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.

Ocular Manifestations of Herpes Zoster Ophthalmicus

PURPOSE: To analyze ocular manifestations of herpes zoster ophthalmicus and evaluate risk factors and complications affecting visual acuity. METHODS: Ocular, cutaneous, and systemic findings were analyzed retrospectively from the medical records of 81 patients, admitted between 1994 and 2007, to the dermatology department of our hospital for the management of herpes zoster ophthalmicus. RESULTS: Herpes zoster ophthalmicus was manifested as eyelid eruption (93%), conjunctivitis (80%), keratitis (67%), iridocyclitis (36%), secondary glaucoma (20%), or extraocular muscle palsy (1%). Some patients had accompanying systemic illnesses, including malignancy, hepatitis, diabetes mellitus, chronic obstructive pulmonary disease, tuberculosis, and cerebrovascular disease. Patients with decreased vision during the follow-up period were statistically more likely to have presented with keratitis (p=0.032). However, 86% of these patients recovered vision over a 6-month period. CONCLUSIONS: Patients presenting with keratitis upon initial evaluation are at risk for decreased vision and require appropriate ophthalmic evaluation and management.

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.

Intraoperative Adjustment in Horizontal Strabismus Surgery Using Corneal Reflex

PURPOSE: Using corneal reflex, we performed intraoperative adjustments in horizontal strabismus patients who had very poor visual acuities with good compliance and analyzed various aspects of intraoperative adjustment. METHODS: We retrospectively reviewed the records of patients with horizontal strabismus who underwent intraoperative adjustment using corneal reflex from May 1997 to April 2005. We evaluated various aspects of intraoperative adjustment. RESULTS: Fifty-five patients (40 exotropes, 15 esotropes) were included in our study. 11 of 40 extropes (27.5%) and 4 of 15 esotropes (26.7%) eventually underwent operations that were adjusted intraoperatively. Successful results were seen in 35 of 40 exotropes (87.5%) and 8 of 15 esotropes (53.3%). Fifteen patients (27.3%) received intraoperative adjustments, and of these patients 11 (20.0%) who had successful results would have experienced either undercorrection or overcorrection if their operation were performed as scheduled. Four patients underwent operation on one muscle rather than on the scheduled two muscles. All 4 of these patients (100%) would have experienced significantly large overcorrection had they not received intraoperative adjustment. CONCLUSIONS: Patients who would have had difficulty with fixation due to low visual acuity could avoid under- or overcorrection and are expected to have higher success rates because of intraoperative adjustment using corneal reflex.

Ophthalmic Manifestations in Patients With Neurofibromatosis

PURPOSE: To report the ophthalmic manifestations of neurofibromatosis in Korea. METHODS: Ophthalmologic examinations were performed from November 2001 to January 2008 for 153 consecutive patients who were diagnosed with neurofibromatosis according to the diagnostic criteria for neurofibromatosis. A retrospective analysis was performed according to the medical records of these 153 patients. RESULTS: Seventy seven out of the 153 patients were men, 76 were women and the mean age was 20.44 +/- 14.34 years old. One hundred twelve were neurofibromatosis type 1 and six were neurofibromatosis type 2. Remained thirty five were segmental neurofibromatosis type 1. Ophthalmic manifestations of the neurofibromatosis type 1 were Lisch nodule (52.68%), high myopia (14.29%), plexiform neurofibroma in the orbit (4.46%), cafe au lait spots (4.46%) and optic glioma (3.58%). In the neurofibromatosis type 2, epiretinal membrane (33.33%) showed highest incidence and posterior subcapsular opacity (16.67%), Lisch nodule (16.67%), optic disc edema (16.67%), and optic nerve glioma (16.67%) were also noted. Lisch nodule (25.71%) was the most common ophthalmic finding in segmental neurofibromatosis type 1. CONCLUSIONS: Lisch nodule, which was the most common manifestation of the neurofibromatosis type 1, was less manifested in our cases compared to the previous reports of western countries. In the neurofibromatosis type 2, epiretinal membrane and posterior subcapsular cataract showed higher incidence than those of other types of neurofibromatosis.

The Assessment of Stereoacuity in Patients with Strabismus

PURPOSE: To analyze stereoacuity in patients with strabismus using various stereotests. METHODS: Stereoacuity was assessed in children who were diagnosed with intermittent exotropia or refractive accommodative esotropia using the Titmus stereotest, TNO stereotest, and the Lang II stereotest. Patients with amblyopia or previous ocular surgery were excluded. RESULTS: Ninety-four patients with intermittent exotropia and 36 patients with refractive accommodative esotropia were included; the mean age was 7.2 years. The mean stereoacuity in intermittent exotropia was 143.1+/-207.9 seconds of arc with the Titmus stereotest, 130.2+/-103.7 seconds of arc with the TNO stereotest, and 200.0+/-0.0 seconds of arc with the Lang II stereotest. The mean stereoacuity in refractive accommodative esotropia was 430.3+/-288.6 seconds of arc, 232.5+/-90.0 seconds of arc, and 230.0+/-97.9 seconds of arc, respectively. The absence of stereoacuity was more frequent in patients with refractive accommodative esotropia than in patients with intermittent exotropia, and both groups of patients showed the largest proportion of absent stereopsis with the TNO stereotest. No factor was significant for stereopsis in patients with intermittent exotropia and patients with refractive accommodative esotropia. CONCLUSIONS: Stereoacuity showed various seconds of arc according to the type of stereotest in the same patient. Patients with refractive accommodative esotropia showed lower stereoacuity in all stereotests than patients with intermittent exotropia. TNO stereotests are sensitive enough to detect the absence of stereopsis in patients with strabismus.

Outcomes of 6 Hour Part-time Occlusion Treatment Combined with Near Activities for Unilateral Amblyopia

PURPOSE: To evaluate the outcome of the part-time occlusion therapy with near activities in monocular amblyopic patients according to gender, age, severity of amblyopia, and the cause of amblyopia. METHODS: Fifty eight patients who were prescribed part-time occlusion therapy with near activity from July 1998 to October 2004, were included in this retrospective study. All patients were divided into groups by gender, age, severity of amblyopia, and the cause of amblyopia. Main outcome measures were best corrected visual acuity, line improvement, and success rate. RESULTS: At the end of patch therapy, visual acuity improved from baseline by an average of 3.2+/-2.5 lines (0.33+/-0.26 log MAR), and follow-up period was 19.71+/-14.61 months (1.62+/-1.20 years). At the last follow-up, visual acuity improved from baseline by an average of 3.7+/-2.4 lines (0.38+/-0.26 log MAR), and follow-up period was 37.41+/-25.83 months (3.08+/-2.12 years). The success rate was 86% (50 patients) at the end of patch therapy. In 44 patients out of 50 patients (88%), the visual acuity was maintained. While 43 patients out of 47 patients who were less than 7 years old (91%) achieved success, 7 patients out of 11 patients 7 years or older (64%) achieved success (p=0.035). CONCLUSIONS: Six-hour part-time occlusion treatment combined with near activities appears to be favorable in treating 58 children during follow-up of mean 3.08 years. The significant factor was the age at initial treatment.

Outcomes of 6 Hour Part-time Occlusion Treatment Combined with Near Activities for Unilateral Amblyopia

PURPOSE: To evaluate the outcome of the part-time occlusion therapy with near activities in monocular amblyopic patients according to gender, age, severity of amblyopia, and the cause of amblyopia. METHODS: Fifty eight patients who were prescribed part-time occlusion therapy with near activity from July 1998 to October 2004, were included in this retrospective study. All patients were divided into groups by gender, age, severity of amblyopia, and the cause of amblyopia. Main outcome measures were best corrected visual acuity, line improvement, and success rate. RESULTS: At the end of patch therapy, visual acuity improved from baseline by an average of 3.2+/-2.5 lines (0.33+/-0.26 log MAR), and follow-up period was 19.71+/-14.61 months (1.62+/-1.20 years). At the last follow-up, visual acuity improved from baseline by an average of 3.7+/-2.4 lines (0.38+/-0.26 log MAR), and follow-up period was 37.41+/-25.83 months (3.08+/-2.12 years). The success rate was 86% (50 patients) at the end of patch therapy. In 44 patients out of 50 patients (88%), the visual acuity was maintained. While 43 patients out of 47 patients who were less than 7 years old (91%) achieved success, 7 patients out of 11 patients 7 years or older (64%) achieved success (p=0.035). CONCLUSIONS: Six-hour part-time occlusion treatment combined with near activities appears to be favorable in treating 58 children during follow-up of mean 3.08 years. The significant factor was the age at initial treatment.

One Stage Repair of Berry Syndrome in a Neonate Using an Autologous Arterial Flap / 대한흉부외과학회지

Berry syndrome (a distal aortopulmonary window and a right pulmonary artery originating from the ascending aorta, an intact ventricular septum, a patent ductus arteriosus and an interrupted aortic arch) is a rare complex congenital cardiac malformation. We describe a case of one stage repair with using an autologous arterial flap in a 19-day-old neonate who was suffering with this malformation, and we report on the development of postoperative right pulmonary artery stenosis and its successful management with performing multiple balloon angioplasties.

The Effect on Outcome of Amblyopia Treatment in Children with Anisometropic Amblyopia

PURPOSE: To evaluate the factors affecting treatment outcome of children with anisometropic amblyopia. METHODS: We retrospectively investigated the treatment outcome of 57 children who were diagnosed as anisometropic amblyopia. The age at initial treatment, initial best corrected visual acuity of the amblyopic eye, amount and type of anisometropia, strabismus and compliance of treatment were investigated. RESULTS: The mean age and standard deviation at initial treatment was 5.3+/-1.8(3-9) years. The absolute average values of spherical and cylindrical anisometropia were 2.87+/-1.99D and 1.87+/-2.24D respectively. While compliance was significantly related to treatment outcome, the age at initial treatment, visual acuity on amblyopic eye, amount and type of anisometropia, and strabismus had no significant influence on treatment outcome. CONCLUSIONS: Treatment compliance was the most significant factor in the treatment of anisometropic amblyopia.

Midterm Result of Starnes Operation: A case report / 대한흉부외과학회지

We report here on the midterm results after a Starnes operation for a severely symptomatic neonate with Ebstein's anomaly. A one-day-old baby presented with cyanosis and severe cardiomegaly. We performed patch closure of the tricuspid valve with a central shunt after failure of tricuspid valve repair with vertical plication of the atrialized ventricle at her age of 19 days. The coronary sinus was drained into the right ventricle. She underwent bidirectional cavopulmonary shunt and extracardiac conduit Fontan operation at her age of 16 and 30 months, respectively. She is now 56 months old and is doing very well. The recent follow-up study revealed that she was in normal sinus rhythm and had a normal sized left ventricle with good function and the small right ventricle without thrombus formation.

The Amblyopia and Strabismus Accompanied with Anisometropia

PURPOSE: To study the characteristics of the accompanying amblyopia and strabismus in patients with anisometropia. METHODS: We retrospectively reviewed the medical records of 193 patients, who had either spherical or cylindrical anisometropia of more than 1.00D. Patients were divided into four groups: spherical hyperopic anisometropia, spherical myopic anisometropia, cylindrical hyperopic anisometropia, and cylindrical myopic anisometropia. We investigated the accompanying amblyopia and strabismus. Amblyopia was treated with lens correction and patch therapy and we analyzed the results for 78 patients who fulfilled six-month follow-up examinations. RESULTS: There was no significant difference in the frequency of amblyopia between spherical and cylindrical anisometropia. Spherical myopic anisometropia of more than 3.00D showed a significant increase in the incidence of amblyopia (p=0.001). Spherical hyperopic anisometropia of more than 1.00D, cylindrical hyperopic anisometropia of more than 2.00D, and cylindrical myopic anisometropia of more than 2.00D showed an increased tendency for amblyopia. Between spherical and cylindrical anisometropia, there were no significant differences in the results and duration of amblyopia treatment, and type and frequency of strabismus. CONCLUSIONS: In spherical anisometropia, hyperopic anisometropia has a higher risk for developing amblyopia. We could find the threshold for the development of amblyopia.

Congenital Ptosis Repair by Preserved Fascia Lata with Direct Tarsal and Frontalis Fixation

PURPOSE: To investigate the outcome of frontalis suspension surgery congenital blepharoptosis with poor levator palpebral muscle function using preserved fascia lata with direct tarsal and frontalis fixation method. METHODS: Twelve congenital ptosis patients (fourteen eyes) who underwent frontalis suspension using preserved fascia lata with direct tarsal and frontalis fixation method between July 1999 and June 2002 with the mean follow-up time of 54.8 months (31 months~78 months) included. And the postoperative results were obtained from medical records retrospectively. RESULTS: The desired lid height was achieved in eight out of twelve patients (71.4%) after surgery. In four patients (4 eyes) (28.6%), adjustment was required due to under-correction within one month postoperatively. At a mean follow-up period of 54.8 months, all twelve patients had good final results with no postoperative complications. CONCLUSIONS: Frontalis suspension using preserved fascia lata with direct tarsal and frontalis fixation method provided cosmetically pleasing results with a low rate of ptosis recurrence and complication related to procedures. This method using preserved facia lata could be considered as alternative to the use of autogenous facia lata for the repair of ptosis.

Congenital Ptosis Repair by Preserved Fascia Lata with Direct Tarsal and Frontalis Fixation

PURPOSE: To investigate the outcome of frontalis suspension surgery congenital blepharoptosis with poor levator palpebral muscle function using preserved fascia lata with direct tarsal and frontalis fixation method. METHODS: Twelve congenital ptosis patients (fourteen eyes) who underwent frontalis suspension using preserved fascia lata with direct tarsal and frontalis fixation method between July 1999 and June 2002 with the mean follow-up time of 54.8 months (31 months~78 months) included. And the postoperative results were obtained from medical records retrospectively. RESULTS: The desired lid height was achieved in eight out of twelve patients (71.4%) after surgery. In four patients (4 eyes) (28.6%), adjustment was required due to under-correction within one month postoperatively. At a mean follow-up period of 54.8 months, all twelve patients had good final results with no postoperative complications. CONCLUSIONS: Frontalis suspension using preserved fascia lata with direct tarsal and frontalis fixation method provided cosmetically pleasing results with a low rate of ptosis recurrence and complication related to procedures. This method using preserved facia lata could be considered as alternative to the use of autogenous facia lata for the repair of ptosis.

A Case of Toxic Amblyopia Caused by Methanol Intoxication

PURPOSE: To report a case of visual improvement in methanol poisoning treated with intravenous methylprednisolone. CASE SUMMARY: A 64-year-old man presented with decreasing vision in both eyes after ingesting a car window cleanser. His initial visual acuity was the ability to count fingers in the right eye and hand motion in the left eye. The patient received intravenous methylprednisolone (1.0 gram), slowly over 1 hour. The same dose of methyl prednisolone was repeated on the second and third day. Then, oral prednisolone was given and tapered over a period of 7 weeks. On the 5th day after treatment, there was an improvement in the visual acuity of the right eye to 0.4 but no improvement of vision was observed in the left eye. On 16th day after treatment, the visual acuity was 0.7 in the right eye and counting fingers in the left eye. At 2 months after ingestion, the visual acuity of the right eye returned to 1.0 with no improvement in the left eye. Optic disc pallor was suspected and P100 delay was observed in the left eye with VEP showing a favorable outcome in the right eye. CONCLUSIONS: A visual improvement of 1 eye was observed in methanol poisoning treated with intravenous methylprednisolone.

A Case of Kabuki Syndrome with Ocular Manifestation

PURPOSE: Kabuki syndrome is a rare syndrome of multiple congenital anomalies and mental retardation, which is characterized by a peculiar face resembles Kabuki actor, postnatal growth retardation, and skeletal abnormalities. The ocular feature such as strabismus, amblyopia, ptosis, blue sclera and long palpebral fissure with eversion of the lateral portion of lower eyelid can be seen in this syndrome. We experienced a Kabuki syndrome patient with ocular feature. CASE SUMMARY: A 6 years old girl visited ophthalmology department for frequent blinking, abnormal movement of eyelid. She showed growth retardation, high palate arch, bifid uvula and low hairline. Best corrected visual acuity was 0.5 in the right eye and 0.4 in the left eye. She also presented with mixed astigmatism (right: +sph 1.00;-cyl 3.00 Ax 180, left: +sph 1.00;-cyl 3.50 Ax 180). In addition, Marcus-Gunn jaw winking in her left eye and a long palpebral fissure were noted. She had intermittent exotropia and a tilted optic disc in the left eye.

Replacement of Obstructed Extracardiac Conduits with Autologous Tissue Reconstructions (Peel operation); Early and Midterm Results / 대한흉부외과학회지

BACKGROUND: Reoperation is usually required for a right ventricle to pulmonary artery conduit obstruction caused by valve degeneration, conduit peel formation or somatic growth of the patient. An autologous tissue reconstruction (peel operation), where a prosthetic roof is placed over the fibrotic tissue bed of the explanted conduit, has been used to manage conduit obstructions at our institute since May 2002. Herein, the early and midterm results are evaluated. MATERIAL AND METHOD: Between May 2002 and July 2006, 9 patients underwent obstructed extracardiac conduit replacement with an autologous tissue reconstruction, at a mean of 5.1 years after a Rastelli operation. The mean age at reoperation was 7.5+/-2.4 years, ranging from 2.9 to 10.1 years. The diagnoses included 6 pulmonary atresia with VSD, 2 truncus arteriosus and 1 transposition of the great arteries. The preoperative mean systolic gradient was 88.3+/-22.2 mmHg, ranging from 58 to 125 mmHg. The explanted conduits were all Polystan valved pulmonary conduit (Polystan, Denmark). A bioprosthetic valve was inserted in 8 patients, and a monocusp ventricular outflow patch (MVOP) was used in 1 patient. The anterior wall was constructed with a Gore-Tex patch (n=7), MVOP (n=1) and bovine pericardium (n=1). Pulmonary artery angioplasty was required in 5 patients and anterior aortopexy in 2. The mean cardiopulmonary bypass time was 154 minutes, ranging from 133 to 181 minutes; an aortic crossclamp was not performed in all patients. The mean follow-up duration was 20 months, ranging from 1 to 51 months. All patients were evaluated for their right ventricular outflow pathway using a 3-D CT scan. RESULT: There was no operative mortality or late death. The mean pressure gradient, assessed by echocardiography through the right ventricular outflow tract, was 20.4 mmHg, ranging from 0 to 29.6 mmHg, at discharge and 26 mmHg, ranging from 13 to 36 mmHg, at the latest follow-up (n=7, follow-up duration >1 year). There were no pseudoaneurysms, strictures or thrombotic occlusions. CONCLUSION: A peel operation was concluded to be a safe and effective re-operative option for an obstructed extracardiac conduit following a Rastelli operation.

Full Tendon Transposition Augmented with Posterior Intermuscular Suture and Recession-Resection Surgery

PURPOSE: To report an effect of the full tendon transposition augmented with posterior intermuscular suture and recession-resection surgery, for the patient with monocular elevation deficiency (MED) and large exotropia. METHODS: Interventional case report. Full tendon transposition augmented with posterior intermuscular suture and recession-resection surgery was performed for a 26-year-old male patient had monocular elevation deficiency (MED) and large exotropia. RESULTS: Preoperative angle of deviation was 56 prism diopters (PD) hypotropia and 45 PD right exotropia, compared with 18 PD left hypertropia and 10 PD right esotropia postoperatively. Essotropia persisted after 2.5 years, however, and so the right medial rectus was recessed after removal of the previous posterior intermuscular suture. At a three-year follow-up after the second surgery, alignment was straight in the primary position at near and far distances. CONCLUSIONS: Full tendon transposition augmented with posterior intermuscular suture and recession-resection surgery was effective for a patient with MED associated with significant horizontal deviation, and a second operation was easily performed when overcorrection occurred.

Morphological Changes in Extraocular Muscle of Rabbit Eye Produced by Subtenon's Botulinum A Toxin Chemodenervation

PURPOSE: Currently, when injecting botulinum a toxin into the extraocular muscle, EMG (Electromyography) is used for accurate location. In this study, we examined the effects of subtenon botulinum toxin injection without EMG guidance by quantifying the morphological changes of the extraocular muscle fibers in rabbits. METHODS: Using 10 New Zealand white rabbits, 10 units of botulinum a toxin in 0.1 ml of normal saline was injected into the subtenon space of the superior rectus muscles, 5 mm from the muscle insertion in right eyes. As a control, 0.1 ml of normal saline was injected into the subtenon space of the superior rectus muscles in left eyes. At 3 weeks after injections, the bilateral superior rectus muscles of each rabbit were carefully dissected from the globe. Cross-sections of 5 micrometer thickness were obtained at the site, 5 mm from the insertion of each superior rectus muscle. Sections were stained with Masson's trichrome and observed by light microscopy. Using Image-Pro Plus software, the diameter of the orbital layer myofibers was measured and statistical analysis was done using the Kruskal-Wallis test. RESULTS: The average diameter of the orbital layer fiber cells after botulinum toxin injection was 11.5+/-2.26 micrometer at 3 weeks, whereas that of the control was 14.4+/-3.77 micrometer. The difference was statistically significant (p<0.01). CONCLUSIONS: The diameter of myofibers in the orbital layer was reduced after subtenon botulinum a toxin injection. Further studies on the duration of botulium toxin in subtenon space and the change in the size of myofibers depending on the dosage of botulinum toxin will be necessary.

Calcium Uptake and Release through Sarcoplasmic Reticulum in the Inferior Oblique Muscles of Patients with Inferior Oblique Overaction

We characterized and compared the characteristics of Ca2+ movements through the sarcoplasmic reticulum of inferior oblique muscles in the various conditions including primary inferior oblique overaction (IOOA), secondary IOOA, and controls, so as to further understand the pathogenesis of primary IOOA. Of 15 specimens obtained through inferior oblique myectomy, six were from primary IOOA, 6 from secondary IOOA, and the remaining 3 were controls from enucleated eyes. Ryanodine binding assays were performed, and Ca2+ uptake rates, calsequestrins and SERCA levels were determined. Ryanodine bindings and sarcoplasmic reticulum Ca2+ uptake rates were significantly decreased in primary IOOA (p < 0.05). Western blot analysis conducted to quantify calsequestrins and SERCA, found no significant difference between primary IOOA, secondary IOOA, and the controls. Increased intracellular Ca2+ concentration due to reduced sarcoplasmic reticulum Ca2+ uptake may play a role in primary IOOA.