Efficacy of Soft Contact Lenses for Myopia Control: A Systematic Review

PURPOSE

To summarize and analyze critically the scientific evidence focused on the effectiveness of the use of hydrophilic contact lenses (HCLs) in myopia control, as well as their impact on visual quality and the involvement on the accommodative and binocular function.

METHODS

This systematic review was developed selecting all original studies which evaluated HCLs for myopia control with follow-up of at least 1 year. Eligible randomized controlled trials (RCTs) were retrieved from PubMed MEDLINE and Scopus. Methodological quality of the studies was assessed using the Critical Appraisal Skills Programme (CASP) for RCTs.

RESULTS

The search provided a total of 276 articles, selecting 13 according to the inclusion and exclusion criteria. The majority of studies evaluating the effectiveness of HCL showed a good efficacy in myopia progression, providing a good quality of vision. The quality of these studies was found to be suitable according to the CASP tool. The accommodative and binocular function with these lenses was evaluated in few studies, reporting a trend to an increase in the accommodative response and exophoria in near vision, while maintaining good level of stereopsis. Aberrometry and pupillometry were only studied in one trial, in which the authors did not find changes in these variables after the use of a myopia control HCL.

CONCLUSIONS

There is a strong evidence about the effectiveness of different HCLs designs for slowing down myopia progression in children, providing all of them good levels of visual quality. However, there is still poor evidence about changes in accommodation and binocular function, as well as in pupil size and aberrometry with myopia control HCLs, being necessary more studies focused on this issue.

Office-based vergence and anti-suppression therapy for the treatment of small-to-moderate angle intermittent exotropia: A randomised clinical trial

PURPOSE

To evaluate the short-term (1 week after completion of treatment) effect of office-based vergence and anti-suppression therapy (OBVAT) on the Office Control Score when compared to observation alone in children with small-to-moderate angle intermittent exotropia (IXT).

METHODS

In this single-masked (examiner masked), two-arm, single-centre randomised clinical trial, 40 participants, 6 to <18 years of age with untreated IXT, were randomly assigned to OBVAT or observation alone. Participants assigned to therapy received 60 min of OBVAT with home reinforcement once per week for 16 weeks. Therapy included vergence, accommodation and anti-suppression techniques. The primary outcome measure was the comparison of the distance Office Control Score between the two groups at the primary outcome visit (i.e., 17-week follow-up visit).

RESULTS

At the primary outcome visit, the OBVAT group (n = 20) had a significantly better distance Office Control Score (adjusted mean difference: -0.9; 95% CI: -0.2 to -1.5; p = 0.008; partial eta squared: 0.19) than the observation group (n = 16). Participants from the OBVAT group were more likely than those from the observation group to have ≥1 point of improvement at the 17-week visit (OBVAT group: 75%; Observation group: 25%; p = 0.006).

CONCLUSIONS

In this randomised clinical trial of participants aged 6 to <18 years with IXT, we found that the OBVAT group had a significantly better distance Office Control Score than the observation group at the 17-week visit. This study provides the first data from a randomised clinical trial demonstrating the effectiveness of OBVAT for improving the control of IXT. Eye care practitioners should consider OBVAT as a viable, non-surgical treatment option for IXT. A full-scale randomised clinical trial investigating the long-term effectiveness of OBVAT in treating IXT is warranted.

Comparison of retinal nerve fiber layer thickness between monocular and alternating exotropia in patients with intermittent exotropia

PURPOSE

To investigate differences in intraocular structure based on the presence or absence of fixation preference in children with intermittent exotropia (IXT) by comparing the thickness of the retinal nerve fiber layer (RNFL).

METHODS

From October 2018 to March 2022, RNFL thickness was retrospectively analyzed using spectral domain optical coherence tomography. Participants had uncorrected visual acuity of 20/20, refractive errors close to emmetropia, and no anisometropia. The patients were divided into monocular and alternating exotropia groups through a cover-uncover test. The average and sectoral thickness of the RNFL in both groups were compared.

RESULTS

The average global thickness and average thickness of each of the six sectors of the RNFL did not significantly differ between dominant and non-dominant eyes in the monocular exotropia group and between right and left eyes in the alternating exotropia group. The thickness did not significantly differ between the monocular exotropia group and the right or left eye of the alternating exotropia group. Interocular differences in RNFL thickness were negative in the monocular exotropia group (dominant eye-non-dominant eye) and positive in the alternating exotropia group (right eye-left eye) for the average, inferonasal, and inferior sectors, exhibiting statistically significant between-group differences (p = 0.019, p = 0.003, p = 0.023, respectively).

CONCLUSIONS

In children with IXT without obvious refractive error, there was a significant interocular difference in RNFL thickness of the average, inferonasal, and inferior sectors between monocular and alternating exotropia groups. The presence of fixation preference may affect RNFL thickness.

Incidence, Risk Factors and Management of Postoperative Complications in Horizontal Strabismus Surgery

OBJECTIVE

To report the incidence, risk factors and management of postoperative complications after horizontal strabismus surgery.

DESIGN

Retrospective Cohort study.

PARTICIPANTS

The study assessed 1,273 patients with 1,035 cases of exotropia and 238 cases of esotropia, with a minimum 18-month follow-up.

METHODS

Retrospective review of strabismus operation patients' medical records included baseline demographics, age at surgery, pre/postoperative visual acuity, and deviation. Complications were categorized as surgical site (infection, scarring, cyst, granuloma, ischemia) and strabismus-related (recurrence, diplopia), with analysis of incidence, risk factors, and management.

RESULTS

Among surgical site complications, the incidence of infection, pyogenic granuloma, and anterior segment ischemia were similar between the exotropia (0.3%, 0.3%, 0.2%) and esotropia (0.8%, 0%, 0.4%) groups (p = .221, 0.406, 0.515). In contrast, the esotropia group presented a higher risk of conjunctival inclusion cyst and conjunctival scar than the exotropia group, with incidences of 5.0% vs 2.2% and 6.3% vs 1.3%, respectively (p = .004, <0.001). Regarding strabismus complications, the incidence of early recurrence was not significant between the two groups, with 10.0% in the exotropia group and 10.5% in the esotropia group (p = .553). Older age and poor initial visual acuity were associated with early recurrence (p < .001). The esotropia group had a higher risk of persistent diplopia than the exotropia group, with incidences of 4.2% vs 2.0%, respectively (p = .003).

CONCLUSION

Esotropia carries a higher risk of conjunctival inclusion cysts, conjunctival scarring, and persistent diplopia compared to the exotropia group, while both groups exhibit similar rates of early recurrence and other surgical site complications.

[Application of modified fusion convergence index in intermittent exotropia]

Objective: To investigate a modified fusional convergence parameter-total convergence amplitude/distance angle and its relationship with exotropia control, stereoacuity, and other visual functions in intermittent exotropia. Methods: The cross-sectional study included children diagnosed with intermittent exotropia at the First Affiliated Hospital of Nanjing Medical University from August 2020 to June 2021. A modification was made by combining total convergence amplitude using synoptophore and distance angle at distance using prism bars to calculate total convergence amplitude/distance angle. Exotropia control at distance and near measured by Office-based Scale for Assessing Control was classified as good control (scale 0-1) and poor control (scale 2-5). Statistical analysis was performed using Spearman correlation analysis, Mann-Whitney U test, Fisher's exact test, χ2 test, logistic regression analysis, and mediation effect analysis. Results: The study included 212 patients, of which 105 (49.5%) were male and 107 (50.5%) were female. The median (interquartile range) age was 9.0 (8.0, 10.0) years. Of 211 cases, 201 (94.8%) had binocular fusional function, while 11 cases (5.2%) did not have binocular fusional function. Among patients with binocular fusional function, inverse correlation was observed between total convergence amplitude and exotropia control scores for both distance (r=-0.427, P<0.001) and near (r=-0.194, P=0.006). Total convergence amplitude/distance angle was an independent predictive factor for exotropia control at distance (OR=0.195; 95%CI, 0.060-0.630; P=0.006) and near (OR=0.252; 95%CI, 0.085-0.746; P=0.013). Stereoacuity at distance (OR=3.110; 95%CI, 1.311-7.379; P=0.010) and near (OR=2.780; 95%CI, 1.401-5.517; P=0.003) were also factors associated with distance exotropia control. Mediation analysis revealed that stereoacuity was not a mediating factor between the ratio and distance control (distance: P=0.066; near: P=0.181). In patients with ratio≥1.5 °/PD, all the 15 patients demonstrated good control. On the contrary, patients with ratio<1.5 °/PD showed worse exotropia control (distance: P=0.001; near: P=0.040) and larger angles of deviation (distance: P<0.001; near: P<0.001). Conclusion: The modified fusional ratio, total convergence amplitude/distance angle, combining synoptophore and prism bars, could be used to evaluate the severity of intermittent exotropia. A higher ratio may be associated with poorer exotropia control. Though it may also be associated with distance exotropia control, stereoacuity is not the mediating factor between the modified ratio and distance exotropia control.

Occurrence of Dry Eye Disease in Patients With Concomitant Strabismus: A Preliminary Cross-sectional Analysis

PURPOSE

To determine the effects of strabismus on dry eye parameters.

METHODS

In this cross-sectional study, the preliminary assessment of ocular parameters related to dry eye disease was performed in patients with untreated concomitant strabismus. In total, 204 patients with concomitant strabismus and 125 volunteers without strabismus (4 to 30 years old, 170 male and 159 female) were enrolled. The Ocular Surface Disease Index questionnaire (OSDI) was administered, and ocular surface was examined using the Oculus Keratograph 5M (Oculus Optikgeräte GmbH) to collect data on tear film break-up time (TBUT), ocular redness index (based on bulbar conjunctival blood vessel engorgement), and meibomian gland atrophy. Subgroup analysis was performed based on strabismus type (concomitant exotropia, concomitant esotropia, and non-strabismus); age (juvenile versus adults age > 18 years); and 5- to 10-year and 10- to 20-year strabismus course, according to an age of 12 years.

RESULTS

Concomitant exotropia and esotropia were reported in 134 and 70 patients, respectively. A total of 125 healthy volunteers were recruited. The three groups showed significant differences in the ocular redness index (right eye: P = .012, left eye: P = .018). In contrast, other parameters were not significantly different. Similarly, no statistical differences in ocular surface indicators were observed when patients were divided by age (P > .05 for all) and the 5- to 10-year and 10- to 20-year strabismus course. The meibomian gland showed varying degrees of atrophy in both the strabismus and non-strabismus groups.

CONCLUSIONS

Strabismus does not affect tear film stability with age in this cohort with constant strabismus up to 30 years, indicating that strabismus may not increase the risk of dry eye disease. [J Pediatr Ophthalmol Strabismus. 2024;61(1):30-37.].

Creating consistency in the diagnosis of convergence insufficiency: screening methods

PURPOSE

To determine the sensitivity of various clinical tests in the diagnosis of convergence insufficiency.

METHODS

A total of 254 patients were recruited with complaints consistent with convergence problems but no prior history of strabismus surgery, eye exercises, prism use, recent concussion, or other ocular or neurological diseases. Each patient completed the convergence insufficiency symptom survey (CISS), and the following data were collected: ocular alignment at distance and near, convergence and divergence fusional amplitudes at distance and near, near-point of convergence (NPC) using an accommodative target and red lens, and assessment of quality of convergence movement (QoCM) and quality of fusional movements (QoFM). The sensitivity of each clinical test was calculated.

RESULTS

Measurement of NPC using red lens and subjective assessment of the QoCM and QoFM were the most sensitive diagnostic tools for near symptoms consistent with convergence insufficiency: 93.3%, 98.4%, and 94.5% respectively. CISS score, convergence fusional amplitude at near, and exophoria at near had lower sensitivities: 62.9%, 46.0%, and 72.0%, respectively. Although the majority of our patients had a heterophoria or heterotropia at distance (96.8%) and/or near (98.8%), most presented with only small phorias. Furthermore, of those who had a deviation at near, only 22% had the near exophoria exceeding the distance exophoria by 10Δ.

CONCLUSIONS

In our study cohort, NPC with red lens and subjective assessment of QoCM and QoFM proved to be the most sensitive screening tools for near symptoms consistent with convergence insufficiency.

Altered Large-Scale Resting-State Functional Network Connectivity in Convergence Insufficiency Young Adults Compared With Binocularly Normal Controls

Purpose

To investigate the underlying resting-state functional connectivity (RSFC) of symptomatic convergence insufficiency (CI) compared with binocularly normal controls (BNC) using functional magnetic resonance imaging (fMRI) under The Convergence Insufficiency Neuro‑mechanism Adult Population Study (NCT03593031).

Methods

A total of 101 participants were eligible for this study. After removing datasets with motion artifacts, 49 CI and 47 BNC resting-state functional magnetic resonance imaging datasets were analyzed. CI was diagnosed with the following signs: (1) receded near point of convergence of 6 cm or greater, (2) decreased positive fusional vergence of less than 15∆ or failing Sheard's criteria of twice the near phoria, (3) near phoria of at least 4∆ more exophoric compared with the distance phoria, and (4) symptoms using the Convergence Insufficiency Symptom Survey (score of ≥21). RSFC was assessed using a group-level independent components analysis and dual regression. A behavioral correlation analysis using linear regression method was performed between clinical measures and RSFC using the significant difference between the CI and BNC.

Results

On average, a decreased RSFC was observed within the frontoparietal network, default mode network and visual network in patients with CI, compared with the participants with BNC (P < 0.05, corrected for multiple comparisons). The default mode network RSFC strength was significantly correlated with the PFV, near point of convergence, and difference between the horizontal phoria at near compared with far (P < 0.05).

Conclusions

Results support altered RSFC in patients with CI compared with participants with BNC and suggest that these differences in underlying neurophysiology may in part be in connection with the differences in optometric visual function used to diagnose CI.

How Do Most Young Moderate Hyperopes Avoid Strabismus?

Purpose

Uncorrected hyperopic children must overcome an apparent conflict between accommodation and vergence demands to focus and align their retinal images. This study tested hypotheses about simultaneous accommodation and vergence performance of young hyperopes to gain insight into ocular motor strategies used to maintain eye alignment.

Methods

Simultaneous eccentric photorefraction and Purkinje image tracking were used to assess accommodative and vergence responses of 26 adult emmetropes (AE) and 94 children (0-13 years) viewing cartoons. Children were habitually uncorrected (CU) (spherical equivalent refractive error [SE] -0.5 to +4 D), corrected and aligned (CCA), or corrected with a history of refractive esotropia (CCS). Accommodative and vergence accuracy, dissociated heterophoria, and vergence/accommodation ratios in the absence of retinal disparity cues were measured for 33- and 80-cm viewing distances.

Results

In binocular viewing, median accommodative lags for 33 cm were 1.0 D (AE), 1.33 D (CU), 1.25 D (CCA), and 1.0 D (CCS). Median exophorias at 80 and 33 cm were 1.2 and 4.5 pd (AE), 0.8 and 2.5 pd (CU), and 0 and 1.2 pd (CCA), respectively. Without disparity cues, most response vergence/accommodation ratios were between 1 and 2 meter angle/D (∼5-10 pd/D) (69% of AE, 44% of CU, 60% of CCA, and 50% of CCS).

Conclusions

Despite apparent conflict in motor coupling, uncorrected hyperopes were typically exophoric and achieved adultlike accuracy of both vergence and accommodation simultaneously, indicating ability to compensate for conflicting demands rather than bias to accurate vergence while tolerating inaccurate accommodation. Large lags and esophoria are therefore atypical. This analysis provides normative guidelines for clinicians and a deeper mechanistic understanding of how hyperopes avoid strabismus.

Assessment of distance-near control disparity in basic and divergence excess paediatric intermittent exotropia

CLINICAL RELEVANCE

In intermittent exotropia (IXT), deviation is better controlled at near fixation. Understanding of the mechanism responsible for this common observation may improve clinical management of IXT.

BACKGROUND

The physiological basis for the distance-near difference in control of deviation in IXT is vastly undetermined. A new parameter, 'control score disparity (CSD)', defined as the difference between distance and near control scores, is introduced. Association of CSD with positive fusional amplitude (PFA), accommodative convergence to accommodation (AC/A) ratio and distance angle of deviation was investigated to further understand the mechanisms.

METHOD

Patients aged between four and fifteen years with basic and divergence excess IXT were included. Subjects with previous strabismus surgery, amblyopia and inability to perform clinical tests were excluded. A standardized office-based scoring system was used to assess IXT controls. Subjects were sub-divided into group 1 (CSD <2) and group 2 (CSD ≥2). Pearson's univariate and regression analysis were used to determine relationships between CSD and other independent variables.

RESULTS

Mean age of the total 141 subjects (57.6% female) was 6.8 ± 2.5 years. Basic IXT was more common (60%) and 60% had CSD ≥2. The mean±SD distance angle of deviation, AC/A ratio, PFA and CSD were 22.1 ± 6.6 prism dioptres, 5.0 ± 1.0, 28.6 ± 6.3 prism dioptre and 2.0 ± 0.5, respectively. CSD was significantly correlated to PFA (r = 0.64, p < 0.001) and AC/A ratio (r = 0.27, p < 0.001) in overall samples and Group 2 subjects (r = 0.41, p = 0.001).

CONCLUSIONS

PFA is a major factor associated with the distance/near difference of IXT control. Individuals with a higher PFA demonstrated greater CSD. While AC/A ratio was associated in better control at near in divergence excess IXT, magnitude of angle appears irrelevant.

Clinical significance of CTGF and Cry61 protein in extraocular muscles of strabismic patients

PURPOSE

To investigate the relationship between clinical features and protein amounts of Cysteine-rich 61 (Cyr61/CCN1) and connective tissue growth factor (CTGF/CCN2), which are vital components and regulators of the extracellular matrix in resected muscles from strabismus surgery.

METHODS

Strabismus patients who were diagnosed with horizontal concomitant strabismus or inferior oblique overaction (IOOA) and required extraocular muscles (EOMs) resection to correct eye position were included in this study. The protein amounts were measured by enzyme-linked immunosorbent assay (ELISA) in resected EOMs. Multivariable linear regression was used to investigate the associations, adjusting for gender, age (continuous), amblyopia, and disease duration.

RESULTS

A total of 141 muscles (including 38 lateral, 81 medial rectus, and 22 inferior oblique muscles) from 128 patients were collected in this study. The amount of Cry61 and CTGF per millimeter was significantly negatively associated with deviation angle in intermittent exotropia patients (Cry61: β, - 1.44; 95%CI, - 2.79 to - 0.10, p = 0.035; CTGF: β, - 3.14; 95%CI, - 5.06 to - 1.22, p = 0.002). The same relationship was also detected in the partially accommodative and non-accommodative esotropia patients, although it was not statistically significant (Cry61: β, - 2.40; 95%CI, - 5.05 to 0.24; p = 0.073; CTGF: β, - 3.47; 95%CI, - 9.18 to 2.87; p = 0.269). The amount of Cry61 and CTGF per millimeter showed significant associations with the degree of IOOA (p < 0.05).

CONCLUSIONS

Taken together, our results demonstrated a significant relationship between deviation angle and protein amount of Cry61 and CTGF and implied that Cry61 and CTGF may play important roles in modulation of EOM contractility, which provide new insights into strabismus pathogenesis.

Ocular Manifestations in Head and Neck Cancer: A Cross-Sectional Study from a Tertiary Care Centre from South India

Introduction: Head and neck cancers (HNCs) present a significant global health burden, especially in India, where oral cavity cancers, notably affecting the tongue, are prevalent. A substantial portion of global HNCs (57.5%) is concentrated in Asia, India contributing with 30%. Despite advancements, challenges persist due to HNCs' invasive nature and metastatic potential. This study aims to explore the link between HNCs and ocular manifestations. Methods: A cross-sectional study was conducted at Bangalore Medical College and Research Institute involving 47 patients with diagnosed HNCs and ocular complaints. Clinical evaluations encompassed visual acuity, anterior and posterior segment examinations, and specialized investigations when necessary. Results: A diverse range of malignancies were observed, with SCC maxilla and xeroderma pigmentosa, each accounting for 10.63% of cases. Ocular examinations unveiled visual acuity challenges, anterior segment findings like masses, exotropia, pigmented lesions, and varied fundus abnormalities. The anterior segment findings encompassed masses often accompanied by protrusion or relative afferent pupillary defect (RAPD). Additionally, exotropia, pigmented lesions, and other conditions were observed. Fundus examination revealed a spectrum of findings, including media haziness (10.63%), lack of view (17.02%), and pale discs (6.38%). Treatment plans were diverse, including excision biopsies (42.55%), exenteration procedures, Mitomycin-C applications, and referrals for chemotherapy and radiotherapy. Conclusion: The present study underscores the significance of ophthalmological assessment and investigations in patients with diagnosed HNCs, emphasizing the value of early detection and intervention. Abbreviations: HNC = Head and Neck Cancer, OCT = Optical Coherence Tomography, WNL = Within Normal Limits, SCC = Squamous Cell Carcinoma, MRI = Magnetic Resonance Imaging, CT = Computed Tomography, RAPD = Relative Afferent Pupillary Defect, XP = Xeroderma Pigmentosa.

Gender differences in horizontal strabismus: Systematic review and meta-analysis shows no difference in prevalence, but gender bias towards females in the clinic

Background

Strabismus is a misalignment of the visual axis that affects 2-3% of the population and can lead to loss of binocular vision. It is currently controversial whether there is a gender difference in the most common form of visual misalignment: horizontal strabismus. Some studies claimed that more females than males have an outward deviation (exotropia), while others concluded that there is no significant gender difference. No previous work has systematically explored gender differences in horizontal strabismus or has compared the results of population-based studies with those of clinic-based studies.

Methods

We conducted a systematic review and meta-analysis of studies reporting the prevalence of horizontal strabismus. We included 73 population-based studies and compared their disclosed gender population with that in 141 comparable clinical-based studies. We analysed the data according to gender, strabismus type (esotropia, exotropia), and geographic region/ethnicity.

Results

Summary statistics showed a nearly identical prevalence of horizontal strabismus (2.558% for males, 2.582% for females), esotropia (1.386% males vs. 1.377% females), and of exotropia (1.035% males vs. 1.043% females). Meta-analysis results showed that these differences between males and females were not statistically significant (odds ratio (OR) = 1.01; 95% confidence interval (CI) = 0.97-1.10), but that females were significantly more frequent (by 7.50%) in clinic-based studies than males, with 5.00% more females for esotropia, and 12.20% more females for exotropia when adjusted for the population's sex ratio. The extent of the female gender bias differed between geographic regions/societies, with Asians having the lowest bias towards females and Latin American countries having the strongest bias.

Conclusions

Males and females have the same prevalence of horizontal strabismus, including exotropia. Females with strabismus seek health care or are brought to clinics significantly more often than males. This is an example of gender bias in health care in favour of females rather than males, apparently because parents - erroneously fearing only cosmetic consequences - are more concerned about strabismus in their daughters than their sons. Societal attitudes towards females, as well as economic factors (insurance status), appear to be relevant factors that determine the magnitude of the gender bias in horizontal strabismus.

Strabismus in Retinopathy of Prematurity: Risk Factors and the Effect of Macular Ectopia

Objectives

This study aimed to examine factors associated with strabismus in patients with retinopathy of prematurity (ROP) and the relationship between strabismus and macular ectopia.

Materials and Methods

Patients with ROP were divided into three groups: Group 1, patients with spontaneous regression (n=45); Group 2, patients who received laser treatment (n=70); and Group 3, patients who underwent surgical treatment (n=91). Rates of anisometropia, amblyopia, nystagmus, macular ectopia, and retinal pathologies were evaluated and their impacts on strabismus development were determined. Disc-to-fovea distance (DFD) was measured from color fundus photographs and the correlation of macular ectopia with severity of strabismus was evaluated.

Results

A total of 206 patients were included. Rates of anisometropia, amblyopia, nystagmus, macular ectopia, retinal pathologies causing vision loss, and strabismus were higher in Group 3 (p=0.0001) and correlated with higher stages of ROP (p=0.0001). Macular ectopia (p=0.005), retinal pathologies (p=0.005), and amblyopia (p=0.012) had the strongest impact on strabismus development in ROP patients. DFD and strabismus severity were not significantly correlated (p=0.364). Mean visual acuity (VA) was significantly higher in orthophoric patients compared to those with esotropia and exotropia (p=0.027). Esotropic patients had lower VA compared to patients with exotropia, but this finding was not statistically significant (p=0.729).

Conclusion

Presence of macular ectopia, retinal pathologies, and amblyopia were the most strongly correlated risk factors for strabismus development in ROP patients. DFD was not associated with severity of strabismus. Exotropia was mostly related to higher DFD and a possible relationship between esotropia and lower VA was observed.

Clinical features of Sudanese patients presenting with binocular vision anomalies: A hospital-based study

Binocular vision anomalies are major causes of asthenopia symptoms, particularly among the younger population. This study aimed to report the clinical characteristics of Sudanese patients with binocular disorders who attended the orthoptic clinic at Al-Neelain Eye Hospital. In this retrospective hospital-based study, we analyzed data from 304 patients with binocular vision anomalies who visited the orthoptic clinic between October 2020 and June 2021. We collected information on demographics, symptoms, and eye tests such as visual acuity (VA), refractive error (RE), angle of deviation, and the assessment of fusional vergence. Our findings indicated that exophoria was the most common binocular vision anomaly, affecting 79.8% of males and 71.6% of females (p=0.731). Children between 6 and 17 years old showed the highest prevalence of exophoria (75.9%) (p=0.0001). Among patients with exophoria, 100% reported itching associated with tearing during fixation, while 89.5% experienced difficulty in fixation. Refractive error varied by the type of binocular vision disorders (p=0.0001), with higher hyperopia observed in cases of unilateral esotropia and alternate esotropia (+3.571±1.238 D and +3.023±1.553 D, respectively). Positive fusional vergence (PFV) differed by types of binocular vision disorders (p=0.0001) with high PFV in esophoria (18.063±6.848∆) compared to low PFV in exophoria (12.80±5.313∆). The most common types of exophoria were convergence weakness exophoria (45.39%), followed by convergence insufficiency (20.39%). The study concluded that exophoria was the most common binocular vision anomaly among Sudanese patients, with convergence weakness and convergence insufficiency being the predominant anomalies. Headache was commonly prevalent among patients with binocular vision problems. Higher hyperopia was found in esodeviation, while low PFV was associated with exodeviation.

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.

Early Ophthalmology Findings in Nonsyndromic Craniosynostosis

Craniosynostosis (CS) occurs 1 in 2500 births and surgical intervention is indicated partly due to risk for elevated intracranial pressure (EICP). Ophthalmological examinations help identify EICP and additional vision concerns. This study describes preoperative and postoperative ophthalmic findings in CS patients (N=314) from chart review. Patients included nonsyndromic CS: multisuture (6.1%), bicoronal (7.3%), sagittal (41.4%), unicoronal (22.6%), metopic (20.4%), and lambdoidal (2.2%). Preoperative ophthalmology visits were at M =8.9±14.1 months for 36% of patients and surgery was at M =8.3±4.2 months. Postoperative ophthalmology visits were at age M =18.7±12.6 months for 42% with follow-up at M =27.1±15.1 months for 29% of patients. A marker for EICP was found for a patient with isolated sagittal CS. Only a third of patients with unicoronal CS had normal eye exams (30.4%) with hyperopia (38.2%) and anisometropia (16.7%) at higher rates than the general population. Most children with sagittal CS had normal exams (74.2%) with higher than expected hyperopia (10.8%) and exotropia (9.7%). The majority of patients with metopic CS had normal eye exams (84.8%). About half of patients with bicoronal CS had normal eye exams (48.5%) and findings included: exotropia (33.3%), hyperopia (27.3%), astigmatism (6%), and anisometropia (3%). Over half of children with nonsyndromic multisuture CS had normal exams (60.7%) with findings of: hyperopia (7.1%), corneal scarring (7.1%), exotropia (3.6%), anisometropia (3.6%), hypertropia (3.6%), esotropia (3.6%), and keratopathy (3.6%). Given the range of findings, early referral to ophthalmology and ongoing monitoring is recommended as part of CS care.

Split-Tendon Medial Transposition of Lateral Rectus for Pediatric Complete Oculomotor Palsy

BACKGROUND

Split-tendon medial transposition of lateral rectus (STMTLR) for complete oculomotor palsy can correct large angles of exotropia in adults, but outcomes are variable, and complications are frequent. Only a few pediatric cases have been reported, and further insight is needed to assess the child's alignment outcomes and ability for postsurgical gain of function. The aim of our study is to report the outcomes of this surgical procedure in pediatric cases of complete oculomotor palsy.

METHODS

A retrospective review of outcomes was conducted on 5 consecutive patients with complete oculomotor palsy treated with STMTLR by a single surgeon (V.S.S.) between 2015 and 2021 at tertiary referral centers. Primary outcome was postoperative horizontal alignment, and secondary outcome was demonstration of gain-of-function activity in the field of action of the paretic medial rectus muscle.

RESULTS

Five cases of pediatric complete oculomotor palsy underwent surgical treatment with STMTLR. Subjects averaged 5.3 years old (range 10 months-16 years). Two were female. Etiologies were heterogeneous, and all presented with unilateral (n = 2) or bilateral complete oculomotor palsy with exodeviations ranging from 45 to >120 prism diopters. Two subjects had bilateral disease secondary to military tuberculosis with CNS involvement. A third subject presented iatrogenically with complete bilateral third nerve palsies secondary to removal of a nongerminomatous germ cell tumor (NGGCT) of the pineal gland. The 2 remaining subjects had monocular involvement in their right eye, 1 from compressive neuropathy after a cavernoma midbrain hemorrhage, and 1 from a congenital right oculomotor palsy. All patients were observed to have stable ocular alignment for a period of at least 6 months before surgery. Unilateral STMTLR was performed in all cases except the subject with NGGCT, in which bilateral STMTLR was performed. Measurement of alignment permanence out to 1-3 years postop resulted in an average correction of 40.83 prism diopters (range 37.5-45 prism diopters) per operated eye. Four of 5 subjects regained limited but active adduction eye movements, and the 2 unilateral cases demonstrated improved convergence. None of the subjects experienced significant complications.

CONCLUSIONS

STMTLR was a safe and effective approach for the surgical correction of complete pediatric oculomotor palsy in our case series. In addition, pediatric patients may benefit from STMTLR with immediate gain-of-function activity in the transposed lateral rectus muscle, which supports the hypothesis that children have a dynamic and adaptive neuroplasticity of visual target selection that predominates established agonist/antagonist neural signaling.

Congenital Cranial Dysinnervation Disorder Complicated by Ipsilateral Orbital Choriostoma

A 20-year-old woman with right-sided congenital cranial dysinnervation disorder (exotropia, ophthalmoplegia, and ptosis) presented for strabismus surgery. Exploration of the right eye confirmed abnormal extraocular muscles. Lateral rectus recession with medial rectus plication and inferior oblique recession improved primary position ocular alignment. However, an unusual pattern of inferior chemosis developed postoperatively and persisted during the next month. Excision and histologic examination of this tissue revealed areas of lacrimal gland and cartilage with surrounding inflammation, suggestive of a disrupted orbital choriostoma. [J Pediatr Ophthalmol Strabismus. 2022;59(6):e66-e68.].

Comparison of Unilateral and Bilateral Surgical Approaches for the Treatment of Age-Related Divergence Insufficiency Esotropia

PURPOSE

Age-related divergence insufficiency-esotropia (ARDIE) is characterized by greater esodeviation at distance than near. This study aims to compare the outcomes of unilateral and bilateral surgical approaches.

PATIENTS AND METHODS

Sixty-two cases treated at the Kellogg Eye Center, the University of Michigan, from 1995 to 2018 were retrospectively reviewed. One surgeon used unilateral procedures including unilateral medial rectus recession (n = 24, group 1) or unilateral recession-resection (n = 18, group 2) with an adjustable suture. Another surgeon used bilateral medial rectus recession with fixed sutures (n = 20, group 3).

RESULTS

For patients with distance esodeviation <15∆, postoperative distance deviations in both group 1 and group 3 were not statistically different (p = .352). For patients with esodeviations 15-20∆, postoperative distance deviations in all 3 groups were also not statistically different (p = .142). Similarly, patients with deviations >20∆ did not show significantly different postoperative distance alignment (p = .082) between group 2 and 3. Overall, group 2 had the highest overall success rate (90%) (mean at distance = 1.17∆ exodeviation, at near = 2.33∆ exodeviation).

CONCLUSION

Both unilateral medial rectus recession ± lateral rectus resection and bilateral medial rectus recession surgical approaches produced similar favorable outcomes in ARDIE.

Physiological exophoria did not increase the incidence of myopia in rural school children in Taiwan

This study evaluated the incidence rate and risk factors for developing myopia in elementary school students in Chiayi, Taiwan. This prospective cohort study comprised 1816 students without myopia (grades 1 to 5 in Chiayi County). The students underwent a noncycloplegic ocular alignment examinations using an autorefractometer and completed a questionnaires at baseline and at a 1-year follow-up. A univariate logistic regression was used to assess the effects of the categorical variables on new cases of myopia. A multinomial logistic regression was then conducted. A chi-squared test was used to compare new cases of myopia in terms of ocular alignment. A Cox hazard ratio model was then used to validate factors associated with changes in ocular alignment. A P value of <.05 was considered significant. In 370 participants with new cases of myopia out of 1816 participants, a spherical error of -1.51 ± 0.6 diopters was noted at follow-up. The baseline ocular alignment was not a significant risk factor for developing myopia (exophoria vs orthophoria: OR 1.26, 95% CI 0.97-1.62; other vs. orthophoria: OR 1.15, 95% CI 0.73-1.82). However, new cases of myopia (HR 1.36, 95% CI 1.14-1.61), and baseline ocular alignment (exophoria vs orthophoria: HR 3.76, 95% CI 3.20-4.42; other vs orthophoria: HR 3.02, 95% CI 2.05-4.45) were associated with exophoria at follow-up. This study provided epidemiological data on the incidence of myopia in elementary school students in Chiayi, Taiwan. It also demonstrated that physiological exophoria does not predispose patients to developing myopia.

Interocular differences in subfoveal choroidal thickness in monocular intermittent exotropia

PURPOSE

To determine whether subfoveal choroidal thickness and central foveal thickness differ according to the presence of fixation preference in patients with intermittent exotropia without anisometropia or amblyopia.

METHODS

Children ≥4 years of age with either monocular (fixation preference) or alternating intermittent exotropia on three consecutive visits who had no anisometropia, no amblyopia, and spherical equivalent of ± 1.25 D or less in both eyes were recruited for this study. Subfoveal choroidal thickness and central foveal thickness, measured using spectral domain optical coherence tomography, in the monocular group and the alternating group were compared.

RESULTS

A total of 81 patients were enrolled: 46 in the monocular exotropia group and 35 in the alternating exotropia group. The interocular difference in subfoveal choroidal thickness was -11.0 ± 18.0 μm in the monocular group (dominant eye - nondominant eye) and 1.9 ± 22.2 μm in the alternating group (right eye - left eye). The difference between groups was statistically significant (P = 0.005). The interocular difference in central foveal thickness was 1.1 ± 5.7 μm in the monocular group (dominant eye - nondominant eye) and 0.9 ± 5.0 μm in the alternating group (right eye - left eye). The difference between groups was not significant.

CONCLUSIONS

In patients with intermittent exotropia without amblyopia, the difference in subfoveal choroidal thickness between the eyes in the monocular group was significantly greater than that between eyes in the alternating group. These findings suggest the presence or absence of fixation preference may affect subfoveal choroidal thickness.

Understanding the Use of the Newcastle, PEDIG, and LACTOSE Control Scores Among Pediatric Ophthalmologists for Intermittent Exotropia

PURPOSE

To determine the clinical use patterns of control scores for intermittent exotropia. The Newcastle Control Score Pediatric Eye Disease Investigator Group (PEDIG) score, and Look And Cover, then Ten seconds of Observation Scale for Exotropia (LACTOSE) Control Score were developed to quantify control of exodeviations.

METHODS

A short survey was posted on the American Association for Pediatric Ophthalmology and Strabismus forum in August and September 2021. Respondents were asked about their assessment of control in intermittent exotropia, including knowledge and use of the various control scales.

RESULTS

One hundred fourteen pediatric ophthalmologists responded; 54.4% (n = 62) reported not using any specific control score for intermittent exotropia, although 61.4% (n = 70) were familiar with the PEDIG score, 37.7% (n = 43) with the Newcastle Control Score, and 7.9% (n = 9) with the LACTOSE Control Score. The PEDIG score was the most widely used (26.3%, n = 30), but 36.7% (n = 11) of respondents reported that the scale is too time-intensive, limiting its use. To improve the use of the control scores, participants recommended promoting wider understanding of the scales (45.6%, n = 52).

CONCLUSIONS

Most responding pediatric ophthalmologists do not use a specific control score in managing intermittent exotropia. The PEDIG score is the most frequently used but is reported as time-intensive. Although the LACTOSE Control Score was designed to provide a quicker alternative, it is not widely known. Promoting wider awareness and understanding of intermittent exotropia control scores may be helpful to allow for more objective quantification of control in intermittent exotropia. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

[Three-muscle surgery for large angle esotropia]

BACKGROUND

Bilateral medial rectus muscle recession with or without Cüppers' posterior fixation suture and recess and resect surgery are used to correct for large angle esotropia. There are only few reports on three muscle surgery (3MS). We analyzed the results of 3MS.

PATIENTS AND METHODS

Between June 2016 and May 2020, 61 patients received 3MS for esotropia ≥ 27° (50 PD) together with oblique muscle surgery, if needed. Angles of strabismus were measured by simultaneous prism and cover testing (SPCT) and alternating prism and cover testing (APCT) at 5 m and 0.3 m. Grading was around 0.51 mm/degree (at 5 m). Medium-term results of 57 patients were available.

RESULTS

Medians and ranges (min-max) were: age, 6 years (3-56 years). Preoperative APCT, far 34° (27-45°), near 36° (27-50°). Amount of surgery, 17 mm (15-21 mm), oblique muscle recession in 21 cases. The APCT after 5 months (3-24 months), far 2° (-10-18), near 2° (-8-18). Success rates (absolute deviation ≤ 6° [10 PD]), APCT far 68%, near 67%, SPCT far 79%, near 74%. Exotropia > 6° occurred in 4 cases (7%) at far and 3 (5%) at near, esotropia > 6° in 14 cases (25%) at far and 16 (28%) at near.

CONCLUSION

The use of 3MS is a suitable first step procedure to correct for large angle esotropia.

Wall-Eyed Monocular Inter-Nuclear Ophthalmoplegia (WEMINO) Syndrome, A Rare Decisive Manifestation Of An Isolated Unilateral Pontine Stroke

Isolated unilateral pontine infarction is an uncommon occurrence. It may bring a complex neuroophthalmic manifestation to the clinicians, making the on-spot-diagnosis a hard challenge. Wall-eyed monocular inter-nuclear ophthalmoplegia (WEMINO) syndrome is a rare variant of inter-nuclear ophthalmoplegia which also includes ipsilesional exotropia. The literature seems deficient in documenting WEMINO syndrome the primary presentation of isolated unilateral pontine stroke. The location of the causative lesion of WEMINO syndrome is a hot topic. Here, we discuss a case of WEMINO syndrome, a rare presentation of limited unilateral pontine stroke and its responsible lesion. To the best of our knowledge this is the first reported case from Pakistan. A short literature review has also been presented on the anatomy, pathophysiology and various manifestations of isolated unilateral pontine lesion in the region of medial longitudinal fascicules (MLF). Hence, this article enhances the understanding of clinicians regarding the responsible lesions limited to pons and its various manifestations, in order to enable clinicians to pick them in the early opportunity.

Subnormal Binocular Contrast Sensitivity Summation in Patients with Intermittent Exotropia

BACKGROUND

To evaluate binocular summation ratio using contrast sensitivity (CS) testing and correlation between binocular summation and stereoacuity, and control scale in intermittent exotropia (IXT).

METHODS

We conducted a prospective case-control study. Thirty-seven IXT and 41 controls were evaluated with both monocular and binocular CS testing. We compared the binocular summation ratio of IXT to that of controls. Near and distance stereoacuity was assessed and office-based control scale was evaluated. We investigated correlation between binocular CS summation ratio and stereoacuity, and control scale in IXT, respectively.

RESULTS

IXT had lower binocular CS summation ratio than controls at 1.5 and 3.0 cycles/degree (1.01 ± 1.02 vs. 1.62 ± 1.88 and 1.17 ± 0.96 vs. 1.86 ± 1.75, Both P < 0.05). We found significant correlation between binocular CS summation ratio at 3.0 cycles/degree and both near and distance stereoacuity (r = -0.411, P = 0.012 and r = -0.624, P = 0.005), and ratio at 1.5 cycles/degree also correlated significantly with distance stereoacuity (r = -0.397, P = 0.034) in the IXT. Binocular CS summation ratio was correlated to control scale at 1.5 and 3.0 cycles/degree (r = -0.327, P = 0.041 and r = -0.418, P = 0.028), and the ratio significantly differed in control scale groupings analysis at the same frequencies (Both P < 0.05).

CONCLUSION

Our findings of subnormal binocular CS summation ratio in IXT had correlation with stereoacuity and control scale suggest that binocular CS testing may be a useful method in assessing binocular visual function in IXT.

Congenital Brown's Syndrome: Clinical and Surgical Approach

Brown's syndrome is a well-recognized clinical disorder of ocular motility consisting mainly of a restriction of active and passive elevation in adduction. We report a series of 17 patients with true Brown's syndrome and discuss the clinical features and results of surgical intervention. Surgery should be considered carefully for the treatment of this syndrome as reoperation may be necessary and spontaneous resolution is seen during long-term follow-up of some patients.

Type 4 Duane syndrome

PURPOSE

To identify cases of synergistic divergence whose characteristics suggest that this entity is a form of Duane syndrome.

METHODS

The records of all patients with a Duane syndrome diagnosis, including standardized eye position photographs, from the E-Consultation program of Cybersight, Orbis International were analyzed.

RESULTS

A total of 350 Duane syndrome cases were identified. Of these, 19 (5%) had features consistent with synergistic divergence, or type 4 Duane syndrome. Of the 19, 16 (84%) were male, 15 (79%) had palpebral fissure narrowing, all had anomalous head posture, and 18 (95%) were exotropic. Only 9 (47%) patients were reported to have undergone surgery.

CONCLUSIONS

Synergistic divergence is a rare entity with features similar to those of Duane syndrome. We suggest that this entity be classified as type 4 Duane syndrome, because it has unique findings and an innervation pattern that differs from the other 3 recognized types.

[Long-Term Follow-up of Age-related Strabismus Patients 50 Years-old and Over]

PURPOSE

To characterize age-related strabismus by long term observation.

METHODS

Clinical Characteristics were collected at two institutions from patients 50 years-old and over with age-related strabismus, who complained of diplopia and were followed up longer than 2 years without surgical intervention.

RESULTS

The cohort consisted of one case of near exotropia (convergence insufficiency, exotropia angle at near was 11.3 degrees), eight cases of distance esotropia (divergence insufficiency, average esotropia angle at distance was 5.8 degrees), and 15 cases of hypertropia (average hypertropia angle at distance was 3.6 degrees). In 14 patients more than one year passed from the onset of diplopia to date of visiting one of the two clinics. The strabismus angle slowly increased (0.3 per year in average; Wicoxon signed-rank test, p < 0.01). 17 patients successfully used prism incorporated glasses. Diplopia was intermittent at first and became more frequent in most cases. Hypertropic patients often showed extorsion of the lower eye.

CONCLUSION

Age-related strabismus eyes slowly develop diplopia and very slowly get worse in deviation angle. Prism incorporated glasses are useful in this condition.

Slanted medial rectus recesection for treatment of exotropia with convergence insufficiency strabismus: a report of results in 15 cases

PURPOSE

To evaluate the surgical and functional results of slanted medial rectus resection for treatment intermittent exotropia of the convergence insufficiency type.

METHODS

Fifteen patients with near vision asthenopia and intermittent exotropia of the convergence insufficiency type were included in this prospective study. The upper edge of the MR was resected more than the lower edge. Slanted bilateral or unilateral medial rectus resection was performed. The mean length of follow-up was 14.9 months.

RESULTS

Slanted medial rectus resection(s) caused a significant postoperative reduction in the mean distance exodeviation from 11.40 to 4.53 PD, as well as a change in the mean near exodeviation from 23.93 to 10.73 PD. Although mean near-distance difference reduced from 12.53 to 6.2 PD. In final examination, 11 patients showed surgical success rate and recurrent exotropia occurred in 4 cases. On the other hand, 13 cases had experienced significant relief from their symptoms.

CONCLUSION

Slanted medial rectus resection is useful in decreasing the symptoms of intermittent exotropia of the convergence insufficiency type. However, it can result in undercorrection in larger deviations.

A retrospective study of 448 cases

PURPOSE

To determine which factors are important in the development of secondary exotropia and the incidence of secondary exotropia occurring after a retroequatorial myopexy of the medial rectus muscle with recession in the treatment for partially accommodative esotropia associated with convergence excess.

METHODS

In this retrospective study, the patients that underwent retroequatorial myopexy on both medial rectus muscles with recessions for partially accommodative esotropia associated with convergence excess were included. The incidences and angles of secondary exotropia at near and distance fixation were evaluated and the risk factors for secondary exotropia were analyzed.

RESULTS

Four hundred forty-eight patients had retroequatorial myopexy on both medial rectus muscles with recessions. Three hundred forty-nine of 448 patients maintained satisfactory near and distance binocular alignment at the final follow-up. Secondary exotropia occurred in 37 of these patients and residual esotropia occurred in 62 patients. There were no significant differences between the incidences and angles of secondary exotropia at near and distance fixation. The preoperative absence of binocularity was the only independent risk factor for developing secondary exotropia after a retroequatorial myopexy of medial rectus muscle with recession.

CONCLUSION

We determined that secondary exotropia was not a common result of retroequatorial myopexy of the medial rectus muscles with recession. We determined that the preoperative absence of binocularity was the only independent risk factor identified in this study.

Inferior oblique muscle palsy with "paradoxical" v-pattern strabismus

BACKGROUND AND PURPOSE

A- and V-patterns are commonly encountered with cyclovertical muscle palsies. Inferior oblique (IO) muscle palsy produces and A-pattern caused mainly by the decreasing abducting action of the IO in upgaze and an increasing abduction action of the superior oblique in downgaze. V-pattern association with an IO palsy has not been, to our knowledge, reported before. The purpose of our paper is to report on a patient iwth IO palsy and a paradoxical V-pattern and explain the proposed pathophysiology behind the V-pattern.

CASE REPORT

We report a 67 year old female with a 3 year history of diplopia. She met the Bielschowsky/Parks three step test to identify an IO muscle palsy, and she showed all the usual criteria of an IO muscle palsy except for a paradoxical V-pattern.

CONCLUSION

Many forces affect patterns in cyclovertical muscle palsies. A V-pattern in IO palsy can be explained by the spread of comitance resulting in inhibitional innervational pseudo-palsy of the superior rectus muscle resulting in V-exotropia or in inhibitional palsy of the contralateral superior oblique muscle resulting in V-esotropia.

Diagnosis and surgical treatment of dissociated horizontal deviation strabismus

PURPOSE

Obtaining satisfactory binocular alignment in patients with Dissociated Horizontal Deviation (DHD) requires a proper diagnosis and a specific surgical strategy. Clinical characteristics, surgical treatment and the results obtained in 20 patients with DHD are reported with a mean of 35 months postsurgical follow up.

PATIENTS AND METHOD

Retrospective record review of patients with DHD who underwent surgery between 2000 and 2007. Patient data were recorded, including age, sex, history of prior surgery, visual acuity, pre-operative angle with each eye fixing, Reversed Fixation Test (RFT) when available, type of operation performed, and final binocular alignment.

RESULTS

Twenty patients were identified, mean age 11.7 years old, all of them with age less than 12 months at the time of strabismus onset. Ten of them had had prior surgery for congenital esotropia. Nine showed exotropia (XT), 9 esotropia (ET) and 2 had ET when fixing with OS and XT when fixing with OD. All of them also had an associated Dissociated Vertical Deviation (DVD). Seven patients had amblyopia in the non-dominant eye. Six patients underwent a single operation, 13 underwent 2 operations and 1 needed 3 surgeries to obtain satisfactory binocular alignment.

CONCLUSIONS

Patients with DHD also exhibit bilateral and, very often, asymmetric DVD. Therefore, a surgical plan for both the horizontal and vertical dissociation drift of the eyes is needed. Bilateral surgery is almost always necessary, even in cases with a strong fixation preference, in order to obtain satisfactory binocular alignment.

Three Similar But Unique Cases Of Isolated Superior Rectus ExtraOcular Muscle (EOM) Palsy Strabismus, Presenting With Large Abnormal Head Tilts (Postures, AHP)

PURPOSE

To report 3 rare cases, seen over 15 years, of isolated superior rectus (SR) palsy in binocularly fusing pediatric patients presenting with appropriate head tilts.

PATIENTS AND METHOD

All 3 children, ages 11, 16, and 34 mos, presented with large right head tilts and secondary overactions of the right inferior oblique indicating LSR palsy. All 3 children received recessions of the antagonist left inferior rectus (LIR) 8 to 9 mm with 3 mm of nasal transposition to prevent exotropia in down gaze.

RESULTS

All 3 children had zero head tilt 4 weeks after their LIR recessions of 8 to 9 mm, but all 3 children developed a significant contralateral left head tilt three months after their LIR recessions. Two of the 3 them three-stepped to produce a pattern of (previously occult) SR palsy. These 2 received recessions of the RIR 5.8 to 6.5 mm. One of the 3 had a pattern that indicated LIR weakness; his LIR was advanced 2.5 mm from a 9 mm recession to a 6.5 mm recession. No significant head tilts remained or developed anew after the second surgery, but two of the three cases eventually developed apparent primary overactions of the inferior obliques and received successful weakening procedures of the inferior obliques. Due to inclusion in each case of special handling of the intermuscular septa and Lockwoods ligament (for details see later text), none of the 3 children had lower lid retraction after the large IR recessions.

CONCLUSIONS

In view of the fact that the superior division of the Third Cranial Nerve also innervates the adjacent levator and these three cases have had no blepharoptosis suggests that these apparently palsied superior rectus muscles may have been congenitally hypoplastic. Classic MRI (Magnetic Resonance Imaging) of the EOM by the techniques of Demer, to confirm this hypothesis, have not been available in these children, because of the current technical limitations of such diagnostic imaging in the case of young children who cannot maintain steady fixation for the time required.

Hereditary wide angle exotropia in a nigerian family

AIM

To present a report of a Nigerian family with wide angle exotropia resulting in amblyopia.

METHODS

A family of two wives and 12 children from Benin City, Edo State, Nigeria were interviewed and examined at the University of Benin Teaching Hospital, Benin City with the aid of a Snellen's chart, pen torch, slit lamp biomicroscope, ophthalmoscope and the pulsair non-contact tonometer.

RESULTS

There was 450 exotropia in the right eye of the 72 year old father, his 36 year old son, his 22 years old daughter and their 24 year old half sister. There was restriction of ocular motility in the right eye medially and some degree of amblyopia in the right eye of all the patients. The father and his 22 years old daughter were myopic of between -4.00 and -6.00 dioptre sphere but the son and his 24 years old half sister had -0.75 and -1.00 dioptre sphere myopia respectively. None of them presented to hospital because of the strabismus.

CONCLUSION

This report highlights the need to screen family members of patients with squint in order to detect the condition early and prevent amblyopia.

Common ophthalmologic concerns in infants and children

Pediatric ophthalmology differs from adult eye care in many aspects. Some disorders are seen only in children although others may be found in adults as well. A major difference between pediatric and adult ophthalmology is the impact that almost any disorder may have on the developing visual system. This article addresses common pediatric eye disorders and their potential effects on the visually impaired immature child. Referral guidelines and vision screening are also discussed.