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.

Non-Arteritic Ischemic Optic Neuropathy Following COVID-19 Vaccination in Korea: A Case Series

BACKGROUND

To report the clinical manifestations of non-arteritic anterior ischemic optic neuropathy (NAION) cases after coronavirus disease 2019 (COVID-19) vaccination in Korea.

METHODS

This multicenter retrospective study included patients diagnosed with NAION within 42 days of COVID-19 vaccination. We collected data on vaccinations, demographic features, presence of vascular risk factors, ocular findings, and visual outcomes of patients with NAION.

RESULTS

The study included 16 eyes of 14 patients (6 men, 8 women) with a mean age of 63.5 ± 9.1 (range, 43-77) years. The most common underlying disease was hypertension, accounting for 28.6% of patients with NAION. Seven patients (50.0%) had no vascular risk factors for NAION. The mean time from vaccination to onset was 13.8 ± 14.2 (range, 1-41) days. All 16 eyes had disc swelling at initial presentation, and 3 of them (18.8%) had peripapillary intraretinal and/or subretinal fluid with severe disc swelling. Peripapillary hemorrhage was found in 50% of the patients, and one (6.3%) patient had peripapillary cotton-wool spots. In eight fellow eyes for which we were able to review the fundus photographs, the horizontal cup/disc ratio was less than 0.25 in four eyes (50.0%). The mean visual acuity was logMAR 0.6 ± 0.7 at the initial presentation and logMAR 0.7 ± 0.8 at the final visit.

CONCLUSION

Only 64% of patients with NAION after COVID-19 vaccination have known vascular and ocular risk factors relevant to ischemic optic neuropathy. This suggests that COVID-19 vaccination may increase the risk of NAION. However, overall clinical features and visual outcomes of the NAION patients after COVID-19 vaccination were similar to those of typical NAION.

First-finder-related Clinical Features of Intermittent Exotropia

Purpose: To determine whether the clinical features of intermittent exotropia (IXT) needing muscle surgery were different in the ophthalmologist-detected and non-specialist-detected groups (including parents).Methods: Medical records of 218 children (mean age: 5.9 ± 1.4 years) with IXT of ≥ 20 prism diopters (PD) were reviewed retrospectively. The angles of deviation were measured using the prism and alternate cover test and assessed by two ophthalmologists using photographs with a translucent occluder (photographic angle). The IXT subtype, fusional control, stereopsis, suppression, and spherical equivalent (SE) were compared between the ophthalmologist-detected and non-specialist-detected groups.Results: Mean 25.8 ± 6.8 PD of distant angle of IXT was first detected by the ophthalmologist in 41 patients (18.8%) and the non-specialists in 177 patients (81.2%). The deviated eye was more myopic in the ophthalmologist-detected than non-specialist- detected group (-0.77 ± 1.59 diopters [D] vs. -0.19 ± 1.48 D, <i>p</i> = 0.03). There were no other differences between the two groups. A comparison of 39 age- and non-dominant eye SE-matched pairs demonstrated that the measured angles for distant and near fixation were smaller in the ophthalmologist-detected than non-specialist-detected group (24.0 ± 6.8 PD vs. 28.5 ± 6.4 PD and 26.9 ± 6.6 PD vs. 31.0 ± 6.4 PD, respectively, <i>p</i> < 0.01), while the remaining characteristics, including the photographic angle, were similar.Conclusions: In cases with small angles of deviation or myopia, IXT with angles requiring surgical correction were commonly first detected by ophthalmologists during examinations.

Acquired Esotropia in an Adolescent Wearing Orthokeratology Lenses

Orthokeratology is a procedure involving the use of reverse-geometry lenses to temporarily correct refractive errors. Switching from spectacles to orthokeratology lenses may influence binocular visual function and accommodation. This is the first report of orthokeratology lens-associated acquired esotropia, a form of distance esotropia, in an adolescent with myopic anisometropia. [J Pediatr Ophthalmol Strabismus. 2022;59(1):e7-e10.].

Progressive Myelinated Retinal Nerve Fibers in Children With Craniosynostosis

The authors found the changes of myelinated retinal nerve fibers in one pair of identical twins with nonsyndromic craniosynostosis and two patients with Crouzon syndrome, who were at risk for impaired lamina cribrosa barrier function. This is the first report of progressive and presumed acquired myelinated retinal nerve fibers in craniosynostosis. [J Pediatr Ophthalmol Strabismus. 2021;58(6):e40-e43.].

Photographic Assessment of Intermittent Exotropia Using a Translucent Cover

PURPOSE

To evaluate the validity of the photographic assessment with a translucent cover that is clinically available for the evaluation of intermittent exotropia.

METHODS

Photographs of 270 patients who cooperated for the prism and alternate cover test (PACT) were reviewed. Full-face images were obtained with a digital camera while a translucent cover was placed in front of either eye. The change in distance from the medial canthus to the nasal limbus with occlusion was measured and the photographic angle was estimated by three independent ophthalmologists based on representative photographs. These two measurements were correlated with the angle measured using the PACT, and clinical features related to the discrepancy between the photographic angle and the angle measured with the PACT were determined.

RESULTS

Patients with intermittent exotropia of 27.0 ± 6.1 prism diopters (PD) showed a 4.5 ± 3.3 mm exodrift and an estimated angle of 29.0 ± 4.3 PD on the photographs with occlusion. The exodrift distance and photographic angle were positively correlated with the angle of PACT (r = 0.256, P < .001 and r = 0.546, P < .001, respectively). Of the 47 patients with a discrepancy of greater than 8 PD, 38 patients (80.9%) were regarded as having a photographic angle that was larger than the angle of PACT, which was more common in older patients, in those with a small distance angle, and when taking off the spectacles.

CONCLUSIONS

Photographs with a translucent cover can reveal the latent components of intermittent exotropia. However, the photographic angle might differ from the real angle, particularly in older patients with a small angle and with the spectacles off. [J Pediatr Ophthalmol Strabismus. 2021;58(5):331-338.].

Reducing the Costs of an Eye Care Adherence Program for Underserved Children Referred Through Inner-City Vision Screenings

PURPOSE

We previously reported costs and outcomes of the Children's Eye Care Adherence Program (CECAP1), a social worker intervention designed to improve adherence to eye care for underserved children in urban Philadelphia. Using cost findings from CECAP1, we revised the intervention to reduce costs. The aim of this study was to evaluate costs and effectiveness of the revised intervention (CECAP2).

DESIGN

Retrospective cohort study.

METHODS

Records of children needing ophthalmic follow-up after 2 community-based vision screening programs were reviewed. We modified CECAP1 to prioritize children more likely to visit, decreased phone calls and scheduling attempts, better documented children already followed by other doctors, and constricted our geographic catchment area for better accessibility. Cost was calculated using time spent executing CECAP2 by our salaried social worker. Effectiveness was defined as the percentage of patients completing at least 1 follow-up visit within the recommended time frame.

RESULTS

Of 462 children referred to CECAP2 from our in-school and on-campus screening programs, 242 (52.4%) completed subsequent recommended eye examinations, a proportion identical to our prior report (52.3%). Social worker time per patient was 0.8 hours; a significant reduction from the previous 2.6 hours (P < .01). Cost per patient was $32.73; a significant reduction compared to the previous $77.20 (P < .01).

CONCLUSIONS

Programmatic changes to reduce social worker intervention time and target potential patients by likelihood to attend along with constriction of the catchment area led to reduced costs by more than 50%, without impairing CECAP effectiveness.

Ocular biometric features of pediatric patients with fibroblast growth factor receptor-related syndromic craniosynostosis

Ametropia is reported as a common ophthalmic manifestation in craniosynostosis. We retrospectively compared childhood refractive error and ocular biometric features of fibroblast growth factor receptor (FGFR)-related syndromic craniosynostosis patients with those of non-syndromic craniosynostosis and control subjects. Thirty-six eyes (18 patients) with FGFR-related syndromic craniosynostosis, 76 eyes (38 patients) with non-syndromic craniosynostosis, and 114 eyes (57 patients) of intermittent exotropes were included in the analysis. Mean age at examination was 7.82 ± 2.51 (range, 4–16) years and mean spherical equivalent was -0.09 ± 1.46 Diopter. Mean age and refractive error were not different between groups, but syndromic craniosynostosis patients had significantly longer axial length, lower corneal power, and lower lens power than other groups (p < 0.01, p < 0.01, and p < 0.01, respectively). Axial length was positively correlated and keratometry and lens power were negatively correlated with age in non-syndromic craniosynostosis and controls, while these correlations between age and ocular biometric parameters were not present in the FGFR-related syndromic craniosynostosis. In conclusion, ocular biometric parameters in FGFR-related syndromic craniosynostosis differed from those of non-syndromic craniosynostosis and age-matched controls, and did not show the relations with age, suggesting this cohort may have abnormal refractive growth.

Sternocleidomastoid muscle asymmetry in unilateral congenital superior oblique palsy

BACKGROUND

To determine whether there is an asymmetry in bilateral sternocleidomastoid muscle (SCM) thickness in patients with unilateral congenital superior oblique palsy (SOP) and its association with surgical results.

METHODS

The medical records of 186 patients with head tilt secondary to unilateral SOP, who were evaluated for the status of the SCM with neck ultrasound or magnetic resonance imaging, were reviewed. The SCM asymmetry index was calculated as a bilateral difference in the maximal muscle thickness divided by each tilted-side SCM thickness. The presence of SCM asymmetry, defined as an index of >10%, and its relationship to residual torticollis ≥5° after SOP surgery were assessed.

RESULTS

Of 186 patients with a median age of 1.2 years, SCM asymmetry was present in 102 (54.8%) patients (6.8 ± 1.9 mm for the SOP side vs. 6.6 ± 2.1 mm for the tilted side). The SCM asymmetry did not differ according to age, amount of head tilt or hypertropia. In the patients with SCM asymmetry, more patients (87.3%) underwent physiotherapy than those without asymmetry (61.9%) (P = 0.021). In 99 patients who underwent surgery for SOP, the resolution of torticollis was not significantly different between patients with and without SCM asymmetry (87.2% vs. 76.9%, P = 0.184).

CONCLUSIONS

Nearly half of the patients with congenital SOP had SCM thickness asymmetry that was already determined at a young age. However, the surgical results did not differ significantly with respect to SCM asymmetry when physiotherapy was combined. Thus, SOP surgery can be considered despite preoperative SCM asymmetry.

Block-building performance test using a virtual reality head-mounted display in children with intermittent exotropia

PURPOSE

To determine whether childhood intermittent exotropia (IXT) affects distance divergence and performance in block-building tasks within a virtual reality (VR) environment.

METHODS

Thirty-nine children with IXT, aged 6-12 years, who underwent muscle surgery and 37 normal controls were enrolled. Children were instructed to watch the target moving away and perform a block-building task while fitted with a VR head-mounted display equipped with eye- and hand-movement tracking systems. The change in inter-ocular distance with binocular distance viewing, time to stack five cube blocks of different sizes in order, and distance disparities between the largest and farthest cubes were assessed. All children were evaluated at baseline and 3-month time points.

RESULTS

The patients with IXT exhibited a larger distance divergence than did controls (p = 0.024), which was associated with greater distance angle of deviation and poorer distance control (r = 0.350, p = 0.001 and r = 0.349, p = 0.004). At baseline, the patients with IXT showed larger distance disparities in the block-building task than did controls in terms of the horizontal, vertical, and 3-dimensional (3-D) measurements (all ps < 0.050). Larger horizontal disparity was associated with greater distance angle of deviation (r = 0.383, p = 0.037). Three months after surgery, the horizontal and 3-D disparities in the patients with IXT improved significantly and were not comparably different compared with controls.

CONCLUSIONS

These preliminary findings suggest that VR-based block-building task may be useful in testing possible deficits in visuo-motor skills associated with childhood IXT.

Anomalous extraocular muscles in Crouzon syndrome with V-pattern exotropia

Strabismus associated with Crouzon syndrome is common and often complex. V-pattern strabismus is most commonly reported in this condition and is mainly thought to be due to an excyclorotation of the orbits and rectus muscle pulleys. We report two cases of children with Crouzon syndrome and V-pattern exotropia who had rectus muscle heterotopy on orbital imaging and were also found intraoperatively to have anomalous extraocular muscles. At the time of surgery, bifid insertion, misdirection, and fibrosis of extraocular muscles were noted. This highlights the various causes of V-pattern strabismus associated with Crouzon syndrome, including dysmorphic orbits and extraocular muscle anomalies.

Binocular discrepancy in lateral rectus muscle attachment in intermittent exotropia with eye dominance

PURPOSE

To determine whether there is asymmetry in the lateral rectus (LR) muscle attachment between both eyes in patients with intermittent exotropia (IXT) with a non-dominant eye, but without amblyopia or anisometropia.

METHODS

In total, 109 patients who underwent bilateral lateral rectus recession for IXT were included, 81 with and 28 without eye dominance. The limbus-insertion distance and tendon width of the LR muscle were measured intraoperatively using callipers. The insertion-equator distance (presumed arc of contact), area of contact (arc of contact × tendon width), and torque value (radius of globe × arc of contact) of the LR muscle were calculated based on intraoperative measurements and axial length measured using a partial interferometer. Parameters regarding LR muscle attachment were compared between fellow eyes and between groups.

RESULTS

Mean measurements in all parameters related to LR muscle attachments other than tendon width were not different between the two eyes or between groups. The mean tendon width of the non-dominant eye was 9.2 ± 0.7 mm, narrower than the 9.4 ± 0.5 mm width in either eye of patients without dominance (p = 0.020). However, there was no difference in all parameters in 21 pairs of patients after matching. The proportion of patients who showed binocular discrepancies in attachment measurements beyond that attributable to potential measuring errors did not differ between the two groups.

CONCLUSIONS

Structural parameters related to LR muscle attachments did not differ based on eye dominance, suggesting that the anatomic structure of LR muscle attachments is not responsible for eye dominance in IXT.

Pupil-Involving Oculomotor Nerve Palsy Following Tonsillectomy and Adenoidectomy

Ocular complications of adenotonsillectomy are rare. The authors describe a 6-year-old boy who developed mydrasis and limitations of supraduction and infraduction after adenotonsillectomy. This was attributed to the hemorrhagic compression of the nerve in the cavernous sinus. This is the first report of pupil-involving oculomotor nerve palsy following adenotonsillectomy. [J Pediatr Ophthalmol Strabismus. 2019;56:e76-e78.].

Use of the Bispectral Index to Predict Eye Position of Children during General Anesthesia

Purpose

To assess the relationship between eye position and anesthesia depth using the bispectral index (BIS) value, a parameter derived from electroencephalography data.

Methods

We investigated the relationship between BIS value and eye position in 32 children who underwent surgery for epiblepharon under general anesthesia. BIS values were recorded continuously throughout the procedure (from induction to awakening). Eye positions were video-recorded and analyzed after surgery. The vertical position of each eye was scored according to its height in relation to the medial canthus. An eye position in which the upper eyelid covered one-third of the cornea was defined as a significant ocular elevation.

Results

The BIS value correlated inversely with the end-tidal concentration of each anesthetic agent, whereas it correlated positively with the eye elevation score (eye position = 0.014 × BIS + 0.699, p = 0.011). The mean eye position score was significantly greater in patients whose BIS values were over 65. Eleven patients (34.4%) had significant ocular elevation; their mean concurrent BIS value was 61.6. Two of these patients had elevation during surgery and 9 had elevation during emergence from anesthesia.

Conclusions

We found that high BIS values were correlated with low levels of anesthetic concentration and high eye position, suggesting that BIS monitoring may be useful for predicting eye position during anesthesia. Particular attention must be given to eye position during ophthalmic surgery. Anesthesia depth can be maintained by assuring that the BIS value remains below 65.

Abducens Nerve Palsy Following Expansion Cranioplasty with Distraction Osteogenesis

Childhood abducens nerve palsy can occur as a result of trauma, tumour, vasculopathic disease, elevated intracranial pressure, infection, inflammation, and congenital or idiopathic causes. The authors present two cases of unilateral abduction deficit secondary to a recent trans-sutural distraction osteogenesis (TSuDO) operation for craniosynostosis. After distractor removal, the problem resolved spontaneously over 2-4 months in both cases. This is a first reported case of sixth nerve palsy as a complication of TSuDO operation.

Pirfenidone attenuates the IL-1β-induced hyaluronic acid increase in orbital fibroblasts from patients with thyroid-associated ophthalmopathy

PURPOSE

This study aimed to investigate the effect of pirfenidone on the IL-1β-induced hyaluronic acid (HA) increase in orbital fibroblasts from patients with thyroid-associated ophthalmopathy (TAO).

METHODS

Primary cultured orbital fibroblasts were obtained from patients with TAO, and the excreted levels of HA from IL-1β-treated cells with or without pirfenidone were measured. The effect of pirfenidone on IL-1β-induced hyaluronic acid synthase (HAS) expression was evaluated. The relevance of the mitogen-activated protein kinase (MAPK)-mediated signaling pathway in IL-1β-induced HAS expression was assessed using specific inhibitors to p38, extracellular signal-regulated kinase (ERK), or c-Jun N-terminal kinase (JNK). The phosphorylation level of each MAPK in IL-1β-treated cells with or without pirfenidone and the level of AP-1 DNA binding were measured. The inhibitory potency of pirfenidone on HA production was evaluated using dexamethasone as a reference agent.

RESULTS

Pirfenidone strongly attenuated the IL-1β-induced HA release in a dose-dependent manner. The IL-1β-induced HAS expression was decreased significantly following cotreatment with pirfenidone at the mRNA and protein levels. The production of mRNAs was halted by cotreatment with inhibitors of ERK and p38, but not by inhibitors of JNK. The IL-1β-induced ERK and p38 phosphorylation, and AP-1 DNA binding were attenuated in the presence of pirfenidone. Pirfenidone showed greater potency than dexamethasone in inhibiting increases in IL-1β-induced HA.

CONCLUSIONS

Pirfenidone attenuates the IL-1β-induced HA production in orbital fibroblasts from patients with TAO, at least in part, through suppression of the MAPK-mediated HAS expression. These results support the potential use of pirfenidone for treatment of patients with TAO.

Photophobia measurement in intermittent exotropia using the contrast sensitivity test

BACKGROUND

To assess the presence and extent of photophobia in children with intermittent exotropia (X[T]) using the contrast sensitivity test.

METHODS

Fifty-eight children with X(T) and 34 normal controls were studied with the functional acuity contrast test. Each participant viewed the stimuli of contrast monocularly and binocularly under photopic and mesopic conditions, performed with and without glare. Photophobia was defined as a reduction of contrast sensitivity caused by glare light. We compared the photophobia of children with X(T) to that of normal controls, and to the photophobia 3 months after muscle surgery.

RESULTS

With stimuli of glare, the contrast sensitivity of children with X(T) was suppressed at intermediate spatial frequencies under mesopic condition (p = 0.006 for 6 cycles per degree [cpd], p = 0.027 for 12 cpd), whereas that of normal controls showed no difference. It occurred when X(T) patients viewed targets binocularly, and significantly improved after strabismus surgery (p = 0.003 at 6 cpd). The measured photophobia of X(T) was strongly correlated to the photophobia symptoms reported by parents (p = 0.002).

CONCLUSIONS

The mesopic contrast sensitivity with glare can represent the photophobia of children with X(T). Contrast sensitivity may be a useful measure for monitoring symptoms related to X(T).

Parent-reported symptoms of attention deficit hyperactivity disorder in children with intermittent exotropia before and after strabismus surgery

PURPOSE

To investigate the symptoms of attention deficit hyperactivity disorder (ADHD) as reported by parents in children with intermittent exotropia [X(T)] and to determine whether strabismus surgery for X(T) affects ADHD symptoms.

MATERIALS AND METHODS

Fifty-one consecutive children undergoing muscle surgery for X(T) were prospectively recruited. One parent of each child completed the ADHD rating scale IV (ADHD RS-IV) assessment consecutively before and one year after surgery. Patients whose preoperative scores were above the cut-off point, the 90th percentile based on a Korean sample, were regarded as demonstrating the ADHD trait. The impact of muscle surgery on ADHD symptoms was assessed by comparing the preoperative scores with the post-operative scores.

RESULTS

Eight (15.7%) of the 51 patients demonstrated the ADHD trait. ADHD RS-IV scores following strabismus surgery significantly decreased in patients with the ADHD trait (p=0.014), while they did not differ in patients without the ADHD trait. Seven (87.5%) of the 8 patients with the ADHD trait showed improvement in their ADHD RS-IV scores after surgery. There was no difference in surgical success rates between X(T) patients with and without the ADHD trait.

CONCLUSION

The ADHD trait was relatively common in children with X(T), and the parent-reported symptoms of the children with the ADHD trait improved after strabismus surgery. These results suggest that childhood X(T) may be one contributing factor to ADHD- related symptoms.

The analysis of AC/A ratio in nonrefractive accommodative esotropia treated with bifocal glasses

Purpose

To report the long term results of bifocal treatment in nonrefractive accommodative esotropia and to analyze the changes of accommodative convergence to accommodation (AC/A) ratio.

Methods

Sixteen patients treated with bifocal glasses for at least 5 years were evaluated retrospectively. Angle of deviation at near and distance, refractive error, and AC/A ratio by the lens gradient method were analyzed. The changes of AC/A ratios were also compared after dividing the patients according to continuation or cessation of bifocal therapy.

Results

Six patients (38%; bifocal stop group, BSG) were able to stop using bifocal glasses at an average age of 10.8 years (range, 6.5 to 15.4 years) during their follow-up. However, the other ten patients (62%; bifocal continue group, BCG) had to continue using bifocal glasses until the final visit, which was 13.8 years on average (range, 11.3 to 18.5 years). The AC/A ratio decreased from time of bifocal prescription to the last visit in both groups, from 4.4 to 2.7 in the BSG and from 5.9 to 4.5 in the BCG. AC/A ratios were significantly higher (p = 0.03) in the BCG than that of the BSG from the beginning of bifocal treatment and this difference was persistent until the final visit (p = 0.03).

Conclusions

The AC/A ratio decreased with age in both groups but was significantly higher throughout the entire follow-up period in the BCG. AC/A ratio at bifocal prescription could be an important factor in predicting response to bifocal treatment.

Changes in the interpupillary distance following general anesthesia in children with intermittent exotropia: a predictor of surgical outcomes

PURPOSE

To determine whether changes in ocular alignment following general anesthesia, as measured by interpupillary distance, can be used as a predictor for surgical outcomes in children with intermittent exotropia.

METHODS

The authors obtained digital photographs of 40 children with exotropia and 20 children with epiblepharon (control group) before and immediately after induction of general anesthesia in the primary supine position. Differences in the anatomic interpupillary distance (aIPD) for each patient were measured and compared with the preoperative angles of deviation. They were also correlated with surgical outcomes on the first day and 1 year after surgery.

RESULTS

All 60 patients demonstrated an increase in aIPD following general anesthesia. The mean change in aIPD in patients with exotropia was similar to that in patients with epiblepharon (3.78% ± 2.53% and 3.15% ± 1.05%, respectively). In patients with exotropia, there was a significant positive linear correlation between the preoperative distance deviation (P) and the change in eye position (A): A = 0.362 P - 4.488, r(2) = 0.476 (P < .001). Five (71%) of seven patients whose changes were outside the 80% confidence interval for expected values had poor surgical outcomes on the first postoperative day and four had unsatisfactory results 1 year after surgery.

CONCLUSIONS

Changes in aIPD following general anesthesia were strongly correlated with preoperative angle of deviation. Therefore, they may be a useful predictor of surgical outcomes in children with exotropia.

Changes in exodeviation following hyperopic correction in patients with intermittent exotropia

PURPOSE

To evaluate changes in the angle of deviation after spectacle correction in patients who had hyperopia and intermittent exotropia (X(T)) and to determine whether the changes and surgical outcomes differ when compared with those of myopic and emmetropic X(T).

METHODS

One hundred fourteen patients with X(T) were recruited and allocated into three groups: X(T) with hyperopia (group I; 38 patients), X(T) with emmetropia (group II; 35 patients), and X(T) with myopia (group III; 41 patients). After at least 6 months wearing spectacles, changes in exodeviation were compared. The results of surgery based on the spectacle-corrected distance angle and the ratios of accommodative convergence over accommodation (AC/A) were also assessed.

RESULTS

With spectacle correction, the mean exodeviation increased significantly in group I, but did not change in groups II or III. Thirteen patients in group I (34%) showed a more than 10 prism diopters (PD) exotropic shift after wearing spectacles. The mean AC/A ratio in group I was 2.63 (PD/D), whereas in groups II and III the ratios were 4.03 and 4.06, respectively. There was no difference in surgical results among the three groups.

CONCLUSION

Although hyperopic correction in patients with X(T) resulted in a limited increase in exodeviation with a subnormal AC/A ratio, one-third of the patients experienced a significant increase in exodeviation. A spectacle correction trial should be considered before surgery in patients with hyperopia and X(T).

Transient increase of higher-order aberrations after lateral rectus recession in children

The changes of higher-order aberrations (HOAs) after bilateral lateral rectus muscle recession were evaluated. Forty eyes of 20 children were enrolled and their wavefront information was assessed until postoperative 3 months. Even though the root mean square (RMS) of total aberration was not changed, the RMS of HOA was transiently increased at postoperative 1 week and returned to baseline level after 1 month. Among individual Zernike coefficient, secondary astigmatism, quadrafoil, secondary coma, secondary trefoil, and pentafoil showed similar tendency with the RMS of HOA. However, coma, trefoil, and spherical aberration were not changed. Regarding recession amount, it did not correlate with any Zernike coefficient. In summary, our data imply that the HOAs are transiently increased after lateral rectus recession surgery. These results are in collusion with previous reports that strabismus surgery induced transient corneal astigmatism.

Practical aspects and efficacy of intraoperative adjustment in concomitant horizontal strabismus surgery

PURPOSE

To analyze the practical aspects and advantages of one-stage adjustable surgery under topical anesthesia in concomitant horizontal strabismus.

METHODS

A retrospective review of 363 patients was completed to assess (1) the frequency of need to perform adjustment, (2) the amount and pattern of adjustment, and (3) the final alignment at least 6 months after surgery. Intraoperative adjustment was performed strictly toward the aim of orthophoria or slight overcorrection (heterophoria < 6 prism diopters [PD]) while avoiding diplopia.

RESULTS

Of the 363 patients, 261 (72%) required intraoperative adjustment. Of these, 85% of exotropes underwent a decreased amount of surgery compared with the standard amount, whereas 58% of esotropes underwent an increased amount of surgery. Forty-two patients underwent a one-muscle surgery instead of the scheduled two-muscle surgery, and all had less than 35 PD preoperative angle of deviation. Success rates were 83% in all patients with one-stage adjustable sutures and 87% in patients who underwent adjustment. In 42 patients with one-muscle surgery instead of two-muscle surgery, 32 (76%) obtained successful results.

CONCLUSION

Intraoperative adjustment was effective in concomitant horizontal strabismus surgery and can provide the opportunity to avoid a large overcorrection, especially in cases with moderate angle horizontal muscle surgery.

Two cases of mirror-image eye anomalies in monozygotic twins

We report two cases of mirror image anomalies in two different pairs of monozygotic twins. In case 1, the twins exhibited mirroring of strabismus and refractive errors. Twin 1 had 35 prism diopters (PD) right intermittent exotropia at distant fixation and myopic anisometropia that was spherical 2.00 diopters more myopic in the right eye. Twin 2 had 35 PD left intermittent exotropia at distant fixation and her left eye was more myopic by - spherical 1.00 diopters. In case 2, the twins were diagnosed with infantile nystagmus with upbeat jerk. Twin 1 exhibited a habitual head turn of 30° to the left with dampening of her nystagmus in dextroversion. Twin 2 also exhibited abnormal head position, but in his case the habitual turn was 30° to the right. We believe that this is the first report describing mirror imaged intermittent exotropia with anisometropia and infantile nystagmus with opposite abnormal head positions in pairs of monozygotic twins.