Recurrent multiple eye muscle palsy as a first sign of sarcoidosis.

Purpose: To report a case of (neuro)sarcoidosis presenting solely with recurrent cranial nerve palsies in a 57-year-old Caucasian female. Methods: Case report with clinical imaging. Results: A 57-year-old female first presented with a right sixth nerve palsy, which resolved spontaneously after 6 months. Three years later she was diagnosed with a sixth nerve palsy in the fellow eye followed by a complete palsy of the left third cranial nerve four months after. Medical history consisted of migraine and hypercholesterolemia. Further neurological and ophthalmic work-up was unrevealing at first. After repeated magnetic resonance imaging, an enhancing lesion in the left cavernous sinus was seen, which was initially diagnosed as a meningioma. However, imaging of the chest revealed an image of sarcoidosis, and the lesion and ophthalmoplegia of the left eye disappeared with systemic corticosteroid treatment. Discussion: Sarcoidosis is the ultimate imitator and the possibility of neurosarcoidosis must be taken into account when presented with unexplained ophthalmoplegia. Neurosarcoidosis has imaging properties very similar to other diseases such as a meningioma, and misdiagnosis occurs easily. Spontaneous recovery of ophthalmoplegia can rarely occur in neurosarcoidosis.

Amblyopia with Eccentric Fixation: Is Inverse Occlusion Still an Option?

Purpose: To present a treatment protocol for patients with amblyopia and eccentric fixation who do not respond to conventional occlusion therapy.Material and methods: In this consecutive case series, 11 patients were included (age 3.5 to 5.0), all with mixed amblyopia and eccentric fixation, who had only minor improvement of their visual acuity (VA) despite good compliance with 6 hours/day to full time occlusion of the sound eye for at least 6 months. Visual acuity of amblyopic eyes ranged from 20/50 to 20/400 at the time of initiation of inverse occlusion. Total inverse occlusion of the amblyopic eye was prescribed for 4 to 8 weeks to convert the steady eccentric fixation to wandering fixation. No binocular viewing was allowed. Once the fixation became wandering, the sound eye was occluded day and night and in most patients, a red filter was placed before the amblyopic eye to stimulate foveal fixation. In nine patients, the fixation became central and occlusion of the sound eye was continued without red filter. All children continued full time occlusion until VA failed to improve after two consecutive visits despite good compliance.Results: In nine children, the VA improved to at least 20/32 in the amblyopic eye. The VA of the sound eye did not change.Conclusion: Inverse occlusion is still a valuable option if conventional occlusion appears to be insufficient to improve VA in amblyopic eyes with eccentric fixation. Full time inverse occlusion should be performed until the eccentric point is no longer used for fixation and should be followed with full time occlusion of the sound eye. Placing a red filter before the amblyopic eye may be helpful to stimulate foveal fixation.

Long-term evolution of age-related distance esotropia.

PURPOSE: To evaluate the evolution of horizontal deviation and fusional amplitudes both at distance and at near in patients with age-related distance esotropia (ARDET). METHODS: The medical records of consecutive patients diagnosed with ARDET between January 2008 and March 2016 were reviewed retrospectively. Patients with at least 60 months' follow-up were eligible for inclusion. Horizontal deviation, fusional convergence amplitude, and fusional divergence amplitude both at distance and at near were compared. RESULTS: Of 131 cases reviewed, 31 patients were identified for inclusion. Median age at diagnosis was 73 years. Median distance esodeviation was 6Δ esotropia at initial examination (range, 2Δ-12Δ esotropia) and 8Δ eostropia at final examination (range, 2Δ-25Δ esotropia). Median near deviation was orthophoria at initial examination (range, 10Δ exophoria to 8Δ esophoria) and 4Δ esophoria at final examination (range, 4Δ exophoria to 14Δ esophoria). Median fusional divergence amplitude at distance was 4Δ at initial and at final examinations. At near, median fusional divergence amplitude was 8Δ at initial and at final examinations. Median fusional convergence amplitude at distance was 14Δ at initial examination and 12Δ at final examination. At near, median fusional convergence amplitude was 26Δ at initial and at final examinations. Base-out prisms were prescribed in all patients. In 23 patients the prism correction gradually increased. Strabismus surgery was performed in 3 patients. CONCLUSIONS: Our patients with ARDET experienced a slight increase in distance esodeviation (P < 0.001), whereas no significant change in fusional amplitudes was observed over time (P ≥ 0.05).

Binocular Vision in Chronic Fatigue Syndrome.

INTRODUCTION AND PURPOSE: To compare binocular vision measurements between Chronic Fatigue Syndrome (CFS) patients and healthy controls. METHODS: Forty-one CFS patients referred by the Reference Centre for Chronic Fatigue Syndrome of the Antwerp University Hospital and forty-one healthy volunteers, matched for age and gender, underwent a complete orthoptic examination. Data of visual acuity, eye position, fusion amplitude, stereopsis, ocular motility, convergence, and accommodation were compared between both groups. RESULTS: Patients with CFS showed highly significant smaller fusion amplitudes (P < 0.001), reduced convergence capacity (P < 0.001), and a smaller accommodation range (P < 0.001) compared to the control group. CONCLUSION: In patients with CFS binocular vision, convergence and accommodation should be routinely examined. CFS patients will benefit from reading glasses either with or without prism correction in an earlier stage compared to their healthy peers. Convergence exercises may be beneficial for CFS patients, despite the fact that they might be very tiring. Further research will be necessary to draw conclusions about the efficacy of treatment, especially regarding convergence exercises. To our knowledge, this is the first prospective study evaluating binocular vision in CFS patients.

Pediatric bag-in-the-lens intraocular lens implantation: long-term follow-up.

PURPOSE: To evaluate long-term follow-up results of pediatric cataract surgery using the bag-in-the-lens (BIL) intraocular lens (IOL) implantation technique. SETTING: Antwerp University Hospital, Edegem, Antwerp, Belgium. DESIGN: Prospective case series. METHODS: All pediatric cataract surgeries with BIL IOL implantation performed at the Antwerp University Hospital were evaluated. Only cases that completed a follow-up of 5 years at the hospital's Department of Ophthalmology were included in this study. RESULTS: Forty-six eyes of 31 children had a complete follow-up of 5 years or more after BIL IOL implantation. Sixteen cases were unilateral and 15 were bilateral. Patient age at time of surgery ranged from 2 months to 14 years. The mean refraction at the end of follow-up was -1.99 diopters (D) ± 3.70 (SD). In bilateral cases, a corrected distance visual acuity (CDVA) of better than 0.5 was attained in 86.7% and a CDVA of 1.0 was achieved in 56.7%. In unilateral cases, 31.2% achieved a CDVA of better than 0.5 but none obtained a CDVA of 1.0. A clear visual axis was maintained in 91.3% of cases during follow-up. Visual axis reopacification was detected in 4 eyes of 3 cases, all due to inadequate BIL IOL positioning. None of these eyes needed more than 1 intervention to maintain visual axis clarity. Other than 1 case of glaucoma, no severe complications were detected. CONCLUSION: Long-term follow-up results show that BIL IOL implantation is a safe, well-tolerated approach for treating pediatric cataract with a very low rate of visual axis reopacification and a low rate of secondary interventions for other postoperative complications. FINANCIAL DISCLOSURE: Dr. Tassignon has intellectual property rights to the bag-in-the-lens intraocular lens (U.S. patent 6 027 531; EU patent 009406794.PCT/120268), which is licensed to Morcher GmbH, Stuttgart, Germany. No other author has a financial or proprietary interest in any material or method mentioned.

Distance esotropia in the elderly.

AIM: To describe the clinical features of an under-recognised small esodeviation and horizontal diplopia on distance fixation seen in elderly patients not associated with lateral rectus underaction or coexisting neurological abnormalities. METHODS: 87 elderly patients (age range 62-91 years) with constant or intermittent horizontal diplopia at distance were prospectively recruited and assessed from February 2008 until February 2012. Ocular alignment, fusion amplitudes, and horizontal eye movements were measured for distance and near. RESULTS: Distance esodeviation varied from 2-18 prism dioptres (PD) esotropia (ET). At near fixation, deviation ranged from 10 PD exophoria to 12 PD esophoria. Divergence fusional amplitude at distance ranged from 0-10 PD while the divergence fusional amplitude at near ranged from 2-18 PD. Horizontal ductions and versions were full in all patients. Six patients presented with an increase of distance esodeviation combined with a decrease of divergent fusional amplitude over a period of 6-12 years. All patients were successfully treated with prisms, ranging from 2-16 PD base-out. CONCLUSIONS: Our findings indicate that patients with age-related distance ET may experience a slight increase in distance esodeviation over time, with a slow decrease of fusional divergence amplitudes with normal ocular motility. The aetiology is still unclear. However, patients may be assured that this is a benign condition with slow progression, and can be successfully treated with prism correction. Surgery may be reserved for the minority of cases with severe esodeviation.

Bag-in-the-lens intraocular lens implantation in the pediatric eye.

PURPOSE: To study the efficacy, safety, and feasibility of implantation of a bag-in-the-lens intraocular lens (IOL) in children and babies. SETTING: Departments of Ophthalmology, University Hospital, Antwerp, Belgium, and the University Hospital, Ljubljana, Slovenia, and a private ophthalmology practice, Oudenaarde, Belgium. METHODS: Thirty-four eyes of 22 children had implantation of a bag-in-the-lens IOL. The ages ranged from 2 months to 14 years. Congenital cataract was present in 26 eyes, and persistent fetal vasculature (PFV) was concomitantly present in 4 eyes. Fifteen patients had bilateral cataract, and 6 had unilateral cataract. RESULTS: In 3 eyes, the IOL could not be properly implanted. In these cases, secondary intervention was necessary because of early posterior capsule opacification. The mean postoperative follow-up was 17.45 months +/- 17.12 (SD) (range 4 to 68 months). None of the children except those presenting with PFV had anterior vitrectomy during surgery. The optical axis remained clear during the follow-up in all patients who had successful IOL implantation. CONCLUSIONS: The bag-in-the-lens implantation technique in children and babies was safe and kept the visual axis clear after cataract surgery. In the near future, 4.0 or 4.5 mm IOLs will be available that may improve the success rate of IOL implantation in the small eyes of babies.

Effect of refractive surgery on binocular vision and ocular alignment in patients with manifest or intermittent strabismus

Evaluamos el efecto de la cirugía refractiva en el alineamiento ocular y en la visión binocular en pacientes con estrabismo manifiesto o intermitente. 21 ojos de 12 pacientes estrábicos tuvieron cirugía refractiva. Cinco pacientes tenían miopía; 4 pacientes, hipermetropía y 3 pacientes, anisometropía. Cuatro pacientes tenían una esotropía manifiesta, 3 con una desviación vertical. Cinco pacientes tenían una exotropía manifiesta, 2 con una desviación vertical. Dos pacientes tenían una exotropía intermitente con visión binocular y un paciente tenía una hipertropía manifiesta con DVD. El ojo dominante fue operado en primer lugar en todos los pacientes que tenían programada una cirugía bilateral (9 pacientes). La cirugía refractiva no cambió significativamente el alineamiento ocular. Las funciones binoculares solamente fueron mejoradas en los pacientes con alta anisometropía.

We evaluated the effect of refractive surgery on binocular vision and ocular alignment in patients with intermittent and manifest strabismus. Twenty-one eyes of 12 strabismic patients underwent refractive surgery. Five patients were myopic, four hyperopic and three anisometropic. Four patients had an esotropia, three of them with a vertical deviation. Five patients had a manifest exotropia, two of them with a vertical deviation. Two patients had an intermittent exotropia with binocular vision and one patient had a manifest hypertropia with dissociated vertical deviation (DVD). The dominant eye was operated first, aiming for emmetropia, in all patients of whom both eyes were treated (9 patients). In all ametropìc patients ocular alignment and binocular functions remained unchanged. Only in the two high anisometropic patients the manifest deviation became intermittent or latent and fusion and stereopsis was restored.

Binocular vision impairment after refractive surgery.

PURPOSE: To illustrate the need for an accurate preoperative orthoptic examination to prevent postoperative changes in binocular vision. SETTING: Department of Ophthalmology, University Hospital Antwerp, Edegem, Belgium. METHODS: Five patients presenting major subjective complaints after refractive surgery were analyzed. RESULTS: In 1 patient, a latent N IV palsy decompensated after laser in situ keratomileusis (LASIK) in the more myopic eye to achieve monovision. A second patient, operated on for N IV palsy 10 years earlier, presented a recurrence of the palsy after bilateral LASIK for myopia. The third patient complained of discomfort in binocular vision caused by aggravation of a preexisting intermittent esotropia that worsened after LASIK for hyperopia. The fourth patient complained of diplopia after LASIK in the highly anisometropic and exotropic eye. The fifth patient experienced a decrease in fusion and stereopsis at the time he became anisometropic after bilateral LASIK. CONCLUSIONS: Special care should be taken of patients who have a preoperative history of strabismus surgery, an overcorrection or undercorrection in 1 or both eyes, or anisometropia and of those who are unhappy with contact lenses. An orthoptic examination should be done with and without spectacle correction to detect underlying vertical phorias. Intended monovision should be examined initially using contact lenses.