Evaluation of graded recession of inferior oblique muscle for correction of different grades of V-pattern strabismus.

BACKGROUND: V pattern identification is essential for proper strabismus management. Graded recession is a tailored approach to treat inferior oblique overaction (IOOA). The aim is to evaluate the efficacy of graded recession of inferior oblique muscle for correction of different grades of V pattern. METHODS: Forty patients from 3 to 18 years old with V pattern strabismus and primary IOOA were evaluated by prism cover test to assess the grade of IOOA and amplitude of V-pattern. Graded recession of IO muscle depends on the amplitude of the V-pattern and degree of IOOA. Eight mm recession for amplitude 15 PD to 20 PD and mild IOOA (10 PD-15 PD or + 1) ,10 mm recession for amplitude 20-30 PD and moderate IOOA (15-25 PD or + 2) and maximum recession for amplitude more than 30 PD and marked IOOA (≥ 25 PD or + 3). Simultaneous correction of the horizontal deviation was performed. Follow up after I week,1 month ,3 month and 6-month. Trial Registration Number (TRN) (NCT05786053) on 23/3/2023. RESULTS: The mean age of the study patients was 9 ± 4.261. Twenty patients (50%) had V-pattern esotropia, 12 (30%) exotropia, 4 (10%) orthotropic and four (10%) had Dissociated vertical deviation (DVD). Four cases 10% were of grade 1, 20 cases (50%) grade 2 and 16 cases (40%) were of grade 3. Of eighty eyes, 66 eyes (82.5%) were fully corrected with no residual IOOA, and 14 eyes (17.5%) were under corrected. V-pattern was corrected in 28 cases 70% and only 12cases (30%) had residual V-pattern grade 1. CONCLUSIONS: Graded recession is an effective procedure for correction of V pattern strabismus with various grades of primary inferior oblique overaction. It can be tailored according to the the degree of IO overaction which is significantly related to the grade of V pattern. The 8 mm recession for IO was significantly related to recurrence or inadequate break of the V pattern in our studied cases. The grade of IOOA correlates with the amplitude of V-pattern. The amount of recession was planned according to preoperative IOOA and grade of V-pattern with frequent undercorrections obtained by the standard 8 mm recession. A + 2 overaction merits a 10-mm recession of the inferior oblique. A + 3 or + 4 overaction merits a 14-mm maximal recession.

A new treatment modality for the enlarged extraocular muscles.

PURPOSE: evaluation of the role of combined injection of triamcinolone acetonide with 5 Fluorouracil in treatment of the enlarged extraocular muscles secondary to chronic non-specific non-infectious inflammation. METHODS: injection of 0.1 ml of triamcinolone acetonide 40 mg/ml and 0.1 ml of 5 Fluorouracil 50 mg/ml in the enlarged extraocular muscles secondary to chronic non-specific non-infectious inflammation in 6 patients, after the confirmation of the histopathological diagnosis of these patients by revising their medical records. RESULTS: There was a significant improvement in the visual acuity, in addition to a significant improvement also in the clinical and the radiological features in the patients who were consented for the trial of the new injection protocol. However, there was failure of clinical and radiological improvement in one case presented with sever fibrosis. There was a significant absence of the side effects in all patients except for one patient that reported discomfort near the inner canthus. CONCLUSION: The new protocol of the treatment is a promising modality that can be used in the chronic non-infectious inflammation without extensive fibrosis.

Role of muscle biopsy in diagnosis of extraocular muscles enlargement.

PURPOSE: To study the role of muscle biopsy in patients with enlarged extraocular muscles. METHODS: A retrospective review of 31 patients who underwent biopsy for extraocular muscle enlargement. Characteristics, including signs, symptoms, imaging findings, and histopathological assessment were examined. RESULTS: Chronic inflammatory disorders represented the most common cause of the muscle enlargement followed by malignancy/metastasis. Multiple muscle involvement was more consistent with benign diseases, whereas single muscle involvement was more consistent with malignant causes. Positive predictive value of muscle biopsy was 0.52 for determining a specific cause of the muscle enlargement. CONCLUSIONS: Muscle biopsy is the standard for diagnosis in patients with extraocular muscle enlargement. This diagnostic test should be performed in every case of non-resolving muscle enlargement, with a specific diagnosis being made in over half of cases.

Evaluation of intraoperative lagophthalmos formula for levator resection in congenital ptosis in Egyptian patients.

PURPOSE: To evaluate the recent intraoperative lagophthalmos formula method for levator resection in determining postoperative lid height in congenital ptosis on Egyptian patients. METHODS: This is a prospective case series which included 20 eyelids of 17 Egyptian children with congenital ptosis whose levator function is 4 mm or better. They underwent levator muscle resection guided by the recently presented intraoperative lagophthalmos formula. Preoperative Margin-to-Reflex Distance 1 (MRD1) and levator function were measured then intraoperative palpebral fissure opening was determined from formula: Intraoperative lagophthalmos = 9.08 - (0.48 × Preoperative MRD1) - (0.26 × Levator function). Success was defined as postoperative MRD1 ⩾ 3 mm and difference between both eyelid height ⩽1 mm at 6 months. RESULTS: From 20 eyelids, there were five cases with mild (25%), 11 with moderate (55%), and four with severe (20%) ptosis. They showed success in four cases (80%), eight cases (73%), and three cases (75%) in each degree respectively with an overall success of 15 cases (75%). CONCLUSION: Proposed intraoperative lagophthalmos formula showed relatively good results in predicting postoperative eyelid level in Egyptian children with simple congenital ptosis with fair to good levator function.

Eyebrow Elevation as a Prognostic Factor for Success of Frontalis Suspension in Severe Congenital Ptosis.

PURPOSE: The study aims at evaluating eyebrow elevation as a prognostic factor for frontalis sling procedure success in patients suffering from severe congenital ptosis with poor levator function. PATIENTS AND METHODS: This is a retrospective study that included 66 eyelids of 57 patients selected from a surgical log database between January 2016 and June 2019. All of them underwent frontalis suspension surgery for treating severe congenital myogenic ptosis with poor levator function. Based on the absence or presence of brow elevation, patients were divided into two groups: 1 and 2, respectively. The latter was further subdivided into subgroup A with unilateral brow elevation and subgroup B with bilateral brow elevation. All included cases completed 6 months of follow-up after surgery. Postoperative functional outcomes in the form of margin reflex distance (MRD1) and palpebral aperture (PA) were recorded and correlated to preoperative brow elevation status. RESULTS: Both principal groups showed improvement of MRD1 and PA compared to the preoperative values. There was no statistically significant difference between both groups for the tested parameters in the 1st postoperative week. By the 6th postoperative month, MRD1 and PA showed statistically significant higher values in group 2 compared to group 1 (p<0.001). However, the difference between subgroups A and B was statistically insignificant for the same parameters. CONCLUSION: Eyebrow elevation is significantly associated with the success of frontalis suspension procedure. Hence, brow position evaluation should be included in the preoperative assessment of patients undergoing frontalis suspension for congenital ptosis.

Anterior Segment Optical Coherence Tomography (AS-OCT) Guided Reversal of Edematous Punctal Occlusion.

AIM: To evaluate the role of anterior segment-optical coherence tomography (AS-OCT) in the diagnosis of punctal stenosis and to compare punctal parameters before and after medical treatment. PATIENTS AND METHODS: The study was conducted on 40 eyes of 24 patients who had acquired inflammatory punctal stenosis and had persistent epiphora (persistent epiphora group - PEG), and 20 eyes of 10 subjects with normal punctal openings as a control group (control group - CG). We measured the outer punctal diameter (OPD), recorded the visibility of the internal punctum and punctal depth (PD) using AS-OCT, before and 1 month after treatment with preservative free methylprednisolone 5% eye drops. Punctal diameter, tear meniscus height (TMH) and Munk's score were compared to the control group before and after treatment. RESULTS: The mean OPD of the PEG before treatment (455.5 ± 174 µm) was significantly smaller than that of the CG (590.9 ± 106.6 µm) (P= 0.002). The mean OPD of the PEG significantly increased to 484.6 ± 175.5 µm after treatment (P <0.001). Also, the visibility of vertical canaliculus lumen and PD were restored in 70% of eyes. The TMH was much higher in the PEG than in the CG before treatment (P<0.05). However, after treatment the difference was not statistically significant. CONCLUSION: AS-OCT parameters were useful in monitoring and measuring the efficacy of medical treatment in relieving punctal edema, which subsequently resulted in reducing the epiphora symptoms.

Effectiveness of Subconjunctival Cyclosporine in Treatment of Acute Allergic Conjunctivitis in a Rat-Model.

BACKGROUND: Eye allergy is widely spread worldwide. The treatment includes topical anti-histamines, steroids and non-steroidal drugs. Steroids are the first choice by many ophthalmologists, but unfortunately they may cause serious side effects. Cyclosporine A (CsA) is an immunomodulator drug that can improve eye allergy and reduce the need for steroids; however, topical preparation of CsA is difficult because of the lipophilic nature of the drug. METHODS: An experimental study included 16 rats with induced allergy were divided into 2 groups. Group 1: allergic non-treated (6 rats), and Group 2: allergic treated with 0.5 mL subconjunctival CsA 1% (10 rats). Half of each group was sacrificed at 24 hrs and the other half at 1 week. Conjunctival hyperemia and eosinophilic cell count were assessed at each time. RESULTS: Group 2 (CsA treated) showed significantly lower hyperemia score and eosinophilic count at both 24 hrs and 1 week. No ocular complications were noted. CONCLUSION: Subconjunctival CsA was safe and effective in treating ocular allergy through improving conjunctival hyperemia and reducing eosinophilic cell count with no significant ocular side effects.

Pattern of Intermediate Uveitis in an Egyptian Cohort.

Purpose: To describe the clinical experience with intermediate uveitis at six Egyptian tertiary eye centers.Methods: A multicenter retrospective chart review of all patients with intermediate uveitis seen at six ocular inflammation referral clinics in Egypt between January 2010 and January 2017.Results: The study included a total of 781 patients with intermediate uveitis. The study cohort comprised of 282 male and 499 female patients. In over half of our cohort (58.77%), no specific cause could be confirmed. The remaining patients had sarcoidosis (16.26%), tuberculosis (14.85%), multiple sclerosis (9.09%), and TINU (1.02%). By the end of our study, 62% of the affected eyes had a BCVA better than 20/40Conclusion: More than 40% of our patients with intermediate uveitis had sarcoidosis, tuberculosis, multiple sclerosis, or TINU as the underlying etiology. Owing to their potential morbidity, these diseases need to be considered in Egyptian patients presenting with intermediate uveitis.

Prevalence and topographical characteristics of keratoconus in patients with refractive errors in the Egyptian delta.

PURPOSE: To study the prevalence of keratoconus (KC) and the topographical characteristics of the affected corneas in patients with refractive errors who were seeking refractive surgery in the Egyptian delta. METHODS: A retrospective study covering four and half years (Jan 2012-June 2016) where the topographical data of 8124 participants were obtained from the records of a refractive center in the Nile delta region, Egypt. The diagnosis of KC was based on the Holladay criteria in one or both eyes, using the Pentacam scans, whereas grading of KC was based on the Amsler-Krumeich classification. RESULTS: The prevalence of KC was 1.12% (91/8124 participants) with 95% confidence interval 0.91-1.3. Of all the affected cases, 5 cases (5.5%) had unilateral, and the other 86 cases (94.5%) had bilateral KC. The affected and unaffected subjects did not show any significant difference regarding gender. Sixty-eight (38.4%) eyes had stage 1 KC, 53 eyes (29.9%) had stage 2, 27 eyes (15.3%) had stage 3, and 29 eyes (16.4%) had stage 4 KC. It was most prevalent (1.2%) among cases with astigmatism (P < 0.001). CONCLUSION: Keratoconus was found in 1.12% of patients seeking refractive surgery, with no gender preference. Most cases had bilateral affection. Astigmatism was the most common refractive error to be associated with keratoconus.

One-stage reconstruction technique for large congenital eyelid coloboma.

PURPOSE: To determine the functional and cosmetic outcome of using skin graft from prepuce (after circumcision) to reconstruct eyelids in congenital lid coloboma. PATIENT & METHODS: Four male infants with large eyelid coloboma and marked exposure keratopathy were included. All the patients were selected from the outpatient clinic of Tanta University Eye Hospital, Egypt from March 2006 till August 2009. One-stage reconstruction was used to repair the defect. For upper eyelid coloboma, sliding tarsoconjunctival flap with a free skin graft from of skin of prepuce (after circumcision) was done.For lower lid coloboma, conjunctival dissection with reflection over the cornea with use of a free skin graft from prepuce. RESULTS: All infants had large unilateral defect, 3 upper lids and 1 lower lid. The cosmetic and functional outcome of using skin of the prepuce was satisfactory with good color match in all cases. Also functional and cosmetic results of tarsoconjunctival sliding flap was excellent. All the cases were followed up for a period ranged from 7 to 36 months. CONCLUSION: Tarsoconjunctival rotational flap and the use of skin of prepuce are very helpful and seems to be an adequate method of reconstruction of large eyelid defect in male patients when the usual donor sites for skin grafts are not available as in infants.