Effect of Watching 3-Dimensional Television on Refractive Error in Children

PURPOSE: To investigate the effect of watching 3-dimensional (3D) television (TV) on refractive error in children. METHODS: Sixty healthy volunteers, aged 6 to 12 years, without any ocular abnormalities other than refractive error were recruited for this study. They watched 3D TV for 50 minutes at a viewing distance of 2.8 meters. The image disparity of the 3D contents was from -1 to 1 degree. Refractive errors were measured both before and immediately after watching TV and were rechecked after a 10-minute rest period. The refractive errors before and after watching TV were compared. The amount of refractive change was also compared between myopes and controls. The refractive error of the participants who showed a myopic shift immediately after watching TV were compared across each time point to assure that the myopic shift persisted after a 10-minute rest. RESULTS: The mean age of the participants was 9.23 ± 1.75 years. The baseline manifest refractive error was -1.70 ± 1.79 (-5.50 to +1.25) diopters. The refractive errors immediately after watching and after a 10-minute rest were -1.75 ± 1.85 and -1.69 ± 1.80 diopters, respectively, which were not different from the baseline values. Myopic participants (34 participants), whose spherical equivalent was worse than -0.75 diopters, also did not show any significant refractive change after watching 3D TV. A myopic shift was observed in 31 participants with a mean score of 0.29 ± 0.23 diopters, which resolved after a 10-minute rest. CONCLUSIONS: Watching properly made 3D content on a 3D TV for 50 minutes with a 10-minute intermission at more than 2.8 meters of viewing distance did not affect the refractive error of children.

Specific Visual Symptoms and Signs of Meares-Irlen Syndrome in Korean

PURPOSE: To discriminate the visual symptoms and signs of Meares-Irlen syndrome (MIS) and nonspecific dyslexia from other ophthalmologic diseases (NODs). METHODS: Forty-five patients were enrolled. Thirty four of the patients with MIS whose symptoms improved with tinted lenses comprised MIS group. The other 11 patients whose reading difficulty improved with other ocular therapy and did not require tinted lenses comprised NODs group. The main symptoms causing dyslexia and associated ocular diseases were evaluated. RESULTS: The mean age was 17.9 +/- 9.5 years in MIS group, and 19.3 +/- 11.0 years in NODs group. In MIS group, the most common symptoms while reading were difficulty to move lines (85%), doubling (53%), and difficulty in bright condition (27%). On the other hand, blurring was the most common symptom in NODs group (45%). The associated ocular diseases in the two groups were refractive error (79% and 73%), dry eye (29% and 18%), and exophoria (6% and 27%), respectively. CONCLUSIONS: Doubling, difficulty to move lines, and difficulty in bright condition while reading are main specific symptoms in MIS compared to nonspecific dyslexia from other ophthalmologic disorders.

The Influence of Suppression on Axial Length Progression in Intermittent Exotropia

PURPOSE: To evaluate the influence of suppression by intermittent exotropia on axial length progression. METHODS: The medical records of patients with intermittent exotropia who had undergone surgery at the Korea University Medical Center from 2003 to 2010 were reviewed. The age upon visit, age at operation, visual acuity, refractive error, type of strabismus, angle of strabismic deviation, suppression test (Vectographic projector test, Reneau, France), and axial length test were analyzed. Subjects with amblyopia or anisometropia were excluded. RESULTS: A total of 75 patients with intermittent exotropia who had definite suppression in 1 eye were identified. The mean age at visit was 6.87 +/- 2.73 years and mean angle of exodeviation was 25.65 +/- 6.68 / 26.17 +/- 6.59 (prism diopters, distant / near). There was no statistical difference in exotropia patients' interocular axial length value who showed suppression in 1 eye (p = 0.992 in the right-eye suppression group, and p = 0.528 in the left-eye suppression group). CONCLUSIONS: In the present study, there was no statistical difference in interocular axial length value of intermittent exotropia patients with suppression in one eye (p > 0.05).

Contemplation of the Surgical Normogram of Lateral Rectus Recession for Exotropia Associated with Superior Oblique Palsy

PURPOSE: To suggest a surgical normogram for lateral rectus recession in exotropia associated with unilateral or bilateral superior oblique muscle palsy (SOP). METHODS: We retrospectively reviewed the charts of 71 patients with exotropia who were successfully corrected over one year. Each patient had undergone unilateral or bilateral rectus recession associated with uni- or bilateral inferior oblique (IO) 14 mm recession, using a modified surgical normogram for lateral rectus (LR) recession, which resulted in 1 to 2 mm of reduction of LR recession. We divided all patients into 2 groups, the 34 patients who had undergone LR recession with unilateral IO (UIO) recession group and the remaining 37 patients who had undergone LR recession with bilateral IO (BIO) recession group. Lateral incomitancy was defined when the exoangle was reduced by more than 20% compared to the primary gaze angle. The surgical effects (prism diopters [PD]/mm) of LR recession were compared between the two groups using the previous surgical normogram as a reference (Parks' normogram). RESULTS: The mean preoperative exodeviation was 20.4 PD in the UIO group and 26.4 PD in the BIO group. The recession amount of the lateral rectus muscle ranged from 4 to 8.5 mm in the UIO group and 5 to 9 mm in the BIO group. Lateral incomitancy was noted as 36.4% and 70.3% in both groups, respectively (p = 0.02). The effect of LR recession was 3.23 +/- 0.84 PD/mm in the UIO group and 2.98 +/- 0.62 PD/mm in the BIO group and there was no statistically significant difference between two the groups (p = 0.15). CONCLUSIONS: Reduction of the LR recession by about 1 to 2 mm was successful and safe to prevent overcorrection when using on IO weakening procedure, irrespective of the laterality of SOP.

A Study of Patient Concerns and Return to Daily Life after Strabismus Surgery

PURPOSE: To investigate preoperative concerns and expectations of caretakers and patients who underwent strabismus surgery and the patients course of return to daily life. METHODS: Eighty-five strabismus surgery patients were enrolled in this study. We performed a questionnaire survey including 11 questions about the concerns, expectations of strabismus surgery and the course of return to daily life after surgery. In total, 25 adult patients and 60 children with their caretakers were asked to fill out the questionnaire. RESULTS: The results showed that 77% of all patients and their caretakers expected that the strabismus would be cured after a single operation. The greatest concern before surgery was the possibility of strabismus recurrence (60%). Fifty five percent of the patients reported the use of an eye patch for 2 weeks to 1 month after surgery and 88% of them showed a 75-100% increase in performance after the operation. The most common reason for decreased performance was the use of an eye patch (61%). Most patients returned to normal daily activities within 1 to 2 weeks after surgery. CONCLUSIONS: Proper preoperative explanation about the possibility of recurrence may reduce concerns and false expectations about surgical outcomes. It appears to take 1 to 2 weeks for patients to return to their daily lives.

The Effect of Colored Filters in Patients with Meares-Irlen Syndrome

PURPOSE: To evaluate the benefit of colored filters in Meares-Irlen Syndrome patients with reading difficulties. METHODS: Twenty-five patients were selected through a brief questionnaire aimed to determine symptoms of eyestrain or visual distortion after thorough eye examinations. The cutoff value of the questionnaire was 2.13. The rates of Korean reading and writing were measured using the RWSM (Reading Writing Speed Meter) test with and without the use of colored filters. Two months after wearing the individually prescribed colored filters, a questionnaire on the patient's subjective satisfaction with the colored filters were completed and evaluated. RESULTS: The blue (n = 8, 32%) and gray (n = 4, 16%) colors were the most frequently selected filters. The mean score of the questionnaire on reading difficulties was 2.72. The mean reading rate improved from 82.72 wpm (words per minute) to 101.84 wpm with the colored filters, a statistically significant change (p = 0.019). The mean writing rate did not improve. The overall satisfaction score with the colored lenses was 3.6, with the highest score given to ease of reading (4.08) and the lowest to writing (2.92). CONCLUSIONS: In cases of reading difficulty, colored filters were effective for alleviating visual symptoms and improving reading speed. It is important to achieve an adequate understanding of the specific symptoms of Meares-Irlen Syndrome and to perform a thorough eye examination to differentiate this from other ocular disorders.

Postoperative Stabilization of the Strabismic Angle in Intermittent Exotropia

PURPOSE: To analyze the postoperative strabismic angle for five years or more and to investigate when the angle stabilized in intermittent exotropia. METHODS: We retrospectively reviewed the clinical records of 89 patients who had undergone surgery for intermittent exotropia. The postoperative strabismic angles measured were analyzed at one-year intervals up to five years postoperatively. We divided them into two groups according to their age at the time of surgery. Group 1 was less than 5 years of age, while Group 2 participants were 5 years of age or older. RESULTS: For our 89 total patients, average exo-angles were 7.8 +/- 7.26, 7.9 +/- 7.51, 9.5 +/- 7.05, 10.1 +/- 6.87, and 9.4 +/- 6.90 prism diopters at one, two, three, four, and five years postoperatively, respectively. Average exo-angles between postoperative year one and year three, as well as between postoperative year two and year three, were statistically significant (p = 0.015, 0.022). However, the angles were not statistically significant between postoperative year three and year four or between years three and five, respectively (p = 0.707, p = 0.948). The stabilization characteristics of the angle were somewhat different according to age group. In Group 1, the average exo-angle in postoperative years one and three were statistically significant (p = 0.016), but the angle in the same period was not statistically significant in Group 2 (p = 0.203). CONCLUSIONS: There was no significant interval change after three years postoperatively in intermittent exotropia, but if the patient's age at surgery was 5 years or higher, no significant change of exo-angle was found following postoperative year one in this study.

Analysis of the Effects of Medial Rectus Muscle Resection for Recurrent Exotropia

PURPOSE: The purpose of this paper is to investigate how much correction is obtained per millimeter of medial rectus (MR) resection for recurrent exotropia after bilateral lateral rectus (BLR) recession, and to determine the difference in the effects between unilateral and bilateral resection, and the influence of previous lateral rectus (LR) recession on the effects of MR resection. METHODS: A total of 59 patients who had undergone MR resection after BLR recession were included in this study. The unilateral group consisted of 38 patients and bilateral group, 21 patients. Thirty patients in the unilateral group were divided into two groups: patients who had undergone previous LR recession of 7 mm or greater (21 patients) and less than 7 mm (9 patients). Main outcome measures were average deviation corrected per millimeter of MR resection at 1 month postoperative. RESULTS: The average effect of MR resection was 4.2 prism diopters (PD, 2.0 to 6.7 PD)/mm. The average effect in the unilateral group was 4.2 PD/mm and 4.1 PD/mm in the bilateral group. There was no significant difference between groups (P = 0.60). The average effect in the recession 7 mm or greater group was 4.0 PD/mm, and the average effect in the recession less than 7 mm group was 4.2 PD/mm (P = 0.698). CONCLUSIONS: The effect of MR resection per millimeter was variable. The laterality and previous amount of LR recession did not influence the effect of MR resection. These variable outcomes dictate that caution be exercised when MR resection is performed for recurrent exotropia.

Analysis of the Effects of Medial Rectus Muscle Resection for Recurrent Exotropia

PURPOSE: The purpose of this paper is to investigate how much correction is obtained per millimeter of medial rectus (MR) resection for recurrent exotropia after bilateral lateral rectus (BLR) recession, and to determine the difference in the effects between unilateral and bilateral resection, and the influence of previous lateral rectus (LR) recession on the effects of MR resection. METHODS: A total of 59 patients who had undergone MR resection after BLR recession were included in this study. The unilateral group consisted of 38 patients and bilateral group, 21 patients. Thirty patients in the unilateral group were divided into two groups: patients who had undergone previous LR recession of 7 mm or greater (21 patients) and less than 7 mm (9 patients). Main outcome measures were average deviation corrected per millimeter of MR resection at 1 month postoperative. RESULTS: The average effect of MR resection was 4.2 prism diopters (PD, 2.0 to 6.7 PD)/mm. The average effect in the unilateral group was 4.2 PD/mm and 4.1 PD/mm in the bilateral group. There was no significant difference between groups (P = 0.60). The average effect in the recession 7 mm or greater group was 4.0 PD/mm, and the average effect in the recession less than 7 mm group was 4.2 PD/mm (P = 0.698). CONCLUSIONS: The effect of MR resection per millimeter was variable. The laterality and previous amount of LR recession did not influence the effect of MR resection. These variable outcomes dictate that caution be exercised when MR resection is performed for recurrent exotropia.

Clinical Findings of Constant Exotropia Developed from Intermittent Exotropia

PURPOSE: To investigate clinical characteristics of constant exotropia patients with a previous history of intermittent exotropia. METHODS: Constant exotropia patients (CXT) with a previous history of intermittency, and intermittent exotropia patients (X [T]) who had undergone surgery for exotropia were included in the present study. Patching therapy of the fixating eye was performed for all patients. Surgical results, the effect of patching, lateral incomitancy, and suppression were retrospectively reviewed and compared between the 2 groups. RESULTS: The number of CXT was 51 and X (T) was 84. The angles of deviation at the initial visit and at surgery were significantly larger in CXT. After 3 months of patching therapy, there was no difference between the 2 groups in the reduction of distant angle of deviation. However, the reduction of near angle of deviation was 0.29 +/- 5.44 in CXT and 4.42 +/- 6.26 Delta in X (T), which was significantly different (p = 0.04). Lateral incomitancy was observed in 7.8% of CXT and 34.5% of X (T) (p < 0.001). The angles of deviation at the final visit and surgical success rate were not different between the groups. Preoperative suppression at distant was found in 100% of CXT and 88.7% of X (T), and postoperative suppression was in 17.6% and 18.3%, respectively. CONCLUSIONS: The surgical success rate and postoperative suppression were not different between constant exotropia and intermittent exotropia. However, the frequency of lateral incomitancy and the response to the patching therapy was lower in constant exotropia.

A Case of Congenital Absence of the Superior Oblique Muscle Treated With Anterior and Nasal Transposition of the Inferior Oblique Muscle

PURPOSE: To report a patient with absence of the superior oblique (SO) muscle of the left eye, who showed improvement after anterior and nasal transposition of the inferior oblique muscle for left hyperdeviation and right head tilt. CASE SUMMARY: A two-year-old boy presented with hypertropia of the left eye and right head tilt. Alternate prism-cover test in the primary position demonstrated 18 prism diopters (PD) of left hypertropia, which increased to 35 PD in the left head tilt position. A version test demonstrated overaction of the left inferior oblique muscle and underaction of the left superior oblique muscle. As an orbit CT scan showed absence of the SO muscle, the patient was diagnosed with congenital absence of SO and left anterior and nasal transposition of the inferior oblique muscle was performed. Three weeks after surgery, the patient presented with orthotropia at distant and near. The version test revealed normal oblique muscles. There was no vertical deviation shown on the Bielschowsky head tilt test. The abnormal head posturing was no longer observed. CONCLUSIONS: The authorsreport a patient manifesting abnormal head posture and hypertropia, diagnosed with absence of SO muscle, which was successfully corrected using anterior and nasal transposition of the inferior oblique muscle.

A Case of Acquired Brown Syndrome after Surgical Repair of a Medial Orbital Wall Fracture

A case of acquired Brown syndrome caused by surgical repair of medial orbital wall fracture is reported in the present paper. A 23-year-old man presented at the hospital with right periorbital trauma. Although the patient did not complain of any diplopia, the imaging study revealed a blow-out fracture of the medial orbital wall. Surgical repair with a calvarial bone autograft was performed at the department of plastic surgery. The patient was referred to the ophthalmologic department due to diplopia that newly developed after surgery. The prism cover test at distant fixation showed hypotropia of the right eye, which was 4 prism diopters (PD) in primary gaze, 20 PD in left gaze, while orthophoric in right gaze. Eye movement of the right eye was markedly limited on elevation in adduction with normal elevation in abduction with intorsion in the right eye present. Forced duction test of the right eye showed restricted elevation in adduction. Computerized tomography scan of the orbits showed the right superior oblique muscle was entrapped between the autografted bone fragment and posterior margin of the fracture. When repairing medial orbital wall fracture that causes Brown syndrome, surgeons should always be careful of entrapment of the superior oblique muscle if the implant is inserted without identifying the superior and posterior margin of the orbital fracture site.

Clinical Characteristics of Patients With Dyslexia in Korea : Correlation With Meares-Irlen Syndrome

PURPOSE: To evaluate the main symptoms and associated ocular diseases in patients with dyslexia (reading difficulty) in Korean subjects. METHODS: A total of 16 patients were enrolled in the present study. Eleven of the patients with Meares-Irlen syndrome whose symptoms improved with tinted lenses comprised Group 1. The other 5 patients whose reading difficulty improved with other ocular therapy and did not require tinted lenses comprised Group 2. The main symptoms causing dyslexia and associated ocular diseases were evaluated. RESULTS: The mean age was 18.9 +/- 8.9 years in Group 1, and 20.4 +/- 12.3 years in Group 2. In Group 1, the most common symptoms while reading were doubling (72%), difficulty to move lines (46%), letter reversal (27%) and blurring or ocular pain (27%). On the other hand, blurring (100%) with fatigue or pain (20%) was documented in Group 2. The associated ocular diseases in Group 1 and Group 2 were refractive error (63% and 20%), dry eye (18% and 60%), and exophoria (18% and 60%), respectively. CONCLUSIONS: Doubling and difficulty to move lines while reading were the main specific symptoms in Meares-Irlen syndrome in the present study. Refractive error, dry eye, and exophoria were commonly associated in patients with dyslexia.

Long-Term Study of Levodopa/Carbidopa for Refractory Childhood Amblyopia

PURPOSE: To evaluate the long-term (12 to 30 months) effect of L-dopa with part-time occlusion in patients in which occlusion therapy failed. METHODS: Seventeen eyes of 12 amblyopic children who failed with part-time occlusion (4 to 8 hours/day) treatment for a minimum period of 6 months were studied. The follow-up period was 12 to 30 months. The average best corrected visual acuity (BCVA) before treatment was 0.28+/-0.20 (0.05-0.5). After full informed consent was obtained from their parents, the children received levodopa (2 to 4 mg/kg) for 8 weeks combined with part-time occlusion and spectacles. RESULTS: The average age of the subjects was 7.0+/-2.7 years and the mean follow-up period was 23.7+/-7.7 (12 to 30) months. After the administration of levodopa for 8 weeks, 9 eyes (53%) showed improvement in BCVA, and only 4 eyes showing a mean regression of 0.20+/-0.11 logMAR visual acuities. The BCVA reached the maximum value after a mean of 8.47 months. After 8 weeks from baseline, 13 eyes (76%) reached the maximum BCVA. After 12 to 30 months of follow-up, 12 out of 17 eyes (70.6%) showed a BCVA improvement of 0.14+/-0.19 logMAR. CONCLUSIONS: After the long-term (12 to 30 months) follow-up, L-dopa with part-time occlusion in patients in which occlusion therapy failed showed improved visual acuities in 76% of the cases.

The Long-Term Effect of Part-Time Occlusion Therapy According to Compliance in Recurrent Intermittent Exotropia

PURPOSE: To evaluate the reoperation rate and the change of exo-angle according to compliance level of part time occlusion therapy in recurrent intermittent exotropia. METHODS: This retrospective study included 52 patients of recurrent intermittent exotropia who followed up more than 5 years after their first operation. They were ordered part time occlusion therapy for recurrent exotropia. The patients were divided into 4 groups according to the level of compliance of part time occlusion therapy ('excellent', 'good', 'fair', 'poor'). We evaluated the reoperation rate in 5 years after the first operation and the change of exo-angle from the early recurrent time according to compliance levels. RESULTS: The reoperation rate within 5 years after the first operation of 'excellent' and 'good' compliance groups was lower than that of 'fair' and 'poor' groups (33.3, 26.3, 73.7 and 45.5% respectively) and the degree of exo-angle progression from the early recurrent time of the 'excellent' and 'good' compliance groups was less than that of 'fair' and 'poor' compliance groups, both results of which were statistically significant (p=0.02, 0.03). CONCLUSIONS: Part time occlusion therapy in recurrent intermittent exotropia has good long-term effects of decreasingreoperation rates in patients with a high level of compliance.

Antiadhesive Effect of the Mixed Solution of Hyaluronate and Sodium Carboxymethylcellulose After Strabismus Surgery

PURPOSE: To evaluate the effect of the mixed solution of hyaluronate and sodium carboxymethylcellulose (HACMC, Guardix-sol(R)) in reducing postoperative adhesion following strabismus surgery. METHODS: In 16 rabbits out of 20 rabbits, 3 mm recession of the superior rectus muscle was performed on both eyes and HACMC solution was applied only to one eye which was randomly chosen. The rabbits were divided into a surgery-HACMC group and a surgery-no HACMC group. As a control group, the remaining 4 rabbits had no procedures performed. After 3 weeks, both eyes of 8 rabbits with surgery and 2 rabbits of the control group were enucleated. After staining with hematoxylin-eosin and Masson's trichrome, a histologic examination was performed. In the remaining 10 rabbits, the severity of adhesion in muscle and adjacent tissues was observed by blunt dissection. A researcher blind to the experiments performed all the examinations. RESULTS: A significant reduction in the degree of adhesion (P=0.005) as well as decreased fibrosis (P=0.015) was observed in the surgery-HACMC group. CONCLUSIONS: The mixed solution of HACMC was effective in reducing postoperative adhesion after strabismus surgery in rabbits.

Vertical Rectus Muscles Transposition in Large Exotropia with Medial Rectus Muscle Transection Following Endoscopic Sinus Surgery

PURPOSE: To evaluate the effect of transposition procedures on the vertical rectus muscle (VRM) in the patients who underwent a medial rectus muscle (MR) transection after endoscopic sinus surgery (ESS). METHODS: In 4 patients with exotropia (XT) and a lack of adduction after ESS, orbital CT or MRI revealed a complete transection of the midportion of the MR. Full-tendon VRM transposition was performed within 3 months after injury (early surgery) in 2 patients with 40delta XT. Two patients with 70delta and 85delta XT underwent an X-type augmented Hummelsheim procedure, which involved pulling each half-tendon and crossing it through the undersurface of the severed MR to the other end of the MR insertion, concurrently with an ipsilateral lateral rectus (LR) recession 11 months and 36 months after ESS, respectively. The adduction deficits were divided into -1 through to -8. The patients were followed up for more than than 1.5 years. RESULTS: Postoperatively, 3 patients showed orthophoria and no diplopia in the primary position. The adduction deficits improved to -3.5 or -4. One patient who underwent an X-type augmented Hummelsheim procedure showed a residual XT of 25delta. CONCLUSIONS: VRM transposition is effective in correcting a large XT secondary to a MR transection after ESS. When a longstanding large-angle XT with severe contracture of the ipsilateral LR and massive scarring of the adjacent tissues is present, the X-type augmented Hummelsheim procedure coupled with an ipsilateral LR recession had an augmenting effect.

Consecutive Esotropia in Intermittent Exotropia Patients with Immediate Postoperative Overcorrection More Than 17 Prism Diopters

PURPOSE: To report the incidence and the factors of consecutive esotropia (ET) in patients with immediate postoperative overcorrection of at least 17 prism diopters (PD) after surgery for intermittent exotropia (X(T)). METHODS: Four-hundred-five patients under the age of 18 were included in this study. They underwent bilateral lateral rectus recession (LROU-rec) or unilateral recession-resection (R&R) for X(T). On postoperative day one, the patients with at least 17 PD overcorrection were classified as group 1 and those with less than 17 PD as group 2. Age, refractive error, type of surgery, lateral incomitancy, and the incidence of consecutive ET were analyzed for each group. RESULTS: Group 1 consisted of 116 patients (28.6%) and group 2 consisted of 289 (71.4%). At the six-month follow-up visit, consecutive ET had developed in 16 patients (13.8%) in group 1, and in five patients (1.7%) in group 2 (p<0.001). The occurrence of consecutive ET was not related to age at the time of surgery (p=0.46 in group 1 ; p=0.54 in group 2), refractive error (p=0.18 in group 1 ; p=0.08 in group 2), or the type of surgery (p=0.69 in group 1 ; p=1.00 in group 2). The incidence in group 1 was 23.8% in patients with lateral incomitancy and 8.1% in patients without lateral incomitancy (p<0.05). In group 2, the incidence was 4.4% in patients with lateral incomitancy and 0.5% in patients without lateral incomitancy (p=0.04). CONCLUSIONS: Consecutive ET developed in 13.8% of patients with immediate overcorrection of at least 17 PD. Lateral incomitancy was the most important risk factor.

A Case of Horizontal Gaze Palsy with Ipsilateral Esotropia due to Pontine Hemorrhage

PURPOSE: We describe a patient with a horizontal pontine gaze palsy and a concurrent esotropia and discuss the etiology and surgical management of this condition. METHODS: A 42-years-old male visited the hospital with dipopia and left ocular pain. He had a history of pontine hemorrhage a year ago. Because of left ficial palsy, lagophthalmos was noted on the left eye and slit-lamp examination showed filament keraititis and superficial punctate keratitis. Left face turn was noted and a left horizontal gaze palsy with inability to abduct the left eye and to adduct the right eye past the midline was also noted. By Krimsky estimation, 40 prism diopter (PD) left esotropia was present in the primary position. Brain magnetic resonance imaging carried a yeas ago showed a large lobulated hyperdense lesion and the central lesion is on the left dorsal portion of pons. RESULTS: The patient underwent a right lateral rectus muscle recession of 5 mm, a left medial rectus muscle recession of 6 mm and a parial tendon transfer of the left superior and inferior rectus muscles th the left lateral rectus muscle insertion (modified Hummelsheim operation with augmentation). A lateral tarsorrhaphy was also performed. 3 months after operation, he didn't complain diplopia and orthotropia was noted in the primary position by Hirshberg test. His head posture was also right. The lagophthalmos and keratitis was markely improved and ocular pain was not complained. CONCLUSIONS: The lesion in this patient caused by potine hemorrhage may be involve the left PPRF, the left sixth nerve nucleus and the left facial nerve fascicles. Strabismus surgery on the patient improved diplopia and face turn.

Antielevation Syndrome after Unilateral Anteriorization of the Inferior Oblique Muscle

PURPOSE: To report antielevation syndrome with restriction of elevation on abduction in the operated eye and overaction (OA) of the inferior oblique muscle (IO) of the contralateral eye after unilateral IO anteriorization (AT). METHODS: Medical records were reviewed retrospectively in 8 of 24 patients who underwent unilateral IOAT. Four patients were referred from other hospitals after the same surgery. RESULTS: Four patients had infantile esotropes. The rest showed accommodative esotropia, superior oblique palsy, exotropia, and consecutive exotropia. The mean amount of hyperdeviation was 16.3 PD (10~30). The mean restriction of elevation on abduction in the operated eye was -1.6 (-1~-4) and IOOA of the contralateral eye was +2.7 (+2~+3). IOAT of nonoperated eyes in 4 patients, IO weakening procedure of anteriorized eyes in 2 patients, and IO myectomy on an eye with IOAT in 1 patient were performed. Ocular motility was improved after surgery in all patients. CONCLUSIONS: Unilateral IOAT may result in antielevation syndrome. Therefore bilateral IOAT is recommended to balance antielevation in both eyes. A meticulous caution is needed when performing unilateral IOAT.