Unusual and Rare Causes of Monocular Elevation Deficit.

INTRODUCTION: To study the rare and unusual causes of monocular elevation deficit. METHODS: Five patients presenting to us with diplopia and elevation deficit were thoroughly examined and were found to have monocular elevation deficit due to rare causes. OBSERVATIONS: All five were found to have different underlying etiologies - iatrogenic, sphenoid wing meningioma, cysticercosis, sarcoidosis and mid brain infarct, and were managed appropriately. DISCUSSION: Monocular Elevation Deficit can occur due to a variety of causes. Having a high index of suspicion for the more serious etiologies is of utmost importance. Thorough clinical examination and imaging help clinch the diagnosis.

Comprehensive review of amblyopia: Types and management.

The optimal method of treatment for a child depends on the patient's age at the time of diagnosis, the onset and type of amblyopia, and the degree of compliance attainable. In deprivation amblyopia, the cause of visual impairment (e.g., cataract, ptosis) needs to be treated first, and then the disorder can be treated such as other types of amblyopia. Anisometropic amblyopia needs glasses first. In strabismic amblyopia, conventionally amblyopia should be treated first, and then strabismus corrected. Correction of strabismus will have little if any effect on the amblyopia, although the timing of surgery is controversial. Best outcomes are achieved if amblyopia is treated before the age of 7 years. The earlier the treatment, the more efficacious it is. In selected cases of bilateral amblyopia, the more defective eye must be given a competitive advantage over the comparatively good eye. Glasses alone can work when a refractive component is present, but occlusion might make the glasses work faster. The gold standard therapy for amblyopia remains occlusion of the better eye although penalization is also evidenced to achieve equal results. Pharmacotherapy has been shown to achieve suboptimal outcomes. Newer monocular and binocular therapies based on neural tasks and games are adjuncts to patching and can also be used in adults.

The impact of the first peak of the COVID-19 pandemic on childhood myopia control practice patterns among ophthalmologists-an international pediatric ophthalmology and strabismus council global perspective.

BACKGROUND: The prevalence of myopia keeps increasing during the COVID-19 pandemic. We aimed to map the worldwide treatment preferences of ophthalmologists managing myopia control during the first wave of the pandemic. METHODS: An online questionnaire inquiring about pharmacological and optical treatment patterns during the first half of 2020 was sent to pediatric ophthalmology as well as general ophthalmology memberships worldwide. The results among pediatric ophthalmologists were compared to a previous study we performed before the pandemic. RESULTS: A total of 2269 respondents from 94 countries were included. Most respondents were pediatric ophthalmologists (64.6%), followed by ophthalmologists from other subspecialties (32.3%). The preferred modality for all geographical regions was a combination therapy of pharmacological and optical treatments. When evaluated independently, the pharmacological treatment was more popular than the optical treatment in most regions other than East Asia (P < 0.001). Compared to a pre-pandemic questionnaire, the participation of pediatric ophthalmologists affiliated with non-university hospitals increased. Additionally, the prevalence of respondents utilizing either any type of pharmacological treatment and those that using only evidence-based treatments increased globally. Although a decline in the use of optical treatment was evident worldwide, the use of evidence-based optical treatments increased. CONCLUSION: Ophthalmologists around the world preferred a combination therapy of pharmacological and optical treatments. More pediatric ophthalmologists treated myopia progression and preferred a better evidence-based approach to control myopia. These trends reflect a positive response and more awareness of the rising prevalence of myopia due to the increased burden of myopia imposed by the COVID-19 pandemic.

Comparison of Minimally Invasive Strabismus Surgery (MISS) and Conventional Strabismus Surgery Using the Limbal Approach.

PURPOSE: To compare minimally invasive strabismus surgery (MISS) with conventional strabismus surgery for horizontal recti in terms of functional outcome and complications. METHODS: A total of 40 patients requiring surgery for horizontal recti were divided into two groups: those undergoing MISS and those operated on using the conventional limbal technique. In the MISS group, two small keyhole radial cuts were made superior and inferior to the insertion of the muscle margin. Keyhole cut size was almost 1 mm less than the amount of muscle recessed or resected. RESULTS: There were significant differences in conjunctival redness and swelling in both groups on postoperative days 1 and 7 and week 3. However, after the third week, both groups had a similar appearance. Visual acuity was decreased at postoperative day 1 in both groups, but the difference was not significant. No significant differences were found for final alignment, binocular single vision, other visual acuities, refractive changes, or complications. CONCLUSIONS: This study shows that this new, small incision, minimal dissection technique is feasible. The MISS technique seems to be superior in the immediate postoperative period because there were fewer conjunctival and eyelid swelling complications. Long-term results did not differ between the two groups. [J Pediatr Ophthalmol Strabismus. 2017;54(4):208-215.].

Television Video Games in the Treatment of Amblyopia in Children Aged 4-7 Years.

AIM: To investigate the role of television video games in childhood amblyopia treatment. METHOD: This prospective, randomized, interventional study included 40 patients between 4-7 years of age, with unilateral amblyopia (visual acuity in amblyopic eye between 1-0.6 LogMAR equivalents) attending the squint clinic at a tertiary eye hospital. All patients were prescribed optimal spectacle correction and occlusion therapy, i.e. full time patching according to patient's age, was initiated after six weeks.; full-time patching according to patient's age was initiated after 6 weeks. Subjects were randomly divided into two groups of 20 each. Patients in the first group, Group A (control), were prescribed patching alone. Patients in the second group, Group B (study), were made to play action video games, with the help of a commercial television set, along with patching. They attended 12 half-hour sessions each, at weekly intervals. Follow-up assessments included best corrected visual acuity (BCVA) (both distance and near) and stereoacuity measurements at 3, 6, 9, and 12 weeks. RESULTS: The mean age of patients was 6.03 ± 1.14 years. The distance BCVA in the amblyopic eye showed a significant improvement at final follow-up (12 weeks) in both groups: from 0.84 ± 0.19 to 0.55 ± 0.21 LogMAReq in Group A and 0.89 ± 0.16 to 0.46 ± 0.22 LogMAReq in Group B. However, improvement in BCVA was significantly better in group B at all visits (P=0.002, 12 weeks). The study group also had a significantly better outcome in terms near visual acuity improvement (P = 0.006, 12 weeks). There was also greater stereoacuity improvement in group B, with 7 patients improving to 100 secs of arc or better. CONCLUSION: Video games supplemental to occlusion may be considered favorable for visual development in amblyopic children, and the study encourages further research on this subject.

Levodopa/carbidopa in the treatment of amblyopia.

PURPOSE: To evaluate the role of levodopa/carbidopa in the treatment of amblyopia. METHODS: Thirty patients with strabismic amblyopia between the ages of 3 and 12 years were part of this double-blind, randomized study. Patients were divided into two groups. Group A received 0.50 mg + 1.25 mg of levodopa/carbidopa per kilogram body weight three times daily after meals, with a protein rich drink, whereas Group B received placebo. Both groups received full-time conventional occlusion until a visual acuity of 6/6 was achieved or for a maximum of 3 months. RESULTS: The authors observed more than two lines improvement in visual acuity that was greater in the levodopa group (15 of 15) than in the placebo group (9 of 15) (P < .005). Furthermore, improvement in visual acuity of more than two lines was greater in patients younger than 8 years (100%) than in patients older than 8 years of age (60%) (P = .0026). There was also no significant reversal of the improved visual acuity in up to 6 months of follow-up. CONCLUSION: Levodopa/carbidopa improves visual acuity in patients with amblyopia and maintains improved visual acuity, especially in patients younger than 8 years.

Acquired isolated unilateral fourth nerve palsy after ventriculoperitoneal shunt surgery.

Ventriculoperitoneal shunt has been the surgical procedure of choice for many years for both communicating and noncommunicating hydrocephalus.(1) High failure rates and complications have been reported, despite major improvements in shunt technology(2); however, fourth (trochlear) nerve palsy has not been reported after this procedure. We describe 2 patients who developed a fourth nerve palsy after shunt surgery. Recovery was incomplete, and strabismus surgery was required.

Filter paper strip kit: a cost-effective transport media.

This study was undertaken to discover a feasible transport media for the transportation of ocular microbiological material from the periphery to the central laboratory. A total of 94 cases of ocular infection with clinical diagnosis of conjunctivitis and keratitis were studied. In all cases, two representative microbiological samples were collected, and sent by filter paper strip (FPS) kit as well as by direct culture technique. The isolated organisms by both the methods were analysed. Of the total 94 cases studied, bacteria were isolated in 48 cases by direct culture and in 45 cases by FPS kit, whereas, fungus were isolated in 13 cases by each method. FPS kit appears to be an alternative, feasible, and cost-effective technique for transportation of ocular microbiological material from periphery to the central laboratory.

Pattern of intraocular pressure in epidemic dropsy in India.

This study was conducted to report on the intraocular pressure (IOP) pattern in patients with epidemic dropsy. Two hundred and thirty proven cases of epidemic dropsy were sent for ocular examination. We measured IOP by applanation tonometry at different intervals. Patients were followed up until 24 weeks. Intraocular pressure of more than 22 mm of Hg was detected in 10.86% patients at the start of the study. However, at 12 weeks only 0.43% patients needed medication for control of IOP. None required medication for IOP control after 20 weeks. The rise of IOP in this case series of epidemic dropsy appeared to be a transient phenomenon and drugs needed to be titrated on a weekly basis.

Long-term results of unilateral lateral rectus recession in intermittent exotropia.

PURPOSE: Unilateral lateral rectus recession is an alternative procedure in the treatment of moderate angle intermittent exotropia. However, long-term results of unilateral lateral rectus recession have not yet been studied. The aim of this study was to determine the long-term stability of alignment following unilateral lateral rectus recession in patients with intermittent exotropia with a deviation of 25 to 30 PD. PATIENTS AND METHODS: Thirty-two patients with intermittent exotropia with a deviation of 25 to 30 PD were included in this study. All patients underwent 8-mm unilateral lateral rectus recession by conventional techniques. RESULTS: Satisfactory results (+/- 5 PD of orthophoria) were obtained in 77.7% of the patients after a 3-year follow-up period. The mean correction achieved was 22.9 PD. CONCLUSION: Our results indicate that 8-mm unilateral lateral rectus recession is an attractive alternative procedure in the treatment of intermittent exotropia with a deviation of 25 to 30 PD.

Surgical management of unilateral elevator deficiency associated with horizontal deviation using a modified Knapp's procedure.

Both horizontal recti are transpositioned in unilateral elevator deficiency, leaving no alternative to correct any significant ipsilateral horizontal deviation. An effective method to correct vertical and horizontal deviations simultaneously is reported. A modified Knapp's procedure was performed by transposition of the superior half of equally divided (up to 15 mm) medial and lateral recti for vertical deviation and the inferior half after suitable recession or resection for horizontal deviation. This procedure was performed in ten patients who had type II unilateral elevator deficiency with horizontal deviation ranging from 18 to 45 prism diopters (PD). We were able to correct 20 PD of horizontal deviation and 25 PD of vertical deviation with a modified Knapp's procedure without any significant adverse effects after a follow-up of 21 months. A modified Knapp's procedure is recommended for unilateral elevator deficiency associated with horizontal deviation.

Young men with epiphora: management by an innovative surgical technique (the Safdarjang suture).

A congenital medial canthal anomaly was identified as the cause of epiphora in 18 young adult male patients. This anomaly consists of anomalous anterior displacement of the medial palpebral ligament causing a lack of adequate apposition of the medial end of the lower lid to the globe. The lacrimal punctum does not dip into the lacrimal lake, thereby causing epiphora. An innovative surgical technique is described involving the passage of a suture in the pretarsal plane along the lid margin to correct the deformity.

Comeoscleral perforation after pterygium excision and intraoperative mitomycin C.

A 28-year-old man underwent pterygium excision with a single intraoperative application of mitomycin C (0.02%) for 3 minutes. One week after the surgery, the patient developed a corneoscleral perforation with iris prolapse. To the best of our knowledge, corneoscleral melting in the first postoperative week after a single intraoperative application of mitomycin C has not been reported. Moreover, the perforation occurred despite using a minimum concentration of the drug, risk factors were absent, and the surgery was performed by an experienced surgeon. Although a single case, this report questions the safety of using an intraoperative application of mitomycin C for preventing a recurrence of pterygium.