Small tuck for superior oblique palsy.

PURPOSE: To investigate the surgical outcomes of small superior oblique (SO) tuck-denoting minimal tendon laxity-in patients with unilateral SO palsy. METHODS: The medical records of consecutive patients treated with ≤6 mm SO tuck from 2000 to 2018 at Kellogg Eye Center, University of Michigan, were reviewed retrospectively. Tendon tucks were performed to a fairly uniform tension in an amount that just eliminated slack in the tendon. Pre- and postoperative motility measurements were compared. Patients were excluded if they had a history of prior strabismus surgery or concurrent vertical rectus or inferior oblique surgery. RESULTS: A total of 27 cases (14 males) met inclusion criteria. The median age at surgery was 47 years (range 3-74 years). The mean SO tuck (total, both arms of tuck) was 4.9 mm (range, 2-6 mm). After surgery, median hypertropia decreased from 9Δ to 1Δ in primary position and from 20Δ to 4Δ in the SO field of action (contralateral downgaze). Lateral incomitance (difference in hypertropia between contralateral and ipsilateral gaze) decreased from 10Δ to 2Δ (P < 0.001 in each case). Six patients had diplopia in upgaze postoperatively that was not symptomatic enough to require reoperation. Six patients had residual hypertropia requiring additional surgery. CONCLUSIONS: Small SO tuck provided disproportionate correction of hypertropia in the SO field of action and nearly eliminated lateral incomitance without producing unacceptable iatrogenic Brown syndrome. Even in the absence of tendon laxity, SO tuck was a good surgical option for SO palsy in our cohort where there was marked lateral incomitance and the greatest deviation was in the SO field of action.

Multispecialty Management of Metastatic Colon Adenocarcinoma Involving the Extraocular Muscles: Primary Excision and Simultaneous Treatment of Strabismus With a Review of the Literature.

Metastatic colon adenocarcinoma involving the extraocular muscles is extremely rare. It usually develops following the diagnosis of the systemic disease and therefore, management and treatment require a multispecialty approach. Within this manuscript, we provide a summary of cases of orbital metastasis secondary to colon cancer. We further discuss a detailed case of a 42-year-old male patient who developed recent-onset diplopia in the left gaze. Orbital CT imaging showed a localized, well-circumscribed enlargement of the right medial rectus muscle. The biopsy of the right medial rectus showed adenocarcinoma originating from the gastrointestinal system. Further workup revealed colon adenocarcinoma with multiple metastatic sites. The patient started systemic chemotherapy. After 2 months of chemotherapy (5-fluouracil, oxaliplatin, irinotecan, and leucovorin), all systemic metastatic sites regressed; however, his medial rectus muscle continued to grow, causing compressive optic neuropathy. The patient underwent excisional biopsy of the right medial rectus muscle with simultaneous repair of the strabismus with transposition of superior and inferior recti muscles. He continued with systemic chemotherapy. Follow up in 1 year revealed no local orbital tumor recurrence with excellent visual acuity and no diplopia in primary gaze.

Resolution of cyclic esotropia with 5-year follow-up after brief Fresnel prism treatment.

Cyclic esotropia is a rare form of strabismus that is characterized by a recurring esotropic deviation, usually with a 48-hour cycle. On esotropic days, the patient has a constant deviation with suppression, followed by a day with straight eyes and good binocular function. We report a case of cyclic esotropia in which the cycling resolved with 2 months of Fresnel prism for the amount of the distance deviation on her "straight" days. Five years later, with low plus hyperopic correction, she remains with a stable esophoria and normal stereopsis.

Sandblasting promotes shrub encroachment in arid grasslands.

Shrub encroachment is a common ecological state transition in global drylands and has myriad adverse effects on grasslands and the services they provide. This physiognomic shift is often ascribed to changes in climate (e.g. precipitation) and disturbance regimes (e.g. grazing and fire), but this remains debated. Aeolian processes are known to impact resource distribution in drylands, but their potential role in grassland-to-shrubland state changes has received little attention. We quantified the effects of 'sandblasting' (abrasive damage by wind-blown soil) on the ecophysiology of dryland grass vs shrub functional types using a portable wind tunnel to test the hypothesis that grasses would be more susceptible to sandblasting than shrubs and, thus, reinforce transitions to shrub dominance in wind-erodible grasslands when climate- or disturbance-induced reductions in ground cover occur. Grasses and shrubs responded differently to sandblasting, wherein water-use efficiency declined substantially in grasses, but only slightly in shrubs, owing to grasses having greater increases in day/nighttime leaf conductance and transpiration. The differential ecophysiological response to sandblasting exhibited by grass and shrub functional types could consequently alter the vegetation dynamics in dryland grasslands in favour of the xerophytic shrubs. Sandblasting could thus be an overlooked driver of shrub encroachment in wind-erodible grasslands.

Comparison of Unilateral and Bilateral Surgical Approaches for the Treatment of Age-Related Divergence Insufficiency Esotropia.

PURPOSE: Age-related divergence insufficiency-esotropia (ARDIE) is characterized by greater esodeviation at distance than near. This study aims to compare the outcomes of unilateral and bilateral surgical approaches. PATIENTS AND METHODS: Sixty-two cases treated at the Kellogg Eye Center, the University of Michigan, from 1995 to 2018 were retrospectively reviewed. One surgeon used unilateral procedures including unilateral medial rectus recession (n = 24, group 1) or unilateral recession-resection (n = 18, group 2) with an adjustable suture. Another surgeon used bilateral medial rectus recession with fixed sutures (n = 20, group 3). RESULTS: For patients with distance esodeviation <15∆, postoperative distance deviations in both group 1 and group 3 were not statistically different (p = .352). For patients with esodeviations 15-20∆, postoperative distance deviations in all 3 groups were also not statistically different (p = .142). Similarly, patients with deviations >20∆ did not show significantly different postoperative distance alignment (p = .082) between group 2 and 3. Overall, group 2 had the highest overall success rate (90%) (mean at distance = 1.17∆ exodeviation, at near = 2.33∆ exodeviation). CONCLUSION: Both unilateral medial rectus recession ± lateral rectus resection and bilateral medial rectus recession surgical approaches produced similar favorable outcomes in ARDIE.

Woody-plant encroachment: Precipitation, herbivory, and grass-competition interact to affect shrub recruitment.

Woody-plant encroachment is a global phenomenon that has been affecting the southwestern United States since the late 1800s. Drought, overgrazing, herbivory, and competition between grasses and shrub seedlings have been hypothesized as the main drivers of shrub establishment. However, there is limited knowledge about the interactions among these drivers. Using a rainfall manipulation system and various herbivore exclosures, we tested hypotheses about how precipitation (PPT), competition between grasses and shrub seedlings, and predation affect the germination and first-year survival of mesquite (Prosopis glandulosa), a shrub that has encroached in Southern Great Plains and Chihuahuan Desert grasslands. We found that mesquite germination and survival (1) increased with increasing PPT, then saturated at about the mean growing season PPT level, (2) that competition between grasses and shrub seedlings had no effect on either germination or survival, and (3) that herbivory by small mammals decreased seedling establishment and survival, while ant granivory showed no effect. In addition to its direct positive effect on survival, PPT had an indirect negative effect via increasing small mammal activity. Current models predict a decrease in PPT in the southwestern United States with increased frequency of extreme events. The non-linear nature of PPT effects on Mesquite recruitment suggests asymmetric responses, wherein drought has a relatively greater negative effect than the positive effect of wet years. Indirect effects of PPT, through its effects on small mammal abundance, highlight the importance of accounting for interactions between biotic and abiotic drivers of shrub encroachment. This study provides quantitative basis for developing tools that can inform effective shrub management strategies in grasslands and savannas.

A 2020 Update on 20/20 X 2: Diplopia after Ocular Surgery: Diplopia after Orbital Surgery.

In a review of 261 strabismus surgeries performed after previous orbital surgery, it was found that diplopia associated with orbital surgery most commonly occurs after orbital decompression for thyroid eye disease or after repair of orbital fractures. Other types of orbital surgery account for only a small number of cases. While the orbital surgery itself may contribute to the development or worsening of diplopia, in most cases, the post-operative strabismus is largely attributable to the underlying disease or trauma. However, in a small number of cases, a specific surgical misadventure can result in diplopia.

Novel TMEM98, MFRP, PRSS56 variants in a large United States high hyperopia and nanophthalmos cohort.

Nanophthalmos is a rare condition defined by a small, structurally normal eye with resultant high hyperopia. While six genes have been implicated in this hereditary condition (MFRP, PRSS56, MYRF, TMEM98, CRB1,VMD2/BEST1), the relative contribution of these to nanophthalmos or to less severe high hyperopia (≥ + 5.50 spherical equivalent) has not been fully elucidated. We collected probands and families (n = 56) with high hyperopia or nanophthalmos (≤ 21.0 mm axial length). Of 53 families that passed quality control, plausible genetic diagnoses were identified in 10/53 (18.8%) by high-throughput panel or pooled exome sequencing. These include 1 TMEM98 family (1.9%), 5 MFRP families (9.4%), and 4 PRSS56 families (7.5%), with 4 additional families having single allelic hits in MFRP or PRSS56 (7.5%). A novel deleterious TMEM98 variant (NM_015544.3, c.602G>C, p.(Arg201Pro)) segregated with disease in 4 affected members of a family. Multiple novel missense and frameshift variants in MFRP and PRSS56 were identified. PRSS56 families were more likely to have choroidal folds than other solved families, while MFRP families were more likely to have retinal degeneration. Together, this study defines the prevalence of nanophthalmos gene variants in high hyperopia and nanophthalmos and indicates that a large fraction of cases remain outside of single gene coding sequences.

Soil organic carbon in drylands: shrub encroachment and vegetation management effects dwarf those of livestock grazing.

Dryland ecosystems occur worldwide and play a prominent, but potentially shifting, role in global biogeochemical cycling. Widespread woody plant proliferation, often associated with declines in palatable grasses, has jeopardized livestock production in drylands and prompted attempts to reduce woody cover by chemical or mechanical means. Woody encroachment also has the potential to significantly alter terrestrial carbon storage. However, little is known of the long-term biogeochemical consequences of woody encroachment in the broader context of its interaction with common dryland land uses, including "brush management" (woody plant clearing) and livestock grazing. Present assessments exhibit considerable variation in the consequences of these land use/land cover changes, with evidence that brush management may counteract sizeable impacts of shrub encroachment on soil biogeochemical pools. A challenge to assessing the net effects of brush management in shrub-encroached grasslands on soil organic carbon (SOC) and total nitrogen (N) pools is that land management practices are typically considered in isolation, when they are co-occurring phenomena. Furthermore, few studies have assessed spatial patterns in brush management and how these are affected in decades following treatment on sites with contrasting grazing histories. To address these uncertainties and interactions, we quantified the impacts of shrub encroachment and their subsequent mortality resulting from brush management (herbicide application) on SOC and N pools in a Sonoran Desert grassland where long-term grazing manipulations (>100 yr) co-occur with shrub encroachment and brush management. Pools of SOC and N associated with herbicided shrubs declined markedly over ~40 yr, offsetting 66% of the increases from shrub encroachment. However, spatial patterns in SOC induced by shrubs persisted over the decades following brush management. Century-long protection from grazing did little to change SOC and N pools. Accordingly, shrub encroachment and shrub mortality from brush management each far outweighed livestock grazing impacts. Consideration of the patterns of SOC and N through space (e.g., bole-to-dripline gradients), time (e.g., shrub age/size), land use (e.g., livestock grazing and brush management), and their interactions will position us to improve predictions of SOC and N responses to land use/land cover change, inform C-based management decisions, and objectively evaluate trade-offs with other ecosystem services.

Age at Craniosynostosis Surgery and Its Impact on Ophthalmologic Diagnoses: A Single-Center Retrospective Review.

BACKGROUND: Ocular abnormalities in craniosynostosis are a persistent concern for patients and providers, and some surgeons feel that early surgical intervention for synostosis alleviates the progression of ophthalmologic abnormalities. In contradistinction, the authors hypothesize that operating early will have no bearing on postoperative ophthalmologic outcomes. METHODS: Single-suture craniosynostosis patients who underwent surgical correction between 1989 and 2015 were reviewed. Patients with multisuture craniosynostosis, syndromic diagnoses, no preoperative ophthalmology evaluation, and less than 2 years of follow-up were excluded. Logistic regression was used to determine odds of preoperative and postoperative ophthalmologic abnormalities by age, while controlling for patient-level covariates. RESULTS: One hundred seventy-two patients met inclusion criteria. The median age at surgery was 10 months (interquartile range, 7 to 12.9 months). Increasing age at the time of surgery was associated with increased odds of preoperative ophthalmologic diagnoses (OR, 1.06; p = 0.037) but not postoperative diagnoses (OR, 1.00; p = 0.91). Increasing age at surgery was also not associated with increased odds of ophthalmologic diagnoses, regardless of timing (OR, 1.04; p = 0.08). Patients with coronal synostosis (OR, 3.94; p = 0.036) had significantly higher odds of preoperative ophthalmologic diagnoses. Patients with metopic (OR, 5.60; p < 0.001) and coronal (OR, 7.13; p < 0.001) synostosis had significantly higher odds of postoperative ophthalmologic diagnoses. CONCLUSIONS: After reviewing an expansive cohort, associations of both overall and postoperative ophthalmologic diagnoses with age at surgery were not found. The authors' findings thus run counter to the theory that early surgical intervention lessens the likelihood of postoperative ophthalmologic diagnoses and improves ophthalmologic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Variants in myelin regulatory factor (MYRF) cause autosomal dominant and syndromic nanophthalmos in humans and retinal degeneration in mice.

Nanophthalmos is a rare, potentially devastating eye condition characterized by small eyes with relatively normal anatomy, a high hyperopic refractive error, and frequent association with angle closure glaucoma and vision loss. The condition constitutes the extreme of hyperopia or farsightedness, a common refractive error that is associated with strabismus and amblyopia in children. NNO1 was the first mapped nanophthalmos locus. We used combined pooled exome sequencing and strong linkage data in the large family used to map this locus to identify a canonical splice site alteration upstream of the last exon of the gene encoding myelin regulatory factor (MYRF c.3376-1G>A), a membrane bound transcription factor that undergoes autoproteolytic cleavage for nuclear localization. This variant produced a stable RNA transcript, leading to a frameshift mutation p.Gly1126Valfs*31 in the C-terminus of the protein. In addition, we identified an early truncating MYRF frameshift mutation, c.769dupC (p.S264QfsX74), in a patient with extreme axial hyperopia and syndromic features. Myrf conditional knockout mice (CKO) developed depigmentation of the retinal pigment epithelium (RPE) and retinal degeneration supporting a role of this gene in retinal and RPE development. Furthermore, we demonstrated the reduced expression of Tmem98, another known nanophthalmos gene, in Myrf CKO mice, and the physical interaction of MYRF with TMEM98. Our study establishes MYRF as a nanophthalmos gene and uncovers a new pathway for eye growth and development.

Shrub encroachment into grasslands: end of an era?

Shifts in the abundance of grasses and woody plants in drylands have occurred several times during the Holocene. However, our understanding of the rates and dynamics of this state-change in recent decades is limited to scattered studies conducted at disparate spatial and temporal scales; the potential misperceptions of shrub cover change could be remedied using cross spatiotemporal scale analyses that link field observations, repeat ground-level photography and remote sensing perspectives. The study was conducted across a semi-arid landscape in southern Arizona. Local data from long-term transects revealed three distinct chronological phases of shrub cover change: expansion (1961-1991, 0.7% y-1), decline (1992-1997, -2.3% y-1) and stabilization (1998-2012, 22-25% with no net cover change). Twenty-eight years (1984-2011) of broad-scale Landsat Thematic Mapper assessments confirm that shrub cover has been relatively stable in recent decades regardless of grazing regimes and landforms with the exception of the proliferation of succulents at lower elevations (verified by repeat photography acquired in 1987 and 2015) where the physical environment is the harshest, reflecting elevated temperature and winter precipitation deficit. Warmer, drier future climates are predicted to reduce woody plant carrying capacity and promote a shift to xerophytic succulents.

Surgical Management of Ophthalmoplegia.

Surgical management-depending upon the severity of the ophthalmoplegia-ranges from restorative to palliative. In paresis with reasonable residual muscle function and ductions, the goal of the surgery is not only to restore single vision in primary position but also to provide a relatively normal field of single binocular vision. With complete paralysis of a single muscle or more than one muscle served by a single cranial nerve (third), in addition to conventional recess or resect surgery, the transposition of still-functioning muscles is often needed to obtain a durable result and restore at least some field of single binocular vision. In complete ophthalmoplegia, the benefits of the surgery are limited; but even in these cases, surgery can often reduce the need for an awkward head posture and improve appearance.

The effect of oral statin therapy on strabismus in patients with thyroid eye disease.

BACKGROUND: Statins, known to possess anti-inflammatory characteristics, have recently been identified as potentially reducing the risk of developing thyroid eye disease (TED) in Graves disease patients. The current study investigates the effect of oral statin therapy on strabismus related to TED. METHODS: This is a retrospective review of patients with a diagnosis of both TED and restrictive strabismus. Oral statin users and nonusers were analyzed for smoking status, previous radioactive iodine, thyroidectomy, number of decompressions, motility restriction, amount of strabismus, number of surgeries, surgical dose, and number of muscles involved on radiography. RESULTS: Thirty patients (average age, 63.9 years; 50% male; 59% current/former smokers) were included: 12 statin users and 18 nonusers. Statin users averaged fewer decompressions (1.3 in users vs 2.4 in nonusers [P = 0.04]). Statin users on average had 15 mm of total strabismus surgery compared with 21.4 mm in the nonuser group (P = 0.09) and had fewer muscles involved radiographically (4.3 vs 5.1 [P = 0.08]) CONCLUSIONS: Compared to nonusers, statin users tended to have fewer decompressions, less restriction, fewer surgeries, and fewer muscles involved despite having more current smokers (36% vs 5%), more males, more RAI, and fewer thyroidectomies, all of which are associated with worse TED. In our cohort of patients with TED and strabismus, statin therapy significantly reduced the number of orbital decompressions. Oral statin therapy also trended toward reducing the number and amount of strabismus surgeries as well as radiographic indication of muscle involvement, although these did not meet statistical significance.