Long-Term Binocularity in Accommodative Esotropia

PURPOSE: To find clinical factors related to the long-term outcome of binocularity in accommodative esotropia. METHODS: Forty-nine patients with accommodative esotropia who were followed over 5 years after successful optical alignment within 8 prism diopters of orthophoria at near and distance with glasses including bifocals were included. The patients who had stereo acuity better than 50 seconds/arc and central fusion without suppression scotoma at the final visit were divided into the bifoveal fusion group and the others were divided into the peripheral fusion group. Clinical factors were analyzed between the two groups (Chi-square test, student t-test). RESULTS: Of the 49 patients, 15 patients were included in the bifoveal fusion group and 34 patients were included in peripheral fusion group. Mean follow-up was 88.9 +/- 25.4 months. Clinical factors that were significantly related to the bifoveal fusion group were older age of onset, shorter duration of misalignment, intermittent esotropia at the initial visit and after initial optical correction, smaller residual deviations at distance after initial optical correction and at the final visit, and lesser amblyopia. CONCLUSIONS: To obtain better levels of long-term binocularity, optical correction should be done as early as possible, before the presence of constant eye misalignment or amblyopia, and the residual esodeviations after optical correction should be kept as small as possible.

Multilobular Lacrimal Sac Diverticulum Presenting as a Lower Eyelid Mass

Lacrimal sac diverticulum is a rare condition, and its various symptoms complicate differential diagnosis. We present cases of a peculiar type of lacrimal diverticulum. A 5-year-old girl and a 50-year-old woman presented with a protruding mass inferior to the medial canthus. Each lacrimal system was patent to irrigation. The masses compressed and distorted the lacrimal passage and had no apparent connection with the lacrimal sac in dacryocystography or computed tomography. Surgical exploration and complete excision of the masses were completed. Each patient had an inverted Y- and an inverted V-shaped multilobular cystic mass that was pathologically confirmed as a lacrimal sac diverticulum. Lacrimal sac diverticula may rarely take the form of a multilobular cyst and can present as a lower lid mass. We speculate that an abnormality in lacrimal embryogenesis resulted in multiple blind pouches, a peculiar type of lacrimal sac diverticulum.

Long-Term Visual Outcome Following Cessation of Occlusion Therapy in Unilateral Amblyopia

PURPOSE: To evaluate a long-term visual outcome following cessation of occlusion therapy in unilateral amblyopia. METHODS: A total of 70 patients who successfully finished occlusion therapy (including maintenance therapy) for unilateral amblyopia and were followed up for at least 1 year after cessation of occlusion were retrospectively reviewed. Even after the success of occlusion therapy, maintenance therapy or regular examinations were performed until the visual development of the normal fellow eye (NE) was completed. The recurrence of amblyopia was defined as a 2 or more logarithm of the minimum angle of resolution (LogMAR) levels of visual acuity (VA) reduction of the amblyopic eye (AE), as compared to the NE, at the last evaluation. RESULTS: Amblyopia was associated with strabismus in 19 patients, anisometropia in 33 patients, and both in 39 patients. The mean age at the cessation of occlusion and at the last evaluation was 7.7 +/- 1.9 years and 11.4 +/- 2.9 years, respectively. The mean VA of the AE was 0.01 +/- 0.03 and mean stereopsis was 101.7 +/- 87.5 seconds of arc at the cessation of occlusion, and both improved at the last evaluation. However, the improvement of mean VA of the AE was not statistically significant (p = 0.21). The mean duration of maintenance therapy was 25.6 +/- 21.0 months, and was 3 times longer than the duration required to achieve success in the treatment of amblyopia. At the last evaluation, the recurrence of amblyopia was not found, while 3 patients (4.3%) lost 1 LogMAR level of VA in the AE, as compared to the NE. CONCLUSIONS: Visual outcome following successful cessation of occlusion therapy for unilateral amblyopia was favorable without recurrence of amblyopia.

Decreased Visual Acuity of Dominant Eye Compared to Amblyopic Eye During Occlusion Therapy

PURPOSE: To investigate the clinical features of patients with decreased visual acuity (VA) of the dominant eye as compared to that of the amblyopic eye during occlusion therapy. METHODS: The authors analyzed clinical features of 28 patients with VA reversed between the two eyes during occlusion therapy among 500 patients treated with occlusion therapy under the diagnosis of monocular amblyopia. RESULTS: Twenty-one patients with strabismic amblyopia (SA), five patients with anisometropic amblyopia (AA) and two patients with combined amblyopia (CA) were enrolled in the present study. Decreased VA of the dominant eye as compared to that of the amblyopic eye occurred 66.75 +/- 83.63 weeks after the onset of occlusion therapy. Reversion of VA between both eyes occurred during amblyopia treatment in 17 patients and during maintenance therapy in 11 patients. The reversed VA was recovered in all patients. The mean duration (MD) of reversed VA was 15.00 +/- 24.43 weeks, and the number of clinic visits (CV) was 4.68 +/- 8.65. In five patients, the MD of reversed VA (59.80 +/- 30.14 weeks, p = 0.016) and the number of CVs (18.40 +/- 14.48, p < 0.001) were significantly longer than those of the other 23 patients (MD of reversed VA: 5.78 +/- 4.04 weeks, number of CV: 1.70 +/- 1.22); those five patients had low compliances and SAs. CONCLUSIONS: Visual acuity was recovered in all patients with decreased VA of the dominant eye as compared to that of the amblyopic eye during occlusion therapy, rapid recovery was observed in most patients except in several patients with low compliance.

Comparison of Clinical Appearance of Pediatric Ocular Injury, According to Grade Level

PURPOSE: To compare the causes and clinical manifestations of pediatric ocular injuries according to grade level. METHODS: We retrospectively reviewed the medical records of 78 children, 15 years and younger, who had been hospitalized for pediatric ocular injuries, classified them into three groups according to grade level, and compared their clinical manifestations. RESULTS: Eighteen (23.1%) were preschoolers, 39 (50.0%) were elementary school students, and 21 (26.9%) were middle and high school students. The most common causes of injury included toys and household goods at home in the preschool group, toys and sporting activity at home and school in the elementary school group, and sporting activity at school in the middle and high school group. The incidence of ocular injury was higher in the 'without supervision group' (57.7%); however, in the preschool group, it was higher (72.2%) even in the 'supervision group' (P<0.05). In the preschool group, the incidence of perforating ocular injury (P<0.05) and the rate of surgical treatment (P<0.05) were higher than those of other groups. CONCLUSIONS: The causes and clinical manifestations of pediatric ocular injury were different according to school degree. The incidence of pediatric ocular injuries can be decreased more efficiently by recognizing these differences.

The Prevalence and Predictive Factors of Deterioration in Accommodative Esotropia

PURPOSE: A number of patients with accommodative esotropia who were initially well controlled with their optical correction will deteriorate. This study aims to examine the cautious clinical features of patients with accommodative esotropia during follow-up period by obtaining the prevalence and the predictive factors of deterioration in accommodative esotropia. METHODS: The records of 89 patients with accommodative esotropia whose eyes were aligned with optical correction (including bifocals) to 8 prism diopters (PD) of esotropia or less were reviewed. All patients were followed for a period of at least 2 years. The patients whose alignment was increased to 10PD of esotropia or greater during the follow-up period were included into the deteriorated group. We obtained the rate of deterioration and compared the clinical features of the deteriorated and controlled group. RESULTS: The mean follow-up period was 64.1+/-29.3 months. Seven (7.8%) of 89 patients was deteriorated. The mean interval of deterioration after initial optical correction was 41.8+/-26.9 months. The stereopsis was significantly worse in the deteriorated group (p=0.024). The frequency of high AC/A ratio was also significantly higher in the deteriorated group (p=0.003). CONCLUSIONS: This study indicates that accommodative esotropia with high AC/A ratio or worse sensory status has an increased likelihood of deterioration.

The Prevalence and Predictive Factors of Deterioration in Accommodative Esotropia

PURPOSE: A number of patients with accommodative esotropia who were initially well controlled with their optical correction will deteriorate. This study aims to examine the cautious clinical features of patients with accommodative esotropia during follow-up period by obtaining the prevalence and the predictive factors of deterioration in accommodative esotropia. METHODS: The records of 89 patients with accommodative esotropia whose eyes were aligned with optical correction (including bifocals) to 8 prism diopters (PD) of esotropia or less were reviewed. All patients were followed for a period of at least 2 years. The patients whose alignment was increased to 10PD of esotropia or greater during the follow-up period were included into the deteriorated group. We obtained the rate of deterioration and compared the clinical features of the deteriorated and controlled group. RESULTS: The mean follow-up period was 64.1+/-29.3 months. Seven (7.8%) of 89 patients was deteriorated. The mean interval of deterioration after initial optical correction was 41.8+/-26.9 months. The stereopsis was significantly worse in the deteriorated group (p=0.024). The frequency of high AC/A ratio was also significantly higher in the deteriorated group (p=0.003). CONCLUSIONS: This study indicates that accommodative esotropia with high AC/A ratio or worse sensory status has an increased likelihood of deterioration.

The Frequency and Aspects of Ptosis in Korean Old Age

PURPOSE: To study the frequency and aspects of ptosis in Koreans aged 50 years or older. METHODS: In this study, 377 elderly people visiting retirement center were included. Margin-reflex distance 1 (MRD1) and palpebral fissure (PF) were evaluated with an attempt to eliminate eyebrow elevation. Levator function (LF) was measured with Berke's method. If the measured MRD1 was less than 2 mm, ptosis was diagnosed and its frequency, relation to sex, age, levator function and superior deep sulcus were investigated. RESULTS: There was a correlation between decreasing MRD1, PF and LF with increasing age. Ptosis was observed in 207 subjects (54.9%), and its frequency was augmented as age increased. Although it was not statistically significant, the levator function of those with ptosis (10.0+/-1.9 mm) was lower than those without ptosis (11.3+/-1.9 mm). Questionnaires were administered and 196 respondents (51%) said that their eyelid droop had become more pronounced over time. Among these respondents, 33 (16.1%) indicated that their droopy eyelid causes discomfort by blocking their vision. Their MRD1 was 1.2+/-1.0 mm, which was significantly lower than that of the other 163 respondents (1.8+/-1.1 mm, P<0.05). CONCLUSIONS: Koreans aged 50 years or older showed a very high frequency (54.9%) of ptosis and as age increased, the frequency of ptosis also increased. Surgical correction is recommended when the ptosis causes patient discomfort due to impaired vision.

The Frequency and Aspects of Ptosis in Korean Old Age

PURPOSE: To study the frequency and aspects of ptosis in Koreans aged 50 years or older. METHODS: In this study, 377 elderly people visiting retirement center were included. Margin-reflex distance 1 (MRD1) and palpebral fissure (PF) were evaluated with an attempt to eliminate eyebrow elevation. Levator function (LF) was measured with Berke's method. If the measured MRD1 was less than 2 mm, ptosis was diagnosed and its frequency, relation to sex, age, levator function and superior deep sulcus were investigated. RESULTS: There was a correlation between decreasing MRD1, PF and LF with increasing age. Ptosis was observed in 207 subjects (54.9%), and its frequency was augmented as age increased. Although it was not statistically significant, the levator function of those with ptosis (10.0+/-1.9 mm) was lower than those without ptosis (11.3+/-1.9 mm). Questionnaires were administered and 196 respondents (51%) said that their eyelid droop had become more pronounced over time. Among these respondents, 33 (16.1%) indicated that their droopy eyelid causes discomfort by blocking their vision. Their MRD1 was 1.2+/-1.0 mm, which was significantly lower than that of the other 163 respondents (1.8+/-1.1 mm, P<0.05). CONCLUSIONS: Koreans aged 50 years or older showed a very high frequency (54.9%) of ptosis and as age increased, the frequency of ptosis also increased. Surgical correction is recommended when the ptosis causes patient discomfort due to impaired vision.

Changes in Astigmatism after Surgery for Congenital Ptosis

PURPOSE: To determine postoperative astigmatic changes after surgery for congenital ptosis and the astigmatic changes depending on surgical method and to discern cases of postoperatively developed anisometropia or amblyopia. METHODS: Fifty-one patients who underwent surgery due to congenital ptosis were reviewed. Refraction or cycloplegic refraction was conducted preoperatively and 3 to 6 months after surgery to measure astigmatic changes. Astigmatic changes in operated eyes were compared to control eyes. Astigmatic changes were compared depending on surgical method. RESULTS: The mean astigmatism was 1.33+/-1.29D preoperatively and 1.48+/-1.13D postoperatively (P=0.10) and the mean astigmatic change in the ptotic and control eye was an increase in cylinder +0.56+/-0.55D and +0.68+/-0.72D (P=0.37). The mean astigmatic change of patients receiving frontalis sling was +0.57+/-0.67D which was similar to those who received levator resection (+0.56+/-0.50D). Newly developed anisometropia was found in three patients postoperatively due to an increase in astigmatism, but newly developed amblyopia was not found. CONCLUSIONS: The increase of astigmatism by ptosis surgery was not statistically significant and there was no statistically significant difference when accounting for surgical method. However, it is necessary to monitor refractive error carefully in younger patients to prevent amblyopia because postoperative increase of astigmatism can cause anisometropia.

T-Cell Lymphoma Presenting as Painful Ophthalmoplegia

PURPOSE: To present a case of peripheral T-cell lymphoma presenting as painful ophthalmoplegia. METHODS: A 61-year-old woman presented with a 2-week history of headache and eyeball pain. Examination showed mild exophthalmos, complete ophthalmoplegia, and ptosis of the left eye. Under the impression of nonspecific orbital inflammation, she was treated with oral prednisone with initial response. Two months later, she revisited the clinic with exacerbated symptoms. Anterior orbitotomy and incisional biopsy was performed for the inferior rectus muscle lesion. RESULTS: Histopathologic examination revealed an infiltrate of atypical lymphoid cells between degenerative muscle bundles. It was consistent with peripheral T-cell lymphoma. A metastatic workup was performed without any evidence of extraorbital tumor. The patient was recommended to be treated with chemotherapy, however, refused to take the treatment. The patient died of progression of the disease in a month. CONCLUSIONS: T-cell lymphoma in the orbit can present as painful ophthalmoplegia and take a rapid clinical course. The disease should be regarded as one of the differential diagnosis for painful ophthalmoplegia refractory to corticosteroid therapy.

Delayed Canaliculoplasty in Unrepaired Canalicular Laceration

PURPOSE: Conjunctivodacryocystorhinostomy with a Jones tube has been the standard treatment for canalicular obstruction secondary to unrepaired canalicular laceration. We sought to evaluate the efficacy of delayed canaliculoplasty with bicanalicular silicone intubation for patients whose canaliculi were not repaired by initial surgery. METHODS: We retrospectively studied the medical records of 4 patients who had bicanalicular obstruction from previous unrepaired canalicular laceration. After careful dissection through the scarred medial canthal region, canaliculoplasty with bicanalicular silicone intubation was performed. The time interval from initial trauma to canaliculoplasty was between 5 months and 10 years. Follow-up periods ranged from 3 weeks to 13 months. RESULTS: All of the canaliculi were reanastmosed. Epiphora disappeared in two, occurred intermittently in one, and persisted in the last at 3 weeks postoperatively. CONCLUSIONS: Delayed canaliculoplasty was functionally effective in three out of four patients. Even though canalicular reconstruction was delayed for a long time, attempting canalicular reconstruction would be recommendable before considering conjunctivodacryocystorhinostomy with a Jones tube.

Surgical Correction for Upper Lid Epiblepharon and Epicanthal Fold in Children

PURPOSE: We evaluated the surgical correction for upper lid epiblepharon and epicanthal fold. METHODS: Epiblepharon repair of the upper lid and epicanthoplasty were performed for patients who had a significant epicanthal fold, by which resultant cilia-cornea touch would be expected of the epiblepharon repair alone. From June, 1998 to February, 2004, 21 patients were operated on and 7 of the patients had Down's syndrome. RESULTS: The mean age of the patients at the time of the surgery was 8.6 years. In all the patients, the epicanthal folds were type 3, according to the Park's classification. Thirteen patients, including Down's syndrome patients, underwent modified Y-V advancement and eight patients underwent root Z-epicanthoplasty. The cilia-cornea touch was relieved in all of the patients except for those with Down's syndrome. Hypertrophic scar was seen in 7 patients with modified Y-V advancement and in 1 patient with root Z-epicanthoplasty until postoperative 3 months. CONCLUSIONS: Epiblepharon repair along with epicanthoplasty was effective in relieving cilia-cornea touch in children with upper lid epiblepharon and significant epicanthal fold. Root Z-epicanthoplasty can be recommended for growing children, considering that it provides moderate degree epicanthal correction and does not leave noticeable scar.

Position-induced Cyclotorsion under Monocular Fixation

PURPOSE: To determine whether cyclotorsion occurs when a patient moves from the seating to supine position fixating with one eye. METHODS: The axis of astigmatism was measured with the handheld automated refractometer (Retinomax K-plus, Nikon, Japan) in 33 eyes having more than -1.0D cylinder in seated and supine positions under monocular fixation. RESULTS: There was a cyclotorsional deviation in 30 eyes (90.90%). Excyclotorsion was shown in 22 eyes (66.67%) and incyclotorsion in 8 (24.24%). Seventeen eyes (51.50%) had a torsional deviation less than 4 degrees, 5 eyes (15.15%) from 5 to 6 degrees, 7 eyes (21.21%) from 7 to 14 degrees and one eye greater than 15 degrees. CONCLUSIONS: Positionally induced cyclotorsion occurs under fixation with one eye simulating refractive surgery. Surgeons should therefore make an effort to align the wavefront measurement to the ablation onto the cornea.

Eyelid Incision for Dacryocystorhinostomy in Asians

PURPOSE: Dacryocystorhinostomy via an eyelid incision has been described in Western literature. This study was undertaken to confirm that eyelid incision for dacryocystorhinostomy is suitable in Asians, because Asians have anatomic features that differ from those of Westerners. METHODS: We performed dacryocystorhinostomy with an eyelid incision along skin wrinkles or relaxed skin tension lines in 57 eyelids of 49 patients from July 2003 to December 2004. The medical records of the patients were reviewed retrospectively. RESULTS: Postoperative scars were easily camouflaged by wrinkles or relaxed skin tension lines of the eyelid without major complications. CONCLUSIONS: An eyelid incision can be used for dacryocystorhinostomy in Asians, regardless of the lack of a definite lower eyelid crease and the presence of epicanthus.

Effect of Thermal Preconditioning Before Excimer Laser Photoablation

The purposes of this study were to assess the expression patterns of heat shock proteins (Hsps), after eyeball heating or cooling, and to elucidate their relationships with corneal wound healing and intraocular complications after excimer laser treatment. Experimental mice were grouped into three according to local pretreatment type: heating, cooling, and control groups. The preconditioning was to apply saline eyedrops onto the cornea prior to photoablation. Following photoablation, we evaluated corneal wound healing, corneal opacity and lens opacity. Hsp expression patterns were elucidated with Western blot and immunohistochemical staining. The heating and cooling groups recovered more rapidly, and showed less corneal and lens opacity than the control group. In the heating and cooling groups, there were more expressions of Hsps in the cornea and lens than in the control group. These results were confirmed in the Hsp 70.1 knockout mouse model. Our study showed that Hsps were induced by the heating or cooling preconditioning, and appeared to be a major factor in protecting the cornea against serious thermal damage. Induced Hsps also seemed to play an important role in rapid wound healing, and decreased corneal and lens opacity after excimer laser ablation.

Tuberculous Blepharitis Following Removal of Intracanalicular Lacrimal Plug

PURPOSE: Diagnosis of tuberculous blepharitis may be delayed because of its nonspecific symptoms such as periocular edema, nodule, and papule. By investigating the route of infection and clinical course of tuberculous blepharitis, it was attempted to emphasize the importance of early diagnosis and treatment. METHODS: After the trial of intracanalicular plug removal, lid edema and nodule were developed in the patient who had been implanted a intracanalicular plug for dry eye. Excisional biopsy of the lesion was performed after treatment trial with local injection of triamcinolone acetonide. Many acid-fast bacilli were found in the microscopic examination. The patient underwent 9-month-scheduled anti-tuberculous medication. RESULTS: The lesion has improved with the medication. Lid ectropion occurred at the site of biopsy. CONCLUSIONS: Tuberculous blepharitis can be developed as a complication of intracanalicular plug procedure for dry eye. Tuberculous infection should be considered as a possible cause of longstanding blepharitis that is unresponsive to supportive treatment. It is emphasized that early diagnosis and proper management are important.

The clinical outcomes of Occlusion for Monocular Amblyopia in Children More than 8 years

PURPOSE: We schemed to help the therapeutic plan in amblyopic children of old age group by analyzing the clinical outcomes of occlusion therapy in amblyopic children more than 8 years old. METHODS: In 104 unilateral amblyopic children whose occlusion therapy had been finished, the retrospective study was performed. The average age at the beginning of treatment was 5.9 years (1.2~15.2 years). We divide the patients into three groups on the basis of age at the beginning of treatment: below 4 years (group 1, N=41), 5~7 years (group 2, N=44), more than 8 years (group 3, N=19). The success rate of occlusion therapy in group 3 was compared with the success rate of other groups, and the clinical features of group 3 were analyzed. RESULTS: The success rate of occlusion therapy in group 3 (68.4%) was significantly low compared with other groups (p<0.05). In group 3, the success rate of anisometropic amblyopia (90.0%) was significnatly higher compared with the success rate of strabismic amblyopia (44.4%)(P<0.05), and it was similar to the success rate of anisometropic amblyopia of other groups. CONCLUSIONS: The success rate of occlusion therapy in amblyopic children more than 8 years old was significantly lower compared with other groups. But the clinical outcomes were fair, especially in anisometropic amblyopia. We suggest to enforce occlusion therapy in amblyopic children more than 8 years old.

Evaluation of the Functional Nasolacrimal Duct Obstruction with Digital Subtraction Dacryocystography

PURPOSE: We evaluated the structural abnormality of the lacrimal drainage system by using digital subtraction dacryocystography in patients with functional nasolacrimal obstruction. METHODS: From April 2001 to March 2002, digital subtraction dacryocystography was performed in 17 eyes of 11 patients who had patent lacrimal systems on syringing with no known underlying cause of epiphora. RESULTS: Six eyes of 5 patients showed a diffuse incomplete nasolacrimal duct obstruction inferior to the lacrimal sac, and one eye of 1 patient had a filling defect in lacrimal sac. Fifteen eyes of 10 patients were received silicone tube intubation and one eye of 1 patient underwent dacryocystorhinostomy. CONCLUSIONS: There might be anatomical abnormalities in the lacrimal drainage system although it is clinically diagnosed as functional nasolacrimal obstruction. Digital subtraction dacryocystography will provide a better understanding on various causes of epiphora, and give a precise diagnosis and proper treatment.

Astigmatism in Children with Epiblepharon

PURPOSE: To compare the prevalance and the amount of astigmatism between the epiblepharon patients who had been operated epiblepharon and normal school children. METHODS: The noncycloplegic refraction using autorefractor was performed in 120 epiblepharon patients from Jan. 1997 to June 2000. Astigmatism in excess of 0.5 D was studied. We compared the findings of epiblephron patients and 443 normal school children in Seoul. RESULTS: The prevalence of astigmatism was 72.9% in epiblephron group and 41.6% in normal children group, and the difference was statistically significant (P< 0.001). The amount of astigmatism was 1.52 D and 0.73 D in each group, and the difference was statistically significant (P< 0.001).The distribution of astigmatism showed 1.0 D or less in 22.5%, from above 1.0 D to 2.0 D or less in 26.3%, from above 2.0 D to 3.0 D or less in 10.8%, from above 3.0 D to 4.0 D or less in 9.6% and above 4.0 D in 3.8% in epiblepharon group and in normal children group 26.2%, 11.2%, 2.6%, 1.0%, and 0.7% respectively. The difference between both groups was statistically significant (P< 0.001). With-the-rule astigmaism was found in 77.9% and against-the-rule was 22.1% in epiblephron group and 72.8% and 27.2% respectively in normal children group. CONCLUSIONS: The prevalence and the amount of astigmatism were higher in epiblepharon group than in normal children group. It might be caused by the increase of orbicularis muscle tone and the effect of skin fold overriding lid margin in epiblepharon patients.