Transient Inferior Oblique Muscle Palsy Following Transconjunctival Lower Lid Blepharoplasty / 고신대학교의과대학학술지

Although the inferior oblique (IO) muscle is positioned considerably deep in the orbit, transconjunctival lower lid blepharoplasty may affect it and transient or permanent IO muscle palsy might result. Therefore diplopia should be explained before cosmetic blepharoplasty performed with transconjunctival approach.

Korean Version Self-testing Application for Reading Speed

PURPOSE: This study introduces a reading chart application for the iPad tablet in the Korean language and investigates the reading speed in a normal-sighted population according to age group. METHODS: Sixty-three Korean sentences were selected from textbooks for second grade elementary school students. A commonly used typeface in everyday printed material, “BatangChe,” was used. Letter size was presented in logarithm of the minimum angle of resolution (logMAR) 0.0 to 1.0 at 0.1 logMAR steps at a reading distance of 40 cm. A third generation retina display iPad was used to present the chart, and the sentences were presented randomly for each size of letter. The subjects repeated the test silently (reading only) and out loud (reading and speaking) to prevent them from skipping reading words. Pilot testing followed in 65 normal vision adults under 60 years of age. RESULTS: The mean reading only speed for logMAR 0.5 optotype (point 10) was 121.1 ± 47.2 words per minute (wpm) for people in their 20s (n=21), 116.5 ± 38.3 in their 30s (n=27), 93.8 ± 12.6 in their 40s (n=9), and 56.5 ± 42.7 (n=8) in their 50s. There was a significant correlation between age and reading and speaking speed (r=−0.48, p<0.001). The mean reading only speed for logMAR 0.5 optotype (point 10) was 202.3 ± 88.4 wpm and the mean reading and speaking speed was 129.7 ± 25.9 wpm, with significantly different (p<0.001). CONCLUSIONS: This Korean reading chart application could present a new standard when checking reading speed according to age groups.

Evaluation of Prognostic Factors and Outcomes of Single-Stage Adjustable Strabismus Surgery in Thyroid Eye Disease

PURPOSE: To evaluate the prognostic factors that contribute to favorable surgical outcomes of single-stage adjustable strabismus surgery in thyroid eye disease. METHODS: Retrospective review of clinical case notes were done of all patients who had surgical treatment for strabismus related to thyroid eye disease under the care of a single hospital between January 2005 and December 2012 (n = 30). Factors that possibly influenced the outcome were statistically analyzed for significance. "Successful" surgical outcome was defined as patients whose residual deviation was within 8 prism diopters and free from diplopia in the primary position on postoperative 1 year. RESULTS: Mean preoperative vertical deviation was 17.5 prism diopters (PD) and horizontal deviation was 20.3 PD. Mean follow-up time was 12.4 months. Twenty-four patients (80.0%) had successful surgical results. Four patients (13.3%) needed further surgery due to recurrence of previous strabismus and two patients (6.7%) needed prism glasses due to remaining strabismus. Previous history of proptosis (p = 0.02), optic neuropathy (p = 0.01), intravenous (IV) steroid pulse therapy (p = 0.02), number of times of IV steroid pulse therapy (p = 0.01), and orbital decompression surgery (p = 0.03) were different between success and failure groups. CONCLUSIONS: Single-stage adjustable strabismus surgery under topical anesthesia showed a success rate of 80% for strabismus patients with thyroid eye disease. Patients who previously had proptosis, optic neuropathy, IV steroid pulse therapy, and orbital decompression surgery significantly showed unsuccessful results after strabismus surgery.

Bitemporal Hemianopsia in Ethambutol-Induced Optic Neuropathy

PURPOSE: To report three cases with bitemporal hemianopsia after using ethambutol to treat tuberculosis. CASE SUMMARY: A 50-year-old male with chronic renal failure and tuberculous pleurisy, a 57-year-old male with diabetic retinopathy and pulmonary tuberculosis, and a 59-year-old male with diabetes and pulmonary tuberculosis were referred for evaluation due to decreased visual acuity for several months after taking ethambutol to treat tuberculosis. All 3 patients had abnormal color vision and visual evoked potential in both eyes. Visual field showed bitemporal hemianopsia with or without central scotoma. Brain imaging tests were normal. Although ethambutol was discontinued in all three patients, one patient with renal disease showed further decrease in visual acuity and visual field worsened to total field defect. CONCLUSIONS: Ethambutol-induced optic neuropathy is a wide spectrum disorder and based on our cases, can present as bitemporal hemianopsia mimicking compressive chiasmal lesions. A thorough history should be taken and immediate discontinuation of ethambutol is recommended in cases when bitemporal hemianopia occurs.

Clinical Manifestations and Surgical Outcomes of Double Elevator Palsy

PURPOSE: To evaluate the clinical manifestations of double elevator palsy and describe the surgery outcomes in patients. METHODS: We performed a retrospective chart review of all patients who were treated surgically for double elevator palsy between 1999 and 2012 at Yonsei University, Severance Hospital in Seoul, Korea. RESULTS: Overall, 15 subjects (7 males and 8 females) with a mean age of 14.6 years (range, 3-40 years) underwent their first surgery during the study period. All patients received inferior rectus recession as a primary procedure. Nine patients (60.0%) underwent a secondary procedure which included 4 cases of horizontal muscle transposition, 2 cases of correction of exotropia, and 3 cases of correction of hypotropia and exotropia simultaneously. The mean preoperative hypotropia was decreased from 29.9 +/- 8.4 prism diopter (PD) to 4.7 +/- 5.3 PD postoperatively. Mean follow-up period was 40.9 +/- 48.2 months. Seven patients (46.7%) underwent eyelid surgery for true ptosis. At last follow-up, a majority of patients showed mild or no amblyopia. CONCLUSIONS: Primary inferior rectus recession and additive secondary horizontal muscle transposition surgery was effective in treatment of double elevator palsy. The clinical manifestations and surgical outcomes of monocular elevation deficiency in the present study can help in the treatment of Korean patients.

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.

Phacoemulsification Alone versus Phacoemulsification Combined with Trabeculectomy for Primary Angle-Closure Glaucoma

Surgical outcomes of phacoemulsification only and phacoemulsification combined with trabeculectomy were compared in patients with primary angle-closure glaucoma (PACG). Clinical records of 41 consecutive patients were retrospectively reviewed, and there was no difference in best-corrected visual acuity and intraocular pressure preoperatively and at the final follow-up in both study groups. Regarding the number of anti-glaucoma medications, it was higher in the phacoemulsification combined with trabeculectomy group preoperatively than the phacoemulsification only group (p = 0.045), but both groups were taking similar quantities of medication at the final follow-up (p = 0.6). In addition, postoperative hypotony (two cases) occurred only after phacoemulsification combined with trabeculectomy, but not after phacoemulsification only. In one case after phacoemulsification only, a second operation was needed. There were no additional postoperative complications. In conclusion, both phacoemulsification only and phacoemulsification combined with trabeculectomy showed good surgical outcomes in PACG patients. Both procedures might be equally effective in treating patients with PACG.

Attention Deficit Hyperactivity in Exotropia Before and After Strabismus Surgery

PURPOSE:To evaluate the effect of strabismus surgery in exotropia patients suspected of attention deficit hyperactivity disorder (ADHD). METHODS: Parents of 67 exotropia patients answered the Conner Teacher Rating Scale-Revised for suspecting ADHD before and after 3 months of surgery. Patients were divided into 2 groups by preoperative scale scores. Group 1 had scores under 15 and group 2 who were suspected to have ADHD had scores above 15. Characteristics of exotropia and scale score differences were evaluated. RESULTS: Group 1 had 43 patients and group 2 had 24 patients. The ratio of group 2 was significantly higher in boys than in girls (P=0.048). The scale scores increased by 1.30 points in group 1 and decreased by 1.04 points in group 2 but there was no significant difference. Scale scores in each group showed no significant difference according to surgical outcome. CONCLUSIONS: In exotropia patients, there was no significant change in scale scores of ADHD after strabismus surgery.