Motor and Sensory Outcomes of Infantile Exotropia: A 10-Year Study (2008–2017)

Purpose@#We aimed to determine the long-term motor and sensory outcomes of patients with infantile exotropia. @*Methods@#In this longitudinal retrospective (historical cohort) study, the records of 76 patients with infantile exotropia were Studied. Subjects with constant exotropia manifesting before the age of 1 year who were at least 5 years old at recruitment time between 2008 and 2017 were included. @*Results@#The medical records of 26 patients were excluded due to not participating in follow-up examinations or having incomplete records. In total, 54 infantile exotropic patients (51.9% male) with a mean age of 11.1 ± 6.8 years and follow-up of 4.99 ± 3.58 years were studied. Postoperative sensory outcomes (central stereopsis [3,000 sec/arc]) were observed in 38.9%, 38.9%, and 21.2% of patients, respectively. In terms of postoperative motor outcomes, 69%, 24%, and 7% were achieved as orthophoria, residual exotropia, and consecutive esotropia, respectively. Patients with a higher surgical age (p = 0.022) and better visual acuity (p = 0.004) had significantly better sensory outcomes, while higher preoperative deviation resulted in more suppression (p = 0.039, rs = 0.218). @*Conclusions@#With rates of 69% for motor success and 78.8% for sensory success, surgical outcomes of infantile exotropic patients seems to be favorable. Further studies are recommended to verify our findings.

Macular Thickness in Moderate to Severe Amblyopia

PURPOSE: To compare the macular retinal thickness of moderately to severely amblyopic eyes with non-amblyopic eyes as controls. METHODS: This case control study was conducted on 56 children aged 4 to 10 years old (64.3% female subjects). Twenty-eight children had unilateral amblyopia (28 amblyopic eyes as cases and 28 normal fellow eyes as internal controls) and 28 children had normal visual acuity in both eyes and were considered as external controls (n = 56 eyes). Among our cases, 14 had strabismic amblyopia and 14 had anisometropic amblyopia. Macular retinal thickness was measured using optical coherence tomography at the center and in 1-, 3-, and 6-mm rings. RESULTS: Best-corrected visual acuity of the amblyopic eyes was less than that of the internal and external controls, and the best-corrected visual acuity of their fellow eyes was also less than that of the external controls. Thickness of the central macula and a 1-mm ring area in the amblyopic eyes was higher than that of both internal and external controls. Difference of central macular thickness ≥20 µm between two eyes of the amblyopic children was significantly more than non-amblyopic subjects. CONCLUSIONS: Based on the results of this study, the macular retinal thickness was significantly higher in moderate to severe amblyopic eyes compared to their fellow eyes and external controls. This might be due to macular developmental disorders in amblyopic eyes. Therefore, optical coherence tomography imaging is recommended if subtle macular abnormalities are suspected in moderate to severe amblyopic eyes.

Vision therapy/orthoptics among three to seven year old children

Vision Therapy/Orthoptics [VT/O] is a package of treatments that enables patients to achieve the maximum level of visual performance. The aim was to determine the effect of three months vision therapy/orthoptics on best corrected visual acuity [BCVA], fusion, stereopsis and ocular alignment in 3-7 year old children. In this randomized clinical trial study, 80 children with amblyopia and/or nonparalytic horizontal deviations were randomly divided into intervention and control groups. Intervention group was treated by vision therapy/orthoptics for three months. These modalities included patch, red filter, sector patch, over minus lens, prism and synoptophore exercises. Controls were treated by only patching for the same period. Pre and post-treatment BCVA, fusion, stereopsis and alignment were compared. Visual performance was classified as excellent [BCVA >/= 20/30, deviation /= 20/30, deviation 10pd and no stereopsis]. A total of 80 cases [56 girls and 24 boys] with the mean age of 5.6 +/- 1.4 years entered the study. Although more improvement of fusion and stereopsis was seen in the intervention group [P<0.001 for both groups], there was no significant differences in BCVA and alignment between two groups. Also the difference of visual performance was not statistically significant between two groups, whereas the improvement was significant in each group [P<0.001, for both groups]. Vision therapy/orthoptics treatment can be effective for improving sensory status in 3 to 7 year old children with amblyopia and/or strabismus. Further studies with larger sample sizes and focusing on accommodation and fusional amplitude are warranted

Amblyopia treatment knowledge cognition of Iranian practitioners in 2012

Amblyopia is considered as one of the most prevalent vision problems in pediatrics age [1-5%]. Recently, new methods in amblyopia treatment were reported in Amblyopia Treatment Study [ATS'].The objective of this study was to recognize amblyopia treatment knowledge of Iranian ophthalmologists and optometrists which are responsible for amblyopia treatment in our and other countries. This cross sectional study was performed during the Iranian Society of Ophthalmology annual meeting in Tehran in 2012 through questionnaire containing demographic information and 20 closed-answer questions based on ATS results. The questions were classified into seven categories and the sum of correct scores was 100. Optometrists and pediatric ophthalmologists were considered as the group 1 [153 participants], other practitioners [general ophthalmologists and other subspecialists] were regarded as the group 2 [256 participants]. Criteria for inadequate, fair and good knowledge were considered by scores of < 50, 50 to 70, and >70 respectively. Overall, 409 out of a total of 600 questionnaires were completed [response rate: 68.1%]. Mean scores of the group 1 were significantly higher than the group 2 in all 7 categories of questions and in 5 of them the differences were statistically significant. The worst and best scores were related to prescription of atropine [12%] and visual acuity improvement with glasses alone [93%], respectively. Scores for other questions were about 50%. There was no relationship between practice status and the number of referral amblyopic cases per week with the level of knowledge. In all categories except prescription of Atropine and recurrence, mean scores of females were more than the male participants. Knowledge about amblyopia therapy seems to be overall inadequate and should be improved by more education. We suggest paying more attention to new modified methods of amblyopia treatment and increased discussion of such method in annual and CME meetings

Is noncycloplegic photorefraction applicable for screening refractive amblyopia risk factors?

Purpose: To compare the accuracy of noncycloplegic photorefraction [NCP] with that of cycloplegic refraction [CR] for detecting refractive amblyopia risk factors [RARFs] and to determine cutoff points

Methods: In this diagnostic test study, right eyes of 185 children [aged 1 to 14 years] first underwent NCP using the Plusopti Chi SO4 photoscreener followed by CR. Based on CR results, hyperopia [>/=+3.5 D], myopia [>/=-3 D], astigmatism [>/=1.5 D], and anisometropia [>/=1.5 D] were set as diagnostic criteria based on AAPOS guidelines. The difference in the detection of RARFs by the two methods was the main outcome measure

Results: RARFs were present in 57 [30.8%] and 52 [28.1%] of cases by CR and NCP, respectively, with an 89.7% agreement. In contrast to myopia and astigmatism, mean spherical power in hyperopic eyes was significantly different based on the two methods [P<0.001], being higher with CR [+5.96 +/- 2.13 D] as compared to NCP [+2.37 +/- 1.36 D]. Considering CR as the gold standard, specificities for NCP exceeded 93% and sensitivities were also acceptable [>/=83%] for myopia and astigmatism. Nevertheless, sensitivity of NCP for detecting hyperopia was only 45.4%. Using a cutoff point of+1.87 D, instead of+3.5 D, for hyperopia, sensitivity of NCP was increased to 81.8% with specificity of 84%

Conclusion: NCP is a relatively accurate method for detecting RARFs in myopia and astigmatism. Using an alternative cutoff point in this study, NCP may be considered an acceptable device for detecting hyperopia as well

Orthoptic changes following photorefractive keratectomy

To report orthoptic changes after photorefractive keratectomy [PRK]. This interventional case series included 297 eyes of 150 patients scheduled for PRK. Complete ophthalmologic evaluations focusing on orthoptic examinations were performed before and 3 months after PRK. Before PRK, 2 [1.3%] patients had esotropia which remained unchanged; 3 [2%] patients had far exotropia which improved after the procedure. Of 12 cases [8%] with initial exotropia at near, 3 [2%] cases became orthophoric, however 6 patients [4%] developed new near exotropia. A significant reduction in convergence and divergence amplitudes [P < 0.001] and a significant increase in near point of convergence [NPC] [P < 0.006] were noticed after PRK. A reduction of 10 >/= PD or more in convergence amplitude and 5 PD or more in divergence amplitude occurred in 10 and 5 patients, respectively. Four patients had initial NPC > 10 cm which remained unchanged after surgery. Out of 9 [6%] patients with baseline stereopsis > 60 seconds of arc, 2 [1.33%] showed an improvement in stereopsis following PRK. No patient developed diplopia postoperatively. Preexisting strabismus may improve or remain unchanged after PRK, and new deviations can develop following the procedure. A decrease in fusional amplitudes, an increase in NPC, and an improvement in stereopsis may also occur after PRK. Preoperative evaluation of orthoptic status for detection of baseline abnormalities and identification of susceptible patients seem advisable

Extraocular muscle fixation to the orbital wall

The surgical results of severe or complex deviations such as those due to complete third nerve palsy, aberrant innervations of extraocular muscles [EOMs] and Duane syndrome are usually not completely successful. Herein, we describe the surgical technique of EOM fixation to the orbital wall. After a limbal or fornix based conjunctival incision, the related EOM is identified and dissected; the muscle insertion is sutured with non-absorbable sutures and detached from the sclera. The adjacent periosteum is exposed approximately 5 mm posterior to the orbital rim. The sutured muscle is then fixed to the orbital wall with two periosteal bites. The cut edges of the intermuscular membrane are closed over the sclera to avoid adherence of the muscle to the sclera. Finally the conjunctiva is reapproximated or recessed if necessary. This method of EOM inactivation completely eliminates all muscle forces from the globe and can provide better alignment in the above mentioned types of strabismus. The procedure is reversible and can be converted to other types of weakening operations if necessary

effect of trabeculectomy on cataract formation or progression

To determine the effect of trabeculectomy on cataract formation or progression in patients with chronic glaucoma. This controlled clinical trial was performed on patients over 50 years of age with glaucoma who were referred to Imam Hossein Hospital, Tehran, Iran, from 2006 to 2007. Trabeculectomy was indicated only in one eye while the fellow eye had well-controlled intraocular pressure with medication[s]. The fellow eyes served as controls. Lens opacity was evaluated using three criteria: visual acuity [VA], and Lens Opacification Classification System III [LOCS III] photographs and scores. Overall 82 eyes of 41 patients including 53.7% male and 46.3% female subjects with mean age of 62.5 +/- 9.3 [range 50-75] years were evaluated. Cataract progression in operated eyes was statistically significant according to VA [P = 0.02], LOCS III photo-graphs [P = 0.05] and LOCS III scores [P = 0.01]. However, compared to fellow control eyes, cataract progression was significant according to VA [P = 0.023] and LOCS III scores [P = 0.057] but not based on LOCS III photographs. Mean VA reduction was 2 Snellen lines in operated eyes; there were 3 cases of cataract formation or progression without reduced VA. Cataracts seem to progress following trabeculectomy; therefore it might be advisable to perform a combined procedure in older patients with moderate lens opacities

Surgical treatment of heavy eye syndrome; report of two cases

To report the clinical features and surgical outcomes of two patients with heavy eye syndrome who underwent partial Jensen's procedure. A 21-year-old man and a 24-year-old woman with high myopia [-18 and -8 diopters, respectively], high axial length [27.5 and 24.6 ram], progressive esotropia [40 and 50 prism diopters], hypotropia [5 and 2 prism diopters], abduction limitation, and inferior displacement of the lateral rectus on computed tomography were diagnosed with heavy eye syndrome and underwent partial Jensen's procedure. The technique consisted of splitting the lateral and superior recti from their insertion up to the equator and uniting their superior and temporal halves respectively, with non-absorbable sutures without scleral fixation. Two months postoperatively, esotropia was reduced to 10 prism diopters in case #1 and to 25 prism diopters in case #2; limitation of abduction was also considerably diminished. Patients with heavy eye syndrome, large angle esotropia and limitation of abduction, may benefit from partial Jensen's procedure which is a simple and safe surgical option