Lateral rectus pulley concerning the orbital wall. Area of a stereotyped bony insertion.

Purpose: To examine the lateral rectus muscle pulley and its bony insertion concerning the orbital rim and periorbita. Design: Prospective. An observational anatomic study. Methods: Study population: Twenty postmortem orbits (10 right, 10 left) of 10 Caucasian cadavers (8 females, 2 males; age range at death, 57-100 years; median age, 79.5 years) fixed by the Thiel method.Intervention: The floor of the temporal fossa was exposed, and a bone window on the lateral wall of the orbit, posterior to the sphenozygomatic suture, was created, keeping the periorbita intact. The lateral canthus and lateral palpebral ligament were isolated and opened, and the eyelids were folded back. The frontozygomatic suture was identified, and the orbital septum opened adjacent to the orbital rim. The conjunctiva was opened at the limbus, and the lateral rectus insertion was isolated. The bone pillar containing the frontozygomatic suture and the insertion of the periorbita and the pulley was isolated and removed en bloc. The lateral rectus muscle was isolated and excised.Main outcome measures: Position of the pulley ring on the lateral rectus muscle belly and its bony attachment area in the lateral wall of the orbit. Results: The pulley bony attachment was roughly quadrilateral with an approximate area of 90 mm2, 3 mm (mean, range 1-5 mm) posteroinferior to the frontozygomatic suture and 1 mm posterior to the orbital rim. The anterior margin of the pulley sleeve was found at 21.0 mm (median, p25-75 20.0-22.8) from the scleral insertion. Conclusions: The lateral rectus pulley is stereotyped in its position in the muscle belly and its bony insertion, coinciding with the point of greatest adhesion of the periorbita to the anterior part of the lateral wall of the orbit.

Trends and patterns in pediatric ophthalmology and strabismus surgeries: a decade review from a leading Portuguese university hospital.

PURPOSE: Strabismus and Pediatrics Ophthalmology surgeries are pivotal in addressing early-onset visual disorders. An 11-year retrospective study at a tertiary hospital center aimed to elucidate evolving surgical trends, focusing on esotropia cases. METHODS: The surgical records from January 2009 to January 2020 were analyzed according to the baseline diagnosis. Esotropia cases were evaluated based on the patients' deviation types, surgical techniques, and pre-operative characteristics. A total of 2050 surgeries were performed over the study period. RESULTS: Strabismus surgery accounts for 70% of the department's surgical activity. A trend toward a decrease in esotropia surgeries and a proportional increase in exotropia surgeries was noticeable. Esotropia cases, with a median surgical age of 6 years (p25-p75, 4-10) and uniform gender distribution (females, 54.8%), predominantly involved high angular deviations. Posterior fixation sutures emerged as the preferred surgical technique for esotropia. CONCLUSION: The study's insights, while aligning with prior European research, introduce new dimensions to the understanding of strabismus surgeries, emphasizing the significance of early interventions, evolving surgical preferences, and the challenges posed by severe deviations.

Functional anatomy of the orbit in strabismus surgery: Connective tissues, pulleys, and the modern surgical implications of the "arc of contact" paradigm.

Oculomotricity is a multidimensional domain characterised by a delicate interplay of anatomical structures and physiological processes. This manuscript meticulously dissects the nuances of this interplay, bringing to the fore the integral role of the extraocular muscles (EOMs) and their intricate relationship with the myriad orbital connective tissues as it harmoniously orchestrates binocular movements, ensuring synchronised and fluid visual tracking. Historically, the peripheral oculomotor apparatus was conceptualised as a rudimentary system predominantly driven by neural directives. While widely accepted, this perspective offered a limited view of the complexities inherent in ocular movement mechanics. The twentieth century heralded a paradigm shift in this understanding. With advances in anatomical research and imaging techniques, a much clearer picture of the gross anatomy of the EOMs emerged. This clarity challenged traditional viewpoints, suggesting that the inherent biomechanical properties of the EOMs, coupled with their associated tissue pulleys, play a pivotal role in dictating eye movement dynamics. Central to this revised understanding is the "arc of contact" paradigm. This concept delves deep into the mechanics of eye rotation, elucidating the significance of the point of contact between the EOMs and the eyeball. The arc of contact is not just a static anatomical feature; its length and orientation play a crucial role in determining the effective torque generated by a muscle, thereby influencing the amplitude and direction of eye rotation. The dynamic nature of this arc, influenced by the position and tension of the muscle pulleys, offers a more comprehensive model for understanding ocular kinematics. Previously overlooked in traditional models, muscle pulleys have now emerged as central players in the biomechanics of eye movement. These anatomical structures, formed by dense connective tissues, guide the paths of the EOMs, ensuring that their pulling angles remain optimal across a range of gaze directions. The non-linear paths resulting from these pulleys provide a more dynamic and intricate understanding of eye movement, challenging two-dimensional, linear models of orbital anatomy. The implications of these revelations extend beyond mere theoretical knowledge. The insights garnered from this research promise transformative potential in the realm of strabismus surgery. Recognising the pivotal role of muscle pulleys and the "arc of contact" paradigm allows for more precise surgical interventions, ensuring better post-operative outcomes and minimising the risk of complications. Surgical procedures that previously relied on basic mechanical principles now stand to benefit from a more nuanced understanding of the underlying anatomical and physiological dynamics. In conclusion, this manuscript serves as a testament to the ever-evolving nature of scientific knowledge. Challenging established norms and introducing fresh perspectives pave the way for more effective and informed clinical interventions in strabismus surgery.

What to expect from primary inferior oblique overaction after esotropia surgery : Primary inferior oblique overaction in esotropia.

BACKGROUND: Overelevation in adduction is common in patients with primary esotropia. This study evaluates the variation in ocular motility pattern in patients with primary inferior oblique (IO) muscle overaction after esotropia surgery. METHODS: The medical records of consecutive patients who underwent surgery for infantile, partially accommodative, and basic esotropia over eleven years and had at least one year of follow-up were reviewed. Patients with primary inferior oblique muscle overaction (IOOA) presented at baseline or during follow-up were selected and divided according to the first surgery performed concurrently with horizontal rectus surgery: without IO recession (NO-recess), with unilateral IO recession (UNIL-recess), and with bilateral IO recession (BIL-recess). The success (version normalisation or at least 2 points upgrade in severity scale [0-4] in the operated eye), recurrence rates, and the evolution of the non-operated IO muscles were evaluated. RESULTS: One hundred and ten patients were included - 53 NO-recess, 26 UNIL-recess, and 31 BIL-recess. Medial rectus muscle posterior fixation sutures surgery (PFS) was performed in 88.2% of patients for esotropia. A recession with graded anterior transposition was the weakening IO procedure. In the NO-recess group, 28 (52.8%) patients normalised their mild IOOA after PFS surgery alone. In the UNI-recess group, the success rate was 88.5%, with 16 (61.5%) patients showing worsened IO muscle of the fellow eye, which prompted additional surgery in 10 patients. In the BIL-recess group, all 31 patients improved the adduction pattern of the operated eye for an 80.6% success rate (6 improved marginally). CONCLUSION: Graded anterior transposition of the inferior oblique muscle effectively normalises versions. However, it's frequent for a contralateral overaction to become manifest after unilateral IO surgery.

Revisiting Posterior Fixation Sutures Surgery: Unveiling Novel Approaches for Primary Management of Diverse Esotropia Cases.

INTRODUCTION: Strabismus, specifically esotropia, presents a significant challenge in ophthalmic surgery, while several treatment options exist. This study aims to evaluate the results of posterior fixation sutures (PFS) on the medial rectus as a primary approach for some types of esotropia. METHODS: The medical records of consecutive patients who underwent surgery for esotropia over 11 years and had at least 1 year of follow-up were reviewed retrospectively. Patients were classified into one of three types of deviation: infantile (IE), partially accommodative (PAE) and basic (BE) esotropias. An alignment within 16 prism diopters (PD) of orthotropia was a successful outcome. RESULTS: A total of 404 patients were included: 67 IE, 180 PAE and 157 BE. Before surgery, a deviation greater than 30 PD was present in 88.1% and 80.1%, and a deviation greater than 50 PD was present in 66.5% and 52.9% of patients (near and distance, respectively). In the BE group, PFS was the baseline surgery in a smaller number of cases (75%) compared to the other two groups (versus 86.6% [IE] and 88.3% [PAE], p = 0.002). The need for an additional procedure was significantly higher in the infantile esotropia group (44.8% vs. 18.9% and 24.8%, p < 0.001). Final surgical success was achieved in 95.3% of all patients. Orthotropia was achieved in 19.4% (IE), 29.6% (PAE) and 25.5% (BE) of cases. CONCLUSION: PFS of the medial rectus without recession proved successful as a first-line procedure for esotropia in the subtypes of patients evaluated in this study.

Advancement of the muscle insertion toward the limbus as an alternative or adjunct to resection.

PURPOSE: To describe the surgical outcomes of patients that underwent strabismus surgery involving advancement of the muscular insertion line toward the limbus. METHODS: The medical records of patients who underwent rectus muscle advancement surgery between January 2009 and June 2019 and had at least 1 year of follow-up were reviewed retrospectively. Patients were classified into one of four types of deviation: (1) convergence insufficiency, without distance deviation; (2) small-angle distance esotropia, with diplopia; (3) residual strabismus after previous surgery; and (4) large-angle exotropia. The first group underwent 2 mm advancement of the medial rectus insertion bilaterally; the second, 2-3 mm advancement of the lateral rectus muscle bilaterally; the third, 2-3 mm advancement of the lateral or medial rectus muscle, with or without simultaneous resection; and the fourth, 3 mm advancement of the medial rectus with simultaneous resection, with or after maximum recession of the lateral rectus, bilaterally or unilaterally. RESULTS: A total of 25 patients were included (mean age, 28.76 ± 22.75 years): 4 with convergence insufficiency, 3 with small-angle distance esotropia and diplopia, 16 with residual strabismus, and 2 with large-angle exotropia. Mean postoperative follow-up was 4.76 ± 2.03 years. Surgery was successful in all patients at 1 year (residual deviation ≤10Δ), and all but 1 at 5 years; 1 patient required reoperation. CONCLUSIONS: Advancement of the muscle insertion proved successful as an alternative or adjunctive procedure to other forms of muscle tightening in the subtypes of patients evaluated in this study.

Traumatic Cyclodialysis Cleft Treatment Combined with Cataract Surgery: An Original Triple Procedure.

INTRODUCTION: To describe a "triple" surgical procedure, which combined traumatic cataract extraction by phacoemulsification with gas endotamponade and cyclocryotherapy in the successful treatment of a traumatic cyclodialysis cleft. METHODS: A 44-year-old man who suffered severe left eye blunt trauma with an elastic band developed a 4-hour extent cyclodialysis cleft with consequent hypotony. After 7 weeks of persistent hypotonic maculopathy unresponsive to medical treatment, and with an evolving traumatic cataract, the patient underwent cataract surgery combined with intravitreal gas endotamponade (20% SF6) and cyclocryotherapy. RESULTS: Two weeks after the procedure the intraocular pressure increased to 12 mmHg and remained steady during the next 14 months of follow-up. Hypotonic maculopathy resolved and successful closure of the cyclodialysis cleft was confirmed by gonioscopy and ultrasound biomicroscopy. CONCLUSION: Gas endotamponade and cyclocryotherapy constitute a promising option in the treatment of cyclodialysis clefts unresponsive to medical therapy. In our case, this minimally invasive technique was innovatively combined with cataract surgery. Despite early postoperative intraocular inflammation, a successful outcome was achieved.

Prone Positioning Covid-19 Patients: A Double-Edged Sword-A Case Report of a Devastating Ocular Complication.

In the late 1970s, prone positioning was established as an efficient treatment for acute respiratory distress syndrome (ARDS). Currently, with the world facing a global health crisis due to the COVID-19 pandemic, it has become an accepted routine practice in intensive care units dealing with critically ill COVID-19 patients. Ophthalmic complications associated with the prone position are not a novelty in clinical practice. Indeed, it is estimated that in patients undergoing spine surgery, prone positioning carries a tenfold increased risk of eye injury when compared to supine and lateral positioning. The majority of these complications are treatable ocular surface disorders, but irreversible sight-threatening conditions also occur. We report a unique and dramatic case of a ruptured globe in a COVID-19 patient placed in prolonged prone position, emphasizing its difficult diagnosis and management while focusing on life-saving support.

Long-Term Effect of Anti-VEGF Agents on Intraocular Pressure in Age-Related Macular Degeneration.

PURPOSE: To analyze the effect of anti-vascular endothelial growth factor (VEGF) agents on intraocular pressure (IOP) in patients with neovascular age-related macular degeneration (AMD). Materials andMethods: This is a retrospective study that included 72 patients treated unilaterally with anti-VEGF agents according to a pro re nata regimen. Fellow noninjected eyes (n = 72) were used as controls. IOP variation and the development of sustained ocular hypertension (OHT) were assessed both in the injected and in the fellow eyes. RESULTS: While the final IOP was not significantly different between the 2 groups, sustained OHT developed in 4.2% of the injected eyes and 1.4% of the controls. In the study group, no significant IOP variation was noted during follow-up in patients receiving ≤20 injections, but there was a significant increase in IOP with time in more frequently treated patients (p = 0.041). Comparison of both subgroups demonstrated that patients receiving >20 injections suffered significantly greater IOP variation (p = 0.034) during follow-up, and that these patients tended to require IOP-lowering treatment more frequently (p = 0.090). CONCLUSION: Multiple anti-VEGF injections lead to an increase in IOP, although this variation is not sufficient to cause development of OHT in the majority of patients.

Treatment of neovascular age-related macular degeneration with anti-VEGF agents: retrospective analysis of 5-year outcomes.

PURPOSE: To evaluate the 5-year results obtained in clinical practice in the treatment of neovascular age-related macular degeneration (nAMD) with anti-VEGF agents. MATERIALS AND METHODS: We retrospectively analyzed all patients with nAMD who initiated anti-VEGF treatment before October 2009. We collected data regarding visual and anatomical outcomes. RESULTS: A total of 278 patients met the selection criteria. The mean number of intravitreal injections was 5.7 in the first year and 3.7 in the fifth year. A positive mean visual acuity variation of +3.7 Early Treatment Diabetic Retinopathy Study letters occurred in the first year, but no significant differences relative to baseline were observed thereafter. The majority of patients (71%) maintained stable visual acuity throughout follow-up. At 5 years, mean central macular thickness remained substantially inferior to baseline (-96.6 µm), and 56% of patients maintained dry retinas. CONCLUSION: Anti-VEGF therapy leads to long-term visual stabilization in the great majority of patients.

Switch to Aflibercept in the Treatment of Neovascular AMD: One-Year Results in Clinical Practice.

PURPOSE: To report the clinical outcomes of intravitreal aflibercept therapy in eyes with refractory and recurrent neovascular age-related macular degeneration (AMD) switched from intravitreal bevacizumab or ranibizumab. METHODS: This is a retrospective review of eyes with neovascular AMD switched to intravitreal aflibercept with at least 1 year of follow-up after the switch. All patients had had a minimum of 3 injections of bevacizumab or ranibizumab before the switch. Aflibercept was used in patients considered refractory to bevacizumab (group 1) and in recurrent patients on therapy with ranibizumab due to an institutional policy decision (group 2). Changes in best-corrected visual acuity, fluid on optical coherence tomography (OCT), central retinal thickness (CRT) and the frequency of injections were compared. RESULTS: Eighty-five eyes of 69 patients were analyzed, 39 eyes in group 1 and 46 in group 2. The mean follow-up time was 31.6 months prior to the switch and 14.7 months on treatment with aflibercept. One year after the switch, there was a nonsignificant mean decrease of 2 letters in visual acuity in both groups (group 1: from 58.2 to 55.8 letters, p = 0.086; group 2: from 56.4 to 54.5 letters, p = 0.168), but the mean number of injections per month was significantly lower (from 0.76 to 0.57, p < 0.001). With the switch, 90.6% of the patients showed anatomic improvement with a reduction of fluid on OCT, and both groups presented significant improvement in CRT (group 1: 65.3 µm, p = 0.051; group 2: 91.0 µm, p < 0.001). CONCLUSION: Aflibercept appears to be a valuable tool for the management of patients with poor responses to other anti-vascular endothelial growth factor drugs. These patients could have anatomic improvement, and the injection intervals could be extended.

Multimodal imaging in paclitaxel-induced macular edema: the microtubule disfunction.

Taxanes are a rare cause of macular edema. A 63-year-old female, under paclitaxel treatment, was observed with progressively bilateral visual acuity loss and an apparently normal fundus. Optical coherence tomography revealed a bilateral cystoid macular edema with a late petaloid pooling on fluorescein angiography. Fundus autofluorescence exhibited a foveal hiperautofluorescent pattern. There was a great improvement of visual acuity and macular thickness after 5 months of drug withdrawal. Paclitaxel maculopathy diagnosis requires a high degree of suspicion. The pathophysiology remains unclear.

Switch from intravitreal ranibizumab to bevacizumab for the treatment of neovascular age-related macular degeneration: clinical comparison.

OBJECTIVE: To compare outcomes after switching from intravitreal ranibizumab to bevacizumab in neovascular age-related macular degeneration (AMD). METHODS: A retrospective review of 110 eyes treated in a 1+PRN (pro re nata) clinical setting with ranibizumab that were switched to bevacizumab. Patients analyzed had at least 3 ranibizumab injections followed by at least 3 bevacizumab injections. Changes in best-corrected visual acuity (BCVA), retinal thickness and frequency of injections were compared. RESULTS: The mean duration of ranibizumab treatment was 18.1 months, followed by 12.2 months of bevacizumab. Mean injection rates per month were similar (0.54 and 0.56 respectively, p = 0.230). There were no significant differences between BCVA at baseline and at the time of the switch (52.4 and 54.8 letters, p = 0.059). After the switch, there was a statistically significant decrease in BCVA to 51.7 letters (p < 0.001). CONCLUSION: Switching patients to bevacizumab may have a minor negative effect on the initial gain obtained with ranibizumab; however the degenerative history of wet AMD could explain this small variation in visual acuity.

Anti-VEGF therapy in myopic choroidal neovascularization: long-term results.

PURPOSE: To evaluate the medium- and long-term efficacy of anti-VEGF agents in the treatment of choroidal neovascularization secondary to pathologic myopia (mCNV). METHODS: We performed a retrospective analysis of patients with mCNV who had been treated with intravitreous anti-VEGF for at least 2 years. The best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were compared before and after the treatment. The number of injections per year was also assessed. RESULTS: The results were analysed at 2 years for 67 eyes, at 3 years for 52 eyes, at 4 years for 28 eyes and at 5 years for 13 eyes. The mean change from baseline BCVA was significant at 2 years (+8.6 letters; p < 0.001) and this gain remained significantly stable for a period of 5 years. The mean CRT showed a significant decrease over time, with a nadir at 2 years (-104.0 µm; p < 0.001). The mean number of injections performed during the first year was 5.2, being lower in subsequent years (p < 0.001). CONCLUSION: In this subset of patients with mCNV, an intravitreous therapy with anti-VEGF agents proved to have effective results over 5 years, with a sustained increase in BCVA.

Seizure-induced changes in neuropeptide Y-containing cortical neurons: Potential role for seizure threshold and epileptogenesis.

Seizure activity induces transient changes in the levels of neuropeptide Y (NPY) and somatostatin (SS) in various brain regions, but it remains unclear whether this effect can persist for long periods and whether it is relevant to epileptogenesis. We report that brief seizures evoked by electroshock produced an increase in the number of NPY neurons in the dentate hilus and retrosplenial cortex, an effect that lasted 10 weeks. The number of hilar SS neurons remained unchanged. However, the pentylenetetrazole seizure threshold was somewhat decreased in electroshock-treated rats. Despite this, no spontaneous seizures were detected in this group. In contrast, status epilepticus (pilocarpine model) produced loss of the hilar NPY and SS cells. Moreover, all rats with status epilepticus showed spontaneous behavioral seizures and their seizure threshold was markedly decreased. These findings support the notion that sustained NPY overexpression induced by brief seizures can be important in preventing epileptogenesis.