Outcomes of "a new modification of Jensen technique combined with medial rectus recession" in patients with complete sixth cranial nerve palsy.

BACKGROUND: To report the outcomes of "our modified Jensen technique" for treating esotropia in cases with complete sixth cranial nerve (CN VI) palsy. METHODS: This study is a 30-year case series of isolated complete CN VI palsy who underwent combined medial rectus recession and our modified Jensen operation. We modified the original technique by anchoring the muscle-unifying sutures to the sclera near the equator using a non-absorbable suture. Major outcomes such as postoperative diplopia, face turn, horizontal and vertical eye deviations, and abduction limitation were assessed. Successful surgery was defined as orthotropia or esotropia equal to or less than 8 prism diopters (PD) and the absence of any vertical deviation. RESULTS: Fifty-three cases with a mean age of 28 years old were included in this study. The male-to-female ratio was 3 to 1. Forty-five cases (85%) presented with unilateral palsy, whereas 8 patients (15%) had bilateral palsy. Trauma was the most common etiology (85%). Diplopia or face turn, presented in 42 patients before the operation, remained in seven cases after the operation. Primary position esotropia, which was the main complaint in all patients, decreased from 49 PD to 4 PD in unilateral palsy and from 101 PD to 10 PD in bilateral palsy. The mean reduction of abduction deficit was 1.78 in unilateral and 1.75 in bilateral palsy. The success rate was 76% in unilateral and 62% in bilateral palsy. CONCLUSION: Our modified Jensen operation was effective in treating patients with complete CN VI palsy, producing no significant permanent complications.

Case report: Mirror-image hypermetropic anisometropia in nontwin brothers.

Mirror-image is a term to describe a physical characteristic of some identical twins that appear asymmetrically on opposite sides as if they are looking in a mirror. Mirror-image anisometropia in monozygotic twins was previously reported in the ophthalmic literature. In this article, we describe a case of mirror-image hypermetropic anisometropia in siblings aged 8 and 5 years old. Nontwin brothers, 8 and 5 years old, with mirror-image hypermetropic anisometropia, were referred to the pediatric ophthalmology clinic. Corrected distant visual acuity was 20/20 (ocula dextra [OD]), 20/60 (ocula sinistra [OS]) in the older brother, and 20/50 (OD), 20/20 (OS) in the younger brother. Cycloplegic refraction was + 3.5 - 1.25 × 180 (OD), +7.75 - 1.5 × 30 (OS), and + 7.0 - 0.75 × 20 (OD), +2.0 - 1.0 × 170 (OS) in the older and younger brother, respectively. The axial length difference between the two eyes was 1.47 mm in the older and 2.01 mm in the younger brother. Hypermetropic anisometropia that may lead to anisometropic amblyopia may happen in nontwin brothers. This emphasizes the importance of complete ophthalmologic examination in the siblings of all patients with anisometropia.

Long-term results of strabismus surgery for treatment of esotropia in patients with Möbius syndrome.

PURPOSE: To evaluate the surgical results of Möbius syndrome esotropia following bilateral medial rectus recession with and without bilateral Hummelsheim procedure. METHODS: The medical records of patients with Möbius syndrome operated on by a single surgeon from 1993 to 2022 were studied retrospectively. For each patient, age, sex, and ocular deviation before and after surgery were retrieved. Success was defined as a horizontal deviation of up to 15Δ and vertical deviation of <10Δ. RESULTS: Eleven patients were included. Average patient age at the time of surgery was 4 years. Eight patients with esodeviation up to 70Δ underwent bilateral medial rectus recession; 3 patients with esotropia >70Δ underwent recession plus bilateral Hummelsheim procedure. The mean esodeviation before surgery was 52.5Δ in the first group and 86.6Δ in the second group. The mean horizontal deviation at early follow-up was esotropia of 7.4Δ in the first group and of 15Δ in the second group. The early success rate was 87% in the first group and 67% in the second group. Long-term follow-up revealed exoshift in 43% of the patients in the first group and all 3 patients in the second group. CONCLUSIONS: In our small patient cohort of patients with Möbius syndrome, bilateral medial rectus recession corrected esodeviations of up to 70Δ. In more severe cases (>70Δ), adding bilateral Hummelsheim procedure was beneficial.

Long-term Visual and Refractive Outcomes of Argon Laser-treated Retinopathy of Prematurity.

Purpose: In this case-control study, we measured visual acuity, objective refraction, ocular biometric parameters, and strabismus in premature cases classified according to the following categories: argon laser-treated retinopathy of prematurity (ROP), untreated spontaneously regressed ROP, no ROP, and full-term controls. Methods: Cases with a history of prematurity at six years of age were categorized into the following groups: patients with a history of treated type 1 ROP using argon laser (group I), untreated spontaneously regressed ROP (group II), and no history of ROP (group III). Group IV included age-matched healthy full-term controls. Funduscopy was performed for all the cases and the control group. Results: In total, 24 eyes of 12 laser-treated ROP cases, 186 eyes of 93 spontaneously regressed ROP patients, 74 eyes of 37 premature cases with no history of ROP, and 286 eyes of 143 controls were included in the study. The mean spherical equivalent in the treated cases was not significantly different from that in the untreated cases and patients in group III. However, the average cylindrical power was significantly different among the groups (P < 0.004). Furthermore, anisometropia ( ≥ 1.5 diopters) was diagnosed with a higher rate in the treated cases (P = 0.03). The corneal curvature of the laser-treated eyes was significantly steeper and the axial length was significantly shorter than those in the other groups (P < 0.002 and P < 0.001, respectively, for multivariate analysis). Strabismus was found in three treated patients (25%). Additionally, there were three treated eyes (12.5%) diagnosed with macular dragging. Conclusion: Premature cases including those who had a history of argon laser-treated ROP and those with untreated spontaneously regressed ROP showed acceptable long-term visual and refractive outcomes along with a fairly low rate of ocular disorders.

Central corneal thickness measurements in phakic, pseudophakic, and aphakic children with ultrasound pachymetry and different non-contact devices.

AIMS: Evidence for choosing a satisfactory device for central corneal thickness (CCT) measurement in children particularly pseudophakic and aphakic ones is insufficient. The aim of this study is to compare four differently measured CCTs obtained using ultrasound pachymetry (UP), Pentacam, partial coherence interferometry (PCI), and specular microscopy (SM) in phakic, pseudophakic, and aphakic children and assess the agreement between the six pairs of the methods. METHODS: Children with history of cataract surgery at age six or younger and phakic children were recruited into this study. CCT was measured using UP (Optikon 2000, Rome, Italy), Pentacam (Oculus Inc, Wetzlar, Germany), PCI (IOLMaster 700, Carl Zeiss Meditec AG, Jena, Germany), and SM (Topcon SP-3000P; Topcon Corporation, Japan). RESULTS: One-hundred two eyes (53 phakic, 29 pseudophakic, and 20 aphakic eyes) were included. The mean ages (± SD) of phakic, pseudophakic, and aphakic cases were 9.75 (± 3.3), 9.9 (± 2.3), and 8.2 (± 2.8) years, respectively. The mean CCTs (± SE) for phakic children using Pentacam, PCI, UP, and SM were 549.7 (± 5.0), 546.5 (± 4.5), 565.9 (± 5.5), and 506.2 (± 4.4) µm, respectively, for pseudophakic cases were 570.1 (± 6.4), 565.0 (± 6.1), 571.9 (± 6.3), and 524.3 (± 6.3) µm, respectively, and for aphakic participants were 635.3 (± 14.2), 635.4 (± 14.5), 649.0 (± 13.5), and 589.1 (± 13.3) µm, respectively. CONCLUSION: Compared to Pentacam and PCI, SM underestimated CCT particularly in phakic and pseudophakic children, whereas UP slightly overestimated CCT especially in phakic and aphakic children. Furthermore, Pentacam and PCI had the closest agreement. By contrast, SM had the poorest agreement with the other three methods.

Erratum: Long-term Visual and Refractive Outcomes of Argon Laser-treated Retinopathy of Prematurity.

[This corrects the article on p. 384 in vol. 17 PMCPMC9493422.].

Unilateral Duane Retraction Syndrome Associated with Unilateral Congenital Cataract.

PURPOSE: To report unilateral congenital cataract in a case of ipsilateral Duane retraction syndrome. CASE REPORT: In this case, we present a six year old girl who was referred with ocular deviation. She had a history of congenital cataract surgery in the left eye at the age of two years. The subject had no associated systemic disease, developmental delay, or positive family history. She was finally diagnosed as having Duane retraction syndrome in the same eye. CONCLUSION: Duane retraction syndrome can be associated with congenital cataract due to the matching time of gestational development of the lens to that of ocular and non-ocular anomalies associated with Duane syndrome. As both of these disorders are rare, coincidence of both in the same person and the same eye by chance is a very remote possibility.

Levodopa Plus Occlusion Therapy versus Occlusion Therapy Alone for Children with Anisometropic Amblyopia.

PURPOSE: This study aimed to compare the effects of short-term administration of levodopa plus occlusion therapy versus occlusion therapy alone in preschool children with hyperopic anisometropic amblyopia. METHODS: This comparative interventional study included 40 eligible preschool children aged 6 to 7 years with hyperopic anisometropic amblyopia. The primary outcome measure was the logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity recorded at baseline, 3 weeks after the treatment initiation and 12 weeks after the treatment termination. The results were compared between the two groups. RESULTS: No statistically significant intergroup difference was observed in baseline logMAR visual acuities (P = 0.92). The mean logMAR visual acuities of the amblyopic eyes were significantly better in both groups three weeks after the treatment initiation than the baseline (P < 0.01 in both groups). At 12 weeks after treatment termination, the logMAR visual acuities of the amblyopic eyes were significantly better than the baseline values (P < 0.001 in the placebo group and P = 0.09 in the levodopa group). Intergroup comparisons revealed no statistically significant difference in visual acuities 3 weeks after the treatment initiation (P = 0.11) and 12 weeks after the treatment termination (P=0.10). Twelve weeks after the treatment termination, visual acuities regressed 0.037 logMAR in the placebo group and 0.042 logMAR in the levodopa group. These regression rates were not significantly different (P = 0.89). CONCLUSION: The results of this study provide evidence that adding short-term administration of levodopa to occlusion therapy in hyperopic anisometropic amblyopia offers no additional benefit in visual outcomes and provides no advantage in terms of the regression rate.

Mirror image hypermetropic anisometropia in a pair of monozygotic twins.

In monozygotic twins two embryos are formed from a single fertilized egg. In "mirror image twins" identical siblings have reverse asymmetric features in the right and left sides of the body. We report the case of twins with mirror-image hypermetropic anisometropia. They were referred to an ophthalmologist at the age of 3.5 years for amblyopia. Cycloplegic refraction of twin 1 was +1.00 in the right eye and +4.50 -0.75 ×180 in the left eye; of twin 2, +4.75 -1.00 ×180 and +1.25. Keratometry and axial length were measured with Lenstar LS 900 when the twins were 6 years of age. In twin 1, the axial length was 22.18 mm in the right eye and 20.97 in the left eye; in twin 2, 20.94 mm and 22.13. Keratomtry of both eyes of these twins was relatively equal.

Combined Lateral Rectus Myectomy and Maximal Medial Rectus Resection in Complete Third Cranial Nerve Palsy.

This study was performed to describe lateral rectus myectomy and maximal medial rectus resection for correction of eye deviation in complete third cranial nerve palsy. A retrospective review of thirteen patients (fourteen eyes) with complete third cranial nerve palsy, who underwent lateral rectus myectomy and maximal medial rectus resection, was performed. These procedures were combined with superior oblique tendon transposition in nine patients with a large angle of exotropia (more than 60 prism diopters [∆]), or significant hypotropia (more than 5 ∆). Preoperative deviations were exotropia of 50 to 120 ∆ in thirteen cases and hypotropia of 5 to 25 ∆ in eight cases. Six months after the surgery, eleven patients were within 10 ∆ of orthotropia in primary position. Revision surgery was performed for two patients, eight and 18 months after the first operation. Eventually, five patients (38%) achieved orthotropia in the primary position, and seven patients (54%) had < 11 ∆ exotropia and < 6 ∆ vertical deviation. In conclusion, this procedure can be considered as an acceptable approach for treatment of strabismus in complete third cranial nerve palsy. This procedure is simple and can be easily performed even in very young children.

The clinical effect of surgical timing in infantile exotropia.

PURPOSE: To review the association of postoperative ocular alignment, sensory outcomes, and need for reoperation after surgical management of infantile exotropia. METHODS: The clinical records of patients who presented with constant infantile exotropia of >25Δ and subsequently underwent strabismus surgery at a single center from 2004 to 2014 were reviewed retrospectively. Postoperative binocular sensory status was assessed using Worth 4-Dot and Titmus stereoacuity tests. Patients with postoperative exotropia of >10Δ or esotropia of >5Δ were advised to undergo additional surgery. RESULTS: A total of 49 cases were included (28 boys; age at diagnosis, 1-12 months). The patients who underwent reoperation were younger at the time of first surgery (mean age, 13.15 ±1.68 vs 18.58 ± 0.92 months [P = 0.005]). Patients who developed consecutive esotropia were younger at the time of initial operation (P = 0.039). Among 20 patients who were testable for sensory outcome assessment, only 4 patients developed stereopsis, whereas 15 patients achieved bifixation by Worth 4-Dot test. All of the 4 patients with measurable postoperative stereoacuity had initial surgery after 1 year of age. CONCLUSIONS: In this patient cohort, earlier surgery did not necessarily lead to better sensory outcomes, and reoperation was associated with younger age at time of first surgery.

A Comprehensive Meta-analysis on Intra Ocular Pressure and Central Corneal Thickness in Healthy Children.

BACKGROUND: Glaucoma is the major ophthalmic public health issue and a leading basis of blindness. Elevated intraocular pressure (IOP) is still a foremost risk factor in development and progression of glaucoma. Central corneal thickness (CCT) may play as the risk factor for the progression of glaucoma, closely associated with IOP especially in pediatric age group. This study performed a pioneering investigation combining the outcomes of multiple studies using a meta-analytic approach. METHODS: Nineteen published articles between 1980 and 2015 were designated by searching Scopus, PubMed, and Google Scholar and analyzed with random effects model while I2 statistics employed to find out heterogeneity. Subsequently, the information statistically analyzed by Stata software ver. 11.20. RESULTS: The mean IOP has been documented to 16.22 mmHg (95% CI: 15.48-16.97) in all races subgroups. Analyzing the data by race-based subgroups revealed the lowest IOP of 12.02 mmHg (95% CI: 11.40-12.64) in Indian children while IOP of 17.38 mmHg (95% CI: 15.77-18.98) documented in black children as the highest measurement. The mean CCT was 553.69 micrometer (95% CI: 551.60-555.78) among all races. Lowest CCT of 536.60 mm (95% CI: 531.82-541.38) has been documented in mixed Malay-Indian children whereas Chinese children ought to the highest CCT value of 557.68 mm (95% CI: 553.10-562.25). CONCLUSION: Findings of published studies were inconsistent when considered independently; however, meta-analysis of these results showed a significant correlation between CCT and IOP. Owing to non-uniform methods used to measure IOP and CCT in studies, data were stratified into various subgroups according to the instruments used to measure IOP and CCT.

A study of consanguineous marriage as a risk factor for developing comitant strabismus.

Inheritance has an important role in the etiology of comitant strabismus. Consanguineous marriage is a leading factor in birth defects in which inheritance has a role. The aim of this study is to reveal if consanguineous marriage increases the risk of developing comitant strabismus. We included 461 patients who underwent primary surgery for comitant strabismus in Shiraz University Khalili Hospital (Fars province, southern Iran) between years 2003 and 2013 in our study. All the patients were living in Shiraz, Iran. Patients were categorized into the following 4 groups: (1) intermittent or constant exotropia, (2) infantile esotropia, (3) non-accommodative acquired esotropia, and (4) accommodative acquired esotropia. A total of 421 healthy children who were born in Shiraz, at the same period of time, were also studied as a control group. Presence and type of the consanguineous marriages were evaluated in the parents of the patients and control group by a questionnaire. Mean of inbreeding coefficient (α) was calculated in each group of patients and was compared with those of control group. The proportion of parental first cousin marriage was 37.7 and 23.5 % among patient and control groups. The mean of inbreeding coefficients (α) were 0.0236, 0.0283, 0.0288, and 0.0236 in four groups of the patients, respectively. The mean of inbreeding coefficient was 0.0263 in total patients, which was significantly higher than 0.0164 of control group (T = 5.27, df = 880, P < 0.001). Patients with non-accommodative acquired esotropia had the highest mean of inbreeding coefficient (α) (0.0288). It seems that recessive form of inheritance plays an important role in the etiology of comitant strabismus. Modified screening programs may be needed for earlier detection of strabismus in the offspring of consanguineous couples.

Combined resection and anterior transposition of the inferior oblique muscle for treatment of large primary position hypertropia caused by unilateral superior oblique muscle palsy.

PURPOSE: To evaluate the efficacy of combined resection and anterior transposition of the inferior oblique muscle for treatment of unilateral superior oblique muscle palsy with hypertropia from 20(Δ) to 25(Δ) in primary position. METHODS: The medical records of consecutive patients operated on for unilateral superior oblique muscle palsy and hypertropia from 20(Δ) to 25(Δ) in primary position were retrospectively reviewed. All patients had overaction of the inferior oblique muscle. The inferior oblique muscle was disinserted and 4 mm of its distal end was resected and transposed to the lateral border of the inferior rectus muscle insertion. The prism and alternate cover test was used to measure hypertropia. Surgical results were evaluated at 6 months' follow-up. RESULTS: A total of 27 patients were included. The mean hypertropia in primary position was 22.6 ± 0.4(Δ) preoperatively, which decreased to 1.4 ± 0.6(Δ) after surgery. None of the patients developed hypotropia in primary position. Mild limitation of elevation was recorded in 1 patient, and 4 patients developed lower eyelid fullness. CONCLUSIONS: In this patient cohort, combined resection and anterior transposition of the inferior oblique muscle effectively treated unilateral superior oblique muscle palsy with hypertropia from 20(Δ) to 25(Δ) in primary position.

Results of bilateral medial rectus muscle recession in unilateral esotropic Duane syndrome.

PURPOSE: To report the results of bilateral medial rectus muscle recession in improvement of the ocular alignment and motility of patients with unilateral esotropic Duane syndrome. METHODS: All medical files of patients with Duane syndrome seen by the first author between 1997 and 2006 were reviewed. Pre- and postsurgical deviation, angle of abnormal head position, severity of limitation in abduction, severity of globe retraction, and upshoots and downshoots were compared. RESULTS: Twenty-five patients with unilateral esotropic Duane syndrome (type 1) underwent recession of both medial rectus muscles. Mean age of patients was 9.7 years: male-to-female ratio was 0.67 (10:15). The left eye was involved in 23 of the patients. Mean esotropia decreased from 24.3(Delta) (range, 12(Delta)-50(Delta)) to 1.3(Delta) (range, 0(Delta)-10(Delta)). Mean abnormal head position decreased from 21.4 degrees (range, 15 degrees-35 degrees) to 1 degrees (range, 0 degree-5 degrees). Esotropia and abnormal head position disappeared in 80% of the patients and improved in the remaining. None of the patients developed exotropia. Mean limitation in abduction decreased from -3.8 to -3.3. Globe retraction was eliminated in 14 of the patients and improved in the others. Mild upshoots and downshoots, which were observed in 5 patients, disappeared in 2 and improved in 3 patients. CONCLUSIONS: Bilateral recession of medial rectus muscles has resulted in improvement of deviation, abnormal head position, and globe retraction in patients with unilateral esotropic Duane syndrome.

Reliability of fixation preference for detecting amblyopia in strabismic patients.

PURPOSE: To evaluate the association between fixation preference (FP) and amblyopia in strabismic patients. METHODS: This study includes 50 patients with horizontal, vertical or mixed strabismus of at least 10 prism diopters. Best-corrected monocular visual acuity (VA) was measured using Snellen E-chart and the presence of amblyopia was determined accordingly; FP was evaluated and graded from 0 to 3. RESULTS: Of 50 patients, including 27 female and 23 male subjects, 29 (58%) patients had FP but 18 (36%) subjects were truly amblyopic. Overall, the sensitivity and specificity of FP for detection of amblyopia was 88.9% and 59.4% respectively. The positive predictive value (PPV) and negative predictive value (NPV) were 55.2% and 90.5% respectively. Sensitivity, PPV and NPV were significantly higher in esotropic as compared to exotropic patients. Strong monocular FP was correlated with more than 3 lines of interocular difference (IOD) in visual acuity (P=0.001). CONCLUSION: Although FP is not an ideal method for diagnosis of strabismic amblyopia, it has high sensitivity, PPV and NPV in esotropic patients and in subjects with more than 3 lines of IOD in VA.

Sudden unilateral blindness in a girl with Kawasaki disease.

This article describes a 9-year-old girl with clinical and laboratory features of Kawasaki disease. On day 7 of her febrile illness, she developed sudden loss of vision in the right eye. Visual acuity was no light perception. Dilated funduscopy showed diffuse intense retinal whitening, narrowing retinal arterioles, and a pale swollen disk-but no cherry-red spot. These findings suggested ophthalmic artery obstruction. Kawasaki disease can be sight-threatening.

Osteochondroma of the trochlea presenting as acquired Brown syndrome: a case report.

The following is a rare observational case report of a 16-year-old boy who presented with acquired Brown syndrome associated with a painless slowly growing mass in the supranasal area of the left eye. Meticulous surgical removal of the mass resulted in recovery of superior oblique muscle function. Histopathology was consistent with osteochondroma of the trochlea. To the knowledge of the authors, this is the first reported case of osteochondroma of the trochlea causing acquired Brown syndrome.

LASIK after retinal detachment surgery.

PURPOSE: To compare, in the same individuals, the safety and efficacy of laser in situ keratomileusis (LASIK) in eyes with and without previous retinal detachment surgery. METHODS: In a prospective clinical trial, seven myopic patients who had previously undergone scleral buckling surgery in one eye underwent conventional LASIK surgery in both eyes. Uncorrected visual acuity (UCVA), best corrected visual acuity (BCVA), refraction, Orbscan topography and pachymetry were recorded before and 1, 3, 6 and 12 months after surgery. The eyes were divided into two groups: group 1 consisted of eyes that had undergone previous surgery for retinal detachment, and group 2 consisted of the fellow eyes of the same patients, which had not undergone any previous ocular surgery. Student's t-test for match-paired data was used to evaluate the significance of differences. RESULTS: LASIK was performed successfully in all patients. The UCVA improved in all eyes in both groups. The mean change in the spherical equivalent between 1 and 12 months after LASIK surgery was 1.7 +/- 1.1 and 0.6 +/- 0.5 diopter in groups 1 and 2, respectively (p = 0.019). CONCLUSION: LASIK may be considered for treatment of myopia in eyes that have had previous surgery for retinal detachment. However, the risk of regression may be higher in such eyes than in eyes with no previous scleral buckling surgery.