Surgical Outcome of Inferior Oblique Myectomy versus Recession-Anteriorization in the Treatment of Inferior Oblique Overaction

Purpose

This study aimed to compare the surgical outcome of inferior oblique myectomy, IOM versus inferior oblique recession-anteriorization, IORA in the treatment of inferior oblique overaction, IOOA.

Patients and Methods

A retrospective chart review was performed over a 12-year period, from 2009 to 2021. Eighty-nine patients diagnosed with IOOA who underwent IOM or IORA were included. The primary outcome was postoperative residual IOOA (grade 0 to +4) and percentage favorable outcome, defined as IOOA grade ≤1+ at 6 months post operation, in each group. The outcomes were compared between the two surgical procedures (IOM and IORA). The secondary outcome was the percentage of postoperative anti-elevation syndrome cases for each surgical procedure.

Results

The median age at the time of surgery was 10.50 years (interquartile range, IQR: 2.83 to 28.33) in the IOM group and 5.08 years (IQR: 2.75 to 29.42) in the IORA group. The favorable outcome at 6 months was 90.91% in the IOM group, which was lower than the 95.74% in the IORA group but the difference was not statistically significant (P-value = 0.390, 95% CI: 0.07-2.82). The only surgical complication, anti-elevation syndrome, was detected in 3.77% of IOM cases and 5.80% of IORA cases, with an odds ratio of 0.64 on comparing the IOM group to the IORA group (P-value = 0.611, 95% CI: 0.11-3.62).

Conclusion

These two weakening procedures are effective for treating IOOA. Although IORA seemed slightly superior to IOM in terms of favorable outcomes, the difference was not statistically significant. Moreover, the myectomy procedure was easier, was less time-consuming, had a lower risk of globe perforation and presented fewer complications such as anti-elevation syndrome.

Optimal Duration of Monocular Occlusion to Eliminate Fusion Effect in Intermittent Exotropia

Purpose

To determine the optimal duration of monocular occlusion in patients with intermittent exotropia.

Patients and Methods

This prospective cohort study enrolled 40 patients with intermittent exotropia at Ramathibodi Hospital between May 2023 and September 2023. Angles of deviation at distance (6 m) and near fixation (0.33 m) were measured before and after monocular occlusion for 30, 60, and 90 minutes. All measurements were performed by a single ophthalmologist. The mean angle of deviation was calculated at each time point.

Results

The mean age at presentation was 12.5 years (range, 5-33 years). The mean angles of deviation before monocular occlusion were 27.8 ± 15.1 prism diopters (PD) at distance and 26 ± 13.7 PD at near fixation. At distance, mean angles of deviation after monocular occlusion were 32.2 ± 14.6, 32.9 ± 15.0, and 32.6 ± 14.7 PD at 30, 60, and 90 minutes, respectively. At near fixation, mean angles of deviation after monocular occlusion were 37.4 ± 15.0, 39.8 ±14.3, and 39.5 ± 14.6 PD at 30, 60, and 90 minutes, respectively. All angles significantly differed from the pre-occlusion deviation (all P < 0.01). For deviation at distance, there was no statistically significant difference between 60 and 30 minutes of monocular occlusion (P = 0.48). For deviation at near fixation, there was a significant difference between 60 and 30 minutes of monocular occlusion (P = 0.048), but the difference of 2.5 PD was not clinically significant. There were no statistically significant differences between 90 and 60 minutes of monocular occlusion at distance or near fixation (both P = 0.82).

Conclusion

Monocular occlusion is necessary to eliminate the fusion effect in patients with intermittent exotropia; 30 minutes of monocular occlusion is sufficient to achieve the maximum angle of deviation.

Age-Specific Outcomes of Conservative Approach and Probing for Congenital Nasolacrimal Duct Obstruction

Purpose

Patients and Methods

Results

Conclusion

Maximal Levator Resection Beyond Whitnall’s Ligament in Severe Simple Congenital Ptosis with Poor Levator Function

Purpose

To evaluate the functional and cosmetic outcomes, as well as factors that influence surgical success of maximal levator resection beyond Whitnall’s ligament in patients with poor levator function (LF) and severe simple congenital ptosis.

Methods

This retrospective interventional study included patients with severe simple congenital ptosis and LF of ≤4 mm who had undergone maximal levator resection beyond Whitnall’s ligament with a minimum of 12 months follow-up. Postoperative marginal reflex distance-1 (MRD1) was assessed for functional outcomes as excellent, good, fair and poor. Eyelid contour and the difference in MRD1 between eyes were assessed for symmetrical cosmetic outcomes as excellent, good and poor. Demographic data, factors influencing surgical success and postoperative complications were analyzed.

Results

A total of 38 ptotic eyelids in 31 patients were included. Successful surgical outcomes (at least good functional and cosmetic outcomes) were achieved in 26 patients (83.87%) with the mean MRD1 of +3.61 ± 0.27 mm and +3.51 ± 0.17 mm at 1 week and 12 months after surgery, respectively. There were no significant differences in demographic and preoperative data between the successful and unsuccessful surgical outcome groups, mean preoperative ptosis measurements were 4.19 ± 0.20 mm versus 4.72 ± 0.36 mm (p = 0.242) and mean pre-operative LF were 3.16 ± 0.15 mm versus 2.29 ± 0.61 mm (p = 0.561), respectively. The only factor that significantly influenced the surgical success rate was the length of the resected levator muscle. The mean lengths in successful and unsuccessful groups were 18.15 ± 0.44 mm and 14.29 ± 0.94 mm, respectively (p = 0.011).

Conclusion

Maximal levator resection beyond Whitnall’s ligament is an effective procedure for severe simple congenital ptosis with poor LF. Refinement of surgical techniques and careful assessment of the optimal resected length for the levator muscle grants successful surgical outcomes.

Isolated Sixth Nerve Palsy as a First Presentation of Nasopharyngeal Carcinoma: A Case Series

Purpose

To describe isolated sixth nerve palsy as an uncommon presentation of nasopharyngeal carcinoma (NPC).

Patients and Methods

We analyzed the demographics, clinical presentation, neuroimaging findings, and pathological examination results of the nasopharyngeal masses of patients diagnosed with isolated sixth nerve palsy due to NPC.

Results

Isolated sixth nerve palsy as the first presenting sign of NPC was diagnosed in five patients. Two patients were aged <50 years and three were aged >50 years, and one of these three older patients had vascular risk factors. Most of the patients in our case study had an uncommon presentation of isolated sixth nerve palsy with diplopia, followed by typical NPC signs such as a neck lump (two patients), nasal obstruction (two patients), tinnitus (two patients), hearing loss (one patient), and epistaxis (one patient). Pathological examination revealed non-keratinizing NPC in all cases. Neuroimaging showed that the sites of tumor invasion were the clivus, Dorello's canal, and cavernous sinus, which explained the sixth nerve palsy. One patient whose NPC had progressed to the orbital apex later developed other cranial nerve palsies. Three patients underwent concurrent chemoradiotherapy (CCRT), and one patient underwent CCRT with adjuvant chemotherapy. The last patient was unfortunately lost to follow-up. The symptoms of four patients who underwent treatment improved.

Conclusion

Isolated sixth nerve palsy can be the first presentation of NPC, especially in patients aged <50 years old without microvascular risk factors or even in patients aged >50 years old with microvascular risk factors. This case study emphasizes that a thorough clinical history and careful physical and neuroimaging examinations might be necessary to rule out life-threatening conditions in patients with isolated sixth nerve palsy.

The Outcome of One-to-Four Muscle Surgery by Intraoperative Relaxed Muscle Positioning with Adjustable Suture Technique in Thyroid Eye Disease

Purpose

To identify the outcome of one-to-four muscle surgery by intraoperative relaxed muscle positioning with adjustable suture technique for the treatment of thyroid eye disease.

Methods

Ninety patients diagnosed with thyroid eye disease who underwent intraoperative relaxed muscle positioning with adjustable suture technique at Ramathibodi Hospital from January 1, 2015 through December 31, 2020 were included in this retrospective study. The patient demographic data were evaluated. Pre- and post-operative ocular alignment and diplopia status were measured after a follow-up period of at least 6 months. Successful outcomes were categorized into two parts: motor outcome and sensory outcome. Successful motor outcome was defined as vertical deviation equal to 4 prism diopters or less and horizontal deviation equal to 10 prism diopters or less in primary position. Successful sensory outcome was defined as the absence of diplopia in primary position.

Results

Ninety patients were included in this study, and the mean age of strabismic surgery was 56.6 ± 10.1 years old. Thirty-nine patients had a history of orbital decompression surgery. Mean follow-up time was 33.7 ± 11.8 months. The success of motor and sensory outcomes exhibited a decrease from one-to-four muscle surgery. Motor success decreased from one-muscle to four-muscle surgery (84.62%, 81.58%, 75.00%, and 64.29%) and sensory success similarly decreased (84.62%, 84.21%, 75.00%, and 78.57%). However, the comparative outcomes of motor success and sensory success were not statistically different among groups (p = 0.58 and 0.84). Lower lid retractions were found in 12 patients (13.33%).

Conclusion

Intraoperative relaxed muscle positioning technique might be a successful option for the correction of thyroid eye disease-associated strabismus. This technique may be done with one-to-four muscle surgery, which yields success in both motor and sensory outcomes.

A Prospective Study of One-Muscle Surgery in 15-25 Prism Diopters Horizontal Comitant Strabismus in Adults

Purpose

To prospectively evaluate the results of one-muscle surgery in 15-25 prism diopters (PD) horizontal comitant strabismus in adults.

Patients and Methods

15-25 PD horizontal strabismus patients, comprising 25 exotropic (XT) patients and 11 esotropic (ET) patients, who underwent one-muscle recession by a single surgeon with a fixed surgical dosage were included in the study with a minimum follow-up of 3 months. The main outcome was a surgical success, which is defined as a residual deviation of <8 PD at the last examination. Other parameters include postoperative lateral incomitance and patient satisfaction. Postoperative lateral incomitance indicated a difference in deviation of >5 PD between the primary position and lateral gaze, or duction limitation at any visit. Patient satisfaction regarding cosmetic and functional outcomes was assessed by using a 5-point Likert scale.

Results

Successful alignment was obtained in 19 (76%) and 9 (81.81%) XT and ET patients (p = 1.00), with a median and interquartile range (IQR) of follow-up time of 3, 3-3 months and 3, 3-7 months, respectively. Postoperative lateral incomitance was observed in 8 (32%) XT patients and in 1 (9.09%) ET patient (p = 0.22). One XT patient and one ET patient who developed incomitance reported diplopia, which disappeared 3 months after surgery. One XT patient reported diplopia while gazing towards the operated eye whilst one ET patient reported diplopia occasionally which was unrelated to gaze direction. Patient satisfaction was based on Likert scale scores with 4.12 ± 0.97 in XT patients and 4.73 ± 0.65 in ET patients (p = 0.07).

Conclusion

One-muscle recession with a fixed surgical dosage was effective for treating small angle horizontal strabismus with a high rate of surgical success and patient satisfaction. Although postoperative lateral incomitance occurred, only a few patients developed symptomatic diplopia, which completely resolved 3 months after surgery.

The etiologies of isolated fourth cranial nerve palsy: a 10-year review of 158 cases

PURPOSE

To identify the etiologies of isolated fourth cranial nerve palsy in Ramathibodi hospital, Thailand.

METHODS

Patients diagnosed with isolated fourth nerve palsy from January 1, 2009, through July 31, 2020 in Ramathibodi Hospital, were included in this retrospective, observational case series. The demographic data of patients, age at presentation, the etiologies of isolated fourth nerve palsy and neuroimaging results (if indicated) were recorded.

RESULTS

We identified 154 unilateral and 4 bilateral cases of isolated fourth nerve palsy. Mean age at presentation was 38.89 ± 25.71 years old. Most of the unilateral cases were congenital (57.79%), with microvasculopathy (27.92%), intracranial neoplasm (8.44%) and other etiologies. Trauma with closed head injury was the most common etiology of bilateral cases (75%), followed by ruptured arteriovenous malformation (25%). Twenty-one of the 43 (48.84%) patients with microvasculopathy fourth nerve palsy underwent neuroimaging, with normal findings, and all patients' symptoms resolved within 6 months of symptom onset.

CONCLUSIONS

In our series, most of the isolated fourth nerve palsy cases were congenital, followed in frequency by microvasculopathy and intracranial tumor, as in many studies. In cases of microvasculopathy, the clinical signs and symptoms resolved within 6 months in all cases: observation was sufficient, with no necessity for neuroimaging. However, neuroimaging should be considered in cases with atypical presentations, such as headache, periorbital pain, or if there is rapid progression or no recovery.

Acute Acquired Comitant Esotropia: Etiology, Clinical Course, and Management

Purpose

To identify the etiologies, clinical course and management of acute acquired comitant esotropia in Ramathibodi Hospital, Thailand.

Methods

Thirty patients who were diagnosed with acute acquired comitant esotropia at Ramathibodi Hospital from January 1 2017 to December 31 2019 were identified using electronic medical records, from which demographic, etiology, clinical course and management, laboratory, and neuroimaging data were collected.

Results

The etiologies of acute acquired comitant esotropia were Swan (16.67%), Burian–Franceschetti (30.00%), Bielschowsky (36.67%), Arnold Chiari malformation (3.33%) and decompensated esophoria (13.33%). Mean age of onset was 19.8 ± 18.3 years. Mean angle of esodeviation was 28.4 ± 12.1 prism diopters for distance fixation and 29.3 ± 11.8 prism diopters for near fixation. Refraction differed between age groups: children under 10 years had mild hyperopia (median +0.63 diopters, first quartile +0.25 diopters, third quartile +0.75 diopters) and teenagers (10–18 years old) had emmetropia to mild myopia (median +0.25 diopters, first quartile −2.50 diopters, third quartile +0.75 diopters), whereas adults had mild to moderate myopia (median −0.75 diopters, first quartile −5.25 diopters, third quartile ±0.00 diopters). Twelve patients (40.00%) were prescribed spectacles and surgical intervention was performed in 26 patients (86.67%). All patients except one case of Arnold Chiari malformation (96.67%) maintained normal binocular function and alignment following strabismus surgery or spectacles correction.

Conclusion

Bielschowsky was the most common etiology of acute acquired comitant esotropia in our study. We suggest that refraction should be performed in all patients with acute acquired comitant esotropia. Most etiologies were benign and might not require neuroimaging. However, neuroimaging is recommended in those with atypical presentations, such as nystagmus, headache, or cerebellar signs. Surgical intervention with a 0.5–1.0 mm increase in recession was effective for restoring ocular alignment and binocular function in our patients.

Long-term outcomes of intended undercorrection intraocular lens implantation in pediatric cataract

Purpose

To evaluate the postoperative refraction of intended undercorrection after intraocular lens (IOL) implantation in pediatric cataract patients.

Design

A cross-sectional study (data collected by retrospective chart review).

Patients and methods

The medical records of children aged under 10 years, who underwent cataract surgery with IOL implantation at the Ramathibodi Hospital between January 2000 and May 2018, were reviewed. IOL power calculations were 30%, 25%, 20%, 15% and 10% under-corrected if children were aged 6–12, 13–24, 25–36, 37–48 and 49–60 months, respectively. Two diopters (D) undercorrection was used in children aged between 5 and 8 years and one diopter undercorrection was used in children aged between 8 and 10 years. The main outcome measure was the postoperative refractive errors at the last follow-up visit.

Results

In total, 50 children (21 females and 29 males, 16 unilateral and 34 bilateral, 84 eyes) met the inclusion criteria for this study. Mean age at the time of surgery was 77.82±31.24 months. Mean follow-up time was 56.56±45.83 months. The main outcome in this study was the postoperative refractive error in children aged 7 years or more. We found 74 eyes of 44 children who were aged 7 years or more at last follow-up visit. In total, 45 eyes were myopic (−0.25 to −8.25 D) with a mean refraction of −2.26±2.16 D. A further 21 eyes were hyperopic (+0.25 to +3.25 D), with a mean refraction of +1.05±0.79 D and eight eyes were emmetropic or having only astigmatism.

Conclusion

The major postoperative refractive error at the last follow-up time was myopia. We have to adjust the IOL calculation formula to specify more undercorrection, with the aim of achieving more optimal refractive outcomes in adulthood.

Evaluation of retinal structure in unilateral amblyopia using spectral domain optical coherence tomography

PURPOSE

To investigate potential differences in the retinal nerve fiber layer (RNFL) thickness, macular thickness and foveal thickness between amblyopic eyes and normal fellow eyes on spectral domain optical coherence tomography (SD-OCT).

METHODS

A cross-sectional study of patients ≥10 years of age with unilateral amblyopia resulting from an anisometropic, strabismic or deprivative cause. Comprehensive ophthalmic examination was completed and the retinal structures of both eyes were measured using SD-OCT. We compared the measurements obtained between the amblyopic eye and the fellow normal eye in each subject.

RESULTS

Twenty-six unilateral amblyopia patients with a mean age of 29.92 ± 14.19 years old participated in the study, of which 17 (65.4%) were classified as anisometropic, 7 (26.9%) as strabismic, and 2 (7.7%) as deprivative. For the amblyopic eye and fellow normal eye, respectively, the mean RNFL thickness was 95.87 ± 14.56 μm and 97.87 ± 14.56 μm (P = 0.628), the mean macular thickness was 270.87 ± 14.43 μm and 275.60 ± 14.43 μm (P = 0.251) and the mean foveal thickness was 250.59 ± 27.82 μm and 242.91 ± 27.82 μm (P = 0.332). SD-OCT assessments revealed no statistically significant differences between both eyes.

CONCLUSIONS

Using SD-OCT, there were no significant changes in the retinal structure of amblyopic eyes. Therefore, amblyopia does not seem to have a profound structural effect on the retinal nerve fiber layer, the macula, or the fovea.

Outcomes of undercorrection in surgical management and binocular vision gained of adult intermittent exotropia

Purpose

To study the surgical outcomes of intended undercorrection on adult intermittent exotropia (X(T)) performed to avoid postopertively overcorrected diplopia.

Patients and methods

A retrospective chart review was conducted for adult patients (age ≥18 years) with X(T) ≥15 prism diopter (PD) who underwent strabismus surgery by a single surgeon. Inclusion criteria were 1) corrected VA ≥20/40 in either eye; 2) monocular occlusion at least 30 minutes before deviation measurement; 3) difference of ≤10 PD between near and distance deviation; 4) absence of significant A or V pattern or vertical deviation; 5) lateral rectus recession and medial rectus resection procedure were performed unilaterally; and 6) intended surgical number for deviation correction was aimed at 5 PD undercorrection.

Results

Of 234 patients who met the inclusion criteria, 122 were women (52.14%). Average age at the time of surgery was 27.56 years (range, 18–42 years). A total number of 197 patients (84.19%) had postoperative exodeviation under 10 PD. Twenty five (10.68%) and 12 patients (5.13%) had postoperative exodeviation within 10–15 PD and >15 PD, respectively. All patients who had postoperative exodeviation >15 PD exhibited initial deviation of ≥40 PD and had undergone re-operation. In 74 patients (46.25%) out of 160 who had no binocular vision in orthoptic examination before surgery, fusion or stereopsis was gained after good alignment. No postoperative diplopia was found in this study.

Conclusion

Intended undercorrection in surgical management of adult X(T) showed good functional and cosmetic outcomes. No procedure resulted in consecutive esodeviation or persistent diplopia. Fusion or stereopsis could be gained after successful surgical alignment. Our recommendations are as follows: 5 PD undercorrection if deviation is <40 PD and regular correction if deviation is ≥40 PD.

Clinical and molecular characterization of an extended family with Fabry disease

OBJECTIVE

To characterize clinical manifestations, biochemical changes, mutation of alpha-Galactosidase (alpha-Gal A) gene A (GLA), and functional capability of mutant protein.

MATERIAL AND METHOD

Seventeen subjects from a family with a newly diagnosed patient with Fabry disease were enrolled in the present study. In each individual, clinical history, physical examination, leukocyte enzyme activity of alpha-Gal A, and mutation analysis were performed. Those with a mutation were further investigated by ophthalmological and audiological evaluations, electrocardiography, echocardiogram, urinalysis, and blood tests to determine renal insufficiency. Expression study of the mutant protein was performed using a Pichia pastoris expression system.

RESULTS

Four affected males and five symptomatic female carriers were identified. Clinical manifestations included severe neuropathic pain, acroparesthesia, hypo-/hyper-hidrosis, frequent syncope, ischemic stroke, cardiac hypertrophy, corneal dystrophy and cart-wheel cataract, high frequency sensorineural hearing loss, periorbital edema and subcutaneous edema over hands and interphalangeal joints. None had angiokeratoma or renal symptoms. The authors identified a novel mutation, p.L106R, in the GLA gene. Recombinant expression of the mutant protein gave little or no enzyme activity compared to the normal protein.

CONCLUSION

There were intrafamilial clinical variabilities, but consistent findings of the absence of angiokeratoma and renal symptoms, which could represent a unique feature of this particular mutation.

Aneurysmal third nerve palsy

To study the clinical characteristics, treatment and outcome of patients with aneurysmal third nerve palsy. Eleven patients with isolated third nerve palsy from an intracranial aneurysm from 1998 to 2002 at Ramathibodi Hospital were reviewed retrospectively. The average age was 60 years. Ipsilateral headache and/or retroorbital pain occured in 80 percent of the patients. Ten patients had unilateral disease, whereas one patient had bilateral involvement. The most common site of aneurysm was at the origin of the posterior communicating artery. Endovascular treatment with coil embolization provided successful occlusion as well as neurosurgical clipping. Recovery of third nerve function was found in all patients but had variable degrees. Patients who received early treatment, especially within 10 days after onset of oculomotor dysfunction appeared to have the best chance of recovery. Aberrant regeneration developed in 5 cases. The commonest sign was lid retraction during adduction and downward gaze.

Simple technique for silicone intubation in congenital nasolacrimal duct obstruction

OBJECTIVE

To propose a simple and low cost technique of using the simple materials in the operating room for silicone intubation in case of nasolacrimal duct obstruction in children after failed probing.

METHOD

The study was a consecutive case series. Three patients with congenital nasolacrimal duct obstruction aged 42, 51 and 72 months were referred to the authors. Their symptoms persisted after probing twice with or without infracture inferior turbinate. The authors decided to insert a silicone tubing by using an 18-gauge, intravascular catheter as a channel to place a silicone tubing into the nasolacrimal system. Success was defined as a complete resolution of symptoms and signs (tearing, crusting, discharge, regurgitation on pressure over the lacrimal sac) after silicone intubation.

RESULTS

All three patients were free of symptoms and signs after insertion of silicone tubing and an average 5.5 months (9, 6, 1.5 months) after removal of the silicone tubing. There were no intraoperative complications. No unplanned silicone tubing removal was needed and also no complications associated with silicone stent, such as punctal erosion, corneal erosion or granuloma formation occurred.

CONCLUSION

This simple and low cost technique using an intravascular catheter as a channel to place the silicone tubing into the nasolacrimal system in case of congenital nasolacrimal duct obstruction in children works well. This new technique is not only inexpensive but also effortless with no complications.