wilcoxon test for unpaired samples was used to compare data of age, near maximum deviation and best corrected visual acuity (BCVA) for each eye; Student's t test was used to compare far maximum deviation, difference far/near maximum deviation and spherical equivalent data. Fisher exact test was used to compare subtype cases (Bielschowsky vs Non-Bielschowsky) in the two groups. A p-value lower than 0.05 was considered statistically significant.The primary outcome measure was the difference in AACE subtypes between the two groups.

RESULTS

Nineteen patients were included, of which 12 males (63.2%); 7 belong to the pre-lockdown group and 12 to the post-lockdown group. The difference in types between the two groups proved to be statistically significant (p = 0.01977).The differences in the mean of age, right BCVA, right spherical equivalent and mean spherical equivalent between the two groups proved to be statistically significant (p < 0.05).

CONCLUSIONS

After the COVID-19 pandemic, the profile of the typical patient with AACE has probably changed, and now it is more probably myopic and elderly than before. Thus, we observed an increase in the Bielschowsky subtype.

An ON-type direction-selective ganglion cell in primate retina

To maintain a stable and clear image of the world, our eyes reflexively follow the direction in which a visual scene is moving. Such gaze-stabilization mechanisms reduce image blur as we move in the environment. In non-primate mammals, this behaviour is initiated by retinal output neurons called ON-type direction-selective ganglion cells (ON-DSGCs), which detect the direction of image motion and transmit signals to brainstem nuclei that drive compensatory eye movements1. However, ON-DSGCs have not yet been identified in the retina of primates, raising the possibility that this reflex is mediated by cortical visual areas. Here we mined single-cell RNA transcriptomic data from primate retina to identify a candidate ON-DSGC. We then combined two-photon calcium imaging, molecular identification and morphological analysis to reveal a population of ON-DSGCs in the macaque retina. The morphology, molecular signature and GABA (γ-aminobutyric acid)-dependent mechanisms that underlie direction selectivity in primate ON-DSGCs are highly conserved with those in other mammals. We further identify a candidate ON-DSGC in human retina. The presence of ON-DSGCs in primates highlights the need to examine the contribution of subcortical retinal mechanisms to normal and aberrant gaze stabilization in the developing and mature visual system.

Preliminary data on a novel smart glasses system for measuring the angle of deviation in strabismus

BACKGROUND/OBJECTIVES

To propose a novel smart glasses device for recording eye movement and compare its results to the prism alternate cover test (PACT).

SUBJECTS/METHODS

This method comparison study enrolled patients with strabismic conditions, who first underwent conventional strabismus evaluations (PACT in the primary position), followed by the smart glasses NeuroSpeed system (NSS) recording protocols. The video recordings were analysed using specialized software, to calculate the horizontal deviation from the primary position. The results were compared with those of the PACT using Passing‒Bablok regression and Bland‒Altman analysis.

RESULTS

This study included 70 individuals aged 4 to 80 years, of which 38 were men and 32 were women. The overall analysis of horizontal deviations using the Passing‒Bablok regression revealed a correlation coefficient (r) of 0.969, with a systemic bias of 0.00, a proportional bias of 0.809, and a perpendicular residual standard deviation of 4.134.

CONCLUSIONS

The predictive values of eye movement examinations recorded by the NSS were comparable to those of the PACT. Thus, this new system can provide additional information for ophthalmologists to aid in the diagnosis and measurement of strabismus.

Proptosis secondary to bilateral extraocular muscle enlargement in Noonan syndrome with hypertrophic cardiomyopathy: A case report

PURPOSE

To report and investigate proptosis in a young girl with Noonan syndrome.

METHODS

Observational case report.

RESULTS

A 16-year-old girl affected by Noonan syndrome underwent a complete ophthalmological examination showing bilateral proptosis with hypofunction of lateral rectus and superior oblique muscles. Visual acuity, color discrimination and fundus examination were unremarkable. The orbital MRI showed bilateral proptosis and symmetrical enlargement of extraocular muscles, with bellies thickening and tendon sparing. The young patient also complained restrictive hypertrophic cardiomyopathy.

CONCLUSIONS

Proptosis is an uncommon ocular manifestation of Noonan syndrome and its pathophysiology has never been clarified. The MRI evidence of extraocular muscles enlargement associated with hypertrophic cardiomyopathy, led us to hypothesize a common altered pathway beneath these features, more specifically the MAP kinase pathway, since extraocular and cardiac muscles share a mesenchymal embryological origin.

Binocular visual field in adults with horizontal strabismus and driving requirements

OBJECTIVE

To determine the horizontal extent of the binocular visual field (BVF) in subjects with horizontal strabismus and whether the BVF falls below the driving standard.

METHODS AND ANALYSIS

Adults with congenital esotropia and infantile exotropia ≤45 Prism Dioptres (PD), and subjects with orthotropia were recruited. The manifest angle of deviation was measured using a simultaneous prism cover test. Monocular Visual Field (MVF) and BVF were measured using the Esterman visual field test. Subjects with diplopia or a manifest angle of strabismus that varied by>8PD or the present of a vertical tropia >8PD were excluded.

RESULTS

Forty-nine subjects were included: 10 with orthotropia, 20 with exotropia and 19 with esotropia. The horizontal extent of BVF (degrees) was significantly smaller in esotropes (122.8 ± 18.8) than in orthotropes (141 ± 6.6) or exotropes (138.3 ± 8.3) (p < 0.01). In 6 (31.6%) subjects with an esotropia, the BVF was below the driving standard. The horizontal extent of the visual field (VF) of the amblyopic eyes of patients with esotropia (98.70 degrees, SD 19.76) and exotropia (104.75 degrees, SD16.93) were significantly smaller than those with orthotropia (121.00 degrees SD 3.16) by 22.3 degrees (p = 0.004) and 16.25 degrees (p = 0.045), respectively. The difference between the summation of MVFs and the BVF was significantly greater in orthotropes (100.6 ± 2.7) than in exotropes (68.9 ± 34.4) and esotropes (74.2 ± 20.7) (p < 0.01).

CONCLUSION

The horizontal extent of BVF is significantly smaller and more variable in adults with congenital esotropia and may fall below the driving standard.

STRENGTHS AND LIMITATIONS

Largest study on visual fields in subjects with horizontal strabismus including an orthotropic control group who do not have diplopia and who would otherwise meet the driving standard. Visual field quality was high but limitation is that visual field repeatability was not undertaken.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

The findings of this study would suggest that people with an esotropia should be offered the opportunity to have a binocular visual field test before applying for a driving license. The DVLA may want to consider requesting people with an esotropia to have a binocular visual field test as is a requirement with other ophthalmic conditions such as glaucoma.

Effect of bimedial recession on near-distance disparity in esotropia

BACKGROUND

Esotropia may be associated with a difference in the deviation at near and distance fixation termed near-distance disparity (NDD). Convention suggests patients with NDD may benefit more from bilateral medial rectus recessions (BMR) as opposed to a unilateral recession/resection (RR). The aim of this study is to establish the effect of BMR for the treatment of esotropia on both the near and distance deviation and NDD.

METHODS

Retrospective patient records search from 2011 to 2021.

INCLUSION CRITERIA

comitant esotropia, first surgery, equal and normal vision with free alternation.

EXCLUSION CRITERIA

incomitant, neurological or restrictive strabismus, previous surgery, clinically significant amblyopia.

RESULTS

49 patients met the inclusion criteria. 19 patients were female; the average age was 17 years. Following surgery, the average near deviation reduced from 39PD base out (BO) to 11PD BO. The average distance deviation reduced from 33PD to 9PD. Average preoperative NDD was 12 PD. NDD resolved in 15 out of 18 patients with NDD (83%). The average PD gain per mm of recession was 2.7 for near and 2.2 for distance.

CONCLUSIONS

BMR is an effective surgical treatment for esotropia and has a greater effect on near deviation than distance. It is also an effective and simple technique for lesser degrees of NDD. BMR has several advantages over RR: no tissue loss, readily reversible, the scars are easier to hide and it avoids potential motility limitations due to leash effects following resection.

Oculomotor deficits in attention deficit hyperactivity disorder: a systematic review and meta-analysis

There is equivocal evidence on the presence of oculomotor deficits among children with attention deficit hyperactivity disorder (ADHD), which can be an additional challenge in this population, especially with reading-related tasks. This study aimed to review the deficits in the oculomotor parameters among children with ADHD compared with age-matched controls. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A search of original research articles on various databases was done using key terms, such as "oculomotor deficit," "attention deficit hyperactivity disorder," or related terms. We included case-control studies and excluded studies in which children received medications during the test. Twelve original research studies were considered for this review. Ten studies reported data on various types of saccades, two studies reported data on fixation, and one study reported data on pursuit. Among various oculomotor deficits, the forest-plot analysis of an antisaccade task showed that children with ADHD made more direction errors compared to controls. Although independent studies report that ADHD children have poorer performance compared to control populations during oculomotor tasks, there is a lack of evidence to draw a strong conclusion. Children with ADHD are less precise in performing eye movements and need more time to complete the oculomotor tasks than those without ADHD. The overall results provide minimal evidence regarding the presence of various oculomotor deficits in ADHD.

A cross-sectional study of ophthalmologic examination findings in 5385 Koreans presenting with intermittent exotropia

The Korean Intermittent Exotropia Multicenter Study (KIEMS) was a retrospective, cross-sectional and multicenter study for the investigation of intermittent exotropia involved 65 strabismus specialists from 53 institutions in Korea. Purpose of this study was to present ophthalmologic findings of intermittent exotropia from the KIEMS. Consecutive patients with intermittent exotropia of ≥ 8 prism diopters (PD) at distance or near fixation were included. Best-corrected visual acuity, cycloplegic refraction data, angles of deviation at several cardinal positions, ocular dominance, fusion control, oblique muscle function, and binocular sensory outcomes were collected. A total of 5385 participants (2793 females; age 8.2 years) were included. Non-dominant eye was more myopic than the dominant eye (- 0.60 vs. - 0.47 diopters, P < 0.001). Mean exodeviation angles were 23.5 PD at distance and 25.0 PD at near fixation. Basic type (86.2%) was the most, followed by convergence insufficiency (9.4%) and divergence excess (4.4%) types. Alternating ocular dominance and good fusion control were more common at near than at distance fixation. Good stereopsis at 40 cm was observed in 49.3% in Titmus stereo test (≤ 60 arcsec) and in 71.0% in Randot stereo test (≤ 63 arcsec). Intermittent exotropia was mostly diagnosed in childhood and patients with the condition showed relatively good binocular functions. This study may provide objective findings of intermittent exotropia in a most reliable way, given that the study included a large study population and investigated comprehensive ophthalmology examinations.

Acquired Brown Syndrome After a Fist Punch: A Case Report

A 15-year-old male presented with double vision in the left and upward gaze following a hit in the right orbital region. The orthoptic assessment revealed -2 limitation of elevation in the adduction position of the right eye and right hypotropia of 20 prism diopter (PD) in the left gaze and right hypotropia of 10 PD in the upward gaze. He was diagnosed with traumatic Brown syndrome and planned for superior oblique lengthening surgery for the right eye. Two months postoperatively, the patient has a normal extra-ocular motor function with the elimination of diplopia and significant improvement of elevation of the right eye in the adduction position. Herein, we discuss the clinical features, etiologies, tailored evaluation, and management for the patient with traumatic Brown syndrome.

Visual system and motor development in children: a systematic review

PURPOSE

The aim of this study was to review the available scientific literature on the possible relationship between the visual system and motor development in children.

METHODS

This study was performed according to the Preferred Reporting Items for Systematic Reviews (PRISMA) statement recommendations. The review protocol is available in PROSPERO (CRD42021245341). Four different databases, namely Scopus, PubMed, CINAHL and Web of Science, were assessed from April 2005 to February 2021. To determine the quality of the articles, we used the Critical Appraisal Skills Programme (CASP) Quality Appraisal Scale, and a protocol was followed to define the levels of evidence on the basis of the Centre for Evidence-Based Medicine Levels of Evidence. The search strategy included terms describing motor development in children and adolescents with visual disorders.

RESULTS

Among the identified studies, 23 were included in the study. All selected articles examined the relationship between the visual system and development in children. The quality of most of the studies was moderate-high, and they were between evidence levels 2 and 4.

CONCLUSIONS

Our systematic review revealed that all included studies established a relationship between the visual system and development in children. However, the methods for measuring the visual system and motor skills lacked uniformity.

Routine use of non-absorbable sutures in bi-medial rectus recession as a measure to reduce the incidence of consecutive exotropia

OBJECTIVE

To evaluate the incidence of consecutive exotropia following bilateral medial rectus muscle recession surgery (BMR) for esotropia using non-absorbable compared with absorbable sutures in children undergoing strabismus surgery.

METHODS

A retrospective cohort study of all children with esotropia who underwent BMR by a single surgeon in a tertiary public hospital. As of February 2018, only non-absorbable sutures were used. The primary outcome was the incidence of consecutive exotropia.

RESULTS

A total of 121 children were included in the analysis, 3.66 ± 2.62 years, 53% were male. In 80 children (66%) non-absorbable sutures were used (non-absorbable group) and in 41 children (34%) absorbable sutures were used (absorbable group). Consecutive exotropia (≥ 8 prism dioptres) occurred in ten children (24%) in the absorbable group and in three children (4%) in the non-absorbable group (OR = 8.28, 95% CI = 2.13-32.13; P = 0.002). This difference between groups remained significant after adjustment for potential confounders and follow-up time (HR = 4.98, 95% CI = 1.30-19.05, P = 0.019). Mean follow-up time was 22 and 12 months in the absorbable and non-absorbable groups, respectively (P < 0.001). Two children in the non-absorbable group had pyogenic granuloma that resolved after 3 months of topical steroidal therapy.

CONCLUSION

Routine use of non-absorbable sutures in BMR surgery for esotropia may be a preferable alternative to absorbable sutures for the prevention of consecutive exotropia.

An epidemiologic analysis of the association between eyelid disorders and ocular motility disorders in pediatric age

Aim of the study was to assess: (a) the prevalence and type of strabismus, ptosis and eyelid dynamic disorders features, (b) the prevalence of refractive errors, amblyopia and, (c) their association with ocular/systemic syndromes in a cohort of patients. This is a retrospective observational multicenter cohort study. Patients with coexisting ocular motility disorders, comitant and incomitant strabismus, ptosis and dynamic eyelid disorders who have never undergone surgery were enrolled throughout a 3-years a study period. 137 out of 19,089 patients were enrolled, of which 97 with uniocular and 40 with binocular disease. Isolated congenital ptosis was observed in 84 patients. A polymalformative syndrome was present in almost one third of cases, whilst among strabismus type, esotropia was slightly more prevalent. Most patients were hypermetropic. In monocular disease, myopia mainly affected older patients, who were characterized by a worse ptosis margin reflex distance and levator function, and significantly higher astigmatism. Amblyopia occurred in 67.4% of the study sub-population. Of note, in monocular disease this was mild in 25.8%, moderate in 24.2% and severe in 11.3% of cases, whilst in binocular disease it was mild in 25%, moderate in 41.7% and severe in 16.7%. All patients with coexisting eyelid and ocular motility dysfunctions in pediatric age need ophthalmologic and systemic evaluation to accurately assess amblyopia, refractive errors and systemic/ocular disorders.

Longitudinal course of consecutive esotropia in children following surgery for basic-type intermittent exotropia

PURPOSE

To evaluate the longitudinal course of consecutive esotropia following surgery for basic-type intermittent exotropia.

METHODS

Patients who underwent surgery (bilateral lateral rectus muscle recession [BLR] or unilateral lateral rectus muscle recession-medial rectus muscle resection [RR]) for the treatment of intermittent exotropia between 2011 and 2017 with a minimum follow-up period of 2 years were retrospectively reviewed. When esodeviation occurred later in patients with orthotropia or exodeviation at postoperative month 1, it was defined as delayed-onset consecutive esotropia. The number of patients with esodeviation at every follow-up and characteristics of patients were evaluated.

RESULTS

A total of 336 patients (6.2 ± 2.1 years; 236 in the BLR group and 100 in the RR group) were included. After surgery, postoperative esodeviation decreased mostly during the 1st postoperative month in both groups. At postoperative year 2, there were 28 patients (8.3%) with consecutive esotropia: six in the RR group and 22 in the BLR group. Among the 284 patients with orthotropia or exodeviation at postoperative month 1, there were 13 patients with delayed-onset consecutive esotropia; they presented larger preoperative angle of exodeviation, poorer stereopsis, younger at the time of surgery and associated with the types of surgeries for exotropia.

CONCLUSIONS

In patients with consecutive esotropia, the angle of esodeviation decreased and patching/prismatic correction helped achieve the good surgical outcomes. However, delayed-onset consecutive esotropia and persistent esotropia also presented, requiring the reoperation. Therefore, postoperative alignment should be carefully monitored after surgery for intermittent exotropia.

Unreferenced spatial localization under monocular and dichoptic viewing conditions

Knowledge of eye position in the brain is critical for localization of objects in space. To investigate the accuracy and precision of eye position feedback in an unreferenced environment, subjects with normal ocular alignment attempted to localize briefly presented targets during monocular and dichoptic viewing. In the task, subjects' used a computer mouse to position a response disk at the remembered location of the target. Under dichoptic viewing (with red (right eye)-green (left eye) glasses), target and response disks were presented to the same or alternate eyes, leading to four conditions [green target-green response cue (LL), green-red (LR), red-green (RL), and red-red (RR)]. Time interval between target and response disks was varied and localization errors were the difference between the estimated and real positions of the target disk. Overall, the precision of spatial localization (variance across trials) became progressively worse with time. Under dichoptic viewing, localization errors were significantly greater for alternate-eye trials as compared to same-eye trials and were correlated to the average phoria of each subject. Our data suggests that during binocular dissociation, spatial localization may be achieved by combining a reliable versional efference copy signal with a proprioceptive signal that is unreliable perhaps because it is from the wrong eye or is too noisy.

Treatment and prevention of ocular motility restrictions with amniotic membrane transplantation

We intend to investigate the indications, complications, and final results of amniotic membrane (AM) transplantation in ocular motility restrictions. Surgeons have tried to prevent restrictive adhesions between the extraocular muscles and surrounding tissues because they cause unpredictable results. AM transplantation wrapping extraocular musculature has been proposed as a technique with good results for this purpose. A search was carried out in Medline, Embase, Cochrane Library and Clinicaltrial, Lilac and Ibecs databases, using the indexed terms" amnion", "strabismus," "strabismus-subheading-surgery" and "ocular motility disorders." The only exclusion criteria were studies conducted in non-humans or studies with insufficient data on eye motility. No study was discarded for analysis because of language, age or methodology. This review includes 165 patients (223 eyes), with a mean follow-up of 11.49 months. The mean age was 21 years old, 47% were males and 57% were children. 14 studies conducted in humans were eligible: 4 single case, 8 case series, 1 cohort study and 1 randomized clinical trial. In the vast majority of these papers, use of AM transplantation to treat (12 out of 14 papers) or either to prevent (2 out of 14 papers) motility restrictions or restrictive strabismus secondary to muscular adhesions. All the studies except one presents very favorable results improving postsurgical eye motility. The cryopreservation method was more widely used, presenting a good safety profile with few adverse effects in the short and medium term. Significant improvement was reported in most patients after the use of amniotic membrane transplantation to treat or prevent ocular motility limitations. Very few complications or adverse effects were documented.

Home- and Office-Based Vergence and Accommodative Therapies for Treatment of Convergence Insufficiency in Children and Young Adults: A Report by the American Academy of Ophthalmology

PURPOSE

To review home- and office-based vergence and accommodative therapies for treatment of convergence insufficiency (CI) in children and young adults up to 35 years of age.

METHODS

Literature searches were conducted through October 2020 in the PubMed database for English-language studies. The combined searches yielded 359 abstracts, of which 37 were reviewed in full text. Twelve of these were considered appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist.

RESULTS

Of the 12 studies included in this assessment, 8 were graded as level I evidence, 2 were graded as level II evidence, and 2 were graded as level III evidence. Two of the level I studies included older teenagers and young adults; the remainder of the studies exclusively evaluated children. Two randomized controlled trials found that office-based vergence and accommodative therapies were effective in improving motor outcomes in children with symptomatic CI. However, the studies reported conflicting results on the efficacy of office-based therapy for treating symptoms of CI. Data were inconclusive regarding the effectiveness of home-based therapies (including pencil push-ups and home computer therapy) compared with home placebo. In young adults, office-based vergence and accommodative therapies were not superior to placebo in relieving symptoms of CI.

CONCLUSIONS

Level I evidence suggests that office-based vergence and accommodative therapies improve motor outcomes in children with symptomatic CI, although data are inconsistent regarding symptomatic relief. Evidence is insufficient to determine whether home-based therapies are effective.

Duane-minus (Duane sine retraction and Duane sine limitation): possible incomplete forms of Duane retraction syndrome

PURPOSE

To report ocular motility patterns that mimic, but do not fulfil the full clinical picture of Duane retraction syndrome (DRS) and to describe their clinical features and surgical management.

METHODS

This is a retrospective case series study conducted on patients with DRS, mimicking non-comitant exotropia or esotropia and a face turn. Patients were included only if they lacked either globe retraction on adduction (sine retraction) or limitation of adduction or abduction on ductions (sine limitation not >0.5). Any overshoots or pattern strabismus was recorded. The ocular motility and alignment, details of surgery and their surgical outcomes were analysed.

RESULTS

Twenty-one patients were identified; 13 in the sine retraction and 8 in the sine limitation group. All patients presented with a compensatory face turn. Overshoots were present in 10 (77%) and 7 patients (88%) in the sine retraction and sine limitation groups, respectively. Forced duction test showed tightness of the ipsilateral medial and the ipsilateral lateral rectus muscle in esotropic (n = 3) and exotropic patients (n = 18), respectively. Orthotropia was achieved in 82% of patients following ipsilateral medial or lateral rectus muscle recession.

CONCLUSIONS

There is a subset of patients who present with motility pattern similar to DRS but lack its complete diagnostic criteria. The presence of a face turn, overshoots on adduction or an ipsilateral tightness of the affected muscle should make one consider DRS sine retraction/sine limitation. The patients in our study responded well to lines of management similar to those of DRS.

The effects of amblyopia on children's reading performance after patching treatment

PURPOSE

The purpose of this study was to evaluate the effects of amblyopia on children's reading performance after the successful patching treatment with 20/20 visual acuity (VA) in the treated eye.

METHODS

The treated amblyopes group included 10 children with strabismic amblyopia diagnosed on the first visit presenting VA equal or better than 0.0 logMAR (20/20 Snellen) in the better vision eye and VA worse than 0.2 logMAR (20/32 Snellen) in the worse eye that underwent patching treatment of amblyopia reaching a final VA  equal to  0.0 logMAR in the treated eye. The control group comprised 10 children matched by age, gender and school-grade with no visual disorders. Reading performance was evaluated according to reading acuity (RA), critical print size (CPS), reading speed (RS) at 0.7 logMAR, and maximum reading speed (MRS) using the MNREAD chart.

RESULTS

Binocular reading performance was compared between groups and no statistically significant differences were found on RA, CPS, RS, or MRS (p > 0.05). When analyzing monocular reading performances of treated amblyopes, a worse RA (p = 0.04) and CPS (p = 0.04) were observed on the previously amblyopic eye when compared to the fellow eye. When comparing the fellow eye from treated amblyopes and a randomly selected eye from controls, no statistically significant differences on RA, CPS, RS, or MRS were found (p > 0.05).

CONCLUSIONS

The results suggest that even patients who reached 20/20 VA in the treated eye after patching treatment for amblyopia may present persistent impaired reading performance. These findings reinforce the importance of reading performance testing as a tool when evaluating the visual function development in amblyopic patients.

How to assess visual function in acquired brain injury-Asking is not enough

BACKGROUND

Acquired brain injury affects many brain areas and causes a range of dysfunctions including vision-related issues. These issues can have negative impacts on rehabilitation progress and activities of daily life but may easily be overlooked. There is no common recommendation about how to assess visual impairments after ABI. The purpose of this study was to estimate the frequency of objectively measures oculomotor dysfunctions, and also how these findings are related to two inventories intended to support detection of visual impairment.

METHODS

The study was cross-sectional and included 73 outpatients. In addition to the standard evaluation program, the patients went through a comprehensive optometric examination. The inventories used were the Vision Interview (VI) and the Convergence Insufficiency Symptom Survey (CISS).

RESULTS

All three types of examinations showed a high proportion vision-related symptoms. Fusion vergence was the most common objectively measured finding, 83%. There were seven statistically significant associations between five VI items and five visual deficits. The strength of associations was moderate (Phi 0.261-0.487, p < .05). The sensitivity and specificity of the CISS were moderate.

CONCLUSION

We found high percentages of the patients with visual symptoms and dysfunctions. Due to the complexity of visual symptoms and functional deficits in ABI, we find it necessary to combine both symptom assessment and vision examination in order to capture visual function issues.

Fixational eye movements abnormalities and rate of visual acuity and stereoacuity improvement with part time patching

Residual amblyopia is seen in 40% of amblyopic patients treated with part-time patching. Amblyopic patients with infantile onset strabismus or anisometropia can develop fusion maldevelopment nystagmus syndrome (FMNS). The purpose of this study was to understand the effects of presence of FMNS and clinical subtype of amblyopia on visual acuity and stereo-acuity improvement in children treated with part-time patching. Forty amblyopic children who had fixation eye movement recordings and at least 12 months of follow-up after initiating part-time patching were included. We classified amblyopic subjects per the fixational eye movements characteristics into those without any nystagmus, those with FMNS and patients with nystagmus without any structural anomalies that do not meet the criteria of FMNS or idiopathic infantile nystagmus. We also classified the patients per the clinical type of amblyopia. Patching was continued until amblyopia was resolved or no visual acuity improvement was noted at two consecutive visits. Children with anisometropic amblyopia and without FMNS have a faster improvement and plateaued sooner. Regression was only seen in patients with strabismic/mixed amblyopia particularly those with FMNS. Patients with FMNS had improvement in visual acuity but poor stereopsis with part-time patching and required longer duration of treatment.

Concurrence of Congenital Muscular Torticollis and Congenital Torticollis Due to Other Anomalies: Two Case Reports

Introduction: Congenital muscular torticollis (CMT) is the most common cause of torticollis in infants; other causes, including osseous, ocular, and central nervous system torticollis can easily be overlooked. We report two rare cases of CMT with concurrent osseous or ocular torticollis. Case 1: A 1-month-old female infant with a right neck mass and right-tilting head posture was referred. Neck ultrasonography showed diffuse hypertrophy and hyperechoic findings on the right sternocleidomastoid (SCM) muscle, which was consistent with right CMT. A clavicle X-ray imaging was conducted to identify an associated fracture due to birth trauma on the same day and a suspected congenital vertebral anomaly was coincidentally found. Subsequent three-dimensional computed tomography of the cervical spine showed a T1 hemivertebra causing the right-tilting head. The patient was diagnosed with the concurrent manifestation of CMT and congenital osseous torticollis. Case 2: A 3-month-old male infant with a 20° head tilt to the right with a limited cervical range of motion was referred. Neck ultrasonography showed a fibromatosis colli in the right SCM, suggesting CMT. He proceeded to physical therapy for seven months; however, there was little clinical improvement in his head and neck posture. The patient underwent an additional ophthalmologic examination and orbital magnetic resonance imaging (MRI) at 10 months of age. The result showed congenital agenesis of the left fourth cranial nerve with hypoplasia of the superior oblique muscle causing the right-tilting of the head. Ultimately, the boy was diagnosed with a concurrent manifestation of CMT and congenital ocular torticollis. Conclusion: Unless careful examinations are conducted, congenital vertebral anomalies and congenital agenesis of the fourth cranial nerve can go unnoticed in the present two cases. If a patient with CMT displays unusual features or does not respond to physical therapy, clinicians should consider not only a differential diagnosis but also concurrence with other causes of congenital torticollis.

Complete bilateral ophthalmoplegia in malignant intracranial hypertension in a child

PURPOSE

To describe a case of fulminant idiopathic intracranial hypertension (IIH) in a child with "malignant" presentation.

CASE REPORT

A 16-year-old, previously healthy, girl presented with bilateral visual loss and bilateral global limitation of eye movements in the absence of headache. Extensive laboratory evaluation for infectious, inflammatory, autoimmune, and neoplastic conditions was negative. Magnetic resonance imaging (MRI) of the brain and lumbar puncture findings were consistent with a diagnosis of IIH. Extraocular motility improved in the next few days as well as optic disc edema but visual acuity remained poor.

CONCLUSION

The authors believe that the acute, severe, and fulminant ("malignant") presentation with markedly elevated intracranial pressure may produce the unique presentation of severe vision loss and bilateral complete ophthalmoplegia. Interestingly, there was no headache. To our knowledge this is the first such case to be reported in the English language ophthalmic literature.

Saccadic movements assessment in eccentric fixation: A study in patients with Stargardt disease

PURPOSE

To investigate saccadic movements in subjects with eccentric fixation due to a deep central scotoma in Stargardt disease (STGD).

METHODS

We studied 10 patients with STGD and 10 healthy subjects (control group). Saccadic movements of all the 20 subjects were assessed by using the eye tracker technique Tobii Glasses Pro 2. Standard measurements of reading ability (MNREAD charts), visual acuity (ETDRS charts), contrast sensitivity (Pelli-Robson charts), reading contrast threshold and speed (REX charts), retinal sensitivity and stability and localization of the fixation (MP1 fundus perimetry) were obtained in all subjects.

RESULTS

The saccadic movements time was significantly slower in STGD than in healthy subjects (699 ± 193 ms vs 299 ± 40 ms, p < 0.001). When STGD patients moved fixation to the target localized in retinal scotomatous areas, the movement was significantly slower compared to non scotomatous areas in the retina (1103 ± 798 ms vs 524 ± 187 ms, p = 0.039). There was a trend toward a correlation between slow saccadic movements in STGD subjects and the reading performance indices, although statistical significance was not achieved.

CONCLUSION

Ocular saccades guided by eccentric fixation in STGD patients are significantly slower than in the control group, especially when the target corresponds to retinal areas with a deep scotoma. These results can explain the worse reading performance in STGD subjects, in particular when a non-viewing area on the right part of the text is present.

Inferior rectus pulled-in-two syndrome: Surgical results after anterior and nasal transposition of the inferior oblique muscle

Pulled-in-two syndrome (PITS) is a serious intraoperative complication of strabismus surgery in which an extraocular muscle manipulated during the procedure is ruptured and potentially lost. Usually, there is a systemic or local condition that determines muscle weakness when put under tension. If the proximal portion of the broken muscle can be found, it can be reattached to the ocular globe or remaining muscle. If this is not possible, there are multiple varying approaches. We present three cases of PITS of the inferior rectus muscle, treated with good results with anterior and nasal transposition of the inferior oblique muscle. We propose this surgery as another potential technique if the muscle can not be retrieved.

Management of nystagmus in children: a review of the literature and current practice in UK specialist services

Nystagmus is an eye movement disorder characterised by abnormal, involuntary rhythmic oscillations of one or both eyes, initiated by a slow phase. It is not uncommon in the UK and regularly seen in paediatric ophthalmology and adult general/strabismus clinics. In some cases, it occurs in isolation, and in others, it occurs as part of a multisystem disorder, severe visual impairment or neurological disorder. Similarly, in some cases, visual acuity can be normal and in others can be severely degraded. Furthermore, the impact on vision goes well beyond static acuity alone, is rarely measured and may vary on a minute-to-minute, day-to-day or month-to-month basis. For these reasons, management of children with nystagmus in the UK is varied, and patients report hugely different experiences and investigations. In this review, we hope to shine a light on the current management of children with nystagmus across five specialist centres in the UK in order to present, for the first time, a consensus on investigation and clinical management.

The efficacy of biofeedback visual rehabilitation therapy in patients with infantile nystagmus syndrome: A retrospective study

OBJECTIVE

To report fixation stability changes in patients with different forms of infantile nystagmus syndrome (INS), who have undergone a visual rehabilitation through biofeedback fixation training (BFT) with microperimetry (MP).

DESIGN

Retrospective study.

METHODS

Patients 6 to 12 years-old with INS who performed BFT with MP. Initially 10 once-weekly followed by eight twice-weekly sessions of BFT during a minimum of 6 months period were performed. Visual acuity (VA) and MP fixation stability indices were analyzed, including displacement from fixation point (P1, P2) and percentage of retinal loci used during fixation attempt (BCEA 63% and 95%). Statistical analysis was conducted at baseline (BL), 10 weeks (W10) and 6 months (M6).

RESULTS

Twelve patients (mean age 8.9 years.) with INS completed the whole training session. All patients showed significant improvement in the mean BCEA fixation area (deg²): For BCEA@95% BL was 78.0, 46.1 at W10, and 27.4 at M6 (p-value = 0.004). For BCEA@63% BL was 27.3, 15.4 in W10, and 9.17 at M6 (p = 0.01). The ANOVA test for the FS indices of P1 and P2, as well as for BCVA showed no significant difference when compared at the same intervals.

CONCLUSION

Fixation stability (FS) indices of BCEAs (63% and 95%) improved at W10 and M6, while P1 and P2 showed significant improvement at W10 but not at M6, probably because BCEA involves a much larger area than P1 and P2. VA did not show significant improvement at any time point.

Near-infrared transmitting occlusive intraocular lens implantation for intractable diplopia: Report of two cases

OBJECTIVE

The objective of this article is to report two cases of black occlusive intraocular lens and implantation for treating intractable diplopia.

CASE DESCRIPTIONS

Two patients with intractable diplopia after orbitofacial, trauma, and surgical removal of pituitary adenoma failed to conservative management. After uneventful cataract, phacoemulsification, a black intraocular lens was implanted in every case. In both cases, a complete degree of satisfaction was achieved, with no symptoms of diplopia, and no complications have been observed in their follow-up. The use of optical coherence tomography has been possible in both cases to assess the macula and optic nerve, since a fundoscopy is not possible in such cases.

CONCLUSION

Implantation of a near-infrared transmitting occlusive intraocular lens for treating intractable diplopia provided a complete resolution of symptoms without eliminating the possibility of examining macula and optic nerve using optical coherence tomography.

Different Surgical Approaches for Treatment of Dissociated Vertical Deviation (DVD)

Introduction

DVD is a rare, poorly understood eye motility disorder of unknown etiology. In socially unacceptable deviation, surgical treatment is an option. We present patients operated with three different surgical methods.

Aim

To evaluate and compare different surgical approaches for treatment of dissociated vertical deviation (DVD).

Methods

Total amount of 20 patients with DVD of ≥ 20 PD are operated with three different techniques on superior rectus (SR) muscle: Group I with preoperative angle of 20-30 PD was operated with 8 mm recession of SR, Group II with preoperative angle of ≥ 30 PD undergo 3 mm recession with posterior fixation on SR and Group III with preoperative angle of ≥ 30 PD undergo-splitting of SR muscle. Surgeries for associated horizontal deviations were performed before surgery for DVD. Follow up was three years.

Results

In all cases amount of DVD deviation was significantly reduced. No binocularity was gained. Although hyperdeviation of affected eye was reduced in all patients, we didn't eliminate deviation completely. Despite smaller preoperative angle, residual angle was bigger (6-12 PD) in the patients in group I where only recession of SR was performed, compared to Group II and III where postoperative angle was 4-8 PD in both groups.

Conclusion

There are no recommended guidelines for the surgical treatment of DVD and treatment is based more on the surgeon's experience than evidence based data. In our experience recession of the SR should be method of choice in the cases of smaller deviation. SR recession combined with posterior fixation suture and Y-splitting seems to be a safe and effective method for surgical treatment of unilateral DVD with bigger deviation angles. Y splitting with less surgical complications and increasing effect with time can be a good alternative to posterior fixation surgery.

Lateral rectus advancement versus medial rectus recession for consecutive esotropia

PURPOSE

To compare lateral rectus advancement with medial rectus recession for patients with consecutive esotropia without abduction limitation.

METHODS

Forty-three patients who developed consecutive esotropia following bilateral lateral rectus recession for intermittent exotropia were reviewed retrospectively. Twenty-two patients underwent lateral rectus advancement (lateral rectus advancement group) and medial rectus recession was performed in 21 patients (medial rectus recession group). Success rate of the surgery was based on the percentage of postoperative esophoria or exophoria of less than 8 PD, which did not require a third surgery. Mean follow-up after second surgery was 23.5 ± 8.7 months.

RESULTS

Mean consecutive esotropia in the lateral rectus advancement group was 24.8 ± 9.0 PD. Eight patients were orthophoric after second surgery; mean postoperative esophoria and exophoria/tropia was 5.4 ± 3.4 PD and 6.5 ± 5 PD, respectively. Postoperative success rate in this group was 90.9%. Mean consecutive esotropia in the medial rectus recession group was 21 ± 98.4 PD. Three patients were orthophoric after second surgery; mean postoperative esotropia/phoria and exophoria was 9.5 ± 5.0 PD and 5.2 ± 1.3 PD, respectively. Postoperative success rate in this group was 71.4%. Postoperative undercorrection rate of 4.5% in lateral rectus advancement group was significantly less than the similar measure of 28.6% in medial rectus recession group (chi-square, P = 0.03).

CONCLUSION

Advancement of the previously recessed lateral rectus has improved consecutive esotropia better than medial rectus recession.

Prevalence of Mental Health Illness among Patients with Adult-Onset Strabismus

BACKGROUND

Children diagnosed with some forms of strabismus were recently found to have an increased risk of developing mental illness by early adulthood. The purpose of this case-controlled study was to determine if adults with non-paralytic forms of strabismus are similarly at an elevated risk for developing mental illness.

METHODS

The medical records of all patients diagnosed as adults (≥ 19 years of age) with convergence insufficiency (CI) (n = 118), divergence insufficiency (DI) (n = 80), and small angle hypertropia (HT (n = 99) from January 1, 1985, through December 31, 2004, were retrospectively reviewed. Each case was compared with a sex- and birth date-matched non-strabismic control. The medical records were reviewed for mental health diagnoses, including inpatient and outpatient encounters, psychiatric ER visits, and medication use.

RESULTS

Mental health disorders were diagnosed in 65 (55.1%) patients with CI compared to 54 (45.8%) controls (p = 0.15), in 51 (63.8%) patients with DI compared to 42 (52.5%) controls (p = 0.15), and in 63 (63.6%) patients with HT compared to 57 (57.6%) controls (p = 0.38). CI patients were not more likely to have mental health disorders than their controls (p = 0.15). Mental health hospitalizations (p = 0.02), psychiatric medication use (p = 0.04), and unspecified anxiety disorders (p = 0.03) were higher in DI patients compared to controls. HT patients were found to have more generalized anxiety disorders (p = 0.003) than controls.

CONCLUSIONS

Adults with some forms of strabismus (DI and HT) appear to have an increased risk of mental illness and its comorbidities, compared to age- and gender-matched non-strabismic controls.

Reading networks in children with dyslexia compared to children with ocular motility disturbances revealed by fMRI

Key Points

Dyslexia is a neurological disorder with a genetic origin, but the underlying biological and cognitive causes are still being investigated.

This study compares the brain activation pattern while reading in Spanish, a semitransparent language, in three groups of children: typically developing readers, dyslexic readers and readers with functional monocular vision.

Based on our results Dyslexia would be a neurological disorder not related to vision impairments and would require a multidisciplinary treatment based on improving phonological awareness and language development.

Developmental dyslexia is a neurological disorder the underlying biological and cognitive causes of which are still being investigated, a key point, because the findings will determine the best therapeutic approach to use. Using functional magnetic resonance imaging, we studied the brain activation pattern while reading in the language-related cortical areas from the two reading routes, phonological and orthographic, and the strength of their association with reading scores in 66 Spanish-speaking children aged 9–12 years divided into three groups: typically developing readers (controls), dyslexic readers and readers with monocular vision due to ocular motility disorders but with normal reading development, to assess whether (or not) the neuronal network for reading in children with dyslexia has similarities with that in children with impaired binocular vision due to ocular motility disorders. We found that Spanish-speaking children with dyslexia have a brain circuit for reading that differs from that in children with monocular vision. Individuals with dyslexia tend to hypoactivate some of the language-related areas in the left hemisphere engaged by the phonological route, especially the visual word form area and left Wernicke's area, and try to compensate this deficit by activating language-related areas related to the orthographic route, such as the anterior part of the visual word form area and the posterior part of both middle temporal gyri. That is, they seem to compensate for impairment in the phonological route through orthographic routes of both hemispheres. Our results suggest that ocular motility disturbances do not play a causal role in dyslexia. Dyslexia seems to be a neurological disorder that is unrelated to vision impairments and requires early recognition and multidisciplinary treatment, based on improving phonological awareness and language development, to achieve the best possible outcome.

Results of monocular surgery under peribulbar anesthesia for large-angle horizontal strabismus

OBJECTIVE

To evaluate the results of monocular surgery under peribulbar anesthesia for large-angle horizontal strabismus.

INTRODUCTION

Monocular surgery may preserve some muscles if a repeat operation is required, may help to avoid the exposure of the dominant eye to the inherent risks of a surgical procedure and may reduce surgical time.

METHODS

We evaluated ninety-two consecutive patients who underwent monocular surgery under peribulbar anesthesia for large-angle horizontal strabismus (angle of 40 prism diopters or greater). Patients were divided into group 1- esotropia and group 2 -exotropia. The postoperative follow-up was at 6 months, when the residual deviation was evaluated. In cases of residual deviations of over 15 PD (prism diopter), a second procedure was indicated.

RESULTS

In all patients with preoperative deviations up to 60 PD, residual deviations were under 15 PD. Some patients with preoperative deviations of 65 PD (two in group 1 and four in group 2) and all patients with deviations over 65 PD had residual deviations over 15 PD. The 13 patients who underwent a second procedure experienced successful outcomes. Our ROC curve analysis showed that the cutoff point for obtaining a successful surgical result was 62.5 PD. No patient presented with a major limitation in respect of ocular movement.

CONCLUSIONS

Monocular surgery under peribulbar anesthesia can be an alternative for horizontal large-angle strabismus given deviations of up to 60 PD. Monocular surgery did not result in successful outcomes for deviations of over 65 PD.

A catastrophic-onset longitudinal myelitis accompanied by bilateral internuclear ophthalmoplegia in a patient with systemic lupus erythematosus

Transverse myelitis (TM) extending from midbrain to the entire spinal cord accompanied by internuclear ophthalmoplegia is extremely rare but cause serious central nervous system complications in patients with systemic lupus erythematosus. We report a case of a 28-yr-old woman with TM extending from the midbrain to the conus medullaris longitudinally and internuclear ophthalmoplegia associated with systemic lupus erythematosus. Her neurological symptoms had an abrupt catastrophic onset and rapidly progressed to respiratory failure within 24 hr. Bilateral internuclear ophthalmoplegia was also followed by TM. Brain MR images showed definite brainstem lesions, which were deeply associated with internuclear ophthalmoplegia, and diffuse signal changes in the whole spinal cord, medulla, pons and midbrain. Clinical improvement of her ophthalmoplegia and of neurological dysfunction of the upper extremities was noted after prompt and aggressive treatment with intravenous pulsed methylprednisolone and cyclophosphamide. However, the neurological dysfunction of the lower limbs and bladder and colon paralysis were almost unchanged until six months passed.